Sonography of the thickened gallbladder wall: a nonspecific finding

Ultrasonographic measurement of gallbladder wall thickness in fasted dogs without signs of hepatobiliary disease

BACKGROUND

Ultrasound-determined gallbladder wall thickness is widely used to aid in the diagnosis of gallbladder disease, but no reference values supported by published measurement data are available in dogs.

HYPOTHESIS/OBJECTIVE

Establish normal thickness of the gallbladder wall in dogs.

ANIMALS

Fifty-three dogs presented to a referral hospital and required abdominal ultrasound examination for reasons unrelated to primary hepatobiliary disease.

METHODS

Cross-sectional observational study recruiting dogs requiring abdominal ultrasound examination. A standard sequence of gallbladder wall images was recorded for later review. Inclusion criteria were normal ultrasonographic hepatobiliary, pancreatic, and small intestinal findings. Exclusion was determined by 2 European College of Veterinary Internal Medicine (ECVIM)-certified veterinary internists blinded to gallbladder wall thickness data. Dogs were excluded if they had inadequate medical records, a previous history of hepatobiliary, gastrointestinal, or pancreatic disease likely to impact the biliary system (eg, chronic vomiting, nausea, jaundice, diarrhea), unexplained increases in liver enzyme activities, hypoalbuminemia, or ascites. Gallbladder wall thickness was determined by 2 European College of Veterinary Diagnostic Imaging (ECVDI)-certified veterinary radiologists working together to generate a consensus for each dog. The final output was the maximum normal wall thickness for this population of dogs.

RESULTS

The upper limit for gallbladder wall thickness in 53 fasted (8 hours) dogs <40 kg was 1.30 mm (90% confidence interval, 1.19-1.41).

CONCLUSIONS AND CLINICAL IMPORTANCE

Normal gallbladder wall thickness in dogs is lower than previously reported. Additional studies are required to determine potential effects of body weight and the optimal cut-off to distinguish between healthy and diseased gallbladders.

Incidental Findings of Gallbladder and Bile Ducts-Management Strategies: General Aspects, Gallbladder Polyps and Gallbladder Wall Thickening-A World Federation of Ultrasound in Medicine and Biology (WFUMB) Position Paper

The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.

The association of ultrasound assessment of gallbladder wall thickness with dengue fever severity

Objectives

To evaluate the association between ultrasound assessment of gallbladder wall thickness (GBWT) among severe dengue patients and dengue patients with warning signs to their clinical outcomes.

Methods

A prospective, cross-sectional study involving adult dengue patients presented to our emergency department between March until September 2018. The patients were classified based on WHO classification. A gallbladder wall scan was performed on all patients.

Results

A total of 44 patients were enrolled into the study; majority of the patients with GBWT had severe dengue, significantly more than the dengue patients with warning signs (90.5% sensitivity; 69.6% specificity). The sensitivity of GBWT in determining admission to critical care areas or general ward was 100% with a specificity of 62.1%. Our analysis showed that the two variables significant in determining the severity of dengue were age (p = 0.045) and GBWT (p < 0.001). Both factors together gave 81.0% sensitivity and 78.3% specificity in predicting patients for severe dengue. The receiver operator characteristic curve revealed that using variable GBWT status can discriminate 87.1% (95%CI 66.3, 93.7%) of having severe dengue or dengue with warning signs.

Conclusion

The finding of GBWT when consolidated with other clinical parameters may assist clinicians to perform risk stratification in the emergency department and become another adjunct to the assessment of severe dengue.

Development and validation of a nomogram for predicting varices needing treatment in compensated advanced chronic liver disease: A multicenter study

BACKGROUND

Only a small proportion of patients with compensated advanced chronic liver disease (cACLD) had varices needing treatment (VNT) after recommended esophagogastroduodenoscopy (EGD) screening. We aimed to create a non-invasive nomogram based on routine tests to detect VNT in cACLD patients.

METHODS

The training cohort included 162 cACLD patients undergoing EGD in a university hospital, between January 2014 and September 2019. A nomogram was developed based on the independent predictors of VNT, selected using a multivariate logistic regression analysis. Thirty-three patients from eight university hospitals were prospectively enrolled as validation cohort between December 2018 and December 2019.

RESULTS

The prevalence of VNT was 32.7% (53/162) and 39.4% (13/33) in training and validation cohorts, respectively. The univariate analysis identified six risk factors for VNT. On the multivariate analysis, four of them, i.e., gallbladder wall thickness (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 0.98-1.56), spleen diameter (OR: 1.02; 95% CI: 1.00-1.04), platelet count (OR: 0.98; 95% CI: 0.97-0.99), and international normalized ratio (OR: 0.58; 95% CI: 0.06-5.84) were independently associated with VNT. Thus, a nomogram based on the four above - mentioned variables was developed, and showed a favorable performance for detecting VNT, with an area under receiver operating characteristic curve of 0.848 (95% CI: 0.769-0.927) in training cohort. By applying a cut-off value of 105 in validation cohort, 31.0% of EGD were safely spared with 3.4% of missed VNT.

CONCLUSION

A nomogram based on routine clinical parameters was developed for detecting VNT and avoiding unnecessary EGD in cACLD patients.

"Honeycomb" pattern of gallbladder wall thickening - A forward step in early diagnosis of "Severe Dengue Fever"

Aims and Objectives

To study "Honeycomb" pattern of gallbladder wall thickening (GBWT) in dengue fever (DF) and to assess its clinical significance in early diagnosis of severe DF.

Materials and Methods

A total 244 patients of DF were studied, 84 patients were classified as severe DF, 61 patients as DF with warning signs, and 99 patients as DF without warning signs. Abdominal ultrasound was performed for assessment of GBWT patterns, hepatomegaly, splenomegaly, pancreatic enlargement, ascites, pleural effusion, and other additional findings were recorded in severe DF cases. Statistical comparison between "Honeycomb" pattern of GBWT and clinically severe DF was done using Pearson correlation test.

Results

Out of 244 patients, 145 patients were males and 99 patients were females, belonging to various age groups ranging from 1 to 81 years and 14.34% (35 patients) among them included in pediatric group. In total, 65.57% (160 patients) were non-severe DF cases and 34.42% (84 patients) were severe DF cases. A total of 84 patients of severe DF, 92.85% patients showed GBWT, and out of which, 71.42% patients had "Honeycomb" pattern, whereas a total of 160 patients of non-severe DF patients, 45% patients had GBWT and out of which, only 5.6% patients showed "Honeycomb" pattern. "Honeycomb" pattern of GBWT shows sensitivity of 71.4%, 94.37%, Positive predictive value of 86.95%, and Negative predictive value of 86.28% in severe DF.

Conclusion

"Honeycomb" pattern of GBWT is significant finding in severe DF. Its sensitivity and specificity are high in severe DF with significant statistical correlation. It can aid in early diagnosis of severe DF.

Diffuse gallbladder wall thickening in autoimmune hepatitis: an unusual presentation

A 63-year-old woman presented with jaundice and epigastric pain for 2 weeks. Physical examination revealed marked jaundice, and palpable gallbladder with right upper quadrant tenderness. Liver function test was remarkable for hepatocellular injury pattern. Antinuclear antibody and anti-smooth muscle antibody were positive with high titre and serum IgG was elevated more than upper normal range. Ultrasound and CT scan demonstrated mildly diffuse periportal oedema of liver parenchyma and markedly diffuse gallbladder wall thickening up to 2 cm. Liver histology showed focal interface hepatitis with prominent plasma cell infiltration and cluster formation, moderate lobular spotty necrosis and emperipolesis consistent with autoimmune hepatitis. The patient was treated with steroid and azathioprine. She had complete resolution of symptoms and normal biochemical laboratory results. Diffuse gallbladder thickening was seen in acute hepatitis from definite autoimmune hepatitis.

The State of Perplexity During Management of Gall Bladder Malignancy in an Expectant Young Mother

During pregnancy, diagnosed cancer causes a major disturbance in the life of a pregnant woman and her family. The advanced stage of illness requiring systemic treatment inevitably leads the treating practitioner, with two lives at risk, into an ethical dilemma. The unborn child can be affected by the application of cancer medication to the mother as it is exposed to fetotoxic drugs. On the other hand, withholding therapy to allow fetal maturity may make the disease of the mother metastatic. Gall bladder carcinoma is often diagnosed as an unresectable disease (metastatic or locally advanced) due to its nonspecific symptomatology and carries the worst prognosis of any gastrointestinal or hepatobiliary neoplasm. We report a case of locally advanced gall bladder cancer (GBC) diagnosed during late pregnancy wherein the mother opted to continue the pregnancy without any intervention. A review of literature has been done to investigate the role of female hormones in a pregnancy complicating GBC with emphasis on management dilemma and the associated pitfalls.

Rapid enlargement of a hepatic hilar cyst leading to bile duct obstruction after acute exacerbation of chronic hepatitis B

A hepatic cyst is usually asymptomatic but, in some cases, can be associated with various complications. Here we report a rare case with rapid enlargement of a hepatic hilar cyst that induced bile duct obstruction after an acute exacerbation of chronic hepatitis B. The case is a 60-year old female who discontinued entecavir by herself. Hyperbilirubinemia was prolonged along with bile duct obstruction due to an enlarged cyst. After the administration of entecavir and steroid pulse therapy, biliary drainage and punctuation of the cyst were performed. There was no evidence of malignancy in the cyst. The therapies were not effective enough, probably due to the prior liver damage, and she died of acute on chronic liver failure. This case suggests that a hepatic hilar cyst in a patient with acute hepatitis or an acute exacerbation of chronic hepatitis can become enlarged and may affect the clinical course of hepatitis. In such a case, the size of the cyst should be monitored frequently and bile duct obstruction should be treated early if it occurs.

Feline abdominal ultrasonography: what's normal? what's abnormal? The biliary tree

PRACTICAL RELEVANCE

Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. The biliary tree encompasses the liver, gall bladder and bile ducts, although only diseases affecting the latter two are discussed here. Diseases of the bile ducts and gall bladder are more common than those of the liver parenchyma and ultrasound plays an important role in their diagnosis.

CLINICAL CHALLENGES

Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even differentiating between normal variation and pathological changes can be challenging for all but the most experienced. In addition, a lack of pathological change does not necessarily rule out disease; for example, absence of gall bladder and/or extrahepatic biliary distension is not sufficient to exclude the possibility of biliary obstruction, and in many cases of cholangitis the liver and biliary tree are unremarkable on ultrasound examination.

EQUIPMENT

Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience.

AIM

This review, part of an occasional series on feline abdominal ultrasonography, discusses the appearance of the normal and diseased biliary system. It is aimed at general practitioners who wish to improve their knowledge and confidence in feline abdominal ultrasound and is accompanied by high-resolution images. Percutaneous ultrasound-guided cholecystocentesis is also covered. Ultrasound examination of the liver was discussed in an article published in January 2019 and an upcoming article will cover hepatic vascular anomalies.

EVIDENCE BASE

Information provided in this article is drawn from the published literature and the author's own clinical experience.

B-mode ultrasonographic diagnosis in gallbladder wall thickening

Diseases associated with gallbladder wall thickening include benign entities such as adenomyomatosis of the gallbladder, acute and chronic cholecystitis, and hyperplasia associated with pancreaticobiliary maljunction, and also cancer. Unique conditions such as sclerosing cholecystitis and cholecystitis associated with immune checkpoint inhibitor treatment can also manifest as wall thickening, as in some systemic inflammatory conditions. Gallbladder cancer, the most serious disease that can show wall thickening, can be difficult to diagnose early and to distinguish from benign causes of wall thickening, contributing to a poor prognosis. Differentiating between xanthogranulomatous cholecystitis and gallbladder cancer with wall thickening can be particularly problematic. Cancers that thicken the wall while coexisting with benign lesions that cause wall thickening represent another potential pitfall. In contrast, some benign gallbladder lesions that can cause wall thickening, such as adenomyomatosis and acute cholecystitis, typically show characteristic ultrasonographic features that, together with clinical findings, permit easier diagnosis. In this review of the literature, we describe B-mode abdominal ultrasonographic diagnosis of gallbladder lesions showing wall thickening.

Chronic inflammation-related radiological findings of gallbladder adenomyomatosis

PURPOSE

This study aimed to assess radiological findings of adenomyomatosis advancing to chronic inflammation to differentiate between adenomyomatosis with and without chronic inflammation.

MATERIALS AND METHODS

We retrospectively identified 79 patients with pathologically proven adenomyomatosis without (n = 10) or with chronic inflammation (n = 69), who underwent computed tomography (CT) and magnetic resonance imaging (MRI) followed by surgery. MRI analysis included evaluation of GB wall-thickening type, presence and location of intramural cysts, and presence of stones. CT analysis included GB wall-thickening type only. Multivariate logistic regression analysis was used to identify the image-based findings of adenomyomatosis associated with chronic inflammation.

RESULTS

On univariate analysis, MRI-based GB wall-thickening type and presence of stones, and CT-based GB wall-thickening type were significantly different between adenomyomatosis with and without chronic inflammation. On multivariate analysis, only the absence of stones was identified as a significant predictor of adenomyomatosis without chronic inflammation (odds ratio 5.58; 95% confidence interval 1.20-26.01; p = 0.029). There was no significant difference in other MRI- and CT-based findings between adenomyomatosis with and without chronic inflammation.

CONCLUSION

In patients with adenomyomatosis, the presence of stones was independently associated with chronic inflammation.

Clinical relevance of gallbladder wall thickening for dengue severity: A cross-sectional study

Dengue fever is the most important arthropod-borne viral infection worldwide. Secondary prevention to reduce mortality through improved clinical case management has substantially lowered the mortality rate for severe dengue during the past two decades. Gallbladder wall thickening (GBWT) is a nonspecific finding often associated with more severe cases of dengue infection. This study had the aim to describe the ultrasonographic findings in hospitalized patients with dengue infection from Manaus (in the Western Brazilian Amazon) and to correlate the GBWT with dengue severity, symptoms and laboratorial analysis. Patients from 13–84 years admitted to the emergency department at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD) were enrolled in this study. Patients’ selection occurred during the most recent and huge dengue outbreak within the first semester of 2011. All enrolled subjects were systematically tested in order to rule out other possible etiologies for gallbladder inflammation. Abdominal ultrasound was performed by a single physician through bedside portable equipment and all other clinical and laboratorial information were retrieved from patients’ electronic files. 54 subjects were considered for analysis, with confirmed dengue infection by NS1 and/or RT-PCR positivity. From all enrolled patients, 50 (42.4%) presented GBWT. GBWT was significantly and independently related to: age under 31 years, pregnancy, presence of bleeding, presence of any cavitary effusion, DHF classification and severe dengue classifications. During dengue outbreaks, the GBWT identification through a non-invasive and bedside procedure is a confident marker for prompt recognition of potential severe cases.

Evaluation of liver stiffness by 2D-SWE in combination with non-invasive parameters as predictors for esophageal varices in patients with advanced chronic liver disease

Background/aims: Esophageal varices (EV) are common complications in patients with advanced chronic liver disease (ACLD). Non-invasive parameters to exclude EV in patients with ACLD would be desirable. The aim of this study was the evaluation of liver stiffness measurement (LSM) using 2D-shear wave elastography (GE Logiq E9) and other non-invasive parameters as predictors for EV. Methods: Hundred patients with ACLD were enrolled. Abdominal sonography, including measurement of gall bladder wall thickness (GBWT), spleen diameter and LSM, gastroscopy and blood test results were evaluated. Statistical analyses were performed for the association between EV and non-invasive parameters. Results: Fifty-one per cent of the patients had EV. The mean LSM (14.6 kPa) and GBWT (3.88 mm) in the group with EV were significantly higher than in the group without EV (10.6 kPa; 2.94 mm; p < .01). Performing area under the receiver operating characteristic curve, LSM has a better diagnostic performance (0.781) than GBWT (0.707), spleen diameter (0.672) and platelet count (0.635). Combining LSM (cut-off 13.58 kPa) and GBWT (cut-off 3.07 mm) resulted in a sensitivity of 86.3% and a specificity of 71.4% for the presence of EV. A sensitivity of 100% (negative predictive value 1.0) was achieved at LSM >9 kPa or GBWT >4 mm. Following these criteria in our current study population, 18% of the gastroscopies could have been avoided. Conclusions: Combining LSM with non-invasive parameters, especially GBWT, improves the diagnostic accuracy for predicting EV. We suggest reconsidering screening gastroscopy in patients with ACLD who show LSM <9 kPa and GBWT <4 mm due to the very low risk of having varices.

Accuracy of Right Upper Quadrant Ultrasound in Estimating Gallbladder Wall Thickness

OBJECTIVE

Ultrasound (US) evaluation of biliary pathology can be influenced by a variety of factors. This study examines the effect of patient specific factors on the accuracy of sonographic evaluation of gallbladder wall thickness (GBW).

METHODS

We performed a retrospective review of all patients who underwent cholecystectomy at a single institution from November 2012 to October 2015. GBW measured on US was compared with pathology results. Results were analyzed in relation to patient specific factors to include BMI, age, presence of diabetes, sex, and urgent versus elective cases.

RESULTS

In total 601 patients underwent cholecystectomy, 484 of which had paired preoperative US GBW measurement and postoperative pathologic specimen measurement. No significant difference in accuracy or precision of US measurement of the GBW based on BMI was found. Accuracy was not related to age, sex, urgency, or diabetes. Precision decreased with pathologic thickening, age, male sex, and urgent case performance.

CONCLUSIONS

US is accurate in measuring GB wall thickness regardless of patient specific factors. A nonsignificant trend exists with decreased precision with pathologic thickening, age, male sex, and urgently performed cases.

Rapid resolution of extreme gallbladder wall thickening in a patient with acute hepatitis C

Diffuse gallbladder wall thickening is a common radiological finding with a wide range of differential diagnoses, many of which are not due to primary cholecystic disease. We report an unusual case of extreme diffuse gallbladder thickening in a 39-year-old lady, subsequently diagnosed with hepatitis C virus, and with complete resolution of her radiological appearances within 6 weeks—before commencing any treatment.

Ultrasonography of the Gallbladder in Acute Pancreatitis

The sonographic appearance of the gallbladder in 52 patients with acute pancreatitis (AP) was evaluated and compared with the findings in acute cholecystitis (AC) and in normal gallbladders (N). The mean gallbladder wall thickness in the AP group, 3.2 mm, was significantly different from the thickness in the N group, 2.3 mm (p<0.001), and from that in the AC group, 5.2 mm (p<0.001). Wall edema, distension, tenderness (sonographic Murphy sign) and pericholecystic fluid collections were occasional findings in AP, and were not seen in normal gallbladders. A significant difference between the AP and AC groups was found in the prevalence of maximal local tenderness of the gallbladder (in only 2/52 in AP, but in 28/31 in AC).

Ultrasonography and Computed Tomography in Diffuse Liver Disease with Cholestasis

Ultrasonography (US) and computed tomography (CT) were performed on respectively 67 and 42 (altogether 72) patients, for the assessment of intrahepatic cholestasis. The diagnostic ability to differentiate between malignant (17 patients) and benign (55 patients) liver disease was analyzed. Coarse echogenicity of the liver led to inconclusive results in differentiating between cirrhosis (2 out of 29 patients) and malignant infiltration (4 out of 15 patients) by US. Other benign liver diseases in 23 patients, including acute hepatitis, chronic active hepatitis, fatty liver, and liver congestion, were correctly interpreted as benign. CT correctly disclosed malignant liver disease in all cases. A false positive diagnosis of malignancy was encountered in 4 (out of 17) patients with decompensated hepatic cirrhosis because of non-homogeneous expansive areas on CT in 3 cases. The true cause was in 2 patients non-uniform fatty infiltration, and in one patient with acute hepatitis A, small hypodense lesions. Among cholestatic patients, decompensated cirrhosis and malignant liver infiltration could not always be differentiated on US or CT.

Added value of point shear-wave elastography in the diagnosis of acute cholecystitis

OBJECTIVE

To evaluate the added value of point shear-wave elastography (pSWE) in the diagnostic performance of conventional US for diagnosis of acute cholecystitis.

METHODS

B-mode and colour Doppler US and pSWE were performed prospectively in 216 patients with clinically suspected acute cholecystitis. The morphology and mural vascularity of the gallbladder and median shear wave velocity (SWV) of the right liver were evaluated. Two observers independently reviewed conventional US images and subsequently reviewed combined conventional US and pSWE images.

RESULTS

Mean SWVs of the acute cholecystitis group (n = 91) were significantly higher than those of the control group (n = 85) in the right liver within 2 cm lateral to the gallbladder (1.56 versus 1.03 m/s, 1.39 versus 1.04 m/s, P < 0.0001) with a cut-off value of 1.29 or 1.16 m/s. The area under the receiver operating characteristic curve of both observers in the diagnosis of acute cholecystitis improved significantly from 0.790 and 0.777 to 0.963 and 0.962, respectively, after additional review of pSWE images (P < 0.0001). Diagnostic accuracy, sensitivity, specificity, positive and negative predictive values of combined image sets were higher than those of conventional US images alone.

CONCLUSION

Adding pSWE to conventional US improves the diagnosis of acute cholecystitis when compared with conventional US alone.

KEY POINTS

• In acute cholecystitis, stiffness of the right liver increases adjacent to the gallbladder. • The cut-off value for diagnosing acute cholecystitis was 1.29 or 1.16 m/s. • Adding pSWE to conventional US improves the diagnosis of acute cholecystitis.

Contrast-enhanced ultrasound in gallbladder disease: a pictorial review

With its excellent contrast and spatial resolution, and the ability to image in real-time, ultrasound is the main imaging modality for assessing the gallbladder (GB). The application of contrast-enhanced ultrasound (CEUS) of the GB is now increasingly recognized as a useful addition to ultrasound and other cross-sectional imaging in the assessment of neoplastic and non-neoplastic GB disease. With the ability to image microcirculation and optimal contrast resolution, CEUS allows high-quality delineation in real-time, allowing for increased diagnostic confidence. In addition, ultrasound contrast agents have a favorable safety profile and can be used if CT or MR contrast agents are contraindicated or undesired. In this review, the CEUS appearances of a range of GB diseases encountered are presented, including adenomyomatosis, polyps, carcinoma, sludge, and cholecystitis with mural ulceration or perforation.

Is Ultrasound a Useful Tool to Predict Severe Dengue Infection?

OBJECTIVES

To study the role of ultrasound in children with dengue fever and determine its role in predicting the severity of the disease.

METHODS

This was a retrospective hospital based study conducted from 1(st) August 2012 to January 31(st) 2015 at a tertiary care hospital in Puducherry.

RESULTS

Two hundred and fifty four children were admitted with dengue fever and among them non-severe dengue and severe dengue were seen in 62.6 % and 37.4 % respectively. Mean age of presentation was 7.0 (3.3) years. M: F ratio was 1.2:1 Ultrasound was performed on all children with dengue fever during the critical period of illness as an early sign of plasma leakage and at the time of discharge. The diagnosis was confirmed by NS1 antigen and dengue serology. Ultrasonography showed positive findings in 156 cases (61.4 %) during the critical period of illness. Ultrasound findings were analyzed using logistic regression among severe and non-severe dengue and P value of <0.05 was taken as significant. The common ultrasound findings that were significantly associated with severe dengue infection on univariate analysis were gall bladder wall thickening, ascites, pleural effusion, pericardial effusion, pericholecystic fluid, hepatomegaly, splenomegaly and mesenteric adenopathy. On multivariate analysis, gall bladder thickening and hepatomegaly were significantly associated with severe dengue infection. Gall bladder wall thickening (GBWT) with honeycombing pattern was the most specific finding in severe dengue infection in the study and significantly associated with severe thrombocytopenia (Platelet count <50,000/mm(3)). The clinical improvement coincided with resolving of the ultrasound findings at the time of discharge.

CONCLUSIONS

Ultrasound can be used as an early predictor as well as an important prognostic sign for severe dengue infection especially during an epidemic.

Case report: an unrecognized etiology of transient gallbladder pain in heart failure diagnosed with internist-performed point-of-care ultrasound

The excellent sensitivity and specificity of right upper quadrant (RUQ) ultrasound for gallbladder pathology in patients with abdominal pain is heavily relied upon in routine diagnostic evaluation. The hour-to-hour timing of this test in a patient with fluctuating symptoms is not widely recognized as having a significant impact on its sensitivity. However, we present a case report describing the essential role of symptom-timed point-of-care ultrasound in making an elusive diagnosis of transient cholecystalgia in a patient with RUQ pain and congestive heart failure (CHF). This case also demonstrates an important etiology of RUQ pain in patients with CHF beyond that of congestive hepatopathy. A review of the related entities of acalculous cholecystitis, congestive hepatopathy, and diffuse gallbladder wall thickening is provided.

Focal thickening at the fundus of the gallbladder: computed tomography differentiation of fundal type adenomyomatosis and localized chronic cholecystitis

Background/Aims

The objective of our study was to identify useful computed tomography (CT) findings for differentiating fundal type adenomyomatosis from localized chronic cholecystitis involving the fundus of the gallbladder.

Methods

We retrospectively identified cases of 41 patients with pathologically proven adenomyomatosis (n=21) or chronic cholecystitis (n=20) who had fundal thickening of the gallbladder on preoperative abdominal CT. Analysis of the CT findings included evaluation of the thickness, contour, border, intralesional cystic area, adjacent gallbladder wall thickening, presence of inner layer enhancement, enhancement grade, enhancement pattern, and presence of stones. Statistical analyses were performed using the Mann-Whitney U test and Fisher exact test.

Results

Oval contour, inner layer enhancement and intralesional cystic area were more frequently noted in adenomyomatosis than in chronic cholecystitis (p<0.05 for each finding). Flat contour and adjacent gallbladder wall thickening were more frequently observed in chronic cholecystitis than in adenomyomatosis. No differences between adenomyomatosis and chronic cholecystitis in terms of the thickness, enhancement grade, enhancement pattern and presence of stones were apparent.

Conclusions

CT may help to differentiate fundal type adenomyomatosis from localized chronic cholecystitis involving the fundus of the gallbladder.

Oedema of gallbladder wall: correlation with chronic hepatitis B on MR imaging

PURPOSE

The aim of this study was to characterise gallbladder wall oedema and correlate it with chronic hepatitis B (CHB) on magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Sixty-seven patients who were clinically and histologically diagnosed with CHB and 18 healthy individuals without any history of liver disease underwent abdominal MR imaging. Hepatic inflammation (grade 0-4) and fibrosis (stage 0-4) for patients were assessed histologically. Gallbladder wall oedema was noted.

RESULTS

Twelve patients showed gallbladder wall oedema on MR imaging, including six with grade 3 and six with grade 4 disease. There was a statistically significant difference for the presence of gallbladder wall oedema among groups with grade 0-4 (p=0.000), but not between groups with grades 3 and 4 (p=0.729). Gallbladder wall oedema was related to moderate-severe inflammatory activity (p<0.05), alanine transaminase (ALT) (p=0.012) and aspartate aminotransferase (AST) (p=0.027) levels but not to fibrosis or other laboratory data, including serum quantitative DNA for hepatitis B virus (HBV), with the p=0.105-0.846. Sensitivity and specificity for the diagnosis of hepatic moderate-severe inflammation using gallbladder wall oedema were 33.33% and 100%, respectively.

CONCLUSIONS

Gallbladder wall oedema for patients with CHB can be specifically demonstrated on MR imaging and is correlated with hepatic moderate-severe inflammatory activity, elevated ALT and AST levels but not with fibrosis or other laboratory data, including viremia.

Gallbladder patterns in acute pancreatitis: an MRI study

RATIONALE AND OBJECTIVES

The aim of this study was to assess the gallbladder patterns on magnetic resonance imaging (MRI) associated with acute pancreatitis (AP).

MATERIALS AND METHODS

There were 197 patients with AP, all of whom had undergone abdominal MRI. AP was categorized as either edematous or necrotizing according to its findings on MRI and graded as mild (0-3 points), moderate (4-6 points), or severe (7-10 points) according to the magnetic resonance severity index. The changes to the walls and dimensions of the gallbladder and common bile duct, in addition to the presence of biliary stones and pericholecystic fluid, were noted and compared with the severity of AP on the basis of the magnetic resonance severity index.

RESULTS

Of the 197 patients with AP, 81% were classified as edematous and 19% as necrotizing on MRI. There were 35%, 59%, and 6% of patients with mild, moderate, and severe AP according to the magnetic resonance severity index, respectively. Seventy-six percent of patients had at least one gallbladder abnormality on MRI, including a thickened gallbladder wall (42%), pericholecystic fluid (38%), gallbladder stones (35%), an enlarged gallbladder (24%), dilatation of the common bile duct (16%), and subserosal edema (15%). Eighty-nine percent of patients (34 of 38) with necrotizing AP had gallbladder abnormalities, which was significantly higher than the 72% of patients (115 of 159) with edematous AP (P < .05). The prevalence of gallbladder abnormalities was 64% in patients with mild AP, 81% in those with moderate AP, and 91% in those with severe AP (P < .05 among the three groups).

CONCLUSIONS

Most patients with AP have gallbladder abnormalities on MRI, including a thickened gallbladder wall and pericholecystic fluid. The prevalence of gallbladder abnormalities has a positive correlation with the severity of AP on MRI.

Cholelithiasis and its complications in children and adolescents: update and case discussion

In recent years, gallbladder disease, primarily in the form of cholelithiasis, has been on the rise among infants and children. Although pediatric gallbladder disease is still less prevalent than adult gallbladder disease, physicians and other clinicians who care for children need to be aware of this underappreciated problem and understand the manifestations of biliary disease in the pediatric population. In this article, case discussions will serve as a platform for discussing the clinical spectrum of cholelithiasis and its complications in children as well as discussing the latest evidence related to diagnosis and treatment.

Differentiating malignant from benign thickening of the gallbladder wall by the use of acoustic radiation force impulse elastography

OBJECTIVES

The purpose of this study was to determine whether real-time elastography can differentiate gallbladder carcinoma from benign gallbladder wall thickening.

METHODS

Sonographic and real-time elastographic examinations were done in 125 of 2000 consecutive patients who had an increased gallbladder wall thickness of more than 3 mm. Shear wave velocities were determined for a normal gallbladder wall, a benign thickened gallbladder wall, and gallbladder carcinoma, and a value of 2.7 m/s was set as the cutoff to differentiate between benign and malignant wall thickening. Virtual touch and color maps of the gallbladder wall were also obtained. The final diagnosis was confirmed by histopathologic examination of the resected gallbladder or by guided fine-needle aspiration cytologic examination. Statistical analysis was done to determine the sensitivity and specificity of elastography for gallbladder carcinoma and benign wall thickening. Student t test and area under the receiver operating characteristic curve analyses were done to determine the statistical significance of the results.

RESULTS

Elastography had sensitivity and specificity of 100% and 91.3%, respectively, for diagnosing gallbladder carcinoma with a mean shear wave velocity of 3.41 m/s (P < .0001) and an area under the curve of 0.92. False-positive findings of acute cholecystitis occurred in 8.5% of cases, which also had an increased shear wave velocity of greater than 2.7 m/s. The overall accuracy of elastography for differentiating gallbladder carcinoma from benign wall thickening was 92.8%.

CONCLUSIONS

Elastography is an accurate technique for differentiating between benign and malignant gallbladder wall thickening and can be combined with sonography as the prime imaging tool for diagnosing gallbladder carcinoma at an early stage.

Transient reticular gallbladder wall thickening in severe dengue fever: a reliable sign of plasma leakage

BACKGROUND

Dengue fever (DF) is an acute infection caused by a flavivirus. Although most patients present mild symptoms, some progress to a severe condition characterized by hypovolemic shock and hemorrhagic phenomena. The main feature of this severe form of DF is plasma leakage. Gallbladder wall thickening (GBWT), ascites and pleural effusion represent the sonographic triad of plasma leakage in DF.

OBJECTIVE

To evaluate the plasma leakage triad in severe DF with emphasis on the GBWT.

MATERIALS AND METHODS

Thirty-seven children with severe DF underwent abdominal US on the day of admittance and on the day of discharge, or 7 days after the first examination if the child was still hospitalized.

RESULTS

Of the 37 children, 33 (89.2%) presented GBWT, 29 (78.4%) ascites and 26 (70.3%) pleural effusion. All of these findings had resolved by the second examination. Of the 33 GBWTs, 29 (87.9%) presented a reticular pattern, which could be considered typical of plasma leakage in patients with severe DF.

CONCLUSION

GBWT, ascites and pleural effusion are transient findings in DF. The authors have described a typical reticular pattern of GBWT that can be used to diagnose and follow up on patients with severe DF and should not be considered an acalculous cholecystitis.

Diseases of the gallbladder and biliary tree

Most disorders of the biliary system are associated with increased activity of parenchymal transaminases (alanine aminotransferase, aspartate aminotransferase) and cholestatic enzymes (alkaline phosphatase and gamma glutamyl transferase) with or without hyperbilirubinemia or jaundice. While parenchymal liver disease is most common in the dog, inflammatory disorders involving the small- and medium-sized bile ducts and zone 1 (periportal) hepatocytes predominate in the cat. Historically, the incidence of disorders restricted to the gallbladder is low in both species; however, with routine diagnostic use of abdominal ultrasonography, the incidence of gallbladder mucoceles and cholelithiasis has increased. Extrahepatic bile duct obstruction is a well-recognized syndrome because of its association with pancreatitis and obvious jaundice. Less common disorders of the biliary system include a cadre of diverse conditions, including necroinflammatory processes, cholelithiasis, malformations, neoplasia, and an emerging syndrome of gallblader dysmotility.

Gallbladder wall thickening in a patient with acute poststrepotcoccal glomerulonephritis

Although thickening of the gallbladder wall is a relatively frequent finding on diagnostic imaging studies, the condition has never been reported in patients with acute poststreptococcal glomerulonephritis (APSGN). We describe a patient with APSGN who presented with transient thickening of the gallbladder wall. While the precise pathogenic mechanism underlying this change in our patient was unclear, elevated systemic venous pressure or subclinical vasculitis may have caused edema of the gallbladder wall.

Analysis of enhancement pattern of flat gallbladder wall thickening on MDCT to differentiate gallbladder cancer from cholecystitis

OBJECTIVE

The objective of our study was to determine the diagnostic value of analyzing the pattern of gallbladder wall enhancement on MDCT to characterize diffuse gallbladder wall thickening as benign or malignant.

MATERIALS AND METHODS

MDCT scans obtained during the portal venous phase in 78 patients with gallbladder wall thickening caused by various pathologic conditions were retrospectively reviewed by two blinded observers. The CT features of benign and malignant gallbladder wall thickening were compared by means of univariate and multivariate analyses. The study cases were then divided into five patterns according to enhancement pattern. Using these five patterns, two radiologists reviewed the MDCT images and recorded their diagnostic confidence for differentiating benign versus malignant cause on a 5-point scale. The diagnostic performance of CT was evaluated by each observer using a receiver operating characteristic curve analysis.

RESULTS

The thicknesses of the inner and outer layers ("thick" enhancing inner layer > or = 2.6 mm, "thin" outer layer < or = 3.4 mm), strong enhancement of the inner wall, and irregular contour of the affected wall were significant predictors for a malignant cause of gallbladder wall thickening (p < 0.001). The two-layer pattern with a strongly enhancing thick inner layer and weakly enhancing or nonenhancing outer layer and the one-layer pattern with a heterogeneously enhancing thick layer were patterns that were significantly associated with gallbladder cancer (p < 0.05). When we consider those two enhancing patterns as a sign of malignancy, the diagnostic accuracy of MDCT was 89.1% and 87.6% for the two observers, respectively.

CONCLUSION

Analyzing the enhancement pattern of a thickened gallbladder wall on MDCT is helpful in differentiating gallbladder cancer from benign inflammatory diseases.

Gallbladder sludge and acute pancreatitis induced by acute hepatitis A

In this case report, a young woman with gallbladder sludge and acute pancreatitis due to acute hepatitis A (HAV) is presented. She was admitted to our hospital with abnormal hepatic enzymes. Five days prior to her admission, an initial abdominal ultrasound was performed at another hospital and revealed no abnormality, while her serum aspartate aminotransferase (AST) level was at the upper limit of normal (ULN) x 8. A second ultrasound was performed at our hospital and revealed a gallbladder wall thickness (9.3 mm), gallbladder sludge in the gallbladder lumen, pancreatic edema, ascites, and hepatomegaly while AST was at the ULN x 50. Magnetic resonance imaging and magnetic resonance cholangiopancreatography revealed imaging features of an acute stage of pancreatitis and gallbladder wall thickness with coexisting sludge in the gallbladder lumen. HAV infection was diagnosed by the detection of immunoglobulin M against HAV in the serum. The patient underwent two repeated abdominal ultrasound examinations on the 5th (AST was at the ULN x 3) and the 20th days (AST was at the normal) after her discharge, and both revealed normal findings. In our case, we observed reversible changes in the hepatobiliary and pancreatic system which was related to the severity of hepatic necro-inflammation. HAV-associated pancreatitis may be due to the formation of biliary sludge during the acute phase of the viral illness, but this association needs further investigation.

Role of ultrasound in dengue fever

This study was performed to find out whether ultrasound is an important adjunct to clinical and laboratory profile in diagnosing dengue fever or dengue haemorrhagic fever and to further determine whether ultrasound is useful in predicting the severity of the disease. Ultrasound was performed on 128 patients (2-9 years) with clinical suspicion of dengue fever. Serological tests were performed to confirm the diagnosis. 40 patients were serologically negative for dengue fever and later excluded from the study. Of the remaining 88 serologically positive cases, 32 patients underwent ultrasound on second to third day, repeated on fifth to seventh day of fever and in 56 patients ultrasound was done only on fifth to seventh day of fever. Of the 32 patients who underwent the study on second to third day of fever, all showed gall bladder wall thickening and pericholecystic fluid, 21% had hepatomegaly, 6.25% had splenomegaly and right minimal pleural effusion. Follow-up ultrasound on fifth to seventh day revealed ascites in 53% left pleural effusion in 22% and pericardial effusion in 28%. Of the 56 patients who underwent the study on fifth to seventh day of fever for the first time all had gall bladder wall thickening, 21% had hepatomegaly, 7% had splenomegaly, 96% had ascites, 87.5% had right pleural effusion, 66% had left pleural effusion and 28.5% had pericardial fluid. To conclude, in an epidemic of dengue, ultrasound features of thickened gall bladder wall, pleural effusion and ascites should strongly favour the diagnosis of dengue fever.

Gallbladder wall thickening: MR imaging and pathologic correlation with emphasis on layered pattern

The aim of this study was to correlate MR findings of gallbladder wall thickening with pathologic findings on the basis of the layered pattern and to evaluate the diagnostic value of MR imaging in gallbladder disease. We retrospectively evaluated the source images of HASTE sequences for MR cholangiography in 144 patients with gallbladder wall thickening. The layered pattern of thickened wall was classified into four patterns. Type 1 shows two layers with a thin hypointense inner layer and thick hyperintense outer layer. Type 2 has two layers of ill-defined margin. Type 3 shows multiple hyperintense cystic spaces in the wall. Type 4 shows diffuse nodular thickening without layering. MR findings of a layered pattern of thickened gallbladder were well correlated with histopathology. Chronic cholecystitis matched to type 1, acute cholecystitis corresponded to type 2, adenomyomatosis showed type 3, and the gallbladder carcinomas showed type 4. All four layered patterns were associated with PPV of 73% or greater, sensitivity of 92% or greater and specificity of 95% or greater. Our results indicate that MR findings of gallbladder wall thickening are characteristic in each entity and correlate well with pathologic findings. The classification of the layered pattern may be valuable for interpreting thickened gallbladder wall.

MR imaging in abdominal emergencies

The use of MR imaging in the emergency setting is evolving. Clear indications include situations in need of contrast media when iodinated contrast cannot be administered or to facilitate assessments in pregnant patients and children when exposure to ionizing radiation is considered unacceptable. The availability of rapid, motion-immune sequences now makes MR imaging a feasible study in less cooperative patients extending the range of patients for whom a diagnostic study can be achieved. Capitalizing on the unique benefits of MR imaging there is optimism that MR imaging can eliminate test redundancy and impact patient care in a cost-effective manner. Further investigations are needed to identify the diagnostic algorithms for which this favorable use holds true.

Endoscopic sonographic evaluation of the thickened gallbladder wall in patients with acute hepatitis

PURPOSE

Thickening of the gallbladder wall is often observed during abdominal sonographic examination in patients with acute hepatitis. However, there is rarely an opportunity for a histopathologic analysis of these structural changes. Endoscopic sonography (EUS) can accurately delineate the structure of the gallbladder wall and therefore may be useful for visualizing changes in the gallbladder wall in patients with acute hepatitis. Hence, we prospectively studied the ability of EUS to detect specific structural changes in the gallbladder wall in patients with acute hepatitis and examined the effect of high elevation of serum liver enzyme levels on the gallbladder wall.

METHODS

A study group of patients diagnosed with acute hepatitis who had gallbladder wall thickening and a control group of patients without acute hepatitis or gallbladder disease underwent EUS between May 1, 1999, and June 1, 2002. EUS was used to measure the thickness of the gallbladder wall and to visualize each of its layers. Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels of the patients with acute hepatitis were measured at the time of the EUS examination. Statistically significant differences were determined using an independent t test and the chi-squared test. A p value of less than 0.05 was considered statistically significant.

RESULTS

The acute hepatitis group comprised 28 men and 24 women with a mean age of 40.8 years. The control group comprised 25 men and 25 women with a mean age of 45.1 years. The mean gallbladder wall thickness +/- standard deviation in the acute hepatitis group (6.3 +/- 2.6 mm) was significantly greater than that in the control group (1.6 +/- 0.4 mm; p < 0.01). The mean thickness of the gallbladder wall for patients in whom both the AST and the ALT levels were 500 U/l or higher (7.0 +/- 2.6 mm) was significantly greater than that for patients with levels below 500 U/l (5.4 +/- 2.3 mm; p < 0.05). In the acute hepatitis group, EUS showed thickened, well-defined muscular and serosal layers of the gallbladder wall in 24 of the patients and a diffusely thickened gallbladder wall, in which each layer was ill defined, in the other 28 patients. The mean thickness of the gallbladder wall for patients with the pattern of ill-defined layers was significantly greater than that for the patients with the pattern of well-defined layers (p < 0.05). The pattern of ill-defined layers was more common among patients in whom the serum AST and ALT levels were at least 500 U/l than among patients with levels below 500 U/l (p < 0.05).

CONCLUSIONS

We propose that gallbladder wall thickening in patients with acute hepatitis is associated with prominent changes in the muscular and serosal layers. Patients with highly elevated serum liver enzyme levels are more likely to have gallbladder wall thickening and disruption of planes between the muscular and serosal layers than are patients with normal liver enzyme levels.

Gallbladder contractility in patients with cirrhotic versus malignant ascites

PURPOSE

The aim of this study was to evaluate differences in gallbladder contractility by measuring gallbladder wall thickness, fasting and residual gallbladder volume, and gallbladder ejection fraction in patients with cirrhotic and malignant ascites.

METHODS

Twenty-four patients (16 women and 8 men) with malignant ascites (2 cervical, 2 colon, 2 stomach, 6 pancreatic, and 12 ovarian carcinomas), aged 59 +/- 12 years, and 26 patients (14 women and 12 men) with cirrhotic ascites, aged 57 +/- 16 years, were included in the study. After patients fasted overnight for 8 hours, gallbladder wall thickness, fasting gallbladder volume, and gallbladder volume and ejection fraction were measured sonographically at 10, 20, 30, 40, 50, 60, 70, 80, and 90 minutes after ingestion of a standard liquid test meal.

RESULTS

The mean gallbladder wall thickness was higher in patients with cirrhotic ascites than in those with malignant ascites (5.5 +/- 1.5 mm [standard deviation] versus 3.1 +/- 0.6 mm, respectively; p < 0.001). The mean fasting gallbladder volume was also higher in patients with cirrhotic ascites than in those with malignant ascites (27.3 +/- 11.5 cm(3) versus 17.6 +/- 8.9 cm(3); p < 0.05). Patients with cirrhotic ascites had significantly higher mean postprandial gallbladder volumes and ejection fractions than did those with malignant ascites at all times except 10 minutes after the meal (p < 0.05).

CONCLUSIONS

Our findings suggest that gallbladder contractility is greater in patients with cirrhotic ascites than in patients with malignant ascites.

Migration of an intrauterine contraceptive device to the urinary bladder: sonographic findings

Migration of an intrauterine contraceptive device (IUD) to the urinary bladder is very rare. We describe a case in which transabdominal sonography demonstrated such migration of an IUD in a 30-year-old woman who sought treatment for pelvic pain and dysuria. The IUD had originally been inserted 10 years earlier, and the patient had given birth without complications 2 years before the onset of her symptoms. Cytoscopic examination confirmed the diagnosis and allowed removal of the IUD.

Imaging the patient with right upper quadrant pain

A variety of high-resolution imaging techniques are currently available for the evaluation of patients with RUQ pain. In these patients, an imaging approach that is based on identifying the presence of certain clinical signs and symptoms can aid in choosing the appropriate imaging modality and establishing the diagnosis. For patients presenting with a positive Murphy sign, sonography and biliary scintigraphy are the most useful initial imaging techniques. In patients with fever and a negative Murphy sign, a combination of sonography and contrast-enhanced CT can establish the diagnosis in most cases. And finally, in patients without fever or a positive Murphy sign, CT and MR are appropriate first-line imaging techniques.

Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study

OBJECTIVE

We assessed the value of sonography in predicting intraoperative difficulties for patients undergoing laparoscopic cholecystectomy and in identifying indicators for conversion to conventional cholecystectomy.

SUBJECTS AND METHODS

Upper abdominal sonography was performed (according to a checklist) in 75 consecutive patients before laparoscopic cholecystectomy. Sonographic findings were verified by the surgeon in the operating room.

RESULTS

Conversion from laparoscopic surgery to laparotomy was performed in five patients (6.7%). Of 75 patients, 19 had sonograms revealing gallbladder wall thickening (>4 mm); surgical preparation difficulties in 16 of these patients led to laparotomy in four patients. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of technical difficulties were 66.7%, 94.1%, 84.2%, and 85.3%, respectively. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of surgical conversion were 80.0%, 78.6%, 21.1%, and 78.7%, respectively. Technical difficulties at laparoscopy occurred in all five patients with pericholecystic fluid on sonography (sensitivity, 20.8%; specificity, 100%; positive predictive value, 100%; accuracy, 74.7%) and led to laparotomy in three patients (sensitivity 60.0%, specificity 97.1%, positive predictive value 60%, accuracy 94.7%). The accuracy of sonography for cholecystolithiasis was 100%.

CONCLUSION

On sonography, gallbladder wall thickening is the most sensitive indicator and pericholecystic fluid is the most specific indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to laparotomy.

Sonographic findings in grade III dengue hemorrhagic fever in adults

PURPOSE

Sonography has been used to evaluate children with dengue hemorrhagic fever, but to our knowledge no such studies have been conducted with adults. We present the sonographic findings in 40 adults with severe (grade III) dengue hemorrhagic fever (DHF).

METHODS

Forty patients (30 men and 10 women, aged 16-65 years) given a presumptive diagnosis of grade III dengue hemorrhagic fever during a documented regional epidemic underwent abdominal sonography. Ten also underwent chest radiography. Serologic confirmation was obtained in 5 patients, and in the rest the diagnosis was based on epidemiologic and clinical findings.

RESULTS

Sonographic findings included pleural effusion in 21 patients (53%), thickening of the gallbladder wall in 17 (43%), and mild ascites in 6 (15%). These findings were similar to those of previous studies of severe DHF in children, although the incidence of pleural effusion and ascites was slightly lower in our series. Neither pleural effusion nor ascites was apparent on clinical examination. Of the 10 patients who underwent both sonography and chest radiography, sonography detected pleural effusion in all 10, whereas radiography detected it in only 3.

CONCLUSIONS

Sonographic findings in DHF in adults (pleural effusions, ascites, and gallbladder wall thickening) were similar to those described for children but seem to be of lesser severity. Abdominal sonography is a useful diagnostic tool for confirming suspected cases of DHF. Sonography was found to be superior to chest radiography in detecting pleural effusions in the 10 patients in whom radiographs were available.

Acute biliary disease: initial CT and follow-up US versus initial US and follow-up CT

PURPOSE

To evaluate the utility of ultrasonography (US) versus that of computed tomography (CT) for assessment of acute biliary disease.

MATERIALS AND METHODS

Radiologic reports and clinical charts were reviewed in all patients who underwent US and CT within 48 hours of each other for evaluation of acute right upper quadrant pain. Radiologic findings and clinical outcome were correlated.

RESULTS

CT was the initial imaging study in 57 patients, and CT findings resulted in underdiagnosis or misdiagnosis of acute biliary disease in eight of 11 patients. Follow-up US results were suggestive of the correct diagnosis and provided additional clinical information in seven of these eight patients. US findings resulted in altered clinical treatment in six of 11 patients with acute biliary disease. US was the initial study in 66 patients, and US findings were suggestive of biliary disease or the correct diagnosis in seven of seven patients with acute biliary disease. Follow-up CT did not result in changes in clinical treatment in any patient with acute biliary disease.

CONCLUSION

Initial US is better than initial CT in patients suspected of having acute biliary disease. Follow-up CT provides no additional information regarding the biliary system, and its use should be limited to those patients with a wider differential diagnosis or with confusing clinical symptoms and signs.

Thickened inner hypoechoic layer of the gallbladder wall in the diagnosis of anomalous pancreaticobiliary ductal union with endosonography

BACKGROUND

An anomalous pancreaticobiliary ductal union (APBD) is a high-risk factor for biliary tract carcinoma, which often is not diagnosed before overt malignancy. The early detection of APBD is therefore clinically important. We evaluated the gallbladder wall in APBD patients with endoscopic ultrasonography.

METHODS

Clinicopathologic features and ultrasonographic findings of the gallbladder in 33 consecutive patients with APBD between 1986 and 1995 were studied in relation to two subtypes of APBD, that is, undilated (n = 17) and dilated (n = 16). The gallbladder wall was evaluated with conventional ultrasonography and/or endoscopic ultrasonography. Histologic examinations of 25 resected gallbladders were made.

RESULTS

Fourteen of the seventeen patients with undilated type APBD (82%) had diffuse thickened gallbladder wall of 4 mm or more, whereas 5 of the 16 with dilated type (31%) had this finding (p < 0.01). The thickened gallbladder wall consisted sonographically of two layers: diffuse thickened inner hypoechoic layer and outer hyperechoic layer. Mucosal hyperplasia was histologically found in 8 of 9 cases (89%) with thickened inner hypoechoic layer on endoscopic ultrasonography. Mucosal hyperplasia was observed in 10 of 11 undilated type APBD cases (91%) in which cholecystectomy was performed. In addition, the presence of anomalous union was shown by endoscopic ultrasonography in 9 of 11 patients with undilated type APBD (82%) and all 7 of those with dilated type. The characteristic ultrasonographic pattern of diffuse thickened inner hypoechoic layer was observed exclusively in patients with mucosal hyperplasia of the gallbladder associated with APBD among 2085 endoscopic ultrasonography examinations performed during the study period.

CONCLUSIONS

Diffuse thickened inner hypoechoic layer of the gallbladder wall was frequently observed in APBD patients, especially those with the undilated type, on ultrasonography and/or endoscopic ultrasonography. This finding corresponded histologically to mucosal hyperplasia of the gallbladder mucosa. Thickened inner hypoechoic layer is a useful ultrasonographic sign that indicates mucosal hyperplasia of the gallbladder and, particularly, the possible coexistence of undilated type APBD before the appearance of overt malignancy.

Gall-bladder wall thickening in patients with liver cirrhosis

Gall-bladder wall thickening is commonly seen in patients with cirrhosis, but its exact causes have not been well established. We evaluated clinical, biochemical and haemodynamic data of patients with cirrhosis with respect to the presence of thickening of the gall-bladder wall. After excluding patients who presented with gallstones, acute or chronic cholecystitis, heart failure, a serum creatinine level greater than 2 mg/dL and/or a serum alanine aminotransferase level greater than 400 U/L, 77 patients with cirrhosis (75 male, two female; mean age 58 +/- 8 years) were enrolled in the study. Clinical, biochemical, ultrasound and haemodynamic data were obtained in every patient. Forty-one (53%) of 77 patients with cirrhosis had gall-bladder wall thickening (> 4 mm). Compared with patients with a normal gall-bladder wall, patients with gall-bladder wall thickening had significantly lower serum albumin levels (3.6 +/- 0.6 vs 2.9 +/- 0.7 gm/dL, respectively; P < 0.05), a longer prothrombin time (13 +/- 6 vs 16 +/- 6 s, respectively; P < 0.05), more patients with Child-Pugh class C (6 vs 37%, respectively; P < 0.05) and more patients with ascites (8 vs 50%, respectively; P < 0.05). In addition, compared with patients with a normal gall-bladder wall, those patients with gall-bladder wall thickening had a higher hepatic venous pressure gradient (13.9 +/- 4.5 vs 17.1 +/- 4.1 mmHg, respectively; P < 0.01) and a lower systemic vascular resistance (SVR; 1144 +/- 332 vs 1010 +/- 318 dyn.s/cm5, respectively; P < 0.05). Using a multivariate analysis, the presence of ascites and SVR lower than 900 dyn.s/cm5 were independently correlated with the presence of gall-bladder wall thickening, while a hepatic vein pressure gradient greater than 10 mmHg had only a marginally significant association. The presence of ascites, decreased SVR and portal hypertension are related to the occurrence of gall-bladder wall thickening in patients with cirrhosis, indicating that the development of gall-bladder wall thickening may be multifactorial.

MRI of acute cholecystitis: comparison with the normal gallbladder and other entities

Our purpose was to prospectively compare MRI findings with histopathologic findings in the evaluation of suspected acute cholecystitis. Fourteen patients with clinically suspected acute cholecystitis were entered into the study. MR sequences included T1-weighted fat-suppression and breath-hold spoiled gradient echo (SGE) before and after intravenous gadolinium chelate administration. Percent contrast enhancement (%CE) of the gallbladder wall and gallbladder wall thickness (WT) were measured and liver enhancement patterns determined prospectively on MR images. Correlation was obtained with pathological findings at cholecytectomy in all patients. In a second phase of the study MR images on 10 additional subjects who underwent MR examination for reasons other than hepatobiliary disease were analyzed to determine normal values for %CE and gallbladder wall thickness. Mean %CE was 124.0% in patients with acute cholecystitis (10 patients), 58.0% in patients with chronic cholecystitis (2 patients), and 73.0% in patients with gallbladder malignancy (2 patients). Mean gallbladder WT was 6.1 mm in acute cholecystitis, 4.5 mm in chronic cholecystitis, and 6.0 mm in malignant disease. There was a significant difference in %CE between acute and chronic cholecystitis (p = 0.03); no other significant differences in %CE or WT were observed among the patients with gallbladder disease. Patients without biliary disease had %CE of 37.3% and WT of 2.9 mm, which were both significantly less (p < 0.001) than in patients with acute cholecystitis. Transient enhancement of pericholecystic hepatic parenchyma on immediate postgadolinium SGE images was seen in 7 of 10 patients with acute cholecystitis, and not observed in other patients. Patients with acute cholecystitis had increased %CE and WT on MR images that were significantly greater than normal and %CE that was significantly greater than in patients with chronic cholecystitis. Transient increased pericholecystic hepatic enhancement was observed in 70% of acute cholecystitis patients and in no other patient groups.

Gallbladder wall thickening in dengue hemorrhagic fever: an ultrasonographic study

This study attempts to investigate whether gallbladder wall thickening (GBWT) measured by ultrasonography can be used in children as a reliable criterion to predict the onset of severe dengue hemorrhage fever (DHF). In this prospective study, we performed ultrasound examinations focusing on the gallbladder wall and the presence of intraperitoneal free fluid in 48 mild DHF cases (grades I-II) and 48 severe cases (grades III-IV). GBWT varied between 1 mm and 8 mm with a mean of 3.77 mm +/- 2.04 mm. The mean value of DHF grades I and II (2.39 mm +/- 1.48 mm) is significantly lower than that of grades III and IV (5.14 mm +/- 1.54 mm), p < 0.001. GBWT exceeded 3 mm in only 16 of 48 (33.3%) grade I-II patients and in 45 of 48 (93.8%) grade III-IV patients. A significant positive correlation was apparent between GBWT and the severity of illness, p < 0.001. Patients with ascites have significantly thicker gallbladder walls than those without, p < 0.01. In clinically confirmed DHF cases, the sonographic finding of GBWT > 3 mm to 5 mm, with 93.8% sensitivity, can be used as a criterion indicating the need for admission and monitoring. A GBWT of > or = 5 mm, with 91.7% specificity, is useful as a criterion for identifying DHF patients at high risk of developing hypovolemic shock.

Acute acalculous cholecystitis due to Vibrio cholerae

The case of a 57-year-old woman admitted with symptoms and signs suggesting an intestinal infection caused by Vibrio cholerae, and who also developed a clinical picture compatible with acute cholecystitis, is presented. Cholera was diagnosed by examining a fresh sample of stools and cultures. An abdominal sonogram disclosed signs of acute acalculous cholecystitis. She underwent cholecystectomy, and cultures of a clear fluid and a "milky" sediment found within the gallbladder were also positive for V. cholerae. This microorganism was seen at the gallbladder mucosa microscopically. The strain was serotyped V. cholerae 01 (El Tor) Ogawa and was the etiology of the acute acalculous cholecystitis in this patient.

Correlative imaging of the liver and hepatobiliary system

Many imaging techniques can be used to assess the liver and hepatobiliary system. Each modality has individual strengths and limitations, which usually vary depending on the specific clinical situation. This review discusses several specific common clinical situations where imaging of the liver and biliary system is necessary and describes the various imaging options. Space-occupying liver lesions are discussed, and particular attention is paid to the assessment of liver metastasis, hepatoma, and incidentally discovered liver lesions such as hemangioma, adenoma, and focal nodular hyperplasia. The value of ultrasound, computed tomography, magnetic resonance imaging, and scintigraphic techniques in this patient population is described. Isolated sulfur colloid hepatic scintigraphy is not of great value in the evaluation of these patients. Therefore, this review describes in some detail the value of physiological liver scintigraphy, including gallium and iminodiacetic acid (IDA) scanning as well as dynamic flow imaging of the liver such as hepatic artery perfusion scintigraphy and tagged red cell scintigraphy. Imaging of the biliary tree also is described. The roles of ultrasound and scintigraphy are compared and contrasted as related to the diagnosis of acute cholecystitis, common duct obstruction, and postoperative complications.