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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.

Received February 7, 2008; accepted after revision July 23, 2008.

 
Address correspondence to E. A. Smith (ethans{at}med.umich.edu).

Abstract

Top Abstract Introduction Acute Uncomplicated... Acute Complicated Cholecystitis Gallbladder Volvulus Acute Hepatitis-Related... Summary References

 
OBJECTIVE. The purpose of this article is to provide a comprehensive review of the clinical and cross-sectional imaging features of a variety of acute and chronic gallbladder inflammatory diseases.

CONCLUSION. Inflammatory gallbladder diseases are a common source of abdominal pain and cause considerable morbidity and mortality. Although acute uncomplicated cholecystitis and chronic cholecystitis are frequently encountered, numerous other gallbladder inflammatory conditions may also occur that can be readily diagnosed by cross-sectional imaging.

Keywords: acute cholecystitis • chronic cholecystitis • complicated cholecystitis • cross-sectional imaging

Introduction

Top Abstract Introduction Acute Uncomplicated... Acute Complicated Cholecystitis Gallbladder Volvulus Acute Hepatitis-Related... Summary References

 
Acute and chronic inflammatory gallbladder diseases are a common cause of upper abdominal pain. Although many of these conditions may cause significant morbidity and mortality if left untreated, the prognosis is generally excellent with prompt diagnosis and management. Imaging often plays an important role in the evaluation of patients with suspected gallbladder inflammatory disease. In this article, we provide a comprehensive, contemporary review of the pertinent clinical and cross-sectional imaging features of numerous acute and chronic gallbladder inflammatory conditions.

Acute Uncomplicated Cholecystitis

Top Abstract Introduction Acute Uncomplicated... Acute Complicated Cholecystitis Gallbladder Volvulus Acute Hepatitis-Related... Summary References

 
Acute cholecystitis is the most frequent acute inflammatory condition of the gallbladder. Approximately 90-95% of cases occur in the setting of cystic duct or gallbladder neck obstruction related to cholelithiasis [1]. This condition characteristically affects middle-aged women, often those who are obese. Clinical findings may include acute persistent right upper quadrant abdominal pain, fever, nausea and emesis, and focal tenderness directly overlying the gallbladder. The patient may have a positive "Murphy sign," defined as inspiratory arrest on firm palpation along the right upper quadrant costal margin. Laboratory findings in this setting may be normal or abnormal and are often nonspecific. Serum liver transaminase, alkaline phosphatase, and bilirubin levels may be abnormally elevated, suggesting a hepatobiliary abnormality. Leukocytosis (often with a left shift) may or may not be present.

Sonography is generally the preferred initial imaging technique when acute cholecystitis is clinically suspected. The sensitivity of sonography for this condition ranges from 80% to 100% and specificity ranges from 60% to 100% [2-4]. Imaging findings may include cholelithiasis, gallbladder wall thickening (> 3-5 mm), pericholecystic fluid, and the presence of a positive sonographic Murphy sign (Fig. 1A). Less-specific imaging findings include abnormally increased gallbladder distention and echogenic bile (sludge). A gallstone may or may not be visualized within the gallbladder neck or cystic duct [1]. Ralls et al. [5] noted that accuracy in diagnosing acute cholecystitis increased when using a combination of findings including cholelithiasis, gallbladder wall thickening, and a positive sonographic Murphy sign. For example, they found that in a population of patients with suspected acute cholecystitis, gallstones alone had a positive predictive value of 88%. When patients had a combination of gallstones and a positive sonographic Murphy sign, the positive predictive value increased to 92%. In patients with gallstones, gallbladder wall thickening, and a positive sonographic Murphy sign, the positive predictive value was 94%.

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).

Management of acute uncomplicated cholecystitis may vary depending on the clinical situation and institution. Many consider acute gallbladder inflammation to be a relative contraindication to cholecystectomy [12]. In this situation, acute cholecystitis may be treated initially with inpatient hospital admission and administration of broad-spectrum IV antimicrobial therapy. Nonemergent cholecystectomy then follows after the acute inflammation has subsided. A recent study by Stevens et al. [12], however, has shown that immediate cholecystectomy may be as safe as delayed surgical intervention. On occasion, when medical management fails or surgery is contraindicated, acute cholecystitis may be treated with percutaneous catheter drainage to decrease intraluminal pressure and decrease the risk of gallbladder perforation [13] (Fig. 1C). When bile aspirated from the gallbladder is cultured, specimens are positive for an infectious agent in only 16-49% of patients [14]. Sosna et al. [14] found clinical improvement in 52% of patients treated with percutaneous aspiration or cholecystostomy tube placement.

Acute Complicated Cholecystitis

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Gangrenous Cholecystitis and Gallbladder Perforation
Gangrenous change may occur in the setting of advanced acute cholecystitis and is associated with increased patient morbidity and mortality [15]. Therefore, prompt diagnosis and treatment of this condition are crucial. Gangrenous change occurs in 2-29% of all cases of acute cholecystitis [6, 15]. Distinguishing acute uncomplicated cholecystitis from gangrenous cholecystitis can be clinically difficult and is important because medical and surgical management of these entities may differ. Although patients with gangrenous cholecystitis are typically more acutely ill at the time of presentation, this may not always be the case. According to a study by Fagan et al. [15], the only statistically significant predictors of gangrenous change in the setting of acute cholecystitis were a history of diabetes mellitus and a WBC greater than 15,000 cells/mL at the time of initial presentation. Gangrenous cholecystitis is thought to occur as a result of abnormally increased gallbladder distention and subsequent ischemic mural necrosis caused by vascular compromise.

Imaging plays an important role in the discrimination of acute uncomplicated cholecystitis from gangrenous cholecystitis. Many imaging features of gangrenous cholecystitis overlap with those of acute uncomplicated cholecystitis on sonography. Sonographic findings suggesting gangrenous change include floating intraluminal membranes (representing sloughed mucosa), echogenic shadowing foci consistent with gas within the gallbladder wall or lumen, frank disruption of the gallbladder wall, and pericholecystic abscess formation [16]. Teefey et al. [17] reported that a specific sign supporting the diagnosis of gangrenous cholecystitis is gallbladder wall striation, or the presence of alternating mural hyperechoic and hypoechoic linear areas, which can be seen in up to 40% of patients.

Evaluation of gangrenous cholecystitis with CT may also be of diagnostic utility. Bennet et al. [6] found that CT was highly specific for gangrenous cholecystitis (96%), although sensitivity was poor (29%). Specific findings that suggest gangrenous cholecystitis include foci of gas within the gallbladder wall, lack of gallbladder wall enhancement (focal or diffuse), intraluminal membranes, and pericholecystic abscess formation. Additional CT findings that suggest gangrenous cholecystitis include mural striation and adjacent hepatic parenchyma hyperenhancement [6, 8].

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.

An important complication of gangrenous cholecystitis is gallbladder perforation. Gall-bladder perforation is caused by transmural necrosis in the setting of acute cholecystitis. Acute uncomplicated cholecystitis will eventually progress to perforation in 2-11% of cases, with a reported mortality rate of up to 60% [18]. On occasion, patients may experience significant pain relief on perforation. Perforation has been classified into three types. Type I perforation involves free spill of gallbladder intraluminal contents into the peritoneal cavity, whereas type II perforation is a more subacute process that is contained by an adjacent abscess. Type III perforation is a chronic process with the formation of a cholecystoenteric fistula [1, 18, 19]. The most common site of perforation is the gallbladder fundus.

Small areas of gallbladder perforation may be difficult to detect on imaging. A focal defect in the gallbladder wall may be visualized on sonography, CT, or MRI. An extraluminal gallstone is a specific imaging finding that indicates perforation (Figs. 2A, and 2B). More often, findings of perforation are nonspecific and include pericholecystic fluid, gallbladder lumen collapse, and pericholecystic abscess [1, 20].

The treatment of gangrenous cholecystitis, with or without perforation, generally requires prompt surgical intervention with cholecystectomy and debridement. IV antimicrobial therapy is also required. Percutaneous catheter drainage may be used in patients for whom surgery is not appropriate. Complications are more frequent in patients with gangrenous cholecystitis and the prognosis is poorer than with acute uncomplicated cholecystitis [21].

Emphysematous Cholecystitis
Emphysematous cholecystitis is defined as the presence of gas within the gallbladder wall or lumen in the setting of acute cholecystitis without demonstrable abnormal fistulous communication between the gallbladder and the gastrointestinal tract. This condition is thought to be secondary to underlying vascular insufficiency and ischemia of the gallbladder wall [1, 22]. As a consequence, gas-forming bacteria are able to proliferate within the gallbladder wall or lumen. Implicated bacterial organisms include Clostridium species, Escherichia coli, Staphylococcus aureus, and Streptococcus species [1, 22]. This condition typically affects elderly men, often in the setting of underlying diabetes mellitus or some other debilitating disease [1, 11, 22]. Although patients with emphysematous cholecystitis may present clinically in a manner similar to those with acute uncomplicated cholecystitis, individuals with diabetic neuropathy may not experience typical right upper quadrant pain [1].

Emphysematous cholecystitis may be diagnosed initially using abdominal radiography. Radiographs that reveal curvilinear lucencies within the gallbladder wall or an air-fluid level within the gallbladder lumen are specific for this entity in the setting of suspected cholecystitis (Fig. 3A). Gill et al. [22] found that the sensitivity of abdominal radiography is low. As a result, sonography is frequently the initial imaging technique for diagnosing this condition. Sonography findings may be similar to those seen in acute uncomplicated cholecystitis. In addition, curvilinear or punctate hyperechoic foci, often with reverberation artifact (also known as ring-down artifact) are present, corresponding to foci of gas within the gallbladder wall or lumen [1, 22, 23] (Fig. 3B).

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.

Complications of emphysematous cholecystitis include gangrenous change, perforation, and pericholecystic abscess formation [24]. Both peritonitis and sepsis may also occur. Garcia-Sancho Tellez et al. [24] reported a mortality rate of up to 25% in the setting of emphysematous cholecystitis. In general, the management of emphysematous cholecystitis involves emergent cholecystectomy and IV antimicrobial therapy. Percutaneous cholecystostomy tube placement may be performed in patients who are not surgical candidates [21].

Suppurative Cholecystitis
Suppurative cholecystitis (gallbladder empyema) may occur as a complication of acute cholecystitis. This condition results when purulent material fills and distends the gallbladder lumen. Patients with suppurative cholecystitis may experience symptoms similar to those experienced by patients with acute uncomplicated cholecystitis, including fever, chills, rigors, and right upper quadrant pain. Signs of sepsis may or may not be present [25].

On sonography and CT, imaging findings of suppurative cholecystitis are nonspecific and similar to those seen in acute uncomplicated cholecystitis. Echogenic (at sonography) or high-attenuation (at CT) material consistent with pus is identified within the distended gallbladder lumen and is indistinguishable from sludge. MRI is sometimes helpful in distinguishing pus from sludge using heavily T2-weighted sequences, which may show a fluid-fluid level with dependent layering of purulent bile [11].

Treatment options for suppurative cholecystitis include both emergent cholecystectomy and percutaneous catheter drainage. The rate of conversion of laparoscopic cholecystectomy to an open procedure is greater than that observed in cases of uncomplicated acute cholecystitis [21]. Patients with this condition are also treated with IV antimicrobial therapy.

Hemorrhagic Cholecystitis
Hemorrhage into the gallbladder wall and lumen may be observed in the setting of acute calculous or acalculous cholecystitis [11]. Hemorrhagic cholecystitis may present clinically with acute onset of biliary colic, jaundice, melena, and hematemesis [1]. Hemorrhagic cholecystitis must be differentiated from other causes of gallbladder hemorrhage, such as trauma, neoplasm, and coagulopathy (often related to anticoagulation therapy).

Hemorrhagic cholecystitis typically presents on sonography and CT with imaging findings suggestive of acute cholecystitis. In addition, sonography may show echogenic or heterogeneous material within the gallbladder wall or lumen because of hemorrhage. On CT, high-attenuation blood products are present within the gallbladder wall or lumen [1, 26] (Fig. 5). On occasion, intraluminal hemorrhage may be difficult to distinguish from sludge. MRI can be quite specific in the diagnosis of this condition. Subacute blood products are generally hyperintense on both T1-weighted and T2-weighted images because of the presence of extracellular methemoglobin [11].

Complications of hemorrhagic cholecystitis include gallbladder wall perforation and associated potentially catastrophic hemoperitoneum [27]. Treatment typically involves cholecystectomy and IV antimicrobial therapy [28].

Acalculous Cholecystitis
Acalculous cholecystitis is most often observed in the critically ill population, including postoperative and trauma patients in an ICU setting as well as those patients receiving total parenteral nutrition [29]. This condition is thought to be caused by a gradual increase in bile viscosity that leads to eventual functional obstruction of the cystic duct [30]. The clinical diagnosis of acute acalculous cholecystitis frequently is difficult because affected patients often have multiple medical comorbidities as well as numerous other complicating issues such as mechanical respiration, sedation, and postoperative pain.

Sonography and CT are commonly used imaging techniques in the evaluation of acalculous cholecystitis. Mirvis et al. [30] determined that sonography had sensitivity of 92% and specificity of 96% for the diagnosis of this condition. Common sonographic findings include abnormally increased gallbladder distention, gallbladder wall thickening (> 3-5 mm), pericholecystic fluid (in the absence of ascites), and sludge (in the absence of cholelithiasis) (Figs. 6A, 6B, and 6C). CT may reveal similar imaging findings as well as pericholecystic inflammatory stranding with adjacent liver hyperemia [30].

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.

Complications of acute acalculous cholecystitis include gangrenous change, perforation, and pericholecystic abscess [29]. Uncomplicated cases may be treated with cholecystectomy if there are no surgical contraindications and IV antimicrobial therapy. Frequently, critically ill patients with acalculous cholecystitis are managed conservatively with either gallbladder aspiration or cholecystostomy tube placement in addition to IV antimicrobial therapy [14, 30, 31].

Chronic Cholecystitis
Chronic cholecystitis is a common inflammatory condition that affects the gallbladder. This condition almost always arises in the setting of cholelithiasis. Patients may have a history of recurrent acute cholecystitis or biliary colic, although some patients may be asymptomatic [32]. Microscopically, there is evidence of chronic inflammation within the gallbladder wall. Gallbladder dysmotility may also be present. Recent studies have also raised a possible connection between chronic cholecystitis and infection with Helicobacter pylori [33].

The most commonly observed cross-sectional imaging findings in the setting of chronic cholecystitis are cholelithiasis and gallbladder wall thickening (Fig. 7). The gallbladder may appear contracted or distended, and pericholecystic inflammation is usually absent [34]. Hepatobiliary scintigraphy may be required to distinguish acute from chronic cholecystitis and to evaluate gallbladder dysmotility by calculation of the gallbladder ejection fraction in response to exogenous cholecystokinin administration [35]. Uncomplicated chronic cholecystitis is generally managed with elective cholecystectomy.

Possible complications related to chronic cholecystitis include acute cholecystitis and gallbladder carcinoma. An uncommon complication is the formation of a biliary-enteric fistula. This can lead to passage of gallstones into the small bowel with resultant obstruction, also known as gallstone ileus. Typically, the gallstones lodge in the terminal ileum near the ileocecal valve; however, gallstones may be found anywhere throughout the small bowel and occasionally within the colon in this disorder [36]. Rarely, an ectopic gallstone will migrate proximally and cause gastric outlet obstruction [37]. Radiographically, the diagnosis can be made by identifying the Rigler's radiographic triad, which includes pneumobilia, an ectopic gallstone, and evidence of bowel obstruction (Figs. 8A, 8B, and 8C). This combination of imaging findings, however, is seen in a minority of patients with gallstone ileus [36]. Gallstone ileus carries a high mortality rate (20-40%) and is treated surgically [36, 38].

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.

Cholelithiasis and gallbladder wall thickening are the most common findings on sonography and CT in patients with xanthogranulomatous cholecystitis. Mural thickening may be focal or diffuse. Pericholecystic inflammatory changes may also be present. Intramural hypoechoic (on sonography) or hypoattenuating (on CT) nodules or bands may suggest the specific diagnosis of xanthogranulomatous cholecystitis [40]. The diagnosis is rarely made before surgery and histopathologic evaluation of the gallbladder [39-41] (Figs. 9A, and 9B). On occasion, xanthogranulomatous cholecystitis may mimic gallbladder carcinoma on cross-sectional imaging [39].

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.

Complications attributed to xanthogranulomatous cholecystitis include gallbladder perforation, hepatic abscess, biliary ductal stricture with or without biliary obstruction, ascending cholangitis, and biliary fistula [41]. Patients with xanthogranulomatous cholecystitis also may be at increased risk of gallbladder malignancy [39, 41]. Treatment is typically elective open cholecystectomy because laparoscopic cholecystectomy is often unsuccessful due to adhesions and adjacent fibrosis.

Mirizzi Syndrome
Mirizzi syndrome may occur as an acute presentation of cholelithiasis or in the setting of acute cholecystitis. The condition occurs when an impacted gallstone in the gallbladder neck or cystic duct causes biliary tree obstruction and cholestasis. Cholestasis is the result of either direct compression of the adjacent common hepatic duct or secondary local inflammation causing bile duct wall edema and fibrosis. Patients may or may not experience right upper quadrant abdominal pain, fever, and leukocytosis [1, 6, 42]. Mirizzi syndrome most commonly presents with a relatively acute onset of obstructive jaundice. Differentiation of this condition from other causes of obstructive jaundice is critical to direct proper medical and surgical management.

Sonography and CT findings observed in Mirizzi syndrome include the presence of a gallstone located within the gallbladder neck or cystic duct and dilatation of the common hepatic duct and the more proximal intrahepatic bile ducts (Figs. 10A, 10B, 10C, 10D, and 10E). Additional findings may include normal caliber of the common bile duct, pericholecystic and peribiliary ductal inflammatory changes, and gallbladder wall thickening [1, 42, 43]. MRI and MRCP are useful for visualizing a dilated common hepatic duct and a normal-caliber more distal common bile duct. Imaging, particularly MRI and MRCP, can help distinguish Mirizzi syndrome from other causes of obstructive jaundice such as pancreatic or biliary neoplasms and sclerosing cholangitis as well as numerous additional benign and malignant biliary narrowing causes [11].

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.

Traditionally, the treatment for Mirizzi syndrome has been surgery. In the past, this specific diagnosis may not have been clear prior to the time of surgical intervention. More recently, however, endoscopic diagnosis and treatment with ERCP has been used. Recognition of related complications, such as biliary fistula formation, biliary tract stricture, and gallbladder perforation, are of clinical importance because they may require an alteration in the treatment approach [42].

Gallbladder Volvulus

Top Abstract Introduction Acute Uncomplicated... Acute Complicated Cholecystitis Gallbladder Volvulus Acute Hepatitis-Related... Summary References

 
Gallbladder volvulus is a rare condition in which variation in normal mesenteric anatomy allows the gallbladder to twist on itself [11, 44]. This condition may also be observed when there has been significant patient weight loss with resultant loss of pericholecystic fat. On torsion, gallbladder venous drainage becomes obstructed and ischemia ensues. Torsion may be complete (> 180°) or incomplete (< 180°). The majority of patients with this condition are elderly women [44].

Imaging findings compatible with gallbladder torsion on sonography and CT include abnormal orientation of the gallbladder, abrupt tapering of the cystic duct, pericholecystic inflammatory changes, and abnormally increased luminal distention [44] (Figs. 11A, and 11B). Cholelithiasis may be absent. MRCP can be useful in the diagnosis of this condition, showing abnormal twisting or tapering of the cystic duct and an abnormally distended gallbladder [11].

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).

Acute Hepatitis-Related Gallbladder Changes

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Inflammatory changes involving the gallbladder may be observed in patients with clinical and laboratory findings of acute hepatitis, regardless of the underlying cause. Such gallbladder changes are most commonly thought to be reactive because of adjacent hepatic inflammation. Maresca et al. [46] identified gallbladder abnormalities on sonography in 51% of consecutive patients presenting with a clinical and laboratory diagnosis of acute hepatitis. Their study also found a direct correlation between the timing of onset of symptoms and imaging findings. Eighty-one percent of patients imaged within 7 days of onset of clinical symptoms had abnormal gallbladder findings on sonography, whereas only 28% of patients imaged at greater than 7 days had sonographic abnormalities. A direct correlation has also been reported between the level of elevation of serum liver transaminases and the degree of gallbladder wall thickening on sonography [46, 47].

Sonography findings observed in the setting of acute hepatitis include marked gallbladder wall thickening, gallbladder contraction, and echogenic bile [47] (Figs. 12A, 12B, 12C, and 12D). The gallbladder wall may also show three distinct layers with central hypoechogenicity [46]. The adjacent liver may show findings suggestive of diffuse edema, including hypoechoic parenchyma with prominent echogenic portal triads (the so-called starry-sky appearance), although this appearance is uncommon. CT may show diffuse gallbladder wall thickening.

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.

Treatment is generally directed at the underlying cause of the acute hepatocellular injury. Of interest, Juttner et al. [47] described a correlation between the normalization of the patient's clinical and laboratory parameters and the resolution of gallbladder abnormalities on sonography.

Summary

Top Abstract Introduction Acute Uncomplicated... Acute Complicated Cholecystitis Gallbladder Volvulus Acute Hepatitis-Related... Summary References

 
Numerous acute and chronic inflammatory conditions may affect the gallbladder. A variety of related complications with significant morbidity and mortality can result. Prompt diagnosis of gallbladder inflammatory disease is important because treatment frequently requires surgery, percutaneous and endoscopic interventions, and IV antimicrobial therapy. Multiple cross-sectional imaging techniques including sonography, CT, and MRI may all play important roles in the diagnosis of gallbladder inflammatory diseases.

References

Top Abstract Introduction Acute Uncomplicated... Acute Complicated Cholecystitis Gallbladder Volvulus Acute Hepatitis-Related... Summary References

 

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