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Focal vs diffuse gall bladder wall thickening

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  • Interestingly non B. edema produces more marked thickening than A. cholecystitis
  • Those were the images of a 49-year-old woman with chronic cholecystitis.
    This patient had fasted overnight, so the wall-thickening does not represent physiologic contraction.
    Correlation of these findings with her clinical history of recurrent colic-like right upper quadrant pain, due to transient gallbladder obstruction, is essential for the diagnosis
  • Interestingly non B. edema produces more marked thickening than A. cholecystitis
  • Transcript

    • 1. Focal Vs Diffuse Gall Bladder Wall Thickening
    • 2. Objectives • Normal GB wall Appearance • Causes Of focal GB wall thickening • Causes of diffuse GB wall thickening • Appearances of different conditions • Differentiating points • Pitfalls of GB wall thickening
    • 3. Gall Bladder • Normal wall thickness < 3mm • The normal gallbladder wall appears as a pencil-thin echogenic line at sonography. • The thickness of the gallbladder wall depends on the degree of gallbladder distention and pseudothickening can occur in the postprandial state.
    • 4. LEFT: US of a normal gallbladder after an overnight fast shows the wall as a pencil-thin echogenic line (arrow).RIGHT: US in the postprandial state shows pseudothickening of the gallbladder
    • 5. The normal gallbladder wall is usually perceptible at CT as a thin rim of soft-tissue density that enhances after contrast injection.
    • 6. Thickened gallbladder wall • Thickening of the gallbladder wall is a relatively frequent finding at diagnostic imaging studies. • A thickened gallbladder wall measures more than 3 mm, typically has a layered appearance at sonography , and at CT frequently contains a hypodense layer of subserosal oedema that mimics pericholecystic fluid.
    • 7. LEFT: US in a 59-year-old woman with acute cholecystitis shows the layered appearance of a thickened gallbladder wall, with a hypoechoic region between echogenic lines RIGHT: At contrast-enhanced CT the thick-walled gallbladder contains a hypodense outer layer (arrow) due to subserosal oedema
    • 8. Focal Wall Thickening • Polyps • Adenomyomatosis • Carcinoma • Xanthogranulomatous cholecystitis • Metastasis • Chronic cholecystitis • Tumefactive sludge / Sludge balls
    • 9. Polyps/ Cholesterolosis • A condition in which triglycerides, cholesterol esters and cholesterol precursors are deposited in lamina propria of GB. • Cause is unknown • Not related to serum lipid level, atherosclerosis, diabetes, cholesterol stones, or hyperconcentration of cholesterol in bile. • Most cases do not produce any detectable change in appearance.
    • 10. • Sometimes referred to as “Strawberry gallbladder” • Minority of cases are of polypoid variety • Cholesterol polyps are “enlarged papillary fronds filled with lipid laden macrophages” • Attached to the wall by a stalk • “Ball on the wall” • 5mm or less, rarely get bigger than 10mm
    • 11. • Do not acoustic shadowing • Do not exhibit postural movement • Other less common types of polyps are adenoma papilloma leiomyoma lipoma neuroma
    • 12. • Polyps < 5mm – no further evaluation 5-10mm – monitoring > 10mm – should be removed • As the polyp enlarges – risk of malignancy increases
    • 13. Large Fibrous Polyps of the Gallbladder Simulating Gallbladder Carcinoma
    • 14. GB Polyp fixed to the ventral wall of the GB
    • 15. Diffuse Wall Thickness • CAUSES • Biliary Causes 1.Cholecystitis 2.Adenomyomatosis 3.Cancer 4.AIDS cholangiopathy 5.Sclerosing cholangitis
    • 16. • NON BILIARY CAUSES 1.Hepatitis 2.Pancreatitis 3.Heart Failure 4.Hypoproteinemia 5.Cirrhosis 6.Portal hypertension 7.Lymphatic obstruction
    • 17. Cholecystitis • Acute • Chronic • Acalculous • Xanthogranulomatous
    • 18. Acute cholecystitis • Fourth most common cause of hospital admissions for patients presenting with an acute abdomen • It is the prime diagnostic concern when a thick-walled gallbladder is found at imaging. • This feature, however, is not pathognomonic and additional imaging signs should be present to support the diagnosis of acute calculous cholecystitis.
    • 19. Signs of Acute cholecystitis • Thickened gall bladder wall • Obstructing gallstone • Hydropical dilatation of the gallbladder, • A positive sonographic Murphy's sign ( i.e., pain elicited by pressure over the sonographically located gallbladder), • Pericholecystic fat inflammation or fluid • Hyperemia of the gallbladder wall at power Doppler
    • 20. Acute calculous cholecystitis. Transverse sonogram at the spot of maximum tenderness shows a non- compressible hydropically distended thick-walled gallbladder (arrowheads), with an intraluminal stone and sludge or debris. Contrast-enhanced CT depicts extensive fat inflammation (arrowheads) surrounding the gallbladder (arrow).
    • 21. Chronic cholecystitis • Chronic cholecystitis is a term used clinically to refer to symptomatic gallbladder stones that cause transient obstruction, leading to a low-grade inflammation with fibrosis . • Correlation of the imaging finding of a stone-containing slightly thick-walled gallbladder with the clinical history is critical.
    • 22. Chronic cholecystitis. Longitudinal sonogram of the gallbladder shows slight wall thickening (arrow) and an intraluminal non-obstructing stone
    • 23. Acalculous cholecystitis • Mainly occurs in critically ill patients, (Major surgery, Major trauma,extensive burns) • Due to Increased bile viscosity from fasting and Medication that causes cholestasis. • The imaging features are those of acute cholecystitis, except for the absence of stones whereas gallbladder sludge is usually present.
    • 24. Acalculous cholecystitis PITFALL • Because in critically ill patients gallbladder abnormalities are frequently found secondary to systemic disease , acalculous cholecystitis can be difficult to diagnose . • In these patients a percutaneous cholecystostomy can be both diagnostic and therapeutic.
    • 25. 74-year-old man with acute acalculous cholecystitis. LEFT: US at the spot of maximum tenderness shows mural thickening of the gallbladder (arrow) that is completely filled with sludge (asterix) without any stones.RIGHT: Power-Doppler sonography shows hypervascularity of the gallbladder wall (arrowhead), as a supporting sign of inflammation.
    • 26. Xanthogranulomatous cholecystitis • Unusual variant of chronic cholecystitis, • Characterized by a Destructive inflammatory process with varying proportions of fibrous tissue, inflammatory cells and lipid laden macrophages • Gall stones +/- • Locally invasive
    • 27. • Imaging studies show marked gallbladder wall thickening, often containing intramural nodules that are hypoechoic at sonography and hypoattenuating at CT, representing abscesses or foci of xanthogranulomatous inflammation. • These features overlap with those of gallbladder carcinoma, making preoperative distinction between these entities often impossible.
    • 28. Xanthogranulomatous cholecystitis. LEFT: US shows marked wall thickening with intramural hypoechoic nodules (arrowheads), and an intraluminal stone (arrow).RIGHT: Contrast-enhanced CT shows a deformed and thickened gallbladder wall containing hypoattenuating nodules
    • 29. Contrast-enhanced CT shows a deformed and thickened gallbladder wall containing hypoattenuating nodules . These represent abscesses or foci of inflammation. The lumen contains several stones (arrow).
    • 30. Adenomyomatosis • Benign condition that requires no specific treatment, • Incidental finding in upto 9% of cholecystectomy specimens Characterized by • 1. Epithelial proliferation, • 2. Muscular hypertrophia and • 3. Intramural diverticula (Rokitansky-Aschoff sinuses), which may segmentally or diffusely involve the gallbladder.
    • 31. • The sonographic finding of cholesterol crystals, shown as 'comet-tail' reverberation artifacts, within a thickened wall of the gallbladder strongly suggests this diagnosis. • Air may produce a similar artifact, however, patients with emphysematous cholecystitis are usually ill in contrast to those with adenomyomatosis. • MR imaging may be able to differentiate adenomyomatosis from gallbladder carcinoma by depicting Rokitansky-Aschoff sinuses.
    • 32. Four types of gallbladder adenomyomatosis • A. Annular type. • B. Segmental type, which describes an annular or segmental wall thickening causing stricture that divides the gallbladder lumen into separate interconnected compartments. • C. Fundal type,(adenomyoma) a focal elevated lesion with a central dimple located at the fundus of the gallbladder. • D .Diffuse type, a thickened wall involving the entire gallbladder.
    • 33. • Exclusion of gallbladder cancer may be most problematic in segmental and focal cases. Focal adenomyomatosis may appear as a discrete mass, known as an adenomyoma.
    • 34. Diffuse adenomyomatosis of gall bladder. These gall bladder ultrasound images show multiple echogenic foci within the GB wall with V-shaped comet-tail .
    • 35. Gallbladder Adenomyomat osis: Axial CT of the abdomen with oral and IV contrast shows focal thickening of the gallbladder wall (arrows)
    • 36. Oral cholecystogram and MRCP • Historically oral cholecystograms were performed, however due to low sensitivity and a high rate of contrast allergies it has now largely been replaced by MRCP which does not rely on contrast opacification of the lumen of the gallbladder. • MRCP would be also to detect : • mural thickening • focal sessile mass • pearl necklace sign (fluid filled intramural diverticula) • hourglass configuration in annular types
    • 37. Rokitansky-Aschoff sinuses shown on the after fatty meal film at cholecystography Stricture is also present.
    • 38. Fundal nodule of adenomyomatosis before and after gallbladder contraction.
    • 39. MRI • The pearl necklace sign alludes to the characteristically curvilinear arrangement of multiple rounded hyperintense intraluminal cavities visualized at T2- weighted MR imaging and MR cholangiopancreatography of adenomyomatosis.
    • 40. pearl necklace sign • It represents the contrast / fluid filled intramural mucosal diverticula (Rokitansky-Aschoff sinuses) which line up reminiscent of pearls on a necklace. • highly specific (92%) • frequently not seen, • only present in ~ 70% of cases
    • 41. coronal T2
    • 42. Gallbladder carcinoma • Fifth most common malignancy of the GIT • found incidentally in 1% to 3% of cholecystectomy specimens. • It is often detected at a late stage of the disease, due to lack of early or specific symptoms. • Gallbladder carcinoma has various imaging appearances, ranging from a - polypoid intra-luminal lesion to -an infiltrating mass replacing the gallbladder, -diffuse mural thickening.
    • 43. Associated findings • -- invasion of adjacent structures, • --secondary bile duct dilatation, and • --liver or nodal metastases may help in differentiating a carcinoma from acute or xanthogranulomatous cholecystitis . • In absence of these associated findings, it may not be possible to differentiate a carcinoma from xanthogranulomatous cholecystitis.
    • 44. Pathology • 90% are adenocarcinoma , • 5% are squamous carcinomas and • 5% is anaplastic carcinomas. • They appear as gallbladder wall thickening and induration. • Most common sites are at the fundus and neck of the gallbladder • Pocelain GB and sclerosing cholangitis are predisposing factors
    • 45. SPREADS 80% are detected after direct invasion or portal node involvement. • Local direct invasion into the hepatic bed, • Lymphatic spread into the cystic nodes, hiatal nodes and then to the superior and posterior pancreaticoduodenal nodes and the periaortic nodes. • Blood borne spreads via the portal vein to the liver • 5 yr survival is < 20%
    • 46. Investigations • Abdominal ultrasound scan : may shows gallbladder wall thickening or a mass filling the gallbladder , which would be suggestive of malignancy. • CT or MRI scan : show a mass in the region of gallbladder. • Arteriographic CT portogram ; Where contrast is injected into the superior mesenteric artery , allows accurate measurements of the extent of the disease and is resectability.
    • 47. Gall bladder carcinoma with portal vein and biliary tree infiltration
    • 48. Abnormal gallbladder with stones and sludge and a thickened irregular wall. Liver metastases and tumor thrombus in the left portal vein.
    • 49. Portal Venous phase--- GB Ca
    • 50. This sagittal sonogram image demonstrates heterogeneous thickening of the gallbladder wall (arrows), found to be primary papillary adenocarcinoma
    • 51. Primary Sclerosing Cholangitis • Etiology –unknown • Inflammatory process affecting intra and extra hepatic ducts • Presentation and course is highly variable • May present in infancy or old age • C/C --- cholestasis • Predisposition ---to bile duct cancer
    • 52. • Multifocal stricture of bile duct • 86% will have both intra and extra hepatic involvement
    • 53. Characteristic intrahepatic strictures of sclerosing cholangitis.
    • 54. Characteristic stricturing of sclerosing cholangitis involving the intra- and extrahepatic biliary system.
    • 55. AIDS cholangiopathy • Obliterative cholangiopathy due to oppurtunistic infection of the bile duct by -CMV -Pnemocystis carinii -Cryptosporidium • Presentation is similar to PSC • C/C abd. Pain and cholangitis • Tx .. Endoscopic sphincterotomy
    • 56. • NON BILIARY CAUSES 1.Hepatitis 2.Pancreatitis 3.Heart Failure 4.Hypoproteinemia 5.Cirrhosis 6.Portal hypertension 7.Lymphatic obstruction
    • 57. Edematous thickening of the gallbladder wall in a patient with cardiac failure and ascites.
    • 58. Edematous thickened gallbladder wall in a patient with cardiac failure
    • 59. Edematous thickened gallbladder wall in a patient with hepatitis
    • 60. Hepatitis with a thickened gallbladder wall
    • 61. Gallbladder wall thickening in a patient with a sepsis and hepatosplenomegaly
    • 62. The image above was taken in a patient with cirrhosis, chronic ascites, and no acute complaints of upper abdominal pain.
    • 63. How to differentiate b/w cholecystitis and non biliary causes ??
    • 64. How to differentiate b/w cholecystitis and non biliary causes • Clinical correlation • Presence and absence of sonographic Murphy’s sign • Associated signs e.g. Pulsatile portal venous flow in heart failure Portal HTN & nodular liver in Cirrhosis
    • 65. Conclusion • GB wall thickness can be --Focal --Generalized • Both biliary and non-biliary causes can result in increase in wall thickness • Clinical correlation is important
    • 66. THANK YOU