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Gallbladder Stones: Imaging and Intervention¹

¹ From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1088. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 23, 1999; revision requested May 4 and received June 21; accepted June 21. Address reprint requests to M.Y.M.C.

View larger version (154K): [in a new window]   Figure 1a.   Acute cholecystitis. (a) CT scan shows gallbladder wall thickening (arrow) and pericholecystic inflammation (arrowhead). However, no gallstones are visible. (b) Transverse US scan clearly shows gallstones (arrow) and posterior shadowing (S).

View larger version (146K): [in a new window]   Figure 1b.   Acute cholecystitis. (a) CT scan shows gallbladder wall thickening (arrow) and pericholecystic inflammation (arrowhead). However, no gallstones are visible. (b) Transverse US scan clearly shows gallstones (arrow) and posterior shadowing (S).

View larger version (126K): [in a new window]   Figure 2a.   Typical US appearance of gallstones. (a) Oblique US scan shows highly reflective echoes within the gallbladder (arrows), which indicate gallstones. Note the marked posterior shadowing (S). (b) Oblique US scan obtained after repositioning the patient shows mobility of the gallstones (arrows).

View larger version (118K): [in a new window]   Figure 2b.   Typical US appearance of gallstones. (a) Oblique US scan shows highly reflective echoes within the gallbladder (arrows), which indicate gallstones. Note the marked posterior shadowing (S). (b) Oblique US scan obtained after repositioning the patient shows mobility of the gallstones (arrows).

View larger version (127K): [in a new window]   Figure 3a.   Gallbladder mass that should not be confused with gallstones at US. (a) Longitudinal US scan shows an echogenic mass (curved arrow) filling the gallbladder lumen with evidence of gallstones as well (straight arrow). Note the lack of shadowing by the majority of the mass. (b, c) CT scans show a gallstone (arrowhead) and an enhancing mass (arrows) located in the gallbladder fossa, partially surrounding the duodenum (D). Gallbladder carcinoma was found at surgery.

View larger version (143K): [in a new window]   Figure 3b.   Gallbladder mass that should not be confused with gallstones at US. (a) Longitudinal US scan shows an echogenic mass (curved arrow) filling the gallbladder lumen with evidence of gallstones as well (straight arrow). Note the lack of shadowing by the majority of the mass. (b, c) CT scans show a gallstone (arrowhead) and an enhancing mass (arrows) located in the gallbladder fossa, partially surrounding the duodenum (D). Gallbladder carcinoma was found at surgery.

View larger version (133K): [in a new window]   Figure 3c.   Gallbladder mass that should not be confused with gallstones at US. (a) Longitudinal US scan shows an echogenic mass (curved arrow) filling the gallbladder lumen with evidence of gallstones as well (straight arrow). Note the lack of shadowing by the majority of the mass. (b, c) CT scans show a gallstone (arrowhead) and an enhancing mass (arrows) located in the gallbladder fossa, partially surrounding the duodenum (D). Gallbladder carcinoma was found at surgery.

View larger version (141K): [in a new window]   Figure 4.   Gallbladder masses that should not be confused with gallstones at US. Longitudinal US scan shows two nonshadowing, nonmobile echogenic masses in the gallbladder (arrows), which represent metastatic melanoma.

View larger version (123K): [in a new window]   Figure 5.   Wall-echo-shadow sign. Longitudinal US scan of a gallbladder filled with gallstones shows the classic wall-echo-shadow sign. The anterior wall of the gallbladder is echogenic (solid arrow). A thin layer of bile immediately underneath the anterior wall is seen as a black line (open arrow), and the most superficial gallstones are seen as an echogenic layer beneath the bile (arrowheads). Intense shadowing (S) obscures the deeper stones and the posterior gallbladder wall.

View larger version (131K): [in a new window]   Figure 6a.   Bowel gas obscuring gallstones. (a) Frontal upper right spot image from initial oral cholecystography shows bowel gas superimposed over the lower aspect of the gallbladder. (b) Oral cholecystogram obtained after repositioning the patient clearly shows a large gallstone in the fundus of the gallbladder (arrow).

View larger version (134K): [in a new window]   Figure 6b.   Bowel gas obscuring gallstones. (a) Frontal upper right spot image from initial oral cholecystography shows bowel gas superimposed over the lower aspect of the gallbladder. (b) Oral cholecystogram obtained after repositioning the patient clearly shows a large gallstone in the fundus of the gallbladder (arrow).

View larger version (145K): [in a new window]   Figure 7.   Acute cholecystitis in a patient with right upper quadrant pain. Transverse US scan shows marked thickening (8 mm) of the gallbladder wall (cursors). Mobile gallstones layering dependently are also seen (arrow). There was maximum tenderness during compression with the transducer directly over the gallbladder, a positive Murphy sign.

View larger version (132K): [in a new window]   Figure 8a.   Acute cholecystitis. (a) Longitudinal US scan shows a nonmobile echogenic focus (arrow) within the gallbladder with subtle shadowing. The patient had recently eaten, which may explain the wall thickening (4 mm). Diagnostic considerations included adherent calculi and cholesterol crystals or polyps. Cholescintigraphy was recommended. (b) Cholescintigram obtained after administration of morphine and with the patient in the supine position shows bowel activity (arrow), but the gallbladder is not seen. The diagnosis of acute cholecystitis was confirmed at surgery. Pathologic analysis also revealed a small gallstone and a small focus of ectopic pancreas in the gallbladder wall.

View larger version (106K): [in a new window]   Figure 8b.   Acute cholecystitis. (a) Longitudinal US scan shows a nonmobile echogenic focus (arrow) within the gallbladder with subtle shadowing. The patient had recently eaten, which may explain the wall thickening (4 mm). Diagnostic considerations included adherent calculi and cholesterol crystals or polyps. Cholescintigraphy was recommended. (b) Cholescintigram obtained after administration of morphine and with the patient in the supine position shows bowel activity (arrow), but the gallbladder is not seen. The diagnosis of acute cholecystitis was confirmed at surgery. Pathologic analysis also revealed a small gallstone and a small focus of ectopic pancreas in the gallbladder wall.

View larger version (120K): [in a new window]   Figure 9a.   False-positive diagnosis of acute cholecystitis. (a) Longitudinal US scan of the gallbladder shows a single gallstone (arrowhead). There was extreme tenderness during compression over the gallbladder, a positive Murphy sign. The thickness of the gallbladder wall is normal. (b) CT scan obtained soon afterward shows a normal-appearing gallbladder. However, a hematoma is seen in the right rectus abdominis muscle (arrow), accounting for the tenderness during compression over the gallbladder. Review of the US scan (a) revealed a superficial hypoechoic mass at the top of the image (arrow), a finding that corresponds to the hematoma. The patient's symptoms abated when the hematoma resolved.

View larger version (145K): [in a new window]   Figure 9b.   False-positive diagnosis of acute cholecystitis. (a) Longitudinal US scan of the gallbladder shows a single gallstone (arrowhead). There was extreme tenderness during compression over the gallbladder, a positive Murphy sign. The thickness of the gallbladder wall is normal. (b) CT scan obtained soon afterward shows a normal-appearing gallbladder. However, a hematoma is seen in the right rectus abdominis muscle (arrow), accounting for the tenderness during compression over the gallbladder. Review of the US scan (a) revealed a superficial hypoechoic mass at the top of the image (arrow), a finding that corresponds to the hematoma. The patient's symptoms abated when the hematoma resolved.

View larger version (170K): [in a new window]   Figure 10a.   Acute cholecystitis. (a) CT scan obtained at the level of the gallbladder shows cholelithiasis (arrowhead), poor definition of the gallbladder wall, and subtle pericholecystic inflammation (arrows). (b) CT scan obtained slightly superior to a shows more obvious pericholecystic inflammation (arrow).

View larger version (165K): [in a new window]   Figure 10b.   Acute cholecystitis. (a) CT scan obtained at the level of the gallbladder shows cholelithiasis (arrowhead), poor definition of the gallbladder wall, and subtle pericholecystic inflammation (arrows). (b) CT scan obtained slightly superior to a shows more obvious pericholecystic inflammation (arrow).

View larger version (157K): [in a new window]   Figure 11.   Transient increased attenuation in the liver adjacent to the gallbladder in a patient with pathologically proved acute cholecystitis. Contrast material-enhanced CT scan shows increased hepatic attenuation adjacent to the gallbladder (arrowheads). Note the thickening of the gallbladder wall.

View larger version (157K): [in a new window]   Figure 12a.   Emphysematous cholecystitis. (a) Plain radiograph shows curvilinear gas collections in the right upper quadrant (arrows), which represent gas within the gallbladder wall. (b) CT scan obtained in another patient shows air within the gallbladder wall and the gallbladder lumen (arrow).

View larger version (136K): [in a new window]   Figure 12b.   Emphysematous cholecystitis. (a) Plain radiograph shows curvilinear gas collections in the right upper quadrant (arrows), which represent gas within the gallbladder wall. (b) CT scan obtained in another patient shows air within the gallbladder wall and the gallbladder lumen (arrow).

View larger version (126K): [in a new window]   Figure 13.   Hemorrhagic cholecystitis. Longitudinal US scan shows mobile foci of increased echogenicity within the gallbladder fossa (arrow) with posterior shadowing (S), findings consistent with gallstones. In addition, there are foci of increased echogenicity without shadowing (arrowhead), which correspond to hemorrhage.

View larger version (157K): [in a new window]   Figure 14a.   Hemorrhagic cholecystitis. CT scans show diffuse increased attenuation in the gallbladder lumen, which represents hemorrhage, surrounding multiple round areas of decreased attenuation, which represent gallstones (arrow). Note the subtle pericholecystic inflammation.

View larger version (159K): [in a new window]   Figure 14b.   Hemorrhagic cholecystitis. CT scans show diffuse increased attenuation in the gallbladder lumen, which represents hemorrhage, surrounding multiple round areas of decreased attenuation, which represent gallstones (arrow). Note the subtle pericholecystic inflammation.

View larger version (127K): [in a new window]   Figure 15a.   Hepatic abscess related to acute cholecystitis. (a) Transverse US scan shows a hypoechoic mass (arrow) in the liver near the gallbladder (GB). Note the thickening of the gallbladder wall (arrowhead). Cholelithiasis was present as well (not shown). (b) CT scan shows a low-attenuation lesion in the liver adjacent to the gallbladder with subtle peripheral enhancement (arrow). The diagnosis of acute cholecystitis with perforation and an intrahepatic abscess was confirmed at surgery.

View larger version (163K): [in a new window]   Figure 15b.   Hepatic abscess related to acute cholecystitis. (a) Transverse US scan shows a hypoechoic mass (arrow) in the liver near the gallbladder (GB). Note the thickening of the gallbladder wall (arrowhead). Cholelithiasis was present as well (not shown). (b) CT scan shows a low-attenuation lesion in the liver adjacent to the gallbladder with subtle peripheral enhancement (arrow). The diagnosis of acute cholecystitis with perforation and an intrahepatic abscess was confirmed at surgery.

View larger version (117K): [in a new window]   Figure 16a.   Gallstone pancreatitis in a 20-year-old woman with no history of alcohol abuse. (a) Longitudinal US scan shows multiple gallstones within the gallbladder (arrow); however, there was no evidence of acute cholecystitis. The pancreas and CBD are poorly visualized. US is commonly performed in this setting to evaluate for gallstones as a possible cause of pancreatitis. (b) Follow-up CT scan shows cholelithiasis (black arrowhead) and extensive peripancreatic inflammation (arrows). Note the normal-sized distal CBD (white arrowhead). Given the patient's age, lack of history of alcohol abuse, and clinical presentation, a diagnosis of gallstone pancreatitis was made. The patient underwent cholecystectomy and has been symptom free for over 1 year.

View larger version (127K): [in a new window]   Figure 16b.   Gallstone pancreatitis in a 20-year-old woman with no history of alcohol abuse. (a) Longitudinal US scan shows multiple gallstones within the gallbladder (arrow); however, there was no evidence of acute cholecystitis. The pancreas and CBD are poorly visualized. US is commonly performed in this setting to evaluate for gallstones as a possible cause of pancreatitis. (b) Follow-up CT scan shows cholelithiasis (black arrowhead) and extensive peripancreatic inflammation (arrows). Note the normal-sized distal CBD (white arrowhead). Given the patient's age, lack of history of alcohol abuse, and clinical presentation, a diagnosis of gallstone pancreatitis was made. The patient underwent cholecystectomy and has been symptom free for over 1 year.

View larger version (154K): [in a new window]   Figure 17a.   Acute cholecystitis and duodenitis. (a) CT scan shows cholelithiasis (straight arrow), gallbladder wall thickening, and pericholecystic inflammation (curved arrow). (b) CT scan obtained inferior to a shows extensive inflammation (arrowheads) extending to and involving the proximal duodenum (D). Surgery revealed gangrenous cholecystitis and extensive duodenitis.

View larger version (161K): [in a new window]   Figure 17b.   Acute cholecystitis and duodenitis. (a) CT scan shows cholelithiasis (straight arrow), gallbladder wall thickening, and pericholecystic inflammation (curved arrow). (b) CT scan obtained inferior to a shows extensive inflammation (arrowheads) extending to and involving the proximal duodenum (D). Surgery revealed gangrenous cholecystitis and extensive duodenitis.

View larger version (27K): [in a new window]   Figure 18.   Biliary fistula. Diagram shows the routes by which gallstones can erode into adjacent hollow visceral organs. Most commonly, the gallstones migrate into the duodenum (D), but any of the routes shown are possible. Gallstones larger than 2.5 cm in diameter can lodge in the terminal ileum, leading to gallstone ileus; this entity is reported to account for 20% of intestinal obstructions in patients over the age of 65 years. Occasionally, the gallstone lodges more proximally in the intestine. Bouveret syndrome is a rare form of proximal obstruction caused by a large gallstone that has usually migrated through route 1. The gallstone then becomes lodged in the duodenum, most often at the level of the bulb, resulting in a gastric outlet obstruction. C  = colon, G  = gallbladder, S  = stomach.

View larger version (126K): [in a new window]   Figure 19a.   Gallstone ileus. (a) Image from a small-bowel follow-through study shows a dilated small intestine and at least two intraluminal filling defects (arrows). Also, contrast material opacifies a communication with the biliary tree (arrowhead). (b) CT scan shows air in the biliary tree (arrow) as a result of the choloenteric fistula. (Reprinted, with permission, from reference 14.)

View larger version (117K): [in a new window]   Figure 19b.   Gallstone ileus. (a) Image from a small-bowel follow-through study shows a dilated small intestine and at least two intraluminal filling defects (arrows). Also, contrast material opacifies a communication with the biliary tree (arrowhead). (b) CT scan shows air in the biliary tree (arrow) as a result of the choloenteric fistula. (Reprinted, with permission, from reference 14.)

View larger version (141K): [in a new window]   Figure 20.   CBD stones. Longitudinal US scan shows two relatively large gallstones (arrows) within a dilated CBD.

View larger version (153K): [in a new window]   Figure 21a.   Choledocholithiasis. (a) CT scan obtained through the distal CBD shows a metallic clip and an adjacent area of soft-tissue attenuation in the region of the CBD (arrowhead). (b) ERCP image shows a mobile round filling defect (arrowhead) surrounding a metallic clip within a markedly dilated CBD. At endoscopy, a stone that had formed around the surgical clip and caused intermittent biliary obstruction was removed.

View larger version (135K): [in a new window]   Figure 21b.   Choledocholithiasis. (a) CT scan obtained through the distal CBD shows a metallic clip and an adjacent area of soft-tissue attenuation in the region of the CBD (arrowhead). (b) ERCP image shows a mobile round filling defect (arrowhead) surrounding a metallic clip within a markedly dilated CBD. At endoscopy, a stone that had formed around the surgical clip and caused intermittent biliary obstruction was removed.

View larger version (154K): [in a new window]   Figure 22.   CBD stones in a patient who had undergone cholecystectomy. Coronal single-shot fast spin-echo MR cholangiopancreatogram shows multiple gallstones (arrows) within a markedly dilated CBD (30 mm wide).

View larger version (105K): [in a new window]   Figure 23a.   Cholecystostomy and percutaneous stone removal in an elderly patient whose condition was too unstable for cholecystectomy. A Foley catheter was surgically placed within the gallbladder. (a) Oblique percutaneous cholecystogram obtained after injection of contrast material via the catheter shows multiple filling defects consistent with gallstones. The surgeons subsequently requested percutaneous stone removal. (b) Image obtained with the patient in the supine position shows a large sheath (arrows), which was exchanged for the catheter over a guide wire. A basket catheter has been advanced into the sheath. Arrowheads indicate the basket. (c) Image shows sequential removal of gallstones with the grasping technique. Arrow indicates a stone within the basket.

View larger version (110K): [in a new window]   Figure 23b.   Cholecystostomy and percutaneous stone removal in an elderly patient whose condition was too unstable for cholecystectomy. A Foley catheter was surgically placed within the gallbladder. (a) Oblique percutaneous cholecystogram obtained after injection of contrast material via the catheter shows multiple filling defects consistent with gallstones. The surgeons subsequently requested percutaneous stone removal. (b) Image obtained with the patient in the supine position shows a large sheath (arrows), which was exchanged for the catheter over a guide wire. A basket catheter has been advanced into the sheath. Arrowheads indicate the basket. (c) Image shows sequential removal of gallstones with the grasping technique. Arrow indicates a stone within the basket.

View larger version (100K): [in a new window]   Figure 23c.   Cholecystostomy and percutaneous stone removal in an elderly patient whose condition was too unstable for cholecystectomy. A Foley catheter was surgically placed within the gallbladder. (a) Oblique percutaneous cholecystogram obtained after injection of contrast material via the catheter shows multiple filling defects consistent with gallstones. The surgeons subsequently requested percutaneous stone removal. (b) Image obtained with the patient in the supine position shows a large sheath (arrows), which was exchanged for the catheter over a guide wire. A basket catheter has been advanced into the sheath. Arrowheads indicate the basket. (c) Image shows sequential removal of gallstones with the grasping technique. Arrow indicates a stone within the basket.