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Liver: Gallbladder Disease Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Liver ❯ Gallbladder Disease

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  • “Gallstone ileus (GI) represents a small percentage (0.4–5%) of a range of causes of mechanical intestinal bowel obstruction. It predominantly affects the elderly patient population; 25% are adults over 65 years old. It affects more commonly in the elderly female with an average age of 65–75 years and female–male ratio of 4–7:1. Cases of GI have been reported in as young as 13 years old up to the oldest of 91 years old. Despite the rare incidence, it carries a mortality and morbidity rate of around 7–30%. This is mainly due to the patient’s demographics and delayed diagnosis or misdiagnosis.”


    Pictorial review: the pearls and pitfalls of the
 radiological manifestations of gallstone ileus
 Chuah, P.S., Curtis, J., Misra, N. et al. Abdom Radiol (2017) 42: 1169. doi:10.1007/s00261-016-0996-0
  • Gallstone Ileus: Facts
    • It predominantly affects the elderly patient population; 25% are adults over 65 years old.
    • It affects more commonly in the elderly female with an average age of 65–75 years and female–male ratio of 4–7:1.
    • Despite the rare incidence, it carries a mortality and morbidity rate of around 7–30% [
  • “Mirizzi syndrome refers to hepatic duct obstruction due to extrinsic compression by impacted stone in the neck of gallbladder or cystic duct. As a natural sequel of disease, the stone can erode into adjacent gastrointestinal tract, forming cholecystoenteric fistula such as cholecystoduodenal, cholecysto-gastric, or cholecysto-colonic fistula. The fistula thus provides an exit route for the gallstones leading to the development of GI.”


    Pictorial review: the pearls and pitfalls of the
 radiological manifestations of gallstone ileus
 Chuah, P.S., Curtis, J., Misra, N. et al. Abdom Radiol (2017) 42: 1169. doi:10.1007/s00261-016-0996-0
  • “Bouveret’s syndrome is another subtype of GI, which is gastric outlet obstruction secondary to impaction of gallstone in the pylorus or proximal duodenum. Its occurrence is rare comprising only 1–3% of all cases of GI. It occurs as a result of large gallstone eroding through the gallbladder into the duodenum causing gastroduodenal obstruction and cholecystoduodenal fistulation. Other reported sites of impacted stone are around the gallbladder fossa and stomach. The size of the gallstone is slightly larger than the classic GI, measuring about 4.5 cm.”


    Pictorial review: the pearls and pitfalls of the
 radiological manifestations of gallstone ileus
 Chuah, P.S., Curtis, J., Misra, N. et al. Abdom Radiol (2017) 42: 1169. doi:10.1007/s00261-016-0996-0
  • “If there are one or more visible gallstones with no associated ductal dilation, mass, or clinical symptoms, no additional workup is recommended. Gallbladder ultrasound may be indicated when symptoms such as biliary colic develop.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “Although gallbladder wall calcification (porcelain gallbladder) had been long thought to be associated with a substantially increased risk for gallbladder carcinoma, large retrospective studies have shown that the risk is approximately 5% to 7%. One study of 25,900 gallbladder specimens found that calcification was present in 44 of the specimens. One hundred fifty of 25,900 patients had gallbladder carcinoma, but only 2 of the 44 patients with gallbladder wall calcifications were among the 150 patients who had carcinoma.”

     Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “Therefore, the committee generally does not recommend follow-up in patients with gallbladder wall calcifications. However, if the referring physician desires follow-up, this should be individualized on the basis of the patient's comorbidities and life expectancy. Ultrasound may not be worthwhile for following asymptomatic gallbladder wall calcifications, particularly when concentric, because this would obscure the gallbladder contents. Furthermore, a gallbladder mass may be nearly isoattenuating on noncontrast CT, so when follow-up is performed, contrast-enhanced CT is recommended.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “If the nature of these findings is not known from recent abdominal sonography, this may represent gallbladder sludge, biliary excretion of intravascularly administered contrast (iodine or gadolinium based), hyperconcentrated bile, hemorrhage, or noncalcified gallstones. The patient's clinical history should help narrow the differential diagnosis. Generally, in the absence of other findings such as wall thickening and pericholecystic changes, hyperattenuating gallbladder contents do not warrant further prompt evaluation or follow-up.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings. 

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “In the absence of secondary causes of gallbladder wall thickening, such as hepatitis, congestive heart failure, acute or chronic liver disease, pancreatitis, or hypoproteinemia, a primary cause should be excluded by clinical history. If the thickening is uniform or nearly so, the risk for an underlying gallbladder carcinoma is negligible. There are no data suggesting value in following generalized gallbladder wall thickening, so the committee recommends no specific further evaluation or follow-up for such a finding.”

     Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “ Pericholecystic fluid may occur from gallbladder wall perforation or necrosis and is usually symptomatic and therefore not an incidental finding. Gallbladder wall edema usually has no specific clinical importance but may be mistaken for pericholecystic fluid. However, truly pericholecystic fluid may be an unexpected finding in patients with multiple injuries or altered mental status. In the absence of symptomatic causes of pericholecystic fluid, further evaluation should be individualized on the basis of the patient's condition and the specific nature of the finding.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • Distended Gallbladder (>4 cm Transversely and >9 cm Longitudinally) on CT or MRI

    “In the absence of right upper quadrant symptoms, physiologic distention secondary to fasting is most likely. Otherwise, acute obstruction should be considered. Prompt further evaluation should depend on the patient's symptoms and laboratory findings.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “When measuring a bile duct, short-axis measurements are the most accurate on CT and MR because a tubular structure may seem larger when seen obliquely. Biliary ductal dilation is defined as a common bile duct or common hepatic duct >6 mm in a patient <60 years of age with the gallbladder present or a common duct >10 mm with the gallbladder absent. A diameter >7 mm suggests bile duct obstruction in patients without previous cholecystectomy. Because biliary dilation is often chronic and asymptomatic, liver function tests can help assess the importance of this imaging finding. Mild dilation is unlikely to be clinically important when alkaline phosphatase and bilirubin are normal, and no further imaging evaluation is recommended in these circumstances.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • “Incidental findings include calcified or noncalcified gallstones, diffuse or focal gallbladder wall thickening, distended gallbladder, gallbladder wall polyp or mass, gallbladder wall calcifications, hyperdense gallbladder contents, and biliary ductal dilation. Although cholelithiasis, acute and chronic cholecystitis, carcinoma of the gallbladder, and other serious gallbladder conditions are often symptomatic, they may occasionally be detected incidentally.”

    Managing incidental findings on abdominal and pelvic CT and MRI, Part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings.

    Sebastian S et al.
    J Am Coll Radiol. 2013 Dec;10(12):953-6
  • Acute Cholecystitis: Facts
    - 90-95% of patients with acute cholecystitis have gallstones (remainder have acalculous cholecystitis)
    - Other criteria: distended GB lumen with thick wall, focal tenderness
    - Sonographic Murphy sign on US
    - “Murphy” may be absent in gangrenous cholecystitis
    - Complications: gangrenous & emphysematous cholecystitis, perforation, abscess, fistula to gut
    - Latter more often from chronic cholecystitis
  • “Gallstone ileus is a disease of the elderly, causing up to one fourth of non-strangulation intestinal obstructions in patients older than 65 years of age. It is often missed or diagnosed late. The presentation is that of intestinal obstruction preceded by biliary complaints. Radiological features on plain X-rays include features of intestinal obstruction and pneumobilia, and an aberrant gallstone. Treatment depends on the site of the impacted stone, but surgery is needed in many cases. Gallstone ileus is a rare complication of a common condition. Because it primarily affects the elderly, mortality and morbidity are high, although they have improved over the years. Early diagnosis and treatment improve the outcome.”
    Gallstone Ileus: A Review
    Masannat Y et al.
    Mt Sinai J Med 2006:73(8):1132-34
  • “Radiological features on plain X-rays include features of intestinal obstruction and pneumobilia, and an aberrant gallstone. Treatment depends on the site of the impacted stone, but surgery is needed in many cases. Gallstone ileus is a rare complication of a common condition. Because it primarily affects the elderly, mortality and morbidity are high, although they have improved over the years. Early diagnosis and treatment improve the outcome.”
    Gallstone Ileus: A Review
    Masannat Y et al.
    Mt Sinai J Med 2006:73(8):1132-34
  • Acute Cholecystitis: CT Findings
    - Gallstones
    - Wall thickening
    - Distension
    - Pericholecystic fluid
    - Pericholecystic stranding
    - Increased liver enhancement adjacent to the gallbladder
  • "The most important early predictor of acute cholecystitis on CT was found to be pericholecystic increased liver enhancement on arterial phase CT similar to the rim sign on HIDA Imaging."

    Lessons Learned From Quality Assurance: Errors in the Diagnosis of Acute Cholecystitis on Ultrasound and CT
    Brook OR et al.
    AJR 2011;196:597-604

  • "An important pitfall in the diagnosis of acute cholecystitis is lack of recognition of gallbladder wall edema on CT. A relaxed (nondistended) gallbladder provides important evidence against the diagnosis of acute cholecystitis. Intensive care patients with sepsis often have no specific signs for diagnosis of acute cholecystitis, making diagnosis especially challenging."

    Lessons Learned From Quality Assurance: Errors in the Diagnosis of Acute Cholecystitis on Ultrasound and CT
    Brook OR et al.
    AJR 2011;196:597-604

  • "Helical single-detector and MDCT may improve the diagnosis of gallstone ileus, providing important information regarding the exact number, size, and location of ectopic stones and the site of intestinal obstruction or direct visualization of a biliary-enteric fistula, to help clinicians in the therapeutic management of patients."

    Role of Helical CT in Diagnosis of Gallstone Ileus and Related Conditions Lassandro F et al. AJR 2005; 185:1159-1165
  • Gallstone Ileus:Facts

    - Mortality rate of 8-30%
    - Elderly patient
    - More common in woman than men by 3-1
    - Typical hx of cholelithiasis or cholecystitis
    - Usually presents with an SBO
  • Gallstone Ileus: CT Findings

    - Air in biliary tree
    - Air in gall bladder
    - Intestinal obstruction (usually ileum)
    - Biliary enteric fistulae
    - Stone in small bowel (usually at least 2.5 cm)
  • Rigler’s Triad

    - Ectopic stone in the intestine
    - Air in the biliary tree and gallbladder
    - Distal small bowel obstruction
  • Acute Cholecystitis: CT Findings

    - Gallstones
    - Thickening of the gallbladder wall
    - Pericholecystic fluid
    - Blurring of the gallbladder/liver interface
    - Stranding of the pericholecystic fat
    - Transient increase in attenuation of the liver adjacent to the gallblader
  • Emphysematous Cholecystitis: CT Findings and Facts

    - Most commonly seen in diabetics
    - Usually due to gas forming organisms like Clostridium perfringens, E. coli and Klebsiella organisms
    - 15% mortality
    - Air is seen in gallbladder lumen or wall
    - Surgery is open removal of the gallbladder
  • Mirizzi's Syndrome

    - Obstruction of the extrahepatic bile duct by a stone impacted within the cystic duct and subsequent extrinsic compression or inflammation
  • Gallbladder Cancer: Facts

    - 6500 new cases per year in the USA
    - 4:1 female to male ratio
    - Peak incidence is in the 6th and 7th decades of life
    - On CT a mass filling in the gallbladder lumen is most common and a polypoid mass is the 2nd most common appearance

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