Residents’ Section • Pat tern of the Month

Runner et al.
Gallbladder Wall Thickening

Residents’ Section
Pattern of the Month
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Residents

inRadiology Gallbladder Wall Thickening

Gabriel J. Runner 1

Michael T. Corwin1
Bettina Siewert 2
Ronald L. Eisenberg2
Runner GJ, Corwin MT, Siewert B, Eisenberg RL
Keywords: cholecystitis, gallbladder, wall thickening
DOI:10.2214/AJR.12.10386
Received November 15, 2012; accepted after revision
March 29, 2013.
1
Department of Radiology, University of California, Davis,
Medical Center, Sacramento, CA.
2
Department of Radiology, Beth Israel Deaconess
Medical Center, Harvard Medical School, 330 Brookline
Ave, Boston, MA 02215. Address correspondence to
R. L. Eisenberg (rleisenb@bidmc.harvard.edu).
WEB
This is a web exclusive article.
AJR 2014; 202:W1–W12
0361–803X/14/2021–W1
© American Roentgen Ray Society
G
allbladder wall thickening is a
common yet nonspecific finding
that can occur in a wide range of
gallbladder diseases and extracho-
lecystic conditions (Table 1). Distinguishing
among the wide variety of conditions associ-
ated with gallbladder wall thickening is im-
portant for diagnosis and directing appropriate
management. An initial critical diagnostic ob-
servation is whether the general pattern of
thickening is focal or diffuse. Ancillary find-
ings may be useful in further characterizing
the cause of wall thickening.
Although ultrasound is the initial imaging
modality of choice for the evaluation of sus-
pected acute gallbladder disorders, contrast-
enhanced CT also can be useful to evaluate
gallbladder pathology, particularly when the
ultrasound findings are equivocal. CT is also
valuable to assess suspected complications
of acute cholecystitis and to stage gallblad-
der malignancy. Nuclear medicine studies and
MRI may be used to further characterize dif-
ficult diagnostic dilemmas. Contrast-enhanced
ultrasound using microbubbles is less well es-
tablished than routine sonography in the eval-
uation of gallbladder and biliary disease but
has the potential advantage of use in patients
with renal impairment. Real-time gallbladder
elastography using acoustic radiation force im-
pulse is an emerging technique that uses high-
intensity focused ultrasound to evaluate tissue
stiffness properties. It may be useful in differ-
entiating between benign and malignant causes
of gallbladder wall thickening.
Diffuse Pattern
Diffuse gallbladder wall thickening (> 3
mm by ultrasound) can be seen in such prima-
ry gallbladder inflammatory processes as acute,
chronic, and acalculous cholecystitis. It also
may reflect secondary involvement of the gall-
bladder due to direct inflammatory spread from
adjacent structures, as in patients with pancre-
atitis, acute hepatitis, or severe pyelonephritis.
Systemic diseases that may cause diffuse wall
thickening include heart and renal failure, liv-
er dysfunction, portal venous hypertension, and
sepsis. Other causes of diffuse wall thickening
include infiltrative processes, such as gallblad-
der carcinoma, and hyperplastic changes, as
seen in adenomyomatosis, although these may
also present with focal thickening. The thick-
ness of the gallbladder wall depends on the de-
gree of gallbladder distention; pseudothicken-
ing can occur in the postprandial state due to
physiologic contraction.
Cholecystitis
Acute cholecystitis—Acute cholecystitis oc-
curs in the setting of cystic duct or gallblad-
der neck obstruction related to cholelithiasis
(90–95% of cases) and is the most frequent in-
flammatory condition of the gallbladder. The
presence of cholelithiasis in combination with
a positive sonographic Murphy sign is high-
ly specific for acute cholecystitis, with both
gallbladder wall thickening and pericholecys-
tic fluid as secondary findings (Fig. 1). Mural
thickening is secondary to edema and appears
as a sonolucent line between two echogenic
lines in the gallbladder wall. Although non-
specific, gallbladder distention (width > 4 cm)
is a key feature because lack of any distention
makes acute cholecystitis unlikely and should
prompt a thorough search for another cause
for this appearance.
Gangrenous cholecystitis may result from
advanced infection, occasionally shown by
ultrasound as hyperechoic linear structures
within the lumen that represent sloughed
membranes of desquamated gallbladder lin-
ing, marked wall thickening, and irregular lu-
minal protrusions. A striated pattern of alter-
nating hyperechoic and hypoechoic bands in
an irregularly thickened gallbladder has been
suggested to represent advanced disease with
wall necrosis (Fig. 2), although recent work

AJR:202, January 2014 W1


by Teefey et al. [1] suggests that this finding
is not predictive of gangrenous changes. The
sonographic Murphy sign may also be par-
adoxically absent, presumably related to ne-
crosis and gallbladder denervation.
Emphysematous cholecystitis is an addi-
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tional severe form of acute cholecystitis that
is most common in diabetic patients (50% of
cases), with high morbidity and mortality.
Dirty shadowing is highly suggestive of in-
tramural gas and diagnostic of emphysema-
tous cholecystitis (Fig. 3).
In equivocal cases, nonvisualization of the
gallbladder using 99mTc-hepatoiminodiacetic
acid (HIDA) scintigraphy is characteristic of
acute cholecystitis due to cystic duct obstruc-
tion (Fig. 4), whereas visualization of the gall-
bladder excludes the diagnosis (Fig. 5). Al-
though less sensitive than ultrasound, CT may
also show gallbladder wall thickening or dis-
tention, cholelithiasis, mucosal hyperenhance-
ment, pericholecystic fluid, inflammatory fat
stranding, and enhancement of the adjacent
liver parenchyma due to reactive hyperemia
(Fig. 6). It is important to note that approxi-
mately 20% of gallstones are isodense to bile
and therefore will not be visualized on CT. CT
is also useful in evaluating for complications
of acute cholecystitis, such as gallbladder ne-
crosis, perforation, or abscess formation, and
this modality can easily confirm gas within
the gallbladder wall in cases of suspected em-
physematous cholecystitis (Fig. 7). A recent
study has shown the “tensile gallbladder fun-
dus sign” on CT as useful in detection of early
acute cholecystitis. This refers to an absence
of gallbladder fundus flattening by the anterior
abdominal wall because of increased gallblad-
der pressures from outflow obstruction. Sensi-
tivity of 75% and specificity of 97% in cases
of acute cholecystitis has been reported. Most
importantly, this sign occurred earlier than
other CT findings of acute cholecystitis (e.g.,
hepatic hyperemia and gallbladder distention).
Acalculous cholecystitis—Acalculous cho-
lecystitis most often occurs in hospitalized
patients, especially after surgery or trauma,
and those who are critically ill or undergo-
ing total parenteral nutrition. This condition
is thought to be due to a gradual increase in
bile viscosity that eventually leads to func-
tional obstruction of the cystic duct with bile
stasis. Compromise of the vascular supply to
the mucosa may be a contributing factor. Ul-
trasound is highly sensitive and specific for
the diagnosis of acalculous cholecystitis with
characteristic findings including gallbladder
wall thickening, pericholecystic fluid or sub-
W2 AJR:202, January 2014
Runner et al.
TABLE 1: Causes of Gallbladder Wall Thickening
Diffuse Wall Thickening Focal Wall Thickening
Cholecystitis Polyps
Acute calculous Adenomatous
Gangrenous Cholesterol
Emphysematous Malignancy
Acalculous Primary gallbladder carcinoma
Chronic Metastases
Xanthogranulomatous Focal adenomyomatosis
Liver disease Focal xanthogranulomatous cholecystitis
Hepatitis
Cirrhosis
Portal hypertension
Extracholecystic inflammation
Pancreatitis
Colitis
Peritonitis
Pyelonephritis
Systemic diseases
Congestive heart failure
Renal failure
Sepsis
Hypoalbuminemia
Malignancy
Primary gallbladder carcinoma
Lymphoma
Adenomyomatosis
Pseudothickening (contracted state)
Atypical infection
Tuberculous
Dengue hemorrhagic fever
serosal edema, intramural gas, sloughed mu- lelithiasis. The ultrasound findings include
cosa, sludge, and hydropic gallbladder (Fig. lucency of the wall and a distended gallblad-
8). CT may show a similar appearance if the der containing sludge, although pericholecys-
clinical findings are suggestive despite an tic fluid or inflammation is usually absent. Fi-
equivocal ultrasound examination (Fig. 9). brotic changes involving the gallbladder wall
Acalculous cholecystitis in HIV patients may result in a contracted gallbladder. There
has been associated with cytomegalovirus or is often a decreased gallbladder ejection frac-
cryptosporidium infection. Unlike individuals tion that may be seen on 99mTc-HIDA scintig-
with healthy immune systems, these immu- raphy after IV cholecystikinin (CCK) admin-
nocompromised patients are ambulatory and istration. Xanthogranulomatous cholecystitis
present with right upper quadrant pain and ab- is an uncommon form of chronic cholecysti-
normal liver function tests. Gallbladder wall tis. Precipitating factors may include extrava-
thickening is a prominent, although nonspe- sation of bile into the gallbladder wall with in-
cific feature, whereas bile duct strictures and volvement of the Rokitansky-Aschoff sinuses
dilation can present a pattern similar to that of or extravasation through small ulcerations in
primary sclerosing cholangitis (Fig. 10). the mucosa with accumulation of lipid-laden
Chronic cholecystitis—Chronic cholecysti- macrophages, fibrous tissue, and inflammato-
tis almost always occurs in the setting of cho- ry cells. Ultrasound may show a hypoechoic

band within a thickened gallbladder wall (Fig.
11). However, the imaging findings usually
are nonspecific, with both CT and ultrasound
generally showing thickening of the gallblad-
der wall and calculi. At times, the appearance
may mimic carcinoma of the gallbladder at
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both ultrasound and laparotomy.
Liver Disease
Both acute and chronic forms of liver dis-
ease may cause gallbladder wall thickening.
In acute hepatitis, ultrasound findings sug-
gesting the diagnosis include a diffusely thick-
ened and edematous gallbladder wall in con-
junction with a diffusely hypoechogenic liver
with prominent portal triads (“starry sky” ap-
pearance) (Fig. 12). In chronic liver disease
or liver failure with portal venous hyperten-
sion, gallbladder wall thickening and im-
paired contractility may occur. Liver disease
as the cause for gallbladder wall thickening
is suggested by the absence of gallstones or
signs of gallbladder inflammation (e.g., peri-
cholecystic fluid, positive Murphy sign) in
the presence of cirrhotic liver morphology
and stigmata of portal venous hypertension,
such as splenomegaly, varices, and reversal
of hepatopedal flow (Fig. 13).
Systemic Diseases
Systemic diseases, such as heart or renal
failure, may cause gallbladder wall thickening
in the absence of gallbladder inflammation,
possibly related to elevated portal venous pres-
sure, low intravascular osmotic pressure, or a
combination of these factors. Hypoalbumin-
emia and sepsis are additional causes of gall-
bladder wall thickening. The degree of gall-
bladder wall thickening may be pronounced
(> 10 mm) in liver or systemic diseases, and
when coexisting gallbladder distention is ab-
sent, a cause other than acute cholecystitis is
likely (Fig. 14).
Extracholecystic Inflammation
Acute hepatitis, pancreatitis, pyelonephri-
tis, and peritonitis are inflammatory process-
es that may secondarily involve the gallblad-
der and cause wall thickening due either to
direct spread of the primary inflammation
or, less frequently, an immunologic reac-
tion. There may be pericholecystic stranding
within the fat surrounding the gallbladder,
and mural thickening and bowel wall ede-
ma may occur. Identifying an inflammatory
process involving the pancreas, kidney, bow-
el, or peritoneum is important to suggest the
cause (Fig. 15).
AJR:202, January 2014 W3
Gallbladder Wall Thickening
Malignancy
Primary gallbladder carcinoma—Gallblad-
der carcinoma most often manifests as a dif-
fusely infiltrating lesion that replaces the
gallbladder and extends into the liver. Less fre-
quently, it appears as asymmetric mural thick-
ening or an intraluminal polypoid mass. Cho-
lelithiasis is a well-established risk factor for
developing gallbladder carcinoma, and gall-
stones are present in about 80% of cases. Por-
celain gallbladder (calcification of the wall)
may also be a risk factor, although this has re-
cently been debated. The CT or ultrasound vi-
sualization of pronounced wall thickening (>
10 mm) associated with mural irregularity or
marked asymmetry should raise concern for
malignancy. In diffusely infiltrating lesions,
ultrasound findings suggestive of malignancy
include heterogeneous irregular wall thicken-
ing and an extraluminal mass extending into
the liver (Fig. 16). On contrast-enhanced CT,
a hypo- or isoattenuating mass in the gallblad-
der fossa that invades the liver and shows ad-
jacent lymphadenopathy favors the diagnosis
of gallbladder carcinoma (Fig. 17). Less com-
monly, pronounced diffuse wall thickening
with gallstones may be present (Fig. 18).
Lymphoma—Lymphoma of the gallblad-
der, which is exceedingly rare, has been de-
fined previously as extranodal lymphoma lo-
calized to the gallbladder, with or without
contiguous lymph node involvement. Like
adenocarcinoma, lymphoma may present on
CT or ultrasound as an intraluminal mass, a
large mass replacing the gallbladder, or dif-
fuse wall thickening.
Adenomyomatosis
Adenomyomatosis is an acquired hy-
perplastic process of the gallbladder that is
characterized by excessive proliferation of
surface epithelium with abnormally deep-
ened and branching invaginations (Rokitan-
sky-Aschoff sinuses) that extend deep into
the muscular layer of the gallbladder wall.
This process may be focal, segmental, or dif-
fuse, with the focal form most common in
the fundus. Ultrasound findings include mu-
ral thickening with echogenic foci showing
comet-tail artifact, which represents choles-
terol crystals within the lumina of Rokitan-
sky-Aschoff sinuses (Fig. 19). CT is less spe-
cific in the detection of adenomyomatosis,
but this modality may show cystic-appearing
thickening of the gallbladder wall or enhanc-
ing epithelium within intramural diverticula
surrounded by relatively unenhanced hyper-
trophied gallbladder muscularis (Fig. 20).
Pseudothickening
The thickness of the gallbladder wall de-
pends on the degree of gallbladder disten-
tion, and pseudothickening can occur in the
postprandial state. Gallbladder emptying in
response to a meal is a physiologic phenom-
enon, mainly coordinated by the rate of gas-
tric emptying of food in the duodenum and
by the subsequent release of CCK. It is im-
portant not to mistake this normal physiolog-
ic phenomenon for pathologic thickening of
the gallbladder wall (Fig. 21).
Atypical Infection
Tuberculous involvement of the gallblad-
der is rare. It may develop as part of system-
ic miliary tuberculosis, abdominal tubercu-
losis, isolated gallbladder tuberculosis, or
acalculous cholecystitis in anergic patients.
Radiologic diagnosis is difficult because the
imaging features can mimic acute cholecys-
titis, chronic cholecystitis, and gallbladder
malignancy. Most cases are diagnosed after
cholecystectomy or at autopsy.
Dengue hemorrhagic fever is an acute Fla-
vivirus infection, which may cause a triad of
transient wall thickening, ascites, and pleu-
ropericardial effusion. A reticular pattern of
the gallbladder wall is apparently typical of
plasma leakage in severe disease.
Focal Pattern
Focal gallbladder wall thickening (> 3 mm
by ultrasound) has a more narrow differential
diagnosis and can be divided into neoplas-
tic and nonneoplastic processes. Neoplastic
causes include adenomatous polyps, gall-
bladder carcinoma, and metastases. Nonneo-
plastic causes include cholesterol or inflam-
matory polyps, focal adenomyomatosis, and
focal xanthogranulomatous cholecystitis.
Adenomatous Polyps
Adenomatous polyps grow as pedunculated
tumors that project into the gallbladder lumen
and may be premalignant. Ultrasound findings
include a nonmobile nonshadowing polypoid
intraluminal mass that may have internal flow
(Fig. 22). Polyps smaller than 5 mm are un-
likely to be malignant; malignant lesions are
usually smaller than 1 cm. Polyps measuring
5–10 mm should be followed up at 3–6 month
intervals. Cholesterol polyps characteristically
appear as echogenic structures with comet-tail
reverberation artifact (Fig. 23). It is important
to note that some gallbladder “polyps” actu-
ally represent small nonshadowing gallstones
adherent to the wall.

Gallbladder Carcinoma
Gallbladder carcinoma can also present as
focal irregular wall thickening or, less often, as
an intraluminal polypoid mass (Fig. 24). Flow
within the lesion seen on color Doppler ultra-
sound can help distinguish a mass from tu-
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mefactive sludge. Contrast-enhanced CT and
MRI may show asymmetric or irregular wall
thickening with marked enhancement during
the arterial phase, which persists or becomes
isodense or isointense to liver during the por-
tal venous phase. As with the diffuse form of
gallbladder carcinoma, the tumor often locally
invades the adjacent liver and biliary tree.
Metastases
Metastatic disease involving the gallblad-
der is a rare entity and most commonly arises
from melanoma. Primary pulmonary and re-
nal malignancies are less frequently report-
ed. Imaging features include focal irregular
wall thickening and one or more enhancing
polypoid masses (Fig. 25).
Focal Adenomyomatosis (Adenomyoma)
Adenomyoma represents the focal form
of adenomyomatosis and most frequently
involves the gallbladder fundus. Ultrasound
findings may include echogenic intramural
foci that emanate comet-tail reverberation ar-
tifacts (Fig. 26). Visualization of a twinkling
artifact on color Doppler ultrasound is use-
ful in making a diagnosis of focal adenomyo-
A B
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Runner et al.
matosis when reverberation artifact is either
difficult to see or not present on gray-scale
ultrasound. Twinkling artifact is caused by
a strongly reflecting medium that appears as
rapidly alternating red and blue color Dop-
pler signal behind stationary objects. The
hallmark of adenomyomatosis on T2-weight-
ed MR images is the string-of-beads sign,
which refers to cystic high-signal foci in the
gallbladder wall that correspond to bile-filled
Rokitansky-Aschoff sinuses (Fig. 27). A less
common segmental (annular) form appears
as a rind of circumferential involvement of
the gallbladder body, which narrows the lu-
men and creates an hourglass configuration
of the gallbladder (Fig. 27).
Focal Xanthogranulomatous Cholecystitis
Focal xanthogranulomatous cholecystitis
is much less common than the diffuse form.
The ultrasound and CT appearances are non-
specific, frequently consisting of thickening
of the gallbladder wall and calculi. The diag-
nosis is usually made by histopathology.
Conclusion
Gallbladder wall thickening has a wide
differential diagnosis. An important first step
is to distinguish between the diffuse and focal
forms. Subsequently, identification of ancil-
lary imaging findings and directed use of ad-
ditional imaging modalities allow an accurate
diagnosis to be made.
Reference
1. Teefey SA, Dahiya N, Middleton WD, Bajaj S,
Ylagan L, Hildebolt CF. Acute Cholecystitis: Do
sonographic findings and WBC count predict gan-
grenous changes? AJR 2013; 200:363–369
Selected Reading
1. An C, Park S, Ko S, et al. The usefulness of the
tensile gallbladder fundus sign in the diagnosis
of early acute cholecystitis. AJR 2013; 201:340–
346
2. Bennett GL, Balthazar EJ. Ultrasound and CT
evaluation of emergent gallbladder pathology. Ra-
diol Clin North Am 2003; 41:1203–1216
3. Catalano OA, Sahani DV, Kalva SP, et al. MR im-
aging of the gallbladder: a pictorial essay. Radio-
Graphics 2008; 28:135–155
4. Chang BJ, Kim SH, Park HY, et al. Distinguish-
ing xanthogranulomatous cholecystitis from the
wall-thickening type of early-stage gallbladder
cancer. Gut Liver 2010; 4:518–523
5. Ching BH, Yeh BM, Westphalen AC, Joe BN, Qa-
yyum A, Coakley FV. CT differentiation of ade-
nomyomatosis and gallbladder cancer. AJR 2007;
189:62–66
6. Kapoor A, Mahajan G. Differentiating malignant
from benign thickening of the gallbladder wall by
the use of acoustic radiation force impulse elas-
tography. J Ultrasound Med 2011; 30:1499–1507
7. van Breda Vriesman AC, Engelbrecht MR,
Smithuis RH, Puylaert JB. Diffuse gallbladder wall
thickening: differential diagnosis. AJR 2007; 188:
495–501
Fig. 1—Acute cholecystitis in 44-year-old woman.
A and B, Longitudinal (A) and transverse (B)
ultrasound images of gallbladder show diffusely
thickened wall (6.1 mm) (calipers) with multiple
shadowing gallstones (arrow, A) and pericholecystic
fluid (arrow, B). Patient also had positive sonographic
Murphy sign.
AJR:202, January 2014
 Gallbladder Wall Thickening
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A B
Fig. 2—Acute cholecystitis with gallbladder necrosis in 40-year-old woman.
A, Longitudinal ultrasound image of gallbladder shows shadowing gallstones (solid arrow) and diffuse wall thickening (3.5 mm) (calipers)
with alternating hyperechoic and hypoechoic bands (dashed arrow).
B, Contrast-enhanced abdominal CT image shows hydropic gallbladder, diffuse wall thickening, and lack of wall enhancement, with
extensive right upper quadrant mesenteric stranding.

A B

Fig. 3—Emphysematous
cholecystitis.
A and B, Longitudinal
(A) and transverse
(B) ultrasound images
of gallbladder area in
64-year-old diabetic man
show linear echogenic
structures with distal
reverberations and dirty
shadowing, indicating
gas within gallbladder
wall.
C, Contrast-enhanced
abdominal CT image in
different patient shows
hydropic gallbladder
with gas present in
gallbladder wall.
C

AJR:202, January 2014 W5

 Runner et al.

Fig. 4—Acute cholecystitis in 54-year-old man with

equivocal ultrasound.
A, Longitudinal ultrasound image of gallbladder
shows multiple shadowing gallstones near
gallbladder neck (arrow), with borderline wall
thickening.
B, Subsequent hepatobiliary scintigraphy scan shows
prompt liver uptake and excretion of radiotracer into
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bowel with no filling of gallbladder lumen, finding

highly specific for acute cholecystitis.

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 Gallbladder Wall Thickening
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Fig. 5—Negative hepatobiliary scintigraphy scan in 32-year-old woman with right upper quadrant pain shows
prompt liver radiotracer uptake with early gallbladder visualization (arrow), effectively excluding acute
cholecystitis.

Fig. 6—Acute cholecystitis in 58-year-old man. Contrast-enhanced CT image Fig. 7—Acute cholecystitis with abscess in 67-year-old man. Contrast-enhanced
shows hyperemic liver parenchyma adjacent to thickened gallbladder wall (full CT image shows distended gallbladder and thickened wall with adjacent rim-
arrow) with pericholecystic fluid (dashed arrow). enhancing low-density fluid collection (arrow).

AJR:202, January 2014 W7

 Runner et al.

Fig. 8—Acalculous cholecystitis in 42-year-old man.

A and B, Longitudinal (A) and transverse (B) images
of gallbladder show diffuse wall thickening (4 mm)
(calipers) with intraluminal sludge (solid arrow) and
pericholecystic fluid (dashed arrow, A).
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A B

Fig. 9—Acalculous cholecystitis in 40-year-old
woman. Coronal abdominal CT image in septic patient
shows diffuse gallbladder wall thickening. Small
amount of perihepatic fluid is also present.
A B
Fig. 10—HIV cholangiopathy in 36-year-old woman.
A and B, Longitudinal (A) and transverse (B) ultrasound images of gallbladder show diffuse wall thickening.
Subsequent hepatobiliary scintigraphy scan was negative (not shown).

Fig. 11—
Xanthogranulomatous
cholecystitis in 75-year-old
woman.
A, Longitudinal ultrasound
image of gallbladder
shows hypoechoic band
within diffusely thickened
gallbladder wall.
B, Contrast-enhanced
abdominal CT image
shows diffuse gallbladder
wall thickening.
A B

W8 AJR:202, January 2014

 Gallbladder Wall Thickening

Fig. 12—Acute hepatitis in 14-year-old girl.

A and B, Longitudinal (A) and transverse (B)
ultrasound images of gallbladder show diffuse
gallbladder wall thickening (4.7 mm) (calipers)
without stones. Diffuse liver hypoechogenicity with
foci of increased periportal echogenicity in periportal
regions (starry sky) is suggestive of hepatitis.
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A B

A B C
Fig. 13—Cirrhosis in 57-year-old man.
A, Longitudinal ultrasound image of gallbladder shows diffuse gallbladder wall thickening with ascites (arrow).
B, Transverse ultrasound image of liver shows coarsened liver echotexture and nodular liver contour with ascites.
C, Longitudinal ultrasound image of spleen shows splenomegaly (20 cm) (calipers) related to portal hypertension physiology.

A B C
Fig. 14—Congestive heart failure in 52-year-old woman.
A, Longitudinal ultrasound image of gallbladder shows diffusely marked thickened gallbladder wall with decompressed lumen, negative sonographic Murphy sign, and no
stones.
B, Heart failure on follow-up. CT image shows marked diffuse wall thickening.
C, Subsequent hepatobiliary scintigraphy scan was negative, with gallbladder visualization (arrow).

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 Runner et al.
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A B
Fig. 15—Pancreatitis in 51-year-old man.
A, Longitudinal ultrasound image of gallbladder shows diffuse wall thickening (4 mm) (calipers) without other signs of acute cholecystitis.
B, Contrast-enhanced coronal abdominal CT image shows peripancreatic stranding with extension of inflammation into gallbladder fossa.
Pancreatic calcifications indicate chronic pancreatitis. Follow-up hepatobiliary scintigraphy scan (not shown) was negative for acute
cholecystitis.

Fig. 16—Diffuse gallbladder carcinoma in 67-year-old Fig. 17—Diffuse gallbladder carcinoma in 72-year-old
woman. Longitudinal ultrasound image of gallbladder man. Contrast-enhanced CT image shows infiltrative
shows large mass replacing gallbladder in gallbladder mass that arises from gallbladder fossa and invades
fossa, with infiltration of liver. liver.

Fig. 18—Diffuse gallbladder carcinoma in 56-year-old woman. Contrast-enhanced

CT image shows diffuse gallbladder wall thickening with high-density intraluminal
material (arrow), presumed gallstone. Biliary stent is also present (dashed arrow).

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 Gallbladder Wall Thickening
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Fig. 19—Adenomyomatosis in 55-year-old woman. Fig. 20—Adenomyomatosis in 66-year-old man. Fig. 21—Gallbladder pseudothickening in 32-year-old
Transverse ultrasound image of gallbladder shows Contrast-enhanced abdominal CT image shows man. Longitudinal ultrasound image of gallbladder
diffuse mural thickening with areas of ring-down or diffuse mural thickening with multiple small cystic shows contracted gallbladder with apparent wall
comet-tail artifact (arrows). spaces in gallbladder wall (arrows). thickening related to contracted state.

Fig. 22—Gallbladder polyp in 63-year-old woman.
Longitudinal ultrasound of gallbladder with Doppler
flow shows focal nonmobile nonshadowing
echogenic structure near gallbladder fundus (arrow)
without internal vascularity.
Fig. 23—Cholesterol polyp in 43-year-old woman.
Longitudinal ultrasound image of gallbladder shows
focal echogenic structure near gallbladder fundus
(arrow) with ring-down artifact.

Fig. 24—Focal gallbladder carcinoma in 71-year-old

woman.
A and B, Longitudinal ultrasound image of gallbladder
(A) and longitudinal ultrasound of gallbladder with
Doppler flow (B) show 3.6-cm intraluminal gallbladder
mass with internal vascularity (arrow).
(Fig. 24 continues on next page)
A B

AJR:202, January 2014 W11


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Fig. 25—Gallbladder metastases in 62-year-old man
with pancreatic adenocarcinoma. Abdominal CT
image shows multiple irregular areas of gallbladder
wall thickening (arrows).
W12 AJR:202, January 2014
Runner et al.
Fig. 24 (continued)—Focal gallbladder carcinoma in 71-year-old woman.
C, Contrast-enhanced CT image shows enhancing polypoid intraluminal mass
arising from posterior aspect of gallbladder (arrow).
A B
Fig. 26—Fundal adenomyoma in 41-year-old woman.
A and B, Longitudinal (A) and transverse (B) ultrasound images of gallbladder show focal wall thickening (3.7
mm) (calipers) near gallbladder fundus (solid arrow, A) with area of ring-down artifact (dashed arrow, B).
Fig. 27—Adenomyomatosis in 54-year-old man.
T2-weighted MR image of gallbladder shows string-
of-beads appearance reflecting adenomyomatosis
involving gallbladder fundus (dashed arrow).
Coexisting annular or segmental form involves
gallbladder body, narrowing gallbladder lumen and
creating hourglass gallbladder configuration (solid
arrows).