While gallbladder wall thickening is often associated with cholecystitis, it can also be misdiagnosed in situations where the full clinical presentation is not considered.
This piece offers advice for sonographers when a thickened gallbladder wall is detected.
Six Key Points
- Gallbladder wall thickening is usually defined as a measurement of greater than 3mm.1,2 This measurement is taken in the fasted state. Initially check whether the thickening is focal or diffuse.
- Ultrasound has excellent sensitivity in detecting diffuse thickening of the gallbladder wall, however there are extrinsic factors which can cause similar appearances to cholecystitis such as:
- Liver disease/cirrhosis
- Hepatitis
- Congestive heart failure
- Renal failure
- Pancreatitis
- While determining extrinsic causes for gallbladder wall thickening can be difficult using imaging features alone, as always, the clinical history/presentation is key. Things to consider include:
- Are there gallstones and/or sludge present?
- Did the patient present with right upper quadrant (RUQ) pain?
- Does the patient have a positive sonographic Murphy's sign?
- Acalculous cholecystitis is a rare pathology (more common in critically ill patients) and in cases where no gallstones or biliary sludge are identified, other causes should be considered. As above, clinical presentation is important and if there is pain at the RUQ and gallbladder wall thickening, further follow up may be required to clarify.
- Adenomyomatosis is a benign condition of the gallbladder wall where there is “excessive epithelial proliferation associated with hyperplasia of the muscularis propria”, which results in gallbladder wall thickening.3 Adenomyomatosis can cause both diffuse and focal thickening of the gallbladder wall. Appearances such as an hourglass gallbladder and echogenic foci with comet tail artefact arising from the wall can be useful features to discern between other pathologies.
- In cases where there is gallbladder wall thickening with poorly differentiated borders, gallbladder malignancy should be considered, particularly in cases where there are also intraluminal projections, and the patient presents with painless jaundice.
Reflection prompts
- What questions could you ask the patient to help make a diagnosis or suggest differential diagnoses when assessing gallbladder wall thickening? Remember, in cases of cholecystitis patients will generally present with RUQ pain and gallstones/sludge are visible. If this isn’t the case and gallbladder wall thickening is present, consider other causes.
- Do you have a good understanding of the various extrinsic causes that may lead to thickening of the gallbladder wall? What other extrinsic causes could lead to gallbladder wall thickening?
- Do you routinely check previous imaging to establish if the gallbladder wall thickening is an acute /new finding?
- During your examination, do you think about whether the patient demonstrates any features of extrinsic causes for gallbladder wall thickening, such as liver disease or passive hepatic congestion?
- Can you list the various ultrasound features for adenomyomatosis?
References/useful resources
- Gupta, P., Marodia. Y., Bansal. A., Kalra, N., Kumar-M, P., Sharma. V., Dutta, U. and Sandhu, MS. 2020. Imaging-based algorithmic approach to gallbladder wall thickening. World Journal of Gastroenterology, 26(40), pp. 6163-6181. doi: 10.3748/wjg.v26.i40.6163
- van Breda Vriesman, A., Smithuis, R., van Engelen, D. and Julien, B. Puylaert. 2006. Gallbladder wall thickening. Radiology Assistant. https://radiologyassistant.nl/abdomen/biliary-system/gallbladder-wall-thickening
- Bonatti, M., Vezzali, N., Lombardo, F., Ferro, F., Zamboni, G., Tauber, M. and Bonatti, G. 2017. Gallbladder adenomyomatosis: imaging findings, tricks and pitfalls. Insights Imaging, 8 (2), pp.243-253. doi: 10.1007/s13244-017-0544-7