1. Focal Vs Diffuse Gall
Bladder Wall Thickening

2. Objectives
• Normal GB wall Appearance
• Causes Of focal GB wall thickening
• Causes of diffuse GB wall thickening
• Appearances of different conditions
• Differentiating points
• Pitfalls of GB wall thickening

3. Gall Bladder
• Normal wall thickness < 3mm
• The normal gallbladder wall appears as a
pencil-thin echogenic line at sonography.
• The thickness of the gallbladder wall
depends on the degree of gallbladder
distention and pseudothickening can
occur in the postprandial state.

4. LEFT: US of a normal gallbladder after an overnight fast shows
the wall as a pencil-thin echogenic line (arrow).RIGHT: US in
the postprandial state shows pseudothickening of the
gallbladder

5. The normal gallbladder wall is usually perceptible at CT
as a thin rim of soft-tissue density that enhances after
contrast injection.

6. Thickened gallbladder wall
• Thickening of the gallbladder wall is a
relatively frequent finding at diagnostic
imaging studies.
• A thickened gallbladder wall measures
more than 3 mm, typically has a layered
appearance at sonography , and at CT
frequently contains a hypodense layer of
subserosal oedema that mimics
pericholecystic fluid.

7. LEFT: US in a 59-year-old woman with acute cholecystitis shows the
layered appearance of a thickened gallbladder wall, with a hypoechoic
region between echogenic lines
RIGHT: At contrast-enhanced CT the thick-walled gallbladder contains
a hypodense outer layer (arrow) due to subserosal oedema

8. Focal Wall Thickening
• Polyps
• Adenomyomatosis
• Carcinoma
• Xanthogranulomatous cholecystitis
• Metastasis
• Chronic cholecystitis
• Tumefactive sludge / Sludge balls

9. Polyps/ Cholesterolosis
• A condition in which triglycerides, cholesterol
esters and cholesterol precursors are
deposited in lamina propria of GB.
• Cause is unknown
• Not related to serum lipid level,
atherosclerosis, diabetes, cholesterol stones,
or hyperconcentration of cholesterol in bile.
• Most cases do not produce any detectable
change in appearance.

10. • Sometimes referred to as “Strawberry
gallbladder”
• Minority of cases are of polypoid variety
• Cholesterol polyps are “enlarged
papillary fronds filled with lipid laden
macrophages”
• Attached to the wall by a stalk
• “Ball on the wall”
• 5mm or less, rarely get bigger than 10mm

11. • Do not acoustic shadowing
• Do not exhibit postural movement
• Other less common types of polyps are
adenoma
papilloma
leiomyoma
lipoma
neuroma

12. • Polyps
< 5mm – no further evaluation
5-10mm – monitoring
> 10mm – should be removed
• As the polyp enlarges – risk of
malignancy increases

13. Large Fibrous Polyps of the Gallbladder Simulating
Gallbladder Carcinoma

14. GB Polyp fixed to the ventral wall of the GB

15. Diffuse Wall
Thickness
• CAUSES
• Biliary Causes
1.Cholecystitis
2.Adenomyomatosis
3.Cancer
4.AIDS cholangiopathy
5.Sclerosing cholangitis

16. • NON BILIARY CAUSES
1.Hepatitis
2.Pancreatitis
3.Heart Failure
4.Hypoproteinemia
5.Cirrhosis
6.Portal hypertension
7.Lymphatic obstruction

17. Cholecystitis
• Acute
• Chronic
• Acalculous
• Xanthogranulomatous

18. Acute cholecystitis
• Fourth most common cause of hospital
admissions for patients presenting with an
acute abdomen
• It is the prime diagnostic concern when a
thick-walled gallbladder is found at imaging.
• This feature, however, is not pathognomonic
and additional imaging signs should be
present to support the diagnosis of acute
calculous cholecystitis.

19. Signs of Acute cholecystitis
• Thickened gall bladder wall
• Obstructing gallstone
• Hydropical dilatation of the gallbladder,
• A positive sonographic Murphy's sign ( i.e.,
pain elicited by pressure over the
sonographically located gallbladder),
• Pericholecystic fat inflammation or fluid
• Hyperemia of the gallbladder wall at
power Doppler

20. Acute calculous cholecystitis.
Transverse sonogram at the spot of maximum tenderness shows a non-
compressible hydropically distended thick-walled gallbladder
(arrowheads), with an intraluminal stone and sludge or debris.
Contrast-enhanced CT depicts extensive fat inflammation (arrowheads)
surrounding the gallbladder (arrow).

21. Chronic cholecystitis
• Chronic cholecystitis is a term used clinically
to refer to symptomatic gallbladder stones
that cause transient obstruction, leading to
a low-grade inflammation with fibrosis .
• Correlation of the imaging finding of a
stone-containing slightly thick-walled
gallbladder with the clinical history is critical.

22. Chronic cholecystitis. Longitudinal sonogram of the gallbladder shows
slight wall thickening (arrow) and an intraluminal non-obstructing stone

23. Acalculous cholecystitis
• Mainly occurs in critically ill patients,
(Major surgery, Major trauma,extensive burns)
• Due to
Increased bile viscosity from fasting and
Medication that causes cholestasis.
• The imaging features are those of acute
cholecystitis, except for the absence of stones
whereas gallbladder sludge is usually present.

24. Acalculous cholecystitis
PITFALL
• Because in critically ill patients gallbladder
abnormalities are frequently found
secondary to systemic disease , acalculous
cholecystitis can be difficult to diagnose .
• In these patients a percutaneous
cholecystostomy can be both diagnostic
and therapeutic.

25. 74-year-old man with acute acalculous cholecystitis.
LEFT: US at the spot of maximum tenderness shows mural thickening of
the gallbladder (arrow) that is completely filled with sludge (asterix)
without any stones.RIGHT: Power-Doppler sonography shows
hypervascularity of the gallbladder wall (arrowhead), as a supporting
sign of inflammation.

26. Xanthogranulomatous
cholecystitis
• Unusual variant of chronic cholecystitis,
• Characterized by a Destructive
inflammatory process with varying
proportions of fibrous tissue, inflammatory
cells and lipid laden macrophages
• Gall stones +/-
• Locally invasive

27. • Imaging studies show marked gallbladder
wall thickening, often containing intramural
nodules that are hypoechoic at sonography
and hypoattenuating at CT, representing
abscesses or foci of xanthogranulomatous
inflammation.
• These features overlap with those of
gallbladder carcinoma, making preoperative
distinction between these entities often
impossible.

28. Xanthogranulomatous cholecystitis. LEFT: US shows marked wall
thickening with intramural hypoechoic nodules (arrowheads), and an
intraluminal stone (arrow).RIGHT: Contrast-enhanced CT shows a
deformed and thickened gallbladder wall containing hypoattenuating
nodules

29. Contrast-enhanced CT shows a deformed and thickened gallbladder wall containing
hypoattenuating nodules .
These represent abscesses or foci of inflammation. The lumen contains several stones
(arrow).

30. Adenomyomatosis
• Benign condition that requires no specific
treatment,
• Incidental finding in upto 9% of
cholecystectomy specimens
Characterized by
• 1. Epithelial proliferation,
• 2. Muscular hypertrophia and
• 3. Intramural diverticula (Rokitansky-Aschoff
sinuses), which may segmentally or diffusely
involve the gallbladder.

31. • The sonographic finding of cholesterol crystals,
shown as 'comet-tail' reverberation artifacts,
within a thickened wall of the gallbladder strongly
suggests this diagnosis.
• Air may produce a similar artifact, however,
patients with emphysematous cholecystitis are
usually ill in contrast to those with
adenomyomatosis.
• MR imaging may be able to differentiate
adenomyomatosis from gallbladder carcinoma by
depicting Rokitansky-Aschoff sinuses.

33. Four types of gallbladder
adenomyomatosis
• A. Annular type.
• B. Segmental type, which describes an
annular or segmental wall thickening causing
stricture that divides the gallbladder lumen
into separate interconnected compartments.
• C. Fundal type,(adenomyoma) a focal
elevated lesion with a central dimple located
at the fundus of the gallbladder.
• D .Diffuse type, a thickened wall involving the
entire gallbladder.

35. • Exclusion of gallbladder cancer may be
most problematic in segmental and focal
cases. Focal adenomyomatosis may
appear as a discrete mass, known as an
adenomyoma.

37. Diffuse adenomyomatosis of gall bladder. These gall bladder
ultrasound images show multiple echogenic foci within the
GB wall with V-shaped comet-tail .

39. Gallbladder
Adenomyomat
osis: Axial CT
of the
abdomen with
oral and IV
contrast shows
focal
thickening of
the gallbladder
wall (arrows)

40. Oral cholecystogram and
MRCP
• Historically oral cholecystograms were performed,
however due to low sensitivity and a high rate of
contrast allergies it has now largely been replaced
by MRCP which does not rely on contrast
opacification of the lumen of the gallbladder.
• MRCP would be also to detect :
• mural thickening
• focal sessile mass
• pearl necklace sign (fluid filled intramural
diverticula)
• hourglass configuration in annular types

41. Rokitansky-Aschoff
sinuses shown on
the after fatty meal
film at
cholecystography
Stricture is also
present.

42. Fundal nodule of
adenomyomatosis
before and after
gallbladder
contraction.

43. MRI
• The pearl necklace sign alludes to the
characteristically curvilinear arrangement
of multiple rounded hyperintense
intraluminal cavities visualized at T2-
weighted MR imaging and MR
cholangiopancreatography of
adenomyomatosis.

44. pearl necklace sign
• It represents the contrast / fluid filled
intramural mucosal diverticula
(Rokitansky-Aschoff sinuses) which line up
reminiscent of pearls on a necklace.
• highly specific (92%)
• frequently not seen,
• only present in ~ 70% of cases

45. coronal T2

46. Gallbladder carcinoma
• Fifth most common malignancy of the GIT
• found incidentally in 1% to 3% of cholecystectomy
specimens.
• It is often detected at a late stage of the disease, due
to lack of early or specific symptoms.
• Gallbladder carcinoma has various imaging
appearances, ranging from a
- polypoid intra-luminal lesion to
-an infiltrating mass replacing the gallbladder,
-diffuse mural thickening.

47. Associated findings
• -- invasion of adjacent structures,
• --secondary bile duct dilatation, and
• --liver or nodal metastases
may help in differentiating a carcinoma from
acute or xanthogranulomatous cholecystitis .
• In absence of these associated findings, it
may not be possible to differentiate a
carcinoma from xanthogranulomatous
cholecystitis.

48. Pathology
• 90% are adenocarcinoma ,
• 5% are squamous carcinomas and
• 5% is anaplastic carcinomas.
• They appear as gallbladder wall thickening
and induration.
• Most common sites are at the fundus and
neck of the gallbladder
• Pocelain GB and sclerosing cholangitis are
predisposing factors

49. SPREADS
80% are detected after direct invasion or portal
node involvement.
• Local direct invasion into the hepatic bed,
• Lymphatic spread into the cystic nodes,
hiatal nodes and then to the superior and
posterior pancreaticoduodenal nodes
and the periaortic nodes.
• Blood borne spreads via the portal vein
to the liver
• 5 yr survival is < 20%

50. Investigations
• Abdominal ultrasound scan : may shows
gallbladder wall thickening or a mass filling the
gallbladder , which would be suggestive of
malignancy.
• CT or MRI scan : show a mass in the region of
gallbladder.
• Arteriographic CT portogram ; Where contrast is
injected into the superior mesenteric artery ,
allows accurate measurements of the extent of the
disease and is resectability.

51. Gall bladder carcinoma with portal vein and biliary tree infiltration

52. Abnormal gallbladder with stones and sludge and a thickened irregular
wall. Liver metastases and tumor thrombus in the left portal vein.

53. Portal Venous phase--- GB Ca

54. This sagittal sonogram image demonstrates heterogeneous thickening of
the gallbladder wall (arrows), found to be primary papillary
adenocarcinoma

55. Primary Sclerosing
Cholangitis
• Etiology –unknown
• Inflammatory process affecting intra
and extra hepatic ducts
• Presentation and course is highly variable
• May present in infancy or old age
• C/C --- cholestasis
• Predisposition ---to bile duct cancer

56. • Multifocal stricture of bile duct
• 86% will have both intra and extra hepatic
involvement

57. Characteristic intrahepatic strictures of sclerosing
cholangitis.

58. Characteristic stricturing of sclerosing cholangitis involving
the intra- and extrahepatic biliary system.

59. AIDS cholangiopathy
• Obliterative cholangiopathy due to
oppurtunistic infection of the bile duct by
-CMV
-Pnemocystis carinii
-Cryptosporidium
• Presentation is similar to PSC
• C/C abd. Pain and cholangitis
• Tx .. Endoscopic sphincterotomy

60. • NON BILIARY CAUSES
1.Hepatitis
2.Pancreatitis
3.Heart Failure
4.Hypoproteinemia
5.Cirrhosis
6.Portal hypertension
7.Lymphatic obstruction

61. Edematous thickening of the gallbladder wall in a patient with
cardiac failure and ascites.

62. Edematous thickened gallbladder wall in a patient with cardiac failure

63. Edematous thickened gallbladder wall in a patient with
hepatitis

64. Hepatitis with a thickened gallbladder wall

65. Gallbladder wall thickening in a patient with a sepsis and
hepatosplenomegaly

66. The image above was taken in a patient with cirrhosis, chronic ascites,
and no acute complaints of upper abdominal pain.

67. How to differentiate b/w
cholecystitis and non biliary
causes
??

68. How to differentiate b/w
cholecystitis and non biliary
causes
• Clinical correlation
• Presence and absence of sonographic
Murphy’s sign
• Associated signs e.g.
Pulsatile portal venous flow in heart
failure
Portal HTN & nodular liver in Cirrhosis

69. Conclusion
• GB wall thickness can be
--Focal
--Generalized
• Both biliary and non-biliary causes can
result in increase in wall thickness
• Clinical correlation is important

70. THANK YOU