Ultrasound
Gallbladder Wall Thickening: UUrasonic Findings 1 Howard J. Mindel!, M.D., and B. Albert Ring, M.D.
Despite the commonplace pathologic occurrence of gallbladder wall thickening in cholecystitis, ultrasonic evaluation of the gallbladder wall has rarely proved useful. Three additional cases of clearly documented ultrasonically visible gallbladder wall thickening are presented to support recent contentions that this may be a new sign of gallbladder disease. Index terms: Gallbladder, inflammation. Gallbladder. ultrasound studies. 7[ 62 ] .1298 • (Gallbladder, acute cholecystitis, 7 [62J .285) Radiology 133:699-701, December 1979
ALLBLADDER WALL THICKENING
has recently been de-
G scribed as a new ultrasonic sign of cholecystitis (1),
CASE REPORTS
but this finding remains controversial and of uncertain significance. It seems remarkable that gallbladder wall evaluation, even with the advent of gray scale techniques, has not proved more useful considering that in chronic cholecystitis, pathologically the "wall is almost always thickened " (2). Crade, speculating on the significance of gallbladder wall thickening, noted that "no study .. . correlated specimens with ultrasound scans prior to surgery" (3). Our point is to show ultrasonic delineation of gallbladder wall thickening in 3 clearly documented cases of cholecystitis (with cholelithiasis) and to support the proposal (1, 17) that this finding may, at least occasionally, prove a useful finding in gallbladder disease.
CASE I. B.L., a 25-year-old woman, presented with a two-day history of right upper quadrant (RUQ)pain and vomiting and on admission was febrile with white blood count (WBC) of 21,000 (left shift), normal amylase, and RUQ tenderness . Ultrasonic cholecystogram was done as an early procedure (Picker Echovien, 2.25 MHz transducer) showing cholelithias is and a clearly defined moderately echogenic thick (1-cm) gallbladder wall (Figs. 1 and 2). Our feeling was that the rim represented perforation or extramural inflammatory reaction. At surgery, the opened gallbladder showed " mural thickening to at least 8 mm " and cholelithiasis (Fig. 3). Pathologic report confirmed a thickened gallbladder wall measuring at one point 1 cm and composed of pale gray, pliable, fibromuscular tissue. Microscopy confirmed thickening of the gallbladder wall by edema, fibrin, and granulation tissue with ulcerated and necrotic mucosa . CASE II. S.L., a 39-year-old man, had a 15-year history of duodenal
1,2,3
Fig. 1. CASE I. Transverse sector scan, 7 cm above umbilicus , RUQ. Note moderately echogenic gallbladder wall, thicker superiorly (black arrow on outer perimeter of wall) and small lumen with echogenic calculus and acoustic shadowing (open arrow) . Fig. 2. CASE I. Sagittal sector scan , 2 cm right of midline , RUQ, head to right. Note echogenic calcu li (open arrow) with shadowing . Black arrow is on the upper perimeter of the thick (1 cm) echogenic wall. Fig. 3. CASEI. Note calculi and thicken ed wall (open arrows) conf irmed at pathology at up to 1 cm.
1 From the Department of Radiology, Medical Center Hospital of Vermont, and the University of Vermont College of Medicine, Burlington, VT 05401. Submitted for publication 19 Sept. 1978: revision requested 9 Jan. 1979; received 30 Mar. 1979; accepted 2 May 1979. shan
699
700
HOWARD J. MINDELL AND
B. ALBERT RING
December 1979
4,5
Fig. 9. Sagittal RUQ scan, showing gallbladder containing sludge (black arrow). This is a proved case for differential diagnosis .
Fig. 4. CASE II. Sagittal section . RPO, gallbladder wall thicker inferiorly (open arrows), probably visible above (cephalad to the right). Note shadowing by stone in the neck of the gallbladder. Fig. 5. CASE II. Transverse sect ion. Thicker (1-cm) section corresponds to thicker ultrasound section.
6, 7
peptic ulcer disease, hiatal hernia. and prior nonvisualization at oral cholecystography with several days of acute postprandial pain, nausea, and RUQ tenderness . On admission, the patient was febrile with an elevated wac (24.000 left shift), RUQ tenderness, and a palpable 3-4 cm mass beneath the right costal margin. Ultrasonic evaluation showed cholelithiasis and marked thickening of a moderately echogen ic but clearly defined gallbladder wall (Fig. 4). At surgery, there was an inflammatory response in the RUQ and thickening of the gallbladder wall with serosal induration; the gallbladder contained flecks of stone, a large stone in the ampulla. and had hemorrhagic and gangrenous mucosa . Pathologic study found the gallbladder 8.5 X 3 cm with a wall 1 cm at thickest and 0.5 cm at the thinnest points (Fig. 5). Microscopy confirmed ulcerated and hemorrhagic mucosa with a diagnosis of acute hemorrhagic and chronic cholecystitis .
CASE III. EK, a 72-year-old woman with multiple medical problems, including recurrent breast carcinoma, presented on admission with RUQ pain. A palpable tender RUQ mass was found. A temperature of 39°C and a wac of 13,000 (left shift) were recorded . An upper gastrOintestinal series showed extrinsic duodenal compression by the gallbladder which was not visualized on the double-dose oral cholecystogram. Ultrasonic evaluation showed a dramatic round gallbladder with an echogenic thick wall containing calculi (Figs. 6 and 7). Surgical and pathological examination showed a hemorrhagic gallbladder with thickened walls and fibrinous exudate on serosal surfaces (Fig. 8).
8
DISCUSSION
Fig. 6. CASE III. RUQ scan, transverse section demonstrating echogenic gallbladder wall (arrow s) to 1 ern, nearly circumferential. Fig. 7. CASE III. RUQ scan 6 cm cephalad to Figure 6. Echogenic calculi (open arrow) and right lateral trace of wall at this level (black arrow) are seen. Fig. 8. Low-power photomicrograph showing full (1 em) thickne ss of gallbladder wall . Note attenuated mucosa (top of specimen).
Hublitz et al . (4) and Tabrisky et al. (5) present bistable ultrasonic presentation of thickened or irregular walls in cholecystitis (one case each). Although noting that demonstration of a thin wall is " strong evidence against gallbladder disease, " Leopold and Sokoloff (6) spoke for bistable experiences by noting that up to 1973, " This finding . .. (thick wall) has proved an unreliable indicator in our hands." Using gray scale techniques, Cunningham (7) noted a wall lesion that proved to be a melanoma nodule, and Kappelman and Sanders (8) described an edematous gallbladder rim in one case. Most major series correlating gray scale ultrasound techniques with gallbladder disease have not included wall thickening as a sign of disease. Reports by several authors (9-16) with more than 550 proved cases via gray scale techniques do not describe gallbladder wall thickening as an ultrasonic finding in a single case. Handler (17) however, showed gallbladderwall
GALLBLADDER WALL THICKENING
Vol. 133
thickening in 8 of 53 patients with stones and 4 of 53 with cholecystitis without stones. In a later report (18), he concluded that in the absence of ascites or liver disease and with a gallbladderat least 2 cm in width, a wall of 3 mm was abnormal. Sanders and Zerhouni (19) on the other hand, reported gallbladder wall thickening to be as common in patients without symptoms as in those with cholecystitis, and echogenic gallbladder wall thickening was found to be of no pathological significance (300 gallbladders, 50 with proved gallstones). This difference of opinion may be due to a lack of agreement as to what constitutes a "thickened wall." In our 3 cases, the thinnest area in the gallbladder was 5 mm. Consequently, we believe that under the same conditions as given by Handler, a wall 5 mm thick is definitely abnormal. Moderate echogenicity was seen in the thickened gal!bladderwall in the cases under study here, which is not surprising given the mixed tissue reaction described above. Undoubtedly, if edema is the predominent finding, then the rim will be sonolucent, as reported by Kappelman and Sanders (8) or in the minority of Sanders and Zerhouni's patients (19). Differential Diagnosis: Multiple tiny stones along the posterior wall without acoustic shadowing or biliary sludge (Fig. 9) might be considered. While separating these two entities may be impossible (20), gravitational maneuvers, it- should be emphasized, differentiate both from wall thickening. Alcoholic liver disease, especially in patients with ascites, has been associated with gallbladder wall thickening (19). Other considerations include hyperplastic cholecystoces (19), gallbladder perforation, or contraction of the gallbladder (1), as after a fatty meal. Ultrasound imaging, as with the cases shown herein, can clearly demonstrate gallbladder wall thickening. With advancing technology, this may well see increased attention in the future in cholecystitis as well as in other entities as mentioned above.
REFERENCES
Ultrasound
2. Palayew MJ: Chronic cholecystitis and cholelithiasis. Semin RoentgenoI11:249-257, Oct 1976 3. Crade M: Comparison of ultrasound and oral cholecystogram in diagnosis of gallstones. Clin Diag Ultrasound 1:123-135, 1979 4. Hublitz UF, Kahn PC, Sell LA: Cholecystosonography: an approach to the nonvisualized gallbladder. Radiology 103:645-649, Jun 1972 5. Tabrisky J, Lindstrom RR, Herman MW, et al: Value of gallbladder B-scan ultrasonography. Gastroenterology 68:1246-1252, May 1975 6. Leopold GR, Sokoloff J: Ultrasonic scanning in the diagnosis of biliary disease. Surg Clin North Am 53:1043-1052, Oct 1973 7. Cunningham JJ: Atypical cholesonograms in primary and secondary malignant disease of the biliary tract. JCU 5:264-267, Aug 1977 8. Kappelman ND, Sanders RC: Ultrasound in the investigation of gallbladder disease. JAMA 239:1426-1428,3 Apr 1978 9. Crade M, Taylor KJW, Rosenfield AT, et al: Surgical and pathological correlation of cholecystosonography and cholecystography. AJR 131:227-229, Aug 1978 10. Arnon S, Rosenquist CJ: Gray scale cholecystosonography: an evaluation of accuracy. AJR 127:871-818, Nov 1976 11. Lawson TL: Gray scale cholecystosonography: diagnostic criteria and accuracy. Radiology 122:247-251, Jan 1977 12. Leopold GR, Amberg J, Gosink BB, et al: Gray scale ultrasonic cholecystography. A comparison with conventional radiographic techniques. Radiology 121:445-448, Nov 1976 13. Anderson JC, Harned RK: Gray scale ultrasonography of the gallbladder: an evaluation of accuracy and report of additional ultrasound signs. AJR 129:975-977, Dec 1977 14. Bartrum RJ Jr. Crow HC, Foote SR: Ultrasound examination of the gallbladder. An alternative to "double dose" oral cholecystography. JAMA 236:1147-1148, 6 Sep 1976 15. Bartrum RJ Jr, Crow HC, Foote SA: Ultrasonic and radiographic cholecystography. New Engl J Med 296:538-541, 10 Mar 1977 16. Crow HC, Bartrum RJ Jr, Foote SR: Expanded criteria for the ultrasonic diagnosis of gallstones. JCU 4:289-292, Aug 1976 17. Handler SJ: Gray scale ultrasonic detection of gallbladder wall thickening: its association with acute and chronic cholecystitis. Presented at the American Institute of Ultrasound in Medicine, San Diego, CA, Oct 21-23, 1978 18. Handler SJ: Ultrasound of gallbladder wall thickening and its relation to cholecystitis. AJR 132:581-585, Apr 1979 19. Sanders RC, Zerhouni E: The significance of ultrasonic gallbladder wall thickening. Presented at the American Institute of Ultrasound in Medicine, San Diego, CA, Oct 21-23, 1978 20. Azimi F, Marangola JP, Bryan PJ: Ultrasound evaluation of the nonvisualized gallbladder. Gastrointest RadioI1:293-299, 1977
ACKNOWLEDGMENT: We wish to express our appreciation to T. Leavitt, R. T.; M. Koplewitz, M.D. for the operating room slide (CASE I); A. Newberg, M.D. for assistance with the manuscript; and to S. Peterson for secretarial assistance.
1. Marchal G, Crolla 0, Baert AL, et al: Gallbladder wall thickening: a new sign of gallbladder disease visualized by gray scale cholecystosonography. JCU 6: 177-179, Jun 1978
70 1
Howard J. Mindell, M.D. Department of Radiology University of Vermont College of Medicine Burlington, VT 05401
Gallbladder Wall Thickening: UUrasonic Findings 1 Howard J. Mindel!, M.D., and B. Albert Ring, M.D.
Despite the commonplace pathologic occurrence of gallbladder wall thickening in cholecystitis, ultrasonic evaluation of the gallbladder wall has rarely proved useful. Three additional cases of clearly documented ultrasonically visible gallbladder wall thickening are presented to support recent contentions that this may be a new sign of gallbladder disease. Index terms: Gallbladder, inflammation. Gallbladder. ultrasound studies. 7[ 62 ] .1298 • (Gallbladder, acute cholecystitis, 7 [62J .285) Radiology 133:699-701, December 1979
ALLBLADDER WALL THICKENING
has recently been de-
G scribed as a new ultrasonic sign of cholecystitis (1),
CASE REPORTS
but this finding remains controversial and of uncertain significance. It seems remarkable that gallbladder wall evaluation, even with the advent of gray scale techniques, has not proved more useful considering that in chronic cholecystitis, pathologically the "wall is almost always thickened " (2). Crade, speculating on the significance of gallbladder wall thickening, noted that "no study .. . correlated specimens with ultrasound scans prior to surgery" (3). Our point is to show ultrasonic delineation of gallbladder wall thickening in 3 clearly documented cases of cholecystitis (with cholelithiasis) and to support the proposal (1, 17) that this finding may, at least occasionally, prove a useful finding in gallbladder disease.
CASE I. B.L., a 25-year-old woman, presented with a two-day history of right upper quadrant (RUQ)pain and vomiting and on admission was febrile with white blood count (WBC) of 21,000 (left shift), normal amylase, and RUQ tenderness . Ultrasonic cholecystogram was done as an early procedure (Picker Echovien, 2.25 MHz transducer) showing cholelithias is and a clearly defined moderately echogenic thick (1-cm) gallbladder wall (Figs. 1 and 2). Our feeling was that the rim represented perforation or extramural inflammatory reaction. At surgery, the opened gallbladder showed " mural thickening to at least 8 mm " and cholelithiasis (Fig. 3). Pathologic report confirmed a thickened gallbladder wall measuring at one point 1 cm and composed of pale gray, pliable, fibromuscular tissue. Microscopy confirmed thickening of the gallbladder wall by edema, fibrin, and granulation tissue with ulcerated and necrotic mucosa . CASE II. S.L., a 39-year-old man, had a 15-year history of duodenal
1,2,3
Fig. 1. CASE I. Transverse sector scan, 7 cm above umbilicus , RUQ. Note moderately echogenic gallbladder wall, thicker superiorly (black arrow on outer perimeter of wall) and small lumen with echogenic calculus and acoustic shadowing (open arrow) . Fig. 2. CASE I. Sagittal sector scan , 2 cm right of midline , RUQ, head to right. Note echogenic calcu li (open arrow) with shadowing . Black arrow is on the upper perimeter of the thick (1 cm) echogenic wall. Fig. 3. CASEI. Note calculi and thicken ed wall (open arrows) conf irmed at pathology at up to 1 cm.
1 From the Department of Radiology, Medical Center Hospital of Vermont, and the University of Vermont College of Medicine, Burlington, VT 05401. Submitted for publication 19 Sept. 1978: revision requested 9 Jan. 1979; received 30 Mar. 1979; accepted 2 May 1979. shan
699
700
HOWARD J. MINDELL AND
B. ALBERT RING
December 1979
4,5
Fig. 9. Sagittal RUQ scan, showing gallbladder containing sludge (black arrow). This is a proved case for differential diagnosis .
Fig. 4. CASE II. Sagittal section . RPO, gallbladder wall thicker inferiorly (open arrows), probably visible above (cephalad to the right). Note shadowing by stone in the neck of the gallbladder. Fig. 5. CASE II. Transverse sect ion. Thicker (1-cm) section corresponds to thicker ultrasound section.
6, 7
peptic ulcer disease, hiatal hernia. and prior nonvisualization at oral cholecystography with several days of acute postprandial pain, nausea, and RUQ tenderness . On admission, the patient was febrile with an elevated wac (24.000 left shift), RUQ tenderness, and a palpable 3-4 cm mass beneath the right costal margin. Ultrasonic evaluation showed cholelithiasis and marked thickening of a moderately echogen ic but clearly defined gallbladder wall (Fig. 4). At surgery, there was an inflammatory response in the RUQ and thickening of the gallbladder wall with serosal induration; the gallbladder contained flecks of stone, a large stone in the ampulla. and had hemorrhagic and gangrenous mucosa . Pathologic study found the gallbladder 8.5 X 3 cm with a wall 1 cm at thickest and 0.5 cm at the thinnest points (Fig. 5). Microscopy confirmed ulcerated and hemorrhagic mucosa with a diagnosis of acute hemorrhagic and chronic cholecystitis .
CASE III. EK, a 72-year-old woman with multiple medical problems, including recurrent breast carcinoma, presented on admission with RUQ pain. A palpable tender RUQ mass was found. A temperature of 39°C and a wac of 13,000 (left shift) were recorded . An upper gastrOintestinal series showed extrinsic duodenal compression by the gallbladder which was not visualized on the double-dose oral cholecystogram. Ultrasonic evaluation showed a dramatic round gallbladder with an echogenic thick wall containing calculi (Figs. 6 and 7). Surgical and pathological examination showed a hemorrhagic gallbladder with thickened walls and fibrinous exudate on serosal surfaces (Fig. 8).
8
DISCUSSION
Fig. 6. CASE III. RUQ scan, transverse section demonstrating echogenic gallbladder wall (arrow s) to 1 ern, nearly circumferential. Fig. 7. CASE III. RUQ scan 6 cm cephalad to Figure 6. Echogenic calculi (open arrow) and right lateral trace of wall at this level (black arrow) are seen. Fig. 8. Low-power photomicrograph showing full (1 em) thickne ss of gallbladder wall . Note attenuated mucosa (top of specimen).
Hublitz et al . (4) and Tabrisky et al. (5) present bistable ultrasonic presentation of thickened or irregular walls in cholecystitis (one case each). Although noting that demonstration of a thin wall is " strong evidence against gallbladder disease, " Leopold and Sokoloff (6) spoke for bistable experiences by noting that up to 1973, " This finding . .. (thick wall) has proved an unreliable indicator in our hands." Using gray scale techniques, Cunningham (7) noted a wall lesion that proved to be a melanoma nodule, and Kappelman and Sanders (8) described an edematous gallbladder rim in one case. Most major series correlating gray scale ultrasound techniques with gallbladder disease have not included wall thickening as a sign of disease. Reports by several authors (9-16) with more than 550 proved cases via gray scale techniques do not describe gallbladder wall thickening as an ultrasonic finding in a single case. Handler (17) however, showed gallbladderwall
GALLBLADDER WALL THICKENING
Vol. 133
thickening in 8 of 53 patients with stones and 4 of 53 with cholecystitis without stones. In a later report (18), he concluded that in the absence of ascites or liver disease and with a gallbladderat least 2 cm in width, a wall of 3 mm was abnormal. Sanders and Zerhouni (19) on the other hand, reported gallbladder wall thickening to be as common in patients without symptoms as in those with cholecystitis, and echogenic gallbladder wall thickening was found to be of no pathological significance (300 gallbladders, 50 with proved gallstones). This difference of opinion may be due to a lack of agreement as to what constitutes a "thickened wall." In our 3 cases, the thinnest area in the gallbladder was 5 mm. Consequently, we believe that under the same conditions as given by Handler, a wall 5 mm thick is definitely abnormal. Moderate echogenicity was seen in the thickened gal!bladderwall in the cases under study here, which is not surprising given the mixed tissue reaction described above. Undoubtedly, if edema is the predominent finding, then the rim will be sonolucent, as reported by Kappelman and Sanders (8) or in the minority of Sanders and Zerhouni's patients (19). Differential Diagnosis: Multiple tiny stones along the posterior wall without acoustic shadowing or biliary sludge (Fig. 9) might be considered. While separating these two entities may be impossible (20), gravitational maneuvers, it- should be emphasized, differentiate both from wall thickening. Alcoholic liver disease, especially in patients with ascites, has been associated with gallbladder wall thickening (19). Other considerations include hyperplastic cholecystoces (19), gallbladder perforation, or contraction of the gallbladder (1), as after a fatty meal. Ultrasound imaging, as with the cases shown herein, can clearly demonstrate gallbladder wall thickening. With advancing technology, this may well see increased attention in the future in cholecystitis as well as in other entities as mentioned above.
REFERENCES
Ultrasound
2. Palayew MJ: Chronic cholecystitis and cholelithiasis. Semin RoentgenoI11:249-257, Oct 1976 3. Crade M: Comparison of ultrasound and oral cholecystogram in diagnosis of gallstones. Clin Diag Ultrasound 1:123-135, 1979 4. Hublitz UF, Kahn PC, Sell LA: Cholecystosonography: an approach to the nonvisualized gallbladder. Radiology 103:645-649, Jun 1972 5. Tabrisky J, Lindstrom RR, Herman MW, et al: Value of gallbladder B-scan ultrasonography. Gastroenterology 68:1246-1252, May 1975 6. Leopold GR, Sokoloff J: Ultrasonic scanning in the diagnosis of biliary disease. Surg Clin North Am 53:1043-1052, Oct 1973 7. Cunningham JJ: Atypical cholesonograms in primary and secondary malignant disease of the biliary tract. JCU 5:264-267, Aug 1977 8. Kappelman ND, Sanders RC: Ultrasound in the investigation of gallbladder disease. JAMA 239:1426-1428,3 Apr 1978 9. Crade M, Taylor KJW, Rosenfield AT, et al: Surgical and pathological correlation of cholecystosonography and cholecystography. AJR 131:227-229, Aug 1978 10. Arnon S, Rosenquist CJ: Gray scale cholecystosonography: an evaluation of accuracy. AJR 127:871-818, Nov 1976 11. Lawson TL: Gray scale cholecystosonography: diagnostic criteria and accuracy. Radiology 122:247-251, Jan 1977 12. Leopold GR, Amberg J, Gosink BB, et al: Gray scale ultrasonic cholecystography. A comparison with conventional radiographic techniques. Radiology 121:445-448, Nov 1976 13. Anderson JC, Harned RK: Gray scale ultrasonography of the gallbladder: an evaluation of accuracy and report of additional ultrasound signs. AJR 129:975-977, Dec 1977 14. Bartrum RJ Jr. Crow HC, Foote SR: Ultrasound examination of the gallbladder. An alternative to "double dose" oral cholecystography. JAMA 236:1147-1148, 6 Sep 1976 15. Bartrum RJ Jr, Crow HC, Foote SA: Ultrasonic and radiographic cholecystography. New Engl J Med 296:538-541, 10 Mar 1977 16. Crow HC, Bartrum RJ Jr, Foote SR: Expanded criteria for the ultrasonic diagnosis of gallstones. JCU 4:289-292, Aug 1976 17. Handler SJ: Gray scale ultrasonic detection of gallbladder wall thickening: its association with acute and chronic cholecystitis. Presented at the American Institute of Ultrasound in Medicine, San Diego, CA, Oct 21-23, 1978 18. Handler SJ: Ultrasound of gallbladder wall thickening and its relation to cholecystitis. AJR 132:581-585, Apr 1979 19. Sanders RC, Zerhouni E: The significance of ultrasonic gallbladder wall thickening. Presented at the American Institute of Ultrasound in Medicine, San Diego, CA, Oct 21-23, 1978 20. Azimi F, Marangola JP, Bryan PJ: Ultrasound evaluation of the nonvisualized gallbladder. Gastrointest RadioI1:293-299, 1977
ACKNOWLEDGMENT: We wish to express our appreciation to T. Leavitt, R. T.; M. Koplewitz, M.D. for the operating room slide (CASE I); A. Newberg, M.D. for assistance with the manuscript; and to S. Peterson for secretarial assistance.
1. Marchal G, Crolla 0, Baert AL, et al: Gallbladder wall thickening: a new sign of gallbladder disease visualized by gray scale cholecystosonography. JCU 6: 177-179, Jun 1978
70 1
Howard J. Mindell, M.D. Department of Radiology University of Vermont College of Medicine Burlington, VT 05401
