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Diffuse Gallbladder Wall Thickening: Differential Diagnosis

Adriaan C. van Breda Vriesman1, Marc R. Engelbrecht2, Robin H. M. Smithuis1 and Julien B. C. M. Puylaert3

1 Department of Radiology, Rijnland Hospital, Simon Smitweg 1, PO Box 4220, NL-2350 CC Leiderdorp, The Netherlands.
2 Department of Radiology, UMC Radboud, Nijmegen, The Netherlands.
3 Department of Radiology, MCH Westeinde Hospital, The Hague, The Netherlands.


Figure 1
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  		Fig. 1A —35-year-old healthy male volunteer with normal gallbladder. Longitudinal sonogram of gallbladder, obtained after patient fasted for 12 hours, shows wall (arrow) as pencilthin echogenic line.

 

Figure 2
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  		Fig. 1B —35-year-old healthy male volunteer with normal gallbladder. Longitudinal sonogram in postprandial state shows pseudothickening of gallbladder wall (arrow) due to physiologic contraction.

 

Figure 3
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  		Fig. 2 —52-year-old man with normal gallbladder. Contrast-enhanced CT scan shows gallbladder wall as thin rim of enhancing soft-tissue density (arrowhead) surrounded by normal hypoattenuating fat.

 

Figure 4
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  		Fig. 3A —59-year-old woman with diffuse gallbladder wall thickening from acute cholecystitis. Longitudinal sonogram shows layered appearance of thickened gallbladder wall, with relatively hypoechoic region (arrowhead) between echogenic lines.

 

Figure 5
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  		Fig. 3B —59-year-old woman with diffuse gallbladder wall thickening from acute cholecystitis. Contrast-enhanced CT scan shows thick-walled gallbladder contains hypodense outer layer (arrow) that corresponds to subserosal edema, which may simulate pericholecystic fluid.

 

Figure 6
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  		Fig. 4A —43-year-old woman with acute calculous cholecystitis. Contrast-enhanced CT scans show distended gallbladder (arrowheads, A) with slightly thickened wall and subtle regional fat stranding (asterisk, A). Impacted, obstructing stone (arrow, B) is seen in neck of gallbladder.

 

Figure 7
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  		Fig. 4B —43-year-old woman with acute calculous cholecystitis. Contrast-enhanced CT scans show distended gallbladder (arrowheads, A) with slightly thickened wall and subtle regional fat stranding (asterisk, A). Impacted, obstructing stone (arrow, B) is seen in neck of gallbladder.

 

Figure 8
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  		Fig. 5A —62-year-old man with acute calculous cholecystitis. Transverse sonogram at spot of maximum tenderness shows noncompressible hydropically distended thick-walled gallbladder (arrowheads) and intraluminal stone and sludge or debris.

 

Figure 9
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  		Fig. 5B —62-year-old man with acute calculous cholecystitis. Contrast-enhanced CT scan depicts extensive fat inflammation (arrowheads) surrounding gallbladder (arrow).

 

Figure 10
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  		Fig. 6A —74-year-old man with acute acalculous cholecystitis. Longitudinal sonogram at spot of maximum tenderness shows mural thickening of gallbladder (arrow), which is completely filled with sludge (asterisk) without any stones.

 

Figure 11
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  		Fig. 6B —74-year-old man with acute acalculous cholecystitis. Power Doppler sonogram shows hypervascularity of gallbladder wall (arrowhead) as sign supporting diagnosis of inflammation.

 

Figure 12
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  		Fig. 6C —74-year-old man with acute acalculous cholecystitis. Contrast-enhanced CT scan depicts thick-walled gallbladder (arrow) filled with dense sludge (asterisk).

 

Figure 13
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  		Fig. 7 —49-year-old woman with chronic cholecystitis. Longitudinal sonogram of gallbladder shows slight wall thickening (arrow) and intraluminal nonobstructing stone. This patient had fasted overnight, so wall thickening does not represent physiologic contraction. Correlation of these findings with her clinical history of recurrent coliclike right upper quadrant pain due to transient gallbladder obstruction is essential for diagnosis.

 

Figure 14
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  		Fig. 8A —71-year-old man with xanthogranulomatous cholecystitis. Transverse sonogram of gallbladder shows marked wall thickening with intramural hypoechoic nodules (arrowheads) and intraluminal stone (arrow).

 

Figure 15
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  		Fig. 8B —71-year-old man with xanthogranulomatous cholecystitis. Contrast-enhanced CT scans show deformed and thickened gallbladder wall (arrow, B) containing hypoattenuating nodules (arrowheads, C) that correspond to hypoechoic lesions, representing abscesses or foci of inflammation. Lumen contains several stones (arrow, C).

 

Figure 16
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  		Fig. 8C —71-year-old man with xanthogranulomatous cholecystitis. Contrast-enhanced CT scans show deformed and thickened gallbladder wall (arrow, B) containing hypoattenuating nodules (arrowheads, C) that correspond to hypoechoic lesions, representing abscesses or foci of inflammation. Lumen contains several stones (arrow, C).

 

Figure 17
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  		Fig. 9A —56-year-old man with porcelain gallbladder. Conventional abdominal radiograph depicts diffusely calcified gallbladder wall (arrowhead).

 

Figure 18
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  		Fig. 9B —56-year-old man with porcelain gallbladder. Transverse sonogram of gallbladder shows calcification of anterior wall (arrowhead) with acoustic shadowing.

 

Figure 19
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  		Fig. 9C —56-year-old man with porcelain gallbladder. Contrast-enhanced CT scan depicts circumferential calcification of gallbladder wall (arrow).

 

Figure 20
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  		Fig. 10A —79-year-old man with gallbladder carcinoma. Longitudinal sonogram of gallbladder shows marked generalized wall thickening (arrowheads), replacing gallbladder lumen. Multiple gallbladder stones (arrow) indicate probable location of filled lumen.

 

Figure 21
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  		Fig. 10B —79-year-old man with gallbladder carcinoma. Contrast-enhanced CT scan depicts thick-walled gallbladder (arrowhead) with local infiltration of mass in adjacent liver (arrow). In absence of associated findings such as local invasion or metastases, it may not be possible to differentiate carcinoma from xanthogranulomatous cholecystitis. Note that gallstones are occult at CT.

 

Figure 22
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  		Fig. 11 —39-year-old woman with adenomyomatosis of gallbladder. Longitudinal sonogram of gallbladder shows mural thickening with calcifications and stones, with characteristic comet-tail reverberation artifact (arrowhead) emanating from anterior wall. This is due to small cholesterol crystals within Rokitansky-Aschoff sinuses.

 

Figure 23
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  		Fig. 12A —56-year-old man with liver cirrhosis. Longitudinal sonogram of gallbladder depicts wall thickening (arrow) surrounded by ascites. Note irregular cirrhotic liver parenchyma. Secondary gallbladder wall thickening in patients with liver cirrhosis is presumably due to elevated portal venous pressure and decreased intravascular osmotic pressure.

 

Figure 24
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  		Fig. 12B —56-year-old man with liver cirrhosis. Contrast-enhanced CT scan shows wall of gallbladder (arrow) appears nearly normal because subserosal edema cannot be well differentiated from surrounding ascites at CT.

 

Figure 25
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  		Fig. 13A —75-year-old man with drug-induced hepatitis. Longitudinal sonogram of nondistended gallbladder shows diffuse wall thickening (arrow) and incidental cholelithiasis, which may be confusing.

 

Figure 26
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  		Fig. 13B —75-year-old man with drug-induced hepatitis. MR images were obtained to evaluate bile ducts because of abnormal liver function tests. Axial SPIR (spectral presaturation by inversion recovery) T2-weighted image (B) shows small amount of ascites (arrowhead, B), which indicates that thickened gallbladder wall (arrow, B) probably has extrinsic systemic cause. Mural thickening of gallbladder (arrowhead, C) is also shown on oblique HASTE image (C) from MR cholangiography; this study excludes choledocholithiasis.

 

Figure 27
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  		Fig. 13C —75-year-old man with drug-induced hepatitis. MR images were obtained to evaluate bile ducts because of abnormal liver function tests. Axial SPIR (spectral presaturation by inversion recovery) T2-weighted image (B) shows small amount of ascites (arrowhead, B), which indicates that thickened gallbladder wall (arrow, B) probably has extrinsic systemic cause. Mural thickening of gallbladder (arrowhead, C) is also shown on oblique HASTE image (C) from MR cholangiography; this study excludes choledocholithiasis.

 

Figure 28
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  		Fig. 14A —74-year-old man with congestive right heart failure. Longitudinal sonogram of stone-free painless gallbladder depicts diffuse wall thickening (arrow).

 

Figure 29
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  		Fig. 14B —74-year-old man with congestive right heart failure. Transverse sonographic view through liver shows large-caliber hepatic veins (arrowheads) and inferior vena cava as supporting evidence of right heart failure.

 

Figure 30
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  		Fig. 15 —56-year-old man with pancreatitis. Contrast-enhanced CT scan shows peripancreatic inflammatory changes (arrowheads) and thickening of wall of gallbladder (arrow), which is secondarily involved in pancreatic inflammation.

 

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