In this case study, I will present the ultrasound findings of a 55-year-old female patient who presented with right upper quadrant pain and nausea. She had a history of cholelithiasis and chronic cholecystitis.
The ultrasound scan was performed using both curvilinear and linear probes and subcostal approach. The images showed the following features:
- Thickening of the gallbladder wall at the fundus, measuring about 6 mm in thickness (normal <3 mm).
- Multiple echogenic foci within the thickened wall, producing comet tail artifacts that extended into the lumen.
- Two calculi in the gallbladder, measuring about 4 mm each, causing acoustic shadowing.
The ultrasound images are shown below:
Image 1: ultrasound image of gallbladder showing thickened wall at fundus with comet tail artifacts.
Image 2: ultrasound image of gallbladder showing two calculi with acoustic shadowing.
Final diagnosis:
Based on these findings, the most likely diagnosis is gallbladder adenomyomatosis with calculi.
Gallbladder adenomyomatosis is a benign condition characterized by hyperplasia of the mucosa and muscularis of the gallbladder wall, resulting in the formation of intramural diverticula called Rokitansky-Aschoff sinuses . These sinuses may contain cholesterol crystals, which are highly reflective and produce the characteristic comet tail artifacts on ultrasound. The condition is more common in females and older patients, and is often associated with chronic inflammation and gallstones.
The differential diagnoses for gallbladder wall thickening include:
- Acute or chronic cholecystitis: inflammation of the gallbladder wall, usually caused by obstruction of the cystic duct by gallstones or sludge. The wall may appear edematous, hypervascular, and irregular. There may be pericholecystic fluid, gallbladder distension, and positive sonographic Murphy sign ⁷.
- Gallbladder carcinoma: malignant neoplasm of the gallbladder, usually arising from the epithelium. The wall may appear asymmetrically thickened, irregular, and infiltrative. There may be invasion of adjacent structures, lymphadenopathy, and metastases.
- Gallbladder polyps: benign or malignant projections from the gallbladder wall, usually sessile or pedunculated. They appear as echogenic foci without acoustic shadowing. They may be solitary or multiple, and vary in size and shape.
The prognosis and management of gallbladder adenomyomatosis depend on the presence and severity of symptoms, complications, and coexisting conditions. In most cases, adenomyomatosis is asymptomatic and does not require treatment. However, if there are symptoms such as pain, nausea, or jaundice, or complications such as cholecystitis, cholangitis, or pancreatitis, surgical removal of the gallbladder (cholecystectomy) may be indicated . Gallstones may also be treated by cholecystectomy or by nonsurgical methods such as oral dissolution therapy or extracorporeal shock wave lithotripsy .
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I hope you enjoyed this case study and learned something new about gallbladder ultrasound. If you have any questions or comments, please feel free to leave them below. Thank you for reading!
(1) Gallbladder wall thickening | Radiology Reference Article - Radiopaedia.org. https://radiopaedia.org/articles/gallbladder-wall-thickening.
(2) Diffuse gallbladder wall thickening (differential) | Radiology .... https://radiopaedia.org/articles/diffuse-gallbladder-wall-thickening-differential.
(3) Diffuse Gallbladder Wall Thickening | Radiology Key. https://radiologykey.com/diffuse-gallbladder-wall-thickening/.
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