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Cross-Sectional Imaging of Acute and Chronic Gallbladder Inflammatory Disease

¹ Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr., Ann Arbor, MI 48109-5030.
² Department of Radiology, Mallinckrodt Institute of Radiology, St. Louis, MO.

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —85-year-old woman with right upper quadrant abdominal pain, leukocytosis, and fever. Longitudinal sonogram shows multiple shadowing gallstones and mild wall thickening. There was positive sonographic "Murphy sign."

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —85-year-old woman with right upper quadrant abdominal pain, leukocytosis, and fever. Axial contrast-enhanced CT image shows gallbladder wall thickening (arrow) and pericholecystic soft-tissue stranding in fat (arrowhead). This image also shows that gallstones are not always detected with CT.

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —85-year-old woman with right upper quadrant abdominal pain, leukocytosis, and fever. Patient was not surgical candidate due to multiple comorbidities, so cholecystostomy tube was placed. Catheter injection under fluoroscopy 4 weeks later shows multiple filling defects within gallbladder, consistent with gallstones. Gallstone is seen lodged in gallbladder neck (arrow).

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —76-year-old man with history of repaired abdominal aortic aneurysm and recent diagnosis of acute uncomplicated cholecystitis by sonography and hepatobiliary scintigraphy. Patient was subsequently managed conservatively without cholecystectomy but developed worsening abdominal pain and fever a few days later. Follow-up sonogram through gallbladder and hepatorenal fossa shows heterogeneous mass containing multiple echogenic shadowing foci.

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —76-year-old man with history of repaired abdominal aortic aneurysm and recent diagnosis of acute uncomplicated cholecystitis by sonography and hepatobiliary scintigraphy. Patient was subsequently managed conservatively without cholecystectomy but developed worsening abdominal pain and fever a few days later. Axial contrast-enhanced CT image shows indistinct gallbladder wall (arrow), pericholecystic and hepatorenal fossa fluid, and gallstones outside of gallbladder (arrowheads), confirming gallbladder perforation.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —62-year-old man with emphysematous cholecystitis. Abdominal radiograph shows curvilinear lucencies in right upper quadrant in expected location of gallbladder (arrows).

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —62-year-old man with emphysematous cholecystitis. Longitudinal sonogram shows echogenic gas in gallbladder wall (arrowheads). This sonographic appearance may be difficult to distinguish from gallbladder wall calcification without correlative radiography.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —76-year-old man with history of type 2 diabetes mellitus and new right upper quadrant pain. Axial contrast-enhanced CT image shows inflammatory stranding involving fat adjacent to gallbladder (arrow).

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —76-year-old man with history of type 2 diabetes mellitus and new right upper quadrant pain. Contrast-enhanced CT through mid gallbladder shows gas within gallbladder lumen, consistent with emphysematous cholecystitis (arrow).

View larger version (91K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —62-year-old woman with right upper quadrant pain. Axial unenhanced CT image through level of mid gallbladder shows abnormal high-attenuation material within abnormally distended gallbladder lumen. At surgery, imaging findings were confirmed to represent hemorrhagic cholecystitis.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —37-year-old pregnant women who presented to emergency department with new right upper quadrant abdominal pain. Longitudinal sonogram shows gallbladder distention, wall thickening (arrow), and pericholecystic fluid (arrowheads).

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —37-year-old pregnant women who presented to emergency department with new right upper quadrant abdominal pain. Transverse sonogram also reveals wall thickening (arrow), pericholecystic fluid (arrowheads), and echogenic bile (sludge). No gallstones were visualized.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —37-year-old pregnant women who presented to emergency department with new right upper quadrant abdominal pain. Axial contrast-enhanced CT image shows peripheral wedged-shaped areas of low attenuation in right hepatic lobe and spleen (arrowheads), consistent with infarcts. On basis of clinical history, imaging findings, and laboratory blood testing, patient was diagnosed with acalculous cholecystitis in setting of underlying hemolysis, elevated liver enzymes, and low platelet count syndrome.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —80-year-old woman with intermittent right upper quadrant abdominal pain, proven to represent chronic cholecystitis after cholecystectomy. Axial contrast-enhanced CT image shows gallbladder wall thickening and adjacent hepatic hyperenhancement, prospectively thought to represent acute cholecystitis. Subsequent hepatobiliary scintigraphy (hepatoiminodiacetic scan) was negative for acute cholecystitis, as the gallbladder filled with radiotracer.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —82-year-old woman with biliary-enteric fistula and gallstone ileus. (Courtesy of Ravi Kaza, Ann Arbor, MI) CT scout image shows multiple abnormally dilated loops of small bowel, suspicious for small-bowel obstruction.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —82-year-old woman with biliary-enteric fistula and gallstone ileus. (Courtesy of Ravi Kaza, Ann Arbor, MI) Axial contrast-enhanced CT image shows gas within gallbladder (arrow), diffuse gallbladder wall thickening (arrowheads), and pericholecystic fluid. Multiple abnormally dilated fluid-filled loops of small bowel are also seen.

View larger version (91K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —82-year-old woman with biliary-enteric fistula and gallstone ileus. (Courtesy of Ravi Kaza, Ann Arbor, MI) Axial contrast-enhanced CT image inferior in relation to B shows dilated loops of small bowel (arrowheads) and round, lamellated structure within small-bowel loop (arrow), proven to represent ectopic gallstone.

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —Two patients with xanthogranulomatous cholecystitis. In 27-year-old woman with intermittent right upper quadrant abdominal pain, longitudinal sonogram shows cholelithiasis and equivocal gallbladder wall thickening. Although patient was thought to have chronic cholecystitis and underwent elective cholecystectomy, lipid-laden macrophages were identified within gallbladder wall, confirming diagnosis of xanthogranulomatous cholecystitis.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —Two patients with xanthogranulomatous cholecystitis. In 73-year-old woman who also presented with right upper quadrant pain, coronal contrast-enhanced CT image shows irregular gallbladder wall thickening and multiple low-attenuation mural nodules (arrowheads). This patient was found to have xanthogranulomatous cholecystitis at histopathology.

View larger version (97K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —Two patients with Mirizzi syndrome. In 86-year-old man with right upper quadrant pain and new-onset obstructive jaundice (total bilirubin = 3.8 mg/dL), axial contrast-enhanced CT image shows moderate intrahepatic biliary dilatation (arrowheads).

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —Two patients with Mirizzi syndrome. Axial contrast-enhanced CT image slightly inferior to A shows gallbladder wall thickening, pericholecystic stranding, and abnormal gallbladder distention.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —Two patients with Mirizzi syndrome. Coronal reformatted CT image confirms presence of large gallstone in gallbladder neck (arrow).

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10D —Two patients with Mirizzi syndrome. In 68-year-old woman also with Mirizzi syndrome, coronal T2-weighted image shows large hypointense gallstone in gallbladder neck (arrow). A few small, nonobstructing stones are also present more distally in common bile duct (arrowhead).

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10E —Two patients with Mirizzi syndrome. ERCP performed on same patient as in D shows extrinsic compression on common hepatic duct (arrow) by large gallstone within gallbladder neck. Intrahepatic biliary dilatation (arrowheads) is also present.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —100-year-old man with surgically proven gallbladder torsion. Abdominal radiograph shows masslike opacity in right upper quadrant with mass effect on adjacent colon (arrowheads).

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —100-year-old man with surgically proven gallbladder torsion. Longitudinal sonogram is nonspecific, showing abnormally increased gallbladder distention and pericholecystic fluid (arrows).

View larger version (74K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —Two patients with acute hepatitis-related gallbladder changes. 6-year-old girl with new abdominal pain and jaundice. Laboratory evaluation was consistent with acute hepatitis (aspartate aminotransaminase [AST] = 2,205 IU/L, alanine aminotransaminase [ALT] = 2,622 IU/L, total bilirubin = 15.8 mg/dL), later determined to be due to Epstein-Barr virus infection. Transverse (A) and longitudinal (B) sonograms show marked gallbladder wall thickening (arrows) and gallbladder contraction. Visualized portal triads within liver on transverse image (A) appear echogenic, suggesting hepatic edema.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —Two patients with acute hepatitis-related gallbladder changes. 6-year-old girl with new abdominal pain and jaundice. Laboratory evaluation was consistent with acute hepatitis (aspartate aminotransaminase [AST] = 2,205 IU/L, alanine aminotransaminase [ALT] = 2,622 IU/L, total bilirubin = 15.8 mg/dL), later determined to be due to Epstein-Barr virus infection. Transverse (A) and longitudinal (B) sonograms show marked gallbladder wall thickening (arrows) and gallbladder contraction. Visualized portal triads within liver on transverse image (A) appear echogenic, suggesting hepatic edema.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —Two patients with acute hepatitis-related gallbladder changes. 39-year-old woman with acetaminophen-related acute fulminant hepatitis (AST = 5,147 IU/L, ALT = 3,596 IU/L, total bilirubin = 3.5 mg/dL). Transverse (C) and longitudinal (D) sonograms show marked gallbladder wall thickening and pericholecystic fluid thought to be reactive in cause.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12D —Two patients with acute hepatitis-related gallbladder changes. 39-year-old woman with acetaminophen-related acute fulminant hepatitis (AST = 5,147 IU/L, ALT = 3,596 IU/L, total bilirubin = 3.5 mg/dL). Transverse (C) and longitudinal (D) sonograms show marked gallbladder wall thickening and pericholecystic fluid thought to be reactive in cause.

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