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Structured Review Article
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Residents
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
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
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
A B
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.
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F O R YO U R I N F O R M AT I O N
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