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Ultrasound of acute & chronic cholecystitis
- 1. Ultrasound of cholecystitis Samir Haffar M.D. Assistant Professor of Gastroenterology
- 2. Ultrasound of cholecystitis Acute cholecystitis Complications of acute cholecystitis Chronic cholecystitis
- 4. Causes of right upper quadrant pain • Peptic ulcer disease • Pancreatitis • Hepatitis • Appendicitis • Hepatic congestion from right-sided heart failure • Perihepatitis (Fitz-Hugh-Curtis syndrome) • Right lower lobe pneumonia • Right-sided pyelonephritis • Nephro-ureterolithiasis
- 5. Diagnostic standard for acute cholecystitis Tokyo guidelines 2007 Hirota M et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : 78 – 82 . Three categories of diagnostic findings One criterion from each category must be fulfilled (1) Murphy sign or pain/tenderness in RUQ or RUQ mass (2) Fever, leukocytosis, or elevated CRP (3) Confirmation by US or HIDA scan
- 6. Acute cholecystitis – HIDA scan Higher accuracy than ultrasonography Talley NJ et al. Practical gastroenterology & hepatology: Liver & biliary disease. Wiley Blackwell, Oxford, UK, First edition, 2010. Tracer in GB Tracer in CBD Tracer in small bowel GB CBD Small bowel Normal HIDA scan Non-filling of GB Tracer in CBD Tracer in small bowel CBD Small bowel Acute cholecystitis
- 7. Sonographic findings in acute cholecystitis • Impacted stone in cystic duct or GB neck • Positive sonographic Murphy's sign • Thickening of GB wall (>3 mm) • Distention of GB lumen (> 4 cm) • Pericholecystic fluid collections (frequent) • Hyperemic GB wall on color Doppler (supportive test) None of above signs pathognomonic Combination of multiple signs make correct diagnosis Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
- 8. Acute cholecystitis Caused by gallstones in more than 90% of cases Large obstructing stone within GB neck Thick hypoechoic gallbladder wall Positive sonographic Murphy sign Ralls PW et al. Gastroenterol Clin N Am 2002 ; 31 : 801–825.
- 9. Negative sonographic Murphy’s sign • Patients who received pain medicine or steroids • Para or quadriplegic patients • Patients not able to give reliable history or pain response • Denervated GB: DM – gangrenous cholecystitis • Gallbladder rupture Careful attention to clinical status important when assessing for sonographic Murphy’s sign Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
- 10. Gallbladder wall thickening • Generalized edematous states CHF – Renal failure End-stage cirrhosis Hypoalbuminemia • Inflammatory conditions Primary Acute cholecystitis Chronic cholecystitis Cholangitis Secondary Acute hepatitis Perforated DU Pancreatitis Diverticulitis/colitis • Neoplastic conditions Adenocarcinoma – Metastases • Miscellaneous Adenomyomatosis – Varices Rumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
- 11. Diffuse gallbladder wall thickening McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Three echo patterns (not specific) Uniformly echogenic pattern Central hypoechoic zone & 2 peripheral echogenic layers Striated pattern
- 12. Gallbladder wall thickening Uniformly echogenic pattern Echogenic thickening of the wall in chronic cholecystitis McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
- 13. Gallbladder wall thickening Central hypoechoic zone separated by two echogenic layers Gallbladder wall thickening due to ascites
- 14. Gallbladder wall thickening Striated pattern Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413. Striated wall with alternating echogenic & hypoechoic layers Striated wall in setting of acute cholecystitis: gangrenous cholecystitis Striated wall without evidence of acute cholecystitis: non specific
- 15. Gallbladder wall thickening Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413. Gallstones Focal GB wall thickening (7 mm) Free air with reverberation shadows Pericholecystic fluid (arrows) Free air (arrowheads) Extraluminal air (paired arrowheads) Peptic ulcer perforation
- 16. Gallbladder wall thickening Rubens DJ et al.Ultrasound Clin 2007 ; 2 : 391 – 413. Focal pyelonephritis Heterogeneous decreased attenuation area typical of focal pyelonephritis GB wall thickening 3-cm echogenic mass in lower pole of rt kidney
- 17. Pericholecystic fluid Two specific patterns Type I Thin anechoic crescent-shaped collection adjacent to gallbladder wall Nonspecific finding Type II Round or irregularly shaped collection with thick walls, septations, or internal debris Associated with GB perforation & abscess Teefey SA et al. J Ultrasound Med 1991 ; 10 : 603 – 6. Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413.
- 18. Acute cholecystitis Hyperemic GB wall McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Color Doppler sonography Increased vascularity in GB wall Supportive test
- 19. Acute acalculous cholecystitis (AAC) 5 – 15% of acute cholecystitis • Critically ill patients Major surgery Severe trauma Sepsis Total parenteral nutrition Diabetes Atherosclerotic disease HIV infection • Nonhospitalized patients Elderly male with atherosclerosis HIDA scan & sampling of luminal contents help to establish the diagnosis
- 20. Acute acalculous cholecystitis (AAC) Difficult to diagnose clinically & on imaging Marked GB mural thickening Hypoechoic regions within wall Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Marked GB mural thickening with hypo & hyperenhancing areas
- 21. Hemorrhagic cholecystitis Rare – Atherosclerosis – High mortality rate Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216. Echogenic material with higher echogenicity than sludge Increased density of bile
- 22. Hemorrhagic cholecystitis Differential diagnosis • Blood in gallbladder Neoplasm Aneurysms Trauma Anticoagulation Ectopic pancreas Ectopic gastric mucosa • High-density bile Recently administered IV contrast Milk of calcium bile Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216.
- 23. Complications of acute cholecystitis
- 24. Complications of acute cholecystitis • Suppurative cholecystitis (empyema) • Gangrenous cholecystitis Up to 20% • Emphysematous cholecystitis 1 % • Hemorrhagic cholecystitis Rare • Gallbladder perforation 5 – 10%
- 25. Suppurative cholecystitis (Empyema) Patients very ill with fever & acute pain Fine echoes caused by pus in bile Pericholecystic GB collection (leakage) US used to guide drainage before surgery Bates J A. Abdominal Ultrasound: How, why and when. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Large GB full of pus & stones
- 26. Gangrenous cholecystitis No specific diagnostic US findings • Striated thickening of GB wall • Intraluminal membranes (5%) • Marked asymmetry of GB wall • Echogenic debris within GB • Pericholecystic fluid collections • US Murphy’s sign negative in 70% Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287. Mucosal sloughing Echogenic debris within GB
- 27. Gangrenous cholecystitis Mucosal sloughing Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413. Longitudinal US of gallbladder Intraluminal membranes associated gallbladder gangrene Stone impacted in gallbladder neck
- 28. Emphysematous cholecystitis Prompt surgical intervention required • Organisms Clostridium welchii & Escherichia coli • Characteristics Male preponderance (70%) Frequent occurrence in diabetic (50%) Lack of gallstones in up to one third Higher risk of gangrene & perforation • Three stages Stage 1: Gas in GB lumen Stage 2: Gas in GB wall Stage 3: Gas in pericholecystic tissues Bennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 – 1216. Appearance depends on amount of gas present
- 29. Emphysematous cholecystitis Associated with DM & atherosclerotic disease Intraluminal & intramural gas bubbles Debris within necrotic GB Higher sensitivity of CT for the diagnosis Diagnosis should be confirmed by abdominal radiography or CT Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 – 287.
- 30. Emphysematous cholecystitis Small amount of gas Supine position Presence of echoes anteriorly Could be in the lumen or the wall Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413. Upright position Gas moves & breaks into bubbles Distinguishing it from calcium
- 31. Emphysematous cholecystitis Large amount of gas Absence of a normal gallbladder is a clue Gas in GB completely obscures the lumen (dirty shadow) Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Location of GB fossa essential to avoid mistaking this for bowel gas
- 32. Emphysematous cholecystitis Abdominal radiography Intraluminal & intramural gas bubbles Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
- 33. Gallbladder perforation 5 – 10 % of patients with acute cholecystitis Small defect in GB wall: not always seen Deflation of the gallbladder Pericholecystic fluid collection Pericholecystic abscess Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Disruption of GB wall
- 34. GB perforation – Pericholecystic abscess Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Abscess (internal strands typical of abscess) Echogenic inflamed fat Small amount of ascites
- 36. Forms of chronic cholecystitis • Traditional chronic cholecystitis Thick gallbladder wall with gallstones • Wall-Echo-Shadow complex (WES) Double arc-shadow sign • Porcelain gallbladder High incidence of GB carcinoma (10 – 30%) • Xanthogranulomatous cholecystitis (XGC) Difficult to distinguish from adenomyomatosis & gallbladder carcinoma
- 37. Chronic cholecystitis Bates J A. Abdominal Ultrasound: How, Why and When. Churchill Livingstone, Edinburg, UK, 2nd edition, 2004 Thick gallbladder wall Small gallbladder stone with posterior AS Bouts of acute cholecystitis may complicate chronic cholecystitis
- 38. Wall-Echo-Shadow complex (WES) Contracted gallbladder filled with stones 2 parallel arcuate hyperechoic lines Separated by thin hypoechoic space Distal acoustic shadowing McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008. Differentiation from air or calcification in GB wall Normal GB wall not seen; only bright echo & AS seen
- 39. Porcelain gallbladder Calcified wall with acoustic shadow Mistaken for stone within GB lumen No GB wall visible Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005. Dense calcification in GB fundus
- 40. Porcelain gallbladder – Mild calcification Rickes S et al. N Engl J Med, 2002 ; 346 : e4. Computed tomography Gallstones Calcification of GB wall Ultrasonography Gallstones (one in cystic duct) leading to GB enlargement (5 cm) Calcification of GB wall
- 42. Xanthogranulomatous cholecystitis (XGC) 2% of cholecystectomy specimens Compressed lumen Multiple large mural nodules separated by enhancing margins Stone not visualized Compressed lumen Multiple hypoechoic mural nodules Wall markedly thickened Adjacent stone Rubens D J. Ultrasound Clin 2007 ; 2 : 391 – 413.
- 43. Thank You
Editor's Notes
- HIDA (Hepatic Imino-Diacetic Acid) imagesRadionuclide cholescintigraphy with technetium Tc 99m-labelled iminodiacetic acid analogs (hepatobiliaryiminodiacetic acid scan) was first introduced in the late 1970s. The hepatic parenchymal uptake is observed within 1 minute, with peak activity occurring at 10 to 15 minutes. The bile ducts are usually visualized within 10 minute. The gallbladder should fill with isotope within 1 hour if the cystic duct is patent. If the gallbladder is not identified, delayed imaging up to 4 hours should be performed.Prompt biliary excretion of the isotope without visualization of the gallbladder is the hallmark of acute cholecystitis.False-positive results may occur in patients with abnormal bile flow because of hepatic parenchymal disease or a prolonged fast with a distended, sludge-filled gallbladder.Delayed gallbladder filling can be seen in the setting of chronic cholecystitis.
- Positive sonographic Murphy’s sign and the presence of gallstones had a positive predictive value of 92% for the diagnosis of acute cholecystitis.Patients who have thickening of the gallbladder wall caused by etiologies other than acute cholecystitis, the gallbladder often is nondistended, implying a nonobstructive (non-biliary) cause of wall thickening.
- The sonographic Murphy’s sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder. The sonographic Murphy’s sign is different from surgical Murphy’s sign, which consists of arrest of inspiration caused by pain from an inflamed gallbladder when the examiner’s hand is placed on the patient’s subcostal right upper quadrant.
- Striated:مخطط – مقلم - محزز
- Identifying the presence of pericholecystic fluid is useful because it is highly specific for GB disease either:1- Acute cholecystitis2- Pericholecystic abscess3- GB perforation
- AAC typically results from a gradual increase of bile viscosity because of prolonged stasis that leads to functional obstruction of cystic duct.The diagnosis of acalculouscholecystitis can be difficult to make as gallbladder distention, wall thickening, internal sludge, & pericholecystic fluid may all be present in critically ill patients without cholecystitis.Because no stones are present, the diagnosis is more difficult and may be delayed.The patients may be obtunded or receiving analgesics, reducing the sensitivity of Murphy's sign. It is the combination of the findings that suggests the diagnosis; the more signs present, the more the likelihood of cholecystitis. Nevertheless, cholescintigraphy or percutaneous sampling of the luminal contents should be used more liberally to aid in establishing the diagnosis.
- Sonographic findings of AAC include:Gallbladder distention and sludgeMural thickening (other etiologies considered unlikely)Hypoechoic regions within the wallPericholecystic fluidDiffuse increased echogenicity within the gallbladder resulting from hemorrhage, pus, intraluminal membranesPositive sonographic Murphy’s sign (50%)
- This rare complication of acute cholecystitis results from hemorrhage secondary to mucosal ulceration and necrosis and has been reported in the presence and absence of gallstones. Atherosclerosis of the gallbladder wall is a major predisposing factor.Classically the patient presents with biliary colic, jaundice, and melena.Only occasionally does the patient experience a gastrointestinal bleed.At sonography, blood in the gallbladder appears as echogenic material within the lumen which higher echogenicity than sludge. This may form a dependent layer; however, blood clots may appear as clumps or masses adherent to the gallbladder wall.As the hemorrhage evolves, this may have a cystic appearance.Prompt diagnosis is essential because hemorrhagic cholecystitis is associated with a high mortality rate.
- Emphysematous : نفاخي
- Gangrenous cholecystitis is a major complication of acute cholecystitis and is associated with significantly increased morbidity and mortality, requiring emergency cholecystectomy. The pathologic features include hemorrhage, necrosis, and microabscesses within the wall of the gallbladder, mucosal ulcers as well as strands of fibrinousexudate, and purulent debris within the gallbladder. The incidence of gangrenous cholecystitis has been reported to be between 2% and 38% of all patients with acute cholecystitis. Perforation of the gallbladder can occur in up to 10% of cases of acute cholecystitis, frequently a sequela of gangrenous cholecystitis. Clinical findings are variable, and it is difficult to diagnose gangrenous cholecystitis clinically. The disorder has no specific diagnostic sonographic findings. However, in the clinical setting of acute cholecystitis, several sonographic features suggest gangrenous cholecystitis, including striated thickening of the wall, intraluminal membranes, marked asymmetry of the gallbladder wall causing focal irregularities or mass-like intraluminal protrusions from the wall, nonlayeringechogenic debris within the gallbladder, and loculatedpericholecystic fluid collections containing debris. Sonographic Murphy’s sign may be negative in up to 70% of patients with gangrenous cholecystitis, possibly because of denervation of the gallbladder wall by gangrenous changes.
- First described in 1931 by Hegner. Emphysematous cholecystitis is definitively treated with cholecystectomy, although percutaneouscholecystostomy may be used as an initial temporizing procedure in critically ill patients.The overall mortality rate for patients with the emphysematous form of cholecystitis is 15%, compared with a rate of less than 4% in uncomplicated cases of acute cholecystitis.
- Small amounts of gas appear as echogenic lines with posterior dirty shadowing or reverberation artifact (ringdown). Large amounts of gas can be more difficult to appreciate; the absence of a normal gallbladder is a clue.A bright echogenic line with posterior dirty shadowing is seen within the entire gallbladder fossa. Movement of gas bubbles is a helpful finding, and compression of the gallbladder fossa may precipitate this sign.
- Small amounts of gas appear as echogenic lines with posterior dirty shadowing or reverberation artifact (ringdown). Large amounts of gas can be more difficult to appreciate; the absence of a normal gallbladder is a clue.A bright echogenic line with posterior dirty shadowing is seen within the entire gallbladder fossa. Movement of gas bubbles is a helpful finding, and compression of the gallbladder fossa may precipitate this sign.
- Some 5% to 10% of patients with acute cholecystitis develop gallbladder perforation.It occurs most commonly in the setting of gangrenous cholecystitiswith other risk factors including gallstones, impaired vascular supply, infection, malignancy, and steroid use. The fundus of the gallbladder is the most common site of perforation because it has the most tenuous blood supply.The focus of perforation, seen as a small defect or rent in the wall of the gallbladder, is often, but not always, visible.Clues to perforation are the deflation of the gallbladder with loss of its normal gourdlike shape, and a pericholecystic fluid collection.The latter is often a small fluid collection about the wall defect, in distinction to the thin rim of fluid about the entire organ present in uncomplicated cholecystitis.The collection may have internal strands typical of abscesses elsewherePerforation of the gallbladder may extend into the adjacent liver parenchyma, forming an abscess collection. The presence of a cystic liver lesion about the gallbladder fossa should raise the possibility of a pericholecystic abscess.
- Wall-Echo-Shadow complex (WES) or Double arc-shadow signThe proximal hyperechoic arc represents the wall of the gallbladder. The distal hyperechoic arc represents the reflections from gallstonesThe hypoechoic space in between represents either a small sliver of bile between the wall of the gallbladder and the gallstones or a hypoechoic portion of the wall of the gallbladder.When air or calcification is present, the normal gallbladder wall is not seen; only the bright echo and the posterior shadowing are seen.
- Its cause is unknown, but occurs inassociation with gallstone disease and may represent a form of chronic cholecystitis.The term derives from the brittle consistency of the gallbladder.The entire wall or only part of the wall of the gallbladder may be calcified.Patients often have few symptoms, and the diagnosis is often made by detecting a palpable right upper quadrant mass or finding typical calcifications on plain radiographs. Prophylactic cholecystectomy is advocated in these patients, even in the paucity of symptoms, because of the strikingly high incidence (11%–33%) of carcinoma of the gallbladder.Differential diagnosis includes gallstones and emphysematous cholecystitis. Because the calcifications occur in the wall of the gallbladder, the WES complex is absent
- Rare form of chronic cholecystitis. Gallbladder wall is infiltrated by foamy histiocytes, lymphocytes, polymorphonuclear leukocytes, fibroblasts, and giant cells. The cause is probably similar to that of xanthogranulomatouspyelonephritis, which is a chronic infection associated with the formation of calculi. Gallstones are present in most patients with XGC.Presents sonographically as diffuse or focal thickening of the gallbladder wall, with mural nodularity. The hypoechoic nodules or bands within the thickened wall may be seen suggesting the diagnosis.Because the hepatic surface of the gallbladder lacks a serosal layer, the inflammatory process more easily extends to the adjacentliver, and the liver–gallbladder margin is frequently indistinct.