G a s t r o i n t e s t i n a l I m a g i n g • P i c t o r i a l E s s ay

Shakespear et al.
CT of Acute Cholecystitis

Gastrointestinal Imaging
Pictorial Essay

CT Findings of Acute Cholecystitis

and Its Complications
Jonathan S. Shakespear 1 OBJECTIVE. The purpose of this article is to describe and illustrate the CT findings of
Akram M. Shaaban acute cholecystitis and its complications.
Maryam Rezvani CONCLUSION. CT findings suggesting acute cholecystitis should be interpreted with
caution and should probably serve as justification for further investigation with abdominal
Shakespear JS, Shaaban AM, Rezvani M ultrasound. CT has a relatively high negative predictive value, and acute cholecystitis is un-
likely in the setting of a negative CT. Complications of acute cholecystitis have a characteris-
tic CT appearance and include necrosis, perforation, abscess formation, intraluminal hemor-
American Journal of Roentgenology 2010.194:1523-1529.

rhage, and wall emphysema.

Keywords: acute cholecystitis, CT, gallbladder,
ultrasound
DOI:10.2214/AJR.09.3640
Received September 17, 2009; accepted after revision
December 15, 2009.
1
All authors: Department of Radiology, University of
Utah, 30 N 1900 East, #1A71, Salt Lake City, UT
84132-2140. Address correspondence to J. Shakespear
(jonathan.shakespear@hsc.utah.edu).
AJR 2010; 194:1523–1529
0361–803X/10/1946–1523
© American Roentgen Ray Society
E
valuating the gallbladder in the
setting of acute right upper quad-
rant pain is a common endeavor
in many radiology departments—
and justifiably so. A recent meta-analysis
showed that no clinical or laboratory finding
is sufficient to rule in or rule out the diagnosis
without an associated imaging examination.
Thus, patients presenting with clinical fea-
tures suggesting acute cholecystitis should un-
dergo imaging to confirm the diagnosis [1].
Abdominal ultrasound is the obvious study
of choice to evaluate acute gallbladder disease.
Multiple studies have shown its high sensitiv-
ity and specificity in acute cholecystitis and
cholelithiasis. A few articles published in the
early days of MDCT also touted it as a sensi-
tive and specific test for acute cholecystitis, but
such hopes were not supported by later articles.
In fact, in a recent retrospective study evaluat-
ing the utility of ultrasound versus CT in acute
cholecystitis, ultrasound proved to have signif-
icantly higher sensitivity (83% vs 39%), posi-
tive predictive value (75% vs 50%), and nega-
tive predictive value (97% vs 89%) than CT,
with both techniques showing similar speci-
ficity (95% vs 93%) [2]. Although these num-
bers are similar to our experience with CT, to
our knowledge, no large prospective study
has been performed to evaluate CT in acute
cholecystitis. Because ultrasound is sensitive,
specific, and also low in cost and free of ion-
izing radiation, there is little reason to expect
that CT will be pursued as a primary imaging
technique for acute gallbladder disease.
Although ultrasound is the clear initial ex-
amination of choice for a patient with right
upper quadrant pain, fever, leukocytosis, and
a positive Murphy sign, such a classic pre-
sentation may not be typical in daily practice
[3]. CT is frequently performed in patients
with a wider differential diagnosis, confus-
ing signs and symptoms, and pain that ex-
tends beyond the right upper quadrant. CT
may also be performed in those who present
after hours when the general availability of
CT scanners accounts for increasing utiliza-
tion. CT also is often obtained to evaluate for
complications of acute cholecystitis. These
reasons as well as the increasing use of CT
to triage patients in emergency departments
necessitate familiarity with the findings of
acute cholecystitis and its complications.
Pathophysiology
Most acute cholecystitis is associated with
gallstones (90–95%). It is estimated that ap-
proximately 10–20% of people in Western
societies have cholelithiasis and that one
third of those with gallstones will devel-
op cholecystitis [4]. The presumed mecha-
nism is transient or persistent gallbladder
outlet obstruction by a stone, which leads
to cholestasis and subsequent mechanical,
chemical, or infectious irritation of the gall-
bladder wall. Bile breakdown products (lyso-
lecithin), prostaglandins, bacterial infection
(present in 40–70%), and mechanical erosion
from stones are thought to be key factors in
mucosal irritation. Acalculous cholecystitis

AJR:194, June 2010 1523


accounts for 5–10% of all acute cholecysti-
tis. Most patients are critically ill with multi-
ple comorbidities that predispose to cholesta-
sis and gallbladder wall ischemia.
CT Findings in Acute Cholecystitis
Typical CT findings in acute cholecystitis
include gallbladder distention, wall thickening,
mucosal hyperenhancement, pericholecystic
fat stranding or fluid, and gallstones with a suf-
ficient attenuation difference from bile to be vi-
sualized (about 65–75%) (Figs. 1–7). A signifi-
cant fraction of mixed cholesterol or pigment
stones are so similar in attenuation to bile that
they are not reliably identified by standard CT
kilovoltage settings [5–8]. Reactive hyperemia
resulting in increased enhancement of the he-
patic parenchyma of the gallbladder fossa may
also be present (CT rim sign) (Fig. 8).
In a retrospective review of preoperative
CT findings in 29 patients with pathology-
American Journal of Roentgenology 2010.194:1523-1529.
proven cholecystitis, 59% had wall thicken-
ing, 52% had pericholecystic stranding, 41%
had distention, and 31% had pericholecystic
fluid [6]. The gallbladder was considered dis-
tended if it measured greater than 5 cm in the
short axis and greater than 8 cm in length.
Wall thickening was defined at greater than 4
mm in a noncollapsed gallbladder (short axis
greater than 2 cm) [6].
Diffuse gallbladder wall thickening is a
nonspecific finding that is associated with a
wide variety of disease states including hy-
poalbuminemia, ascites, chronic cholecys-
titis, hepatitis, and unrelated inflammatory
processes elsewhere in the abdomen (such
as pancreatitis) [9, 10]. For example, a recent
study identified gallbladder wall thickening
in 19 of 21 patients with acute pyelonephritis
[11] (Figs. 9 and 10).
As noted, abdominal ultrasound is su-
perior to CT in establishing the diagno-
sis of acute cholecystitis. The highest posi-
tive predictive values for acute cholecystitis
with ultrasound are based on the presence of
gallstones in conjunction with a sonograph-
ic Murphy sign (92%) or gallbladder wall
thickening (95%) [12]. It should come as no
surprise then that CT, with its limited ability
to show gallstones and inability to evaluate
for focal tenderness, would prove to be in-
ferior. Additionally, gallbladder wall thick-
ening may occasionally be less optimally vi-
sualized at CT than at ultrasound. And even
when optimally visualized, it may be unre-
lated to primary gallbladder disease.
Although less than that of ultrasound,
the negative predictive value of CT in one
1524 AJR:194, June 2010
Shakespear et al.
study was approximately 89% (compared
with 97% for ultrasound) [2]. CT presum-
ably is most often obtained in patients who
present with abdominal pain that is not
classic for acute cholecystitis. A negative
CT may therefore exclude or at least argue
against acute cholecystitis. If clinical sus-
picion remains, follow-up ultrasound could
be performed to more confidently exclude
the diagnosis.
Gangrenous Cholecystitis
Untreated acute cholecystitis may resolve
within 7–10 days. However, complications
are common. The most common complica-
tion is the development of gallbladder gan-
grene (2–38% of cases) with subsequent
perforation (up to 10% of cases) [13, 14]. De-
fects in the gallbladder mucosa or sloughed
intraluminal membranes suggest gangrene.
Focal transmural defects in the gallbladder
wall may be apparent in the setting of per-
foration. Loculated or freely flowing intra­
peritoneal bile may also be present to further
establish the diagnosis of perforation (Figs.
11–13).
Emphysematous Cholecystitis
Emphysematous cholecystitis is caused by
secondary infection of the gallbladder wall
with gas-forming organisms. Affected pa-
tients are more commonly diabetic (30–50%),
male, and 40–60 years old. Emphysematous
cholecystitis presents as gas within the gall-
bladder wall that, although characteristic on
CT and abdominal radiographs, may compli-
cate ultrasound evaluation. It often heralds
the development of gangrene, perforation,
and abscess formation [15] (Fig. 14).
Pericholecystic Abscess
Acute cholecystitis is complicated with
pericholecystic abscess formation in a re-
ported 3–19% of cases [16]. Abscesses will
present as intramural and pericholecystic
rim-enhancing fluid collections. Adherent,
thickened omentum will often be present.
Extension of the pericholecystic abscess into
the adjacent hepatic parenchyma will appear
as a complex cystic mass with surrounding
parenchymal edema (Figs. 13 and 14). The
abscess can be unilocular or have septations
and an irregular contour. Rim enhancement
is typical, although not always present. In-
tralesional gas is uncommon. The cluster
sign, or multiple adjacent small abscesses,
can be helpful in distinguishing an abscess
from other hepatic masses.
Vascular Complications
Inflammatory vessel wall destruction as-
sociated with acute cholecystitis results in
gallbladder hemorrhage, which will manifest
as high-attenuation material within the gall-
bladder lumen (Fig. 7). Vicarious excretion
of recently administered iodinated contrast
material in the bile is a potential mimic and
an appropriate history should be obtained to
avoid this pitfall (Fig. 8). Portal vein throm-
bosis and cystic artery pseudoaneurysm are
also occasionally seen as sequelae of local
vascular inflammation from acute or chronic
cholecystitis [17, 18] (Figs. 15–16).
Conclusion
Abdominal ultrasound should serve as the
initial study in patients with suspected acute
gallbladder disease. CT is best reserved for
patients with a wider differential diagnosis,
confusing signs and symptoms, and pain that
extends beyond the right upper quadrant.
CT findings suggesting acute cholecystitis
include gallbladder distention, wall thick-
ening, mucosal hyperenhancement, perich-
olecystic fat stranding, gallstones (approxi-
mately 65–75% of which are detectable by
CT), and reactive hyperemia resulting in hy-
perenhancement of the hepatic parenchyma
of the gallbladder fossa.
It is important to keep in mind that CT
does not reliably show gallstones, may un-
derestimate gallbladder wall thickening, and
lacks the ability to detect a Murphy sign.
Nonspecific gallbladder wall thickening and
adjacent fat stranding also may be present in
a wide variety of systemic and intraabdomi-
nal disease processes that do not arise from
the gallbladder.
Because of the low positive predictive val-
ue, CT findings suggestive of acute cholecys-
titis should be interpreted with caution and
should probably serve as justification for fur-
ther investigation with abdominal ultrasound.
CT has a relatively high negative predictive
value (89%), and acute cholecystitis is unlike-
ly in the setting of a negative CT. However,
follow-up may be warranted in a patient with
high clinical suspicion for acute cholecystitis.
Complications of acute cholecystitis have
a characteristic CT appearance and include
necrosis, perforation, abscess formation, in-
traluminal hemorrhage, and wall emphyse-
ma. When complications are suspected, the
gallbladder wall should be carefully exam-
ined for gas, sloughed membranes, focal de-
fects, pericholecystic fluid collections, and
intramural abscess or hemorrhage.
 CT of Acute Cholecystitis

References
1. Trowbridge RL, Rutkowski NK, Shojania KG.
Does this patient have acute cholecystitis? JAMA
2003; 289:80–86
2. Harvey RT, Miller WT Jr. Acute biliary disease:
initial CT and follow-up US versus initial US and
follow-up CT. Radiology 1999; 213:831–836
3. American College of Radiology (ACR) Website.
ACR appropriateness criteria 2008: right upper
quadrant pain. www.acr.org. Accessed March 3,
2010
4. Laing FC. The gallbladder and bile ducts. In: Ru-
mack CM, Wilson SR, Charboneau JW, eds. Di-
agnostic ultrasound, 2nd ed., vol. 1. St Louis,
MO: Mosby Year Book, 1998:175–223
5. Paulson EK. Acute cholecystitis: CT findings.
Semin Ultrasound CT MR 2000; 21:56–63
6. Fidler J, Paulson EK, Layfield L. CT evaluation of
acute cholecystitis: findings and usefulness in di-
agnosis. AJR 1996; 166:1085–1088
American Journal of Roentgenology 2010.194:1523-1529.
7. Barakos JA, Ralls PW, Lapin SA, et al. Chole-
lithiasis: evaluation with CT. Radiology 1987;
162:415–418
8. Chan WC, Joe BN, Coakley FV, et al. Gallstone
detection at CT in vitro: effect of peak voltage set-
ting. Radiology 2006; 241:546–553
9. Cooperberg PL, Gibney RG. Imaging of the gall-
bladder: 1987. Radiology 1987; 163:605–613
10. Shlaer WJ, Leopold GR, Scheible FW. Sonogra-
phy of the thickened gallbladder wall: a nonspe-
cific finding. AJR 1981; 136:337–339
11. Zissin R, Osadchy A, Gayer G, et al. Extrarenal
manifestations of severe acute pyelonephritis: CT
findings in 21 cases. Emerg Radiol 2006; 13:73–77
12. Ralls PW, Collette PM, Lapin SA, et al. Real-time
sonography in suspected acute cholecystitis: pro-
spective evaluation of primary and secondary
signs. Radiology 1985; 155:767–771
13. Jeffrey RB, Laing FC, Wong W, Callen PW. Gan-
grenous cholecystitis: diagnosis by ultrasound.
Radiology 1983; 148:219–221
14. Reiss R, Nudelman I, Gutman C, et al. Changing
trends in surgery for acute cholecystitis. World J
Surg 1990; 14:567–570
15. Garcia-Sancho Tellez L, Rodrigues-Montes JA,
Fernandes LS, et al. Acute emphysematous chole-
cystitis: report of twenty cases. Hepatogastroen-
terology 1999; 46:2144–2148
16. Takada T, Yasuda H, Uchiyama K, et al. Perich-
olecystic abscess: classification of US findings to
determine the proper therapy. Radiology 1989;
172:693–697
17. Choi SH, Lee JM, Lee KH, et al. Relationship be-
tween various patterns of transient increased hepatic
attenuation on CT and portal vein thrombosis related
to acute cholecystitis. AJR 2004; 183:437–442
18. Akatsu T, Tanabe M, Shimizu T, et al. Pseudoan-
eurysm of the cystic artery secondary to cholecys-
titis as a cause of hemobilia: report of a case. Surg
Today 2007; 37:412–417

A B
Fig. 2—Acute cholecystitis in 84-year-old man
Fig. 1—Cholelithiasis in 62-year-old man with abdominal pain and abnormal hepatic enzymes. with nausea, vomiting, and epigastric pain. Axial
A, Longitudinal sonogram shows multiple echogenic, shadowing gallstones within gallbladder lumen. contrast-enhanced CT image shows typical case
B, No stones are visible on contrast-enhanced axial CT image. of acute cholecystitis with calcified gallstones,
wall thickening, mucosal hyperenhancement, and
pericholecystic fat stranding.

A B
Fig. 3—Acute cholecystitis in 67-year-old woman with Murphy sign and right upper quadrant and right
flank pain.
A and B, Axial contrast-enhanced CT images show gallbladder wall thickening, distention (12.5-cm long axis),
and pericholecystic fat stranding. Lamellated gallstone is impacted in gallbladder neck (arrow, B).

AJR:194, June 2010 1525

 Shakespear et al.

Fig. 4—Acute cholecystitis in 86-year-old man with

nausea, vomiting, and right upper quadrant pain.
A, Coronal contrast-enhanced CT image through
gallbladder neck shows impacted lamellated
gallstone, wall thickening, and pericholecystic fluid.
B, Axial contrast-enhanced CT image shows layering
and hyperdense sludge within gallbladder lumen.

A B
American Journal of Roentgenology 2010.194:1523-1529.

A B
Fig. 6—Acalculous cholecystitis in 61-year-old
Fig. 5—Acute cholecystitis in 57-year-old woman with abdominal pain that is not well visualized by CT. woman with multiple comorbidities who exhibited
A, Axial contrast-enhanced CT image through gallbladder shows mildly thickened gallbladder wall (? 5 mm), fever and leukocytosis during extended hospital
but pericholecystic fat is normal. stay. Axial contrast-enhanced CT image through
B, Transverse sonogram shows obvious gallbladder wall thickening and echogenic sludge. Sonographic pelvis shows marked distention of gallbladder that
Murphy sign was also present. measures 7 cm in short axis. Small amount of gas is
present within gallbladder lumen (arrow).

A B
Fig. 7—Acute cholecystitis and secondary colitis in 78-year-old man with diffuse abdominal pain.
A, Axial contrast-enhanced CT image through gallbladder fundus shows intraluminal stone, gallbladder wall
thickening, and inflammation of pericholecystic fat. Hepatic flexure of right colon is also secondarily inflamed
(arrow).
B, Coronal CT reformatted image shows secondary inflammation of hepatic flexure of right colon (arrow).
Inspissated barium and extensive diverticular disease are noted.

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 CT of Acute Cholecystitis

A B C
Fig. 8—Hemorrhagic cholecystitis in 40-year-old man with right upper quadrant pain.
A and B, High-attenuation material fills gallbladder in these contrast-enhanced axial (A) and coronal (B) CT images. Patient had not had any recent contrast-enhanced
examinations. Hyperenhancement of gallbladder fossa indicates transient reactive hyperemia of hepatic parenchyma. This has been described as CT rim sign and is
analogous to rim sign of hepatobiliary scintigraphy.
C, Longitudinal sonogram shows echogenic blood products filling gallbladder. Shadowing gallstones are present in fundus and gallbladder neck. Gross pathologic
specimen was filled with hemorrhage.
American Journal of Roentgenology 2010.194:1523-1529.

Fig. 9—Diffuse secondary gallbladder wall thickening
in 27-year-old woman with left flank pain from
acute pyelonephritis. Axial contrast-enhanced CT
image shows diffuse, circumferential thickening of
gallbladder wall associated with striated nephrogram
in contralateral kidney. Hyperdense bile is due
to vicarious excretion of IV contrast material
administered 24–48 hours before this examination.
A B
Fig. 10—Diffuse secondary gallbladder wall thickening in 47-year-old woman with idiopathic dilated
cardiomyopathy and pelvic pain.
A, Axial contrast-enhanced CT image shows diffuse, circumferential gallbladder wall thickening without
pericholecystic inflammation.
B, Axial contrast-enhanced CT image through liver shows heterogeneous enhancement consistent with
hepatic congestion due to patient’s dilated cardiomyopathy. Associated right pleural effusion is also present.

A B
Fig. 11—Gangrenous cholecystitis in 30-year-old woman with leukocytosis and right lower quadrant pain.
A and B, Axial (A) and coronal (B) contrast-enhanced images show gallbladder wall thickening, pericholecystic
inflammation, and focal mucosal defects without frank perforation. Pathologic specimen exhibited friable
mucosa with focal ulceration. Approximately 30 gallstones were also present that are not well visualized with
this technique.

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 Shakespear et al.

Fig. 12—Gangrenous cholecystitis in 84-year-old

man with abdominal pain and leukocytosis.
A and B, Axial contrast-enhanced CT images show
gallbladder inflammation and hyperdense sloughed
membranes dependently layering within gallbladder
lumen, consistent with necrosis. Perforation was
also reported at surgery, but is not yet evident on this
examination.

A B

Fig. 13—Gangrenous cholecystitis in 78-year-old

man with malaise, hypotension, and right upper
quadrant pain.
A and B, Axial contrast-enhanced CT images show
sloughed intraluminal membranes and hepatic
abscess (arrow, B) adjacent to gallbladder fossa.
Cholecystostomy tube drainage expressed copious
purulent material.
American Journal of Roentgenology 2010.194:1523-1529.

A B

A B C
Fig. 14—Emphysematous cholecystitis and hepatic abscess in 57-year-old woman with leukocytosis and mild right upper quadrant pain.
A, Coronal contrast-enhanced CT image shows gas within gallbladder wall and poor enhancement of adjacent hepatic parenchyma.
B, Axial contrast-enhanced CT image shows secondary hepatic abscess (arrow) with surrounding inflammation.
C, Longitudinal sonogram shows large, shadowing gallstone (cursors) impacted in neck of gallbladder.

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 CT of Acute Cholecystitis

A B C
Fig. 15—Hemorrhagic cholecystitis and intramural pseudoaneurysm in 59-year-old man with acute right upper quadrant pain.
A, Axial unenhanced CT image shows distention of gallbladder with hyperdense blood products. Gallbladder wall edema is also present.
B and C, Axial contrast-enhanced CT images in arterial (B) and portal venous (C) phases show round focus within gallbladder wall that is isodense to aorta in both phases
of contrast, typical of pseudoaneurysm. This pseudoaneurysm affected intramural branch of cystic artery.
American Journal of Roentgenology 2010.194:1523-1529.

A B
Fig. 16—Right portal vein thrombosis due to acute cholecystitis in 62-year-old man with abdominal pain and
elevated hepatic enzymes.
A, Axial contrast-enhanced CT image shows distention of gallbladder and diffuse wall thickening. Opacification
of peripheral right portal vein branches is absent.
B, More superior axial contrast-enhanced CT image shows thrombosis of right portal vein. There is
hyperenhancement of right lobe of liver indicating compensatory hepatic artery perfusion of this region. Acute
onset and absence of other comorbidities in this patient suggest acute cholecystitis with secondary portal vein
thrombosis.

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