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R e s i d e n t s ’ S e c t i o n • S t r u c t u r e d R ev i ew A r t i c l e

O’Connor and Maher


Imaging of Cholecystitis

Residents’ Section
Structured Review Article
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Residents

inRadiology Imaging of Cholecystitis


Owen J. O’Connor 1 Educational Objectives tients, such as those in the ICU, in whom clin-
Michael M. Maher 1,2 1. Acute cholecystitis is one of the most com- ical signs may be masked and imaging signs
mon reasons for hospital admission with are less specific compared with the ambulant
O’Connor OJ, Maher MM acute abdominal pain. population [6]. Forty percent of patients with
2. Approximately 90–95% of acute cholecys- acute cholecystitis develop complications [7]
titis is related to gallstones, with 5–10% of (Table 1), including emphysematous chole-
cases due to acalculous disease. cystitis, which is seen more commonly in men
3. Ultrasound is more useful than CT and and diabetic patients, with calculi present in
MRI for the initial evaluation of acute bil- less than 50% of cases [8]. Recurrent acute
iary disease. cholecystitis or biliary colic usually associat-
4. CT is arguably the best technique for imaging ed with gallstones leads to low-grade inflam-
of complicated gallbladder disease, particu- mation and fibrosis of the gallbladder wall,
larly for direct imaging of emphysematous which characterizes chronic cholecystitis [8].
cholecystitis, gallstone ileus, and confirma-
tion of suspected gallbladder perforation. Imaging Strategies
5. Cholescintigraphy may complement ultra- Conventional radiography is of limited val-
sound and CT for the diagnosis of acalcu- ue in the setting of gallbladder disease because
lous cholecystitis and for differentiating only 15–20% of gallstones are visible on a
acute from chronic cholecystitis. radiograph of the abdomen and little infor-
Gallbladder disease is a common cause of mation about complicated gallbladder dis-
upper abdominal pain, and acute cholecys- ease can be obtained using conventional ra-
Keywords: cholecystitis, CT of abdomen, gallbladder titis is one of the most common reasons for diography [3] (Fig. 1). Ultrasound is preferred
disease, ultrasound of abdomen hospital admission in patients with acute ab- for gallstone detection and is more useful in
dominal pain [1]. Imaging plays an impor- the initial evaluation of acute biliary disease
DOI:10.2214/AJR.10.4340
tant role in the management of cholecysti- than CT because ultrasound helps to triage pa-
Received January 26, 2010; accepted after revision tis because gallbladder disease usually has a tients who require further imaging from those
May 22, 2010. good prognosis provided diagnosis and man- who do not [9]. One of the most important
1
agement occur expeditiously [2] (Table 1). advantages of ultrasound over other imaging
Department of Radiology, Cork University Hospital,
University College Cork, Wilton, Cork, Ireland. Address
techniques in the investigation of acute chole-
correspondence to M. M. Maher (m.maher@ucc.ie). Disease Epidemiology and cystitis is the ability to assess for a sonographic
Pathophysiology Murphy sign, which is a reliable indicator of
2
Department of Radiology, Mercy University Hospital, An estimated 25 million Americans have acute cholecystitis with a sensitivity of 92%
Cork, Ireland.
cholelithiasis. In 80%, the cholelithiasis is [10]. Eliciting a positive sonographic Mur-
CME primarily composed of cholesterol, with pig- phy sign can help distinguish acute acalcu-
This article is available for CME credit. ments, calcium bilirubinate, and calcium car- lous cholecystitis from a distended gallbladder
See www.arrs.org for more information. bonate accounting for most of the remainder caused by prolonged fasting, but it is impor-
[3, 4]. Acute cholecystitis is due to gallstone tant to remember that this sign may be masked
WEB
This is a Web exclusive article.
impaction in the gallbladder neck or cystic by altered mental status or medications [11].
duct in 90–95% of cases, with bile stasis, gall- Ultrasound and CT are less accurate for di-
AJR 2011; 196:W367–W374 bladder ischemia, cystic duct obstruction, and agnosing acalculous cholecystitis compared
systemic infection responsible for most cases with calculus cholecystitis. An assessment of
0361–803X/11/1964–W367
of acalculous cholecystitis [1, 5]. Acalculous cystic duct patency with cholescintigraphy is
© American Roentgen Ray Society cholecystitis can be difficult to diagnose be- probably the best strategy for imaging sus-
cause it is most often seen in critically ill pa- pected acalculous cholecystitis [8].

AJR:196, April 2011 W367


O’Connor and Maher

TABLE 1:  Diseases of the Gallbladder [21, 24]


Type Disease
Calculous disease Gallstones, gallstone ileus, Mirizzi syndrome
Infection Empyema (suppurative cholecystitis), emphysematous cholecystitis, gangrenous cholecystitis, mucocele
Inflammation Cholecystitis (acute, complicated, chronic, xanthogranulomatous), porcelain gallbladder
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Neoplasia Benign neoplasms (adenomyomatosis, lipoma, fibroma, myxoma, granular cell tumor, leiomyoma, hemangioma, neurofibroma),
hyperplastic cholecystosis, gallbladder carcinoma, metastases (pancreatic, gastric, renal, ovarian, melanoma)
Iatrogenic disease Postcholecystectomy (abscess, hematoma, bile leak, cystic duct remnant pathology)
Trauma Perforation, torsion

A B C
Fig. 1—Radiography, ultrasound, and CT images in three patients with gallstones.
A, Radiograph shows abdominal multiple calcific densities conforming to gallbladder shape in right upper quadrant in 57-year-old man.
B, Ultrasound of abdomen in 42-year-old woman shows multiple echogenic foci (arrow), which cast well-defined acoustic shadow in gallbladder, consistent with
gallstones.
C, Axial CT image in 64-year-old man shows multiple hyperattenuating calculi (arrow) in gallbladder.
Ultrasound and cholescintigraphy share
similar sensitivities for the detection of acute
calculus cholecystitis; however, they may also
complement one another when there is diag-
nostic uncertainty [4]. Visualization of gall- Fig. 2—Normal
hepatobiliary
bladder wall thickening in the presence of iminodiacetic acid scan
gallstones using ultrasound has a positive in 64-year-old man
predictive value of 95% for the diagnosis of shows prompt hepatic
accumulation of isotope
acute cholecystitis [10]. Unfortunately, thick- with excretion into biliary
ening of the gallbladder wall in the absence tree observed within
of cholecystitis may be observed in systemic 10 minutes of injection.
conditions, such as liver, renal, and heart fail- The gallbladder (arrow)
is visualized within 20
ure, possibly due to elevated portal and sys- minutes of injection
temic venous pressures [12]. Cholescintigra- and shows progressive
phy using hepatobiliary iminodiacetic acid is accumulation of isotope.
of particular benefit in cases in which the di-
agnosis is uncertain and for the differentiation cated gallbladder disease such as emphyse- echo-shadow sign is observed if the gallblad-
of acute from chronic cholecystitis [6] (Fig. matous cholecystitis, a gallbladder disease in der is filled with gallstones [4, 16] (Fig. 1).
2). Cholescintigraphy with morphine admin- which a positive sonographic Murphy sign Gallstones may appear hyper-, iso-, or hy-
istration may be used to increase gallbladder is observed in less than one third of patients poattenuating at CT [8] (Fig. 1). Nitrogen
filling by enhancing sphincter of Oddi tone. [9, 14]. Oral cholecystography is seldom per- gas accumulation within gallstone fissures is
This technique helps reduce the incidence of formed but is as sensitive for gallstone detec- sometimes observed in a star-shaped pattern
false-positive studies [8]. Chronic cholecysti- tion as ultrasound, better quantifies gallstone on CT, termed the “Mercedes-Benz” sign
tis may be diagnosed by calculating the per- numbers, and confirms cystic duct patency [4]. Ultrasonic imaging signs of acute chole-
centage of isotope excreted (ejection fraction) by showing gallbladder contractility [15]. cystitis include gallbladder wall thickening
from the gallbladder after cholecystokinin or (> 3 mm), wall edema, gallbladder distention
fatty meal administration [13] (Fig. 3). Imaging Appearances (> 40 mm), positive sonographic Murphy
Although CT is inferior to ultrasound for At ultrasound, gallstones are normally sign, and pericholecystic and perihepatic (C
the detection of gallstones in the gallbladder, seen as mobile echogenic foci casting poste- sign) fluid [2, 17] (Fig. 4). On cholescintigra-
it is the best technique for imaging compli- rior acoustic shadows, and sometimes a wall- phy, biliary excretion of radioisotope within

W368 AJR:196, April 2011


Imaging of Cholecystitis

Fig. 3—Normal 10 minutes of injection in the absence of iso-


hepatobiliary
iminodiacetic acid
tope accumulation in the gallbladder with-
scan after fatty meal in 1 hour is typical of acute cholecystitis [8]
in 57-year-old woman (Fig. 5). It is recommended that imaging be
shows progressive continued for a further 3 hours to exclude de-
excretion of isotope from
gallbladder (arrow) after layed filling, or alternatively morphine can
fatty meal ingestion. be administered at 1 hour and imaging con-
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Ejection fraction of 44% tinued for a further 30 minutes [13].


was observed.
Acute cholecystitis on CT is associat-
ed with pericholecystic inflammatory fat
stranding; hypo- or hyperattenuating gall-
stones; and edematous hyperattenuation of
the hepatic gallbladder fossa, termed “tran-
sient hepatic attenuation difference” [2]. CT
is particularly useful for evaluating the many
complications of acute cholecystitis, such as
emphysematous cholecystitis, gangrenous
cholecystitis, hemorrhage, and gallstone ile-
us. Emphysematous cholecystitis is typical-
ly diagnosed on CT by the presence of in-
traluminal or intramural gas, which may be
mistaken for calculi or porcelain gallbladder
on ultrasound (hyperechoic reverberation ar-
tifact) or MRI (signal void) [7, 18] (Figs. 6
and 7). Gangrenous cholecystitis is suggest-
ed on CT by the presence of intraluminal
membranes, gas within the gallbladder wall
or lumen, irregular or discontinuous mural
enhancement, or a wall defect [8] (Fig. 8).
Alternating mural hypo- and hyperattenuat-
ing foci are said to be specific signs of ne-
crosis on CT [19]. Ischemic necrosis of the
gallbladder causing gangrene produces ul-
ceration, hemorrhage, or microabscess for-
mation of the gallbladder wall, which result
in asymmetry and focal intramural hyperin-
tensity on fat-suppressed T2-weighted MRI
A B [1]. On ultrasound, gallbladder wall striation
Fig. 4—Ultrasound and CT in 72-year-old man with acute acalculous cholecystitis. or intraluminal membranes are observed.
A, Ultrasound image of upper abdomen shows gallbladder wall thickening (straight arrow), sludge (arrowhead), Gangrenous cholecystitis leads to mural ne-
and pericholecystic fluid (curved arrow) with no gallstones identified.
B, Portal venous phase CT image of abdomen also shows gallbladder wall thickening (arrow) and crosis, which is the most common cause of
pericholecystic fluid (curved arrow). perforation, and because both necrosis and
perforation share many clinical signs in
common, a high index of suspicion is pru-
dent because early operative intervention is
fundamental to a good outcome [7].
IV contrast administration at MRI and CT
may help diagnose gangrenous cholecystitis,
which lacks enhancement and gallbladder
Fig. 5—
Cholescintigraphy in perforation, seen as a gallbladder wall defect
72-year-old woman [7] (Fig. 9). The three subtypes of gallblad-
with acute cholecystitis der perforation that are described include
shows prompt biliary
excretion of isotope
localized perforation, cholecystoenteric fis-
after injection, tula, and free intraperitoneal spillage that
with subsequent can later result in a loculated biloma [2, 20]
accumulation of isotope (Fig. 10). The most common site of perfora-
in small bowel (arrow).
The gallbladder is not tion is the gallbladder fundus [7] (Fig. 11).
observed. Perforation is often difficult to diagnose, but

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O’Connor and Maher

Fig. 6—Conventional radiography, ultrasound, CT,


and MRI in 87-year-old man with emphysematous
cholecystitis.
A, Conventional radiograph shows dilated air-filled
gallbladder with air in wall (arrow).
B, Ultrasound image shows echogenic material
(arrow) in region of gallbladder, but this cannot be
definitively seen to lie within gallbladder wall or
lumen.
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C, CT image shows air in gallbladder (straight arrow),


pericholecystic fat stranding (arrowhead), and
gallbladder wall thickening (curved arrow), consistent
with emphysematous cholecystitis.
D, T2-weighted fat-saturated MR image shows
reduced signal intensity within lumen of gallbladder,
suggesting sludge or pus. In addition, signal void is
noted anteriorly within lumen of gallbladder (arrow),
suggestive of air, and collection is noted outside
gallbladder (arrowhead).

the detection of an extraluminal gallstone or


gallbladder collapse in the presence of peri­
cholecystic fluid or abscess are helpful signs
[20]. Close inspection of the circumference
A B of the gallbladder wall for focal defects is
also vital in patients with suspected perforat-
ed gallbladder [7]. CT is more sensitive than
ultrasound for the detection of perforation;
nevertheless, a mural defect is observed in
only 70% of cases [21]. ERCP or MRI may
be beneficial in such circumstances and for
the assessment of suspected bile leak after
cholecystectomy (Fig. 12).
CT is arguably the best method for im-
aging gallstone ileus. The imaging signs of
pneumobilia, an ectopic gallstone, and bow-
el obstruction constitute the Rigler triad [2]
(Fig. 13). Additional features of gallstone
C D ileus include gallbladder collapse and a fistu-
lous connection between the gallbladder and
Fig. 7—Ultrasound and conventional radiography in the duodenum, small bowel, or colon [4]. A
64-year-old man with porcelain gallbladder.
central focus of low density within a calcu-
A, Ultrasound image shows hyperechoic focal
area (arrow) in gallbladder bed, initially thought to lus due to the presence of cholesterol may
represent gallstones in gallbladder.
B, Kidneys and upper bladder examination
performed after ultrasound shows concentric mural
calcification of gallbladder (arrow), consistent with
porcelain gallbladder.

Fig. 8—CT image in 54-year-old man with gangrenous


cholecystitis shows pericholecystic fat stranding,
no enhancement of gallbladder wall, and gas in wall
(arrow) and lumen of gallbladder.
A B

W370 AJR:196, April 2011


Imaging of Cholecystitis

Fig. 9—Ultrasound, MRCP, CT, and ERCP in 87-year-


old man before and after gallbladder perforation.
A, Ultrasound shows thickened gallbladder wall
(arrow) and large gallstone in gallbladder neck,
consistent with acute cholecystitis.
B, MRCP image shows large gallstone in gallbladder
and small distal common bile duct stone (arrow).
C, ERCP image obtained after A and B but before D
shows large filling defect in gallbladder (arrow) and
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extravasation of contrast (arrowhead), consistent


with perforation.
D, Ultrasound obtained after A and B shows
heterogeneous mass due to localized gallbladder
perforation (arrow) with no discernible gallbladder
wall.
E, CT image confirms presence of complex collection
A B in gallbladder fossa secondary to perforation (arrow).

C D E

A B
Fig. 10—CT image in 80-year-old woman with
cholecystoenteric fistula due to cholecystitis shows Fig. 11—Ultrasound and CT in 79-year-old man with gallbladder perforation.
collapsed gallbladder with defect in opening into A, Ultrasound shows thickening of gallbladder wall, consistent with cholecystitis.
duodenum (arrow). Biliary stent (arrowhead) is present. B, CT image shows defect in wall of gallbladder at its fundus, with localized biloma (arrowhead).

help identify an ectopic gallstone located Cholecystitis, trauma including iatro- Extracellular methemoglobin may be high on
within the small bowel lumen [4]. CT may genesis, coagulopathy, and malignancy are both T1- and T2-weighted MRI. Gradient-
also identify the level of obstruction, which known causes of gallbladder hemorrhage [2]. echo sequences are particularly sensitive for
is most commonly observed in the terminal CT depicts hyperattenuating fluid and ultra- the presence of hemorrhage [22]. Pus within
ileum [2]. A gallstone also may compress sound depicts echogenic or heterogeneous the gallbladder (empyema) resembles sludge
and obstruct the common bile duct when im- fluid, but MRI may be more specific than on ultrasound, CT, and MRI, with materi-
pacted in the cystic duct or infundibulum of both [2] (Fig. 15). Intracellular methemoglo- al (echogenic, hyperattenuating, low signal)
the gallbladder. This phenomenon is termed bin in hemobilia has high and low signal on in the dependent portion of the gallbladder
“Mirizzi syndrome” [4] (Fig. 14). T1- and T2-weighted MRI, respectively [18]. [7]. Findings therefore need to be correlated

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O’Connor and Maher

Fig. 12—CT, ultrasound, and ERCP in 71-year-old man with bile leak after cholecystectomy.
A, CT image shows collection of hypoattenuating fluid and air (arrow) in gallbladder fossa. Patient had signs of
infection, and this was initially believed to be infected postoperative collection.
B, Ultrasound image shows echogenic collection (arrow) in subhepatic space. Drainage catheter was inserted
at this time.
C, ERCP image shows percutaneous drain (arrowhead) and contrast extravasation (arrow) consistent with bile
leak.
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A B C

Fig. 13—Conventional radiography and CT in 82-year-


old woman with gallstone ileus.
A, Radiograph of abdomen shows multiple dilated
small-bowel loops (arrow) in mid abdomen.
B, CT image confirms small-bowel dilatation (arrow)
to transition point, at which location gallstone was
located. Gallstone contains gas which displays
Mercedes-Benz sign (arrowhead).

A B

Fig. 14—ERCP and coronal maximum-intensity-


projection CT images in 77-year-old woman with
jaundice secondary to Mirizzi syndrome.
A, ERCP image shows smooth extrinsic compression
of proximal common bile duct (arrow) with stenosis of
lumen and intrahepatic biliary dilatation.
B, CT image shows common bile duct obstruction
was due to impacted gallstone in neck of gallbladder
(arrowhead). Stent has been inserted into common
bile duct (black arrow) and portal vein is also seen
(white arrow).
A B

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Imaging of Cholecystitis
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A B C
Fig. 15—Ultrasound and CT in 60-year-old woman with hepatitis C and gallbladder hematoma after liver biopsy.
A, Unenhanced CT image obtained 8 days after liver biopsy shows hyperattenuating lesion (arrow) in gallbladder, suggesting hematoma.
B, Ultrasound image obtained 9 days after liver biopsy shows echogenic hemorrhage (arrow) in gallbladder.
C, Ultrasound image obtained 5 weeks after liver biopsy shows complete resolution.

A B
Fig. 16—Cholescintigraphy in 80-year-old woman with chronic cholecystitis.
A, After conventional cholescintigraphy, 0.01 µg/kg cholecystokinin was infused over 3-minute period and imaging of gallbladder (arrow) was performed for 30 minutes
after injection.
B, Ejection fraction was calculated by subtracting maximum from minimum counts and dividing by maximum number of counts within region of interest drawn around
gallbladder. Ejection fraction in this case was 6%, consistent with chronic cholecystitis.

with clinical history and physical examina-


tion (diabetes or atherosclerosis are impor-
tant in the context of empyema, emphyse-
matous cholecystitis, or hemorrhage) and
ultrasound-guided aspiration or prophylactic
placement of a cholecystostomy catheter may
be necessary for confirmation.
Chronic cholecystitis is characterized by Fig. 17—Ultrasound image in 61-year-old woman with
the presence of gallbladder wall thickening adenomyomatosis shows thickening of gallbladder
in the presence of gallstones with fibrosis of wall with multiple echogenic intramural foci with
associated ring-down artifact consistent with
the wall, which disrupts normal motility and adenomyomatosis. Sludge (arrowhead) is also noted
may result in a contracted appearance [8]. in dependent portion of gallbladder.
The ultrasound and CT features of chron-
ic cholecystitis can be nonspecific. Choles- lation, irregular gallbladder filling, or pho- Porcelain gallbladder is an uncommon man-
cintigraphy is useful for diagnosing chron- topenic areas and septations. A gallbladder ifestation of chronic cholecystitis (Fig. 7). It is
ic cholecystitis and for the differentiation ejection fraction of less than 35% after the best seen on CT as plaques or punctate foci of
of acute from chronic cholecystitis. Signs of administration of cholecystokinin indicates mural calcification. Prophylactic cholecystec-
chronic cholecystitis on cholescintigraphy the presence of chronic calculus or chronic tomy may be performed in these circumstances
include delayed gallbladder isotope accumu- acalculous cholecystitis [23] (Fig. 16). because of the association between porcelain

AJR:196, April 2011 W373


O’Connor and Maher

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W374 AJR:196, April 2011

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