DOI:10.2214/AJR.05.1712
AJR 2007; 188:495-501
© American Roentgen Ray Society
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.
Received September 26, 2005;
accepted after revision November 12, 2005.
Address correspondence to A. C. van Breda Vriesman
(adriaanbreda{at}hotmail.com).
Abstract
OBJECTIVE. The objective of our study was to review and illustrate
the various clinical entities that may cause diffuse thickening of the
gallbladder wall on diagnostic imaging studies.
CONCLUSION. Diffuse gallbladder wall thickening may be caused by a
wide range of gallbladder diseases and extracholecystic pathologic conditions.
In most cases its cause can be determined by correlation of the clinical
presentation and associated imaging findings.
Keywords: abdominal imaging • acute abdomen • adenomyomatosis • cholecystitis • CT • gallbladder carcinoma • gallbladder disease • gallbladder thickening • sonography
Introduction
Thickening of the gallbladder wall is a relatively frequent finding
on diagnostic imaging studies. Historically, a thick-walled gallbladder has
been regarded as proof of primary gallbladder disease, and it is a well-known
hallmark feature of acute cholecystitis. The finding itself, however, is
nonspecific and can also be found in a variety of conditions unrelated to
intrinsic gallbladder disease. Diffuse gallbladder wall thickening may produce
a diagnostic problem because it occurs in symptomatic and asymptomatic
patients and in patients with and those without an indication for
cholecystectomy. Misinterpretation of the cause of this imaging finding can
lead to an unnecessary cholecystectomy in patients without intrinsic
gallbladder disease and, conversely, misdiagnosis in patients who do require a
cholecystectomy may result in delayed treatment with increased morbidity. In
this essay, we discuss and illustrate the various causes of a thickened
gallbladder wall because knowledge of its differential diagnosis is essential
for the correct interpretation of this finding.
Normal and Thickened Gallbladder
Sonography, CT, and MRI all allow direct visualization of the normal and
thickened gallbladder wall. Traditionally, sonography is used as the initial
imaging technique for evaluating patients with suspected gallbladder disease
because of its high sensitivity in the detection of gallbladder stones, its
real-time character, and its speed and portability
[1]. However, CT has become
popular for evaluating the acute abdomen and often is the first technique to
show gallbladder wall thickening
[2], or CT may be used as an
adjunct to an inconclusive sonography examination or for staging of disease.
The potential value of MRI in the evaluation of gallbladder disease has been
shown [3], but it still plays
little role.
The normal gallbladder wall appears as a pencil-thin echogenic line on
sonography (Fig. 1A,
1B) and is usually visible on
CT as a thin rim of soft-tissue density that enhances after contrast injection
(Fig. 2). The thickness of the
gallbladder wall depends on the degree of gallbladder distention, and
pseudothickening can occur in the postprandial state (Fig.
1A,
1B). A thickened gallbladder
wall measures more than 3 mm, typically has a layered appearance at sonography
[1], and frequently contains a
hypodense layer of subserosal edema that mimics pericholecystic fluid at CT
[2] (Fig.
3A,
3B).
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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.
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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.
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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.
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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.
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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.
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Primary Gallbladder Disease
Acute Cholecystitis
Acute cholecystitis is the fourth most common cause of hospital admissions
for patients presenting with an acute abdomen
[4], and 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, such as an
obstructing gallstone (Fig. 4A,
4B), hydropic dilatation of the
gallbladder (Figs. 4A,
4B and
5A,
5B), a positive sonographic
"Murphy's" sign (i.e., pain elicited by pressure over the
sonographically located gallbladder), pericholecystic fat inflammation or
fluid (Figs. 4A,
4B and
5A,
5B), and hyperemia of the
gallbladder wall at power Doppler imaging (Fig.
6A,
6B,
6C).
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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.
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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.
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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.
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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.
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Acute acalculous cholecystitis mainly occurs in critically ill patients
presumably because of increased bile viscosity from fasting and taking
medication that causes cholestasis. The imaging features are those of acute
cholecystitis except for the absence of stones and the presence, usually, of
gallbladder sludge (Fig. 6A,
6B,
6C). Because gallbladder
abnormalities are frequently found secondary to systemic disease in critically
ill patients, as we discuss later in this article, acalculous cholecystitis
can be difficult to diagnose
[5]. In these patients, a
percutaneous cholecystostomy can be both diagnostic and therapeutic.
Chronic Cholecystitis
"Chronic cholecystitis" is a term used clinically to refer to
symptomatic gallbladder stones that cause transient obstruction that leads to
low-grade inflammation with fibrosis
[1]. Correlation of the imaging
finding of a stone-containing, slightly thick-walled gallbladder
(Fig. 7) with clinical history
is critical.
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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.
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Xanthogranulomatous cholecystitis is an unusual variant of chronic
cholecystitis that is characterized by a lipid-laden inflammatory process
comparable to xanthogranulomatous pyelonephritis. Imaging studies show marked
gallbladder wall thickening, with the wall often containing nodules that are
hypoechoic at sonography and hypoattenuating at CT (Fig.
8A,
8B,
8C); these nodules are
abscesses or foci of xanthogranulomatous inflammation. These features overlap
with those of gallbladder carcinoma, often making preoperative distinction
between these entities impossible
[6].
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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).
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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).
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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).
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A porcelain gallbladder is a rare disorder in which chronic cholecystitis
produces mural calcification (Fig.
9A,
9B,
9C). In these patients, a
prophylactic cholecystectomy has been advocated because porcelain gallbladder
has been associated with gallbladder carcinoma
[4]; however, this association
appears to be weak.
Gallbladder Carcinoma
Gallbladder carcinoma is the fifth most common malignancy of the
gastrointestinal tract and is found incidentally in 1-3% of cholecystectomy
specimens [4]. It is often
detected at a late stage of the disease because of the lack of early or
specific symptoms. Gallbladder carcinoma has various imaging appearances,
ranging from a polypoid intraluminal lesion to an infiltrating mass replacing
the gallbladder, and it may also present as diffuse mural thickening (Fig.
10A,
10B). Associated findings such
as invasion of adjacent structures, secondary bile duct dilatation, and liver
or nodal metastases may help in differentiating it from acute or
xanthogranulomatous cholecystitis
[2,
4].
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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.
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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.
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Adenomyomatosis
Adenomyomatosis of the gallbladder is characterized by epithelial
proliferation, muscular hypertrophia, and intramural diverticula
(Rokitansky-Aschoff sinuses), which may segmentally or diffusely involve of
the gallbladder. It is a benign condition that requires no specific treatment
and occurs as an incidental finding in up to 9% of cholecystectomy specimens
[6]. The sonographic finding of
cholesterol crystals, shown as comet-tail reverberation artifacts
(Fig. 11) 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. MRI may be able to
differentiate adenomyomatosis from gallbladder carcinoma by depicting
Rokitansky-Aschoff sinuses
[7].
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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.
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Secondary Gallbladder Involvement
Diffuse thickening of the gallbladder wall may occur in patients who do not
have a primary gallbladder disease, but in whom the gallbladder is secondarily
involved in an extrinsic pathologic condition. In these patients, a
cholecystectomy is unwarranted, and gallbladder wall thickening will usually
return to normal after correction of its extrinsic cause.
Systemic Diseases
Systemic diseases, such as liver dysfunction, heart failure, or kidney
failure, may lead to diffuse gallbladder thickening
[1,
2]. The exact pathophysiologic
mechanism leading to edema of the gallbladder wall in these diverse conditions
is uncertain, but it is likely due to elevated portal venous pressure,
elevated systemic venous pressure, decreased intravascular osmotic pressure,
or a combination of these factors. Liver cirrhosis (Fig.
12A,
12B), hepatitis (Fig.
13A,
13B,
13C), and congestive right
heart failure (Fig. 14A,
14B) are relatively frequent
causes. Hypoproteinemia has also been reported as a cause of extrinsic
gallbladder disease, but this finding has been disputed
[8].
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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.
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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.
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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.
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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.
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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.
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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.
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Extracholecystic Inflammation
Extracholecystic inflammation may secondarily involve the gallbladder,
thereby causing wall thickening due to the direct spread of the primary
inflammation or, less frequently, due to an immunologic reaction
[8]. Theoretically, gallbladder
wall thickening may be caused by any inflammation that extends to the region
of the gallbladder, but only a few entities are regularly encountered,
including hepatitis, pancreatitis (Fig.
15), and pyelonephritis. Gallbladder wall thickening has also been
reported in patients with infectious mononucleosis
[9] and in patients with AIDS
due to opportunistic infections or secondary neoplastic infiltration
[2].
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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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Conclusion
Diffuse gallbladder wall thickening can result from a broad spectrum of
pathologic conditions, including surgical and nonsurgical diseases. Although,
at times, a definite imaging diagnosis may be impossible, the cause of
gallbladder wall thickening can be determined in most cases by correlation of
the clinical presentation and associated imaging findings.
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Abstract
Introduction
