Thick walled gall bladder is very common investigation findings. Approaching this problem in algorithmic manner is necessary for improving patient outcome.

1. Thick walled Gall Bladder
Dr Shashank Agrawal

2. • Gallbladder wall thickening is a commonly encountered imaging
finding and can be seen in a broad spectrum of pathological
conditions.
• The differentiation of benign and malignant gallbladder wall
thickening is critical as well as challenging.
• Appropriate utilization and interpretation of imaging may allow
discrimination between benign and malignant GB wall thickening

3. Definition
• A thickened gallbladder wall measures more than 3 mm

4. Why it is important to differentiate
• Thick walled gall bladder can be caused by- Gall stone disease leading
to acute cholecystitis (reversible), Chronic cholecystitis (irreversible),
Gall bladder cancer or gall bladder polyps
• Management of each modality is different- As benign lesions with
need some form of simple cholecystectomy but malignancy require
algorithmic management

5. Back ground
• Risk factors for GB neoplasm include gallstones and a history of
chronic cholecystitis.
• Others risk factors include choledochal cysts, anomalous
pancreaticobiliary duct junctions, and gallbladder polyps > 1 cm in
size.
• Gallbladder carcinoma has a peak incidence in the sixth and seventh
decades of life and is three to five times more predominant in females

6. There could be two scenarios
Diffuse
• Inflammatory- Acute cholecystitis (calculous,
acalculous), chronic cholecystitis including
xanthogranulomatous cholecystitis
• Hepatic causes-Acute hepatitis, cirrhosis,
portal hypertension
• Extrinsic inflammatory condition-Pancreatitis,
pyelonephritis, colitis, peritonitis
• Systemic causes-Hypoalbuminemia,
congestive cardiac failure, renal failure, sepsis
• Neoplastic- Carcinoma gallbladder, lymphoma
• Adenomyomatosis
• Infective –Tubercular, dengue
Focal
• Polyps- Cholesterol polyposis, adenomatous
• Focal adenomyomatosis, focal
xanthogranulomatous cholecystitis
• Neoplastic-Gallbladder cancer, metastasis

7. Ultrasound
Radiology 1987
The type 1, or “striated,” pattern consisted of
irregular, discontinuous, alternating lucent and
echogenic bands,
while the type 2, on “three-layer,” pattern was
characterized by one smooth circumferential lucent
zone interposed between two relatively uniform
echogenic layers.
Intrinsic
GB
disease
No
intrinsic
GB
disease
Thickness >6mm-
severe inflammation

9. • Adenomyomatosis- Symmetrical
wall thickening, intramural cystic
spaces, intramural echogenic
foci
• CAGB- Irregular thickening of the
outer wall, focal IHL
discontinuity, IHL irregularity, IHL
thickening greater than 1 mm,
loss of the multilayer pattern in
the GB wall and intralesional
vascularity on colour Doppler

11. Gall bladder polyps
• The prevalence of gallbladder polyps varies from 0.3% to 12% in
healthy adults who undergo abdominal ultrasonography (US).
• GB polyps are classifed into 2 groups-- neoplastic (adenomas,
adenocarcinomas) and nonneoplastic (cholesterol polyps,
infammatory polyps, adenomyomatosis)

12. • Ultrasound features to be considered
in diagnosis of polyps are
• number (solitary or multiple),
• size (<6 mm, 6– 10 mm,>1 cm),
• shape (pedunculated or sessile),
• echogenicity (hypo, iso, and hyper),
• surface (smooth or nodular),
• internal echogenicity (homogenous or
inho-mogeneous), and
• hyperechoic spots (single 1–5mm,
highly echogenic dot, or partial
aggregates of1–3mmsized,multiple,
highly echogenic spots)
• EUS is considered superior to
transabdominal US for imaging the
biliary system, with higher ultrasound
frequencies (5–12MHz versus 2–
5MHz).
• Sadamoto et al. proposed EUS
formula:
• Maximum diameter (in millimeters) +
internal echo pattern score
(heterogenous = 4, homogenous = 0) +
hyperechoic spot.
• With this system, the sensitivity and
specificity for the risk of neoplastic
polyps with scores of >12 were 77.8%
and 82.7%, respectively

13. Vijayakumar A, Vijayakumar A, Patil V, Mallikarjuna MN, Shivaswamy BS. Early diagnosis of gallbladder carcinoma: an algorithm
approach. ISRN radiology. 2012 Oct 18;2013.

14. Computed tomography
• Goshima et al. described that the presence of three out of five
findings: Diffuse wall thickening, continuous mucosal layer, intramural
hypoattenuating nodules in the thickened wall, absent liver invasion
and lack of biliary dilatation favors XGC
• The findings of two-layered enhancing pattern of GB wall with
hyperenhancement of thick inner wall ≥ 2.6 mm, non or faint
enhancement of thin outer wall ≤ 3.4mm and focal irregular wall
thickening were seen in GBC
• Presence of enlarged lymph nodes and infiltration of liver favor GBC
• Local staging

15. Positron Emission Tomography
• Increased FDG uptake is seen in malignancy.
• False-positive FDG uptake can be seen in adenomyomatosis or XGC,
resulting in a misdiagnosis of GBC.
• Delayed PET uptake is a feature of malignancy.
• Gupta et al. showed that focal thickening with FDG avidity is a feature
of malignancy.
• For diffuse thickening, SUV value may be helpful. With a cut off value
of 5.95, sensitivity and specificity of PET-CT are 92% and 79%
respectively for diagnosing malignancy
• Systemic staging

16. TWGB with Pancreaticobiliary Mal-junction
• Pancreatic and biliary confluence is outside duodenum and either
sphincters are absent or there is common channel is >6-8mm– High
confluence of pancreaticobiliary ducts (HCPBD)
• There is substantial increase in chance of biliary CA

17. IDUS/PG/ERCP
Vijayakumar A, Vijayakumar A, Patil V, Mallikarjuna MN, Shivaswamy BS. Early diagnosis of gallbladder carcinoma: an algorithm
approach. ISRN radiology. 2012 Oct 18;2013.

18. High suspicion of GBC
• Diffusion weighted MR imaging (DWI) may help to differentiate
between benign and malignant TWGB but is not accurate
• Tumor markers e.g., CEA, CA 19-9 and CA 125 have not been found
to be useful to differentiate between XGC and GBC
• Preoperative FNAC may identify most GBC and some XGC but a
negative FNAC does not exclude GBC.
• Moreover, FNAC is not recommended in resectable GBC because of
fear of tumor spread along the needle tract.
• EUS guided FNAC from TWGB has been reported but requires
equipment and expertise which is not available easily and everywhere.

19. Problem with Simple Cholecystectomy
• If SC is performed for TWGB harboring GBC, it will result in breach
of tumor planes between GB and liver and compromise oncological
principles; this will deny the possible chance of cure in an
early GBC
• Moreover, if SC is done laparoscopically, GB perforation and bile spill
are more likely to happen and may result in peritoneal dissemination
and port site recurrence in malignant TWGB (GBC)

20. What should be done !!
• Refer the patient to higher centres
• Concept of anticipatory Extended cholecystectomy can be exploited
• Extended Cholecystectomy with wedge resection– frozen proceed
• In case of GBC- Radical Cholecystectomy with lymphadenectomy

21. Summary of investigations
Features Benign GB wall thickening Malignant GB wall thickening
Degree of mural thickening Less More *
Symmetry of mural thickening Symmetrical Asymmetrical, irregular, focal thickening
Mural stratification Preserved Lost
Enhancement pattern homogenous or stratified enhancement
Presence of dotted –linear vessels (on CEUS)
Delayed washout (>40 s)
Inhomogeneous enhancement Branched or
linear intralesional vessels (on CEUS) Early
washout (<40 s)
Intramural characteristics Continuous inner wall Intramural cystic
spaces, echogenic foci, hypoechoic nodules,
twinkling artifacts
Focal discontinuity of inner and outer layer
Irregularity and thickening > 1 mm of
innermost layer Irregular thickening of outer
layer
Ancillary findings Pericholecystic fluid in absence of ascites,
intraluminal membranes, sandwich sign, halo
sign, visualization of Rokitansky Aschoff
sinuses
Diffusion restriction, direct invasion of
adjacent organ, biliary obstruction,
lymphadenopathy