Gallbladder wall thickening: tool and limitation in the correct diagnosis of acute cholecystitis.

Transcription

1 Gallbladder wall thickening: tool and limitation in the correct diagnosis of acute cholecystitis. Poster No.: C-1284 Congress: ECR 2013 Type: Educational Exhibit Authors: G. A. Tovar 1, I. Nogueira-Mañas 2, A. BORRAS JOAQUINA 3, R. RODRIGUEZ 4 ; 1 Barcelona/ES, 2 Cerdanyola del vallès/es, 3 Badalona barcelona/es, 4 Catarroja ( C.P )/ES Keywords: Acute, Surgery, Ultrasound, CT, Emergency, Biliary Tract / Gallbladder, Abdomen, Inflammation DOI: /ecr2013/C-1284 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 14

2 Learning objectives Evaluation of gallbladder wall thickness plays an important role in the evaluation of gallbladder pathology. Acute cholecystitis is a major cause of wall thickening, although this sign can be seen in other pathologic processes. we propose to attend this objectives: To understand the importance of the differential diagnosis of gallbladder wall thickening in the correct diagnosis of acute cholecystitis. To outline the limitations of this sign as a diagnostic tool of acute cholecystitis. To describe the most common differential diagnosis based on a series of 17 patients. Background Acute cholecystitis is a common cause of emergency hospital admissions for people with abdominal pain. This represents a challenge for radiologists in the correct diagnosis in order to avoid unnecessary surgical interventions. The normal gallbladder wall is seen as a thin line of a thickness lower than 3mm. The most frequent anomaly of the gallbladder wall is the diffuse thickening, which is diagnosed when the wall has a thickness higher than 3mm. Wall thickening typically appears as an hipoechogenic region between two echogenic lines on US images, and as a hipodense thickened line on CT images. Nowadays the gallbladder wall thickening is considered a nonspecific sign and this appearance is neither sensitive nor specific for an inflammatory process. Approximately 50% and 75% of patients with acute cholecystitis have diffuse thickening of the wall. Inflammation of the gallbladder wall is determined by a variety of pathological processes, so it is not possible to predict a specific vesicular disease based on the appearance of the gallbladder wall. Besides inflammation, other conditions associated with diffuse gallbladder wall thickening include liver dysfunction, heart failure, renal disease, AIDS and sepsis. Although a common pathophysiologic mechanism can not explain these various processes, many of these patients have decreased intravascular osmotic pressure and elevated portal venous pressure. Moreover, given the underlying disease, many patients with diffuse Page 2 of 14

3 thickening of the gallbladder wall also have ascites. Also, there are less common causes of gallbladder wall thickening such as leukemic infiltration, interleukin-2 chemotherapy and gallbladder wall varices. Although hepatitis often produces diffuse and regular thickening of the vesicular wall, in exceptional cases may exist marked thickening of its wall, with obliteration of the vesicular lumen. Other conditions to note are the focal lesions of the gallbladder wall, such as carcinoma or polyps, which although usually presents as a focal and irregular thickening, it can mimic other diseases such as complicated cholecystitis. After a review of 17 cases of patients who attended the emergency room with abdominal pain, focused on right hypochondrium and infection demonstrated in blood analysis, in which acute cholecystitis was suspected (to a greater or lesser degree) and presented with a severe wall thickening of the gallbladder, in most cases was due to chronic liver disease with ascites and heart failure, and only a small number of patients had acute cholecystitis. From the reviewed serie, as mentioned, just a few of them had actually acute cholecystitis (demonstrated), and the final diagnosis in the other cases were mostly acute hepatitis, cholangitis (associated or not to gallbladder carcinoma) and sepsis from other abdominal focus like right pyelonephritis or colitis in right colon. Given the low specificity of this sign, it should be considered a secondary sign, and it must be complemented with major signs for the correct diagnosis of acute cholecystitis, which include impacted gallstones or other cause of gallbladder neck obstruction and positive US Murphy's sign. This wall thickening is even less important if another hepatic or cardiac disease is present. Images for this section: Page 3 of 14

4 Fig. 1: Transverse US scan shows the typical signs of acute cholecystitis: mild gallbladder wall thickening, impacted gallstone, gallbladder hydrops and positive Murphy's sign. Page 4 of 14

5 Fig. 2: Transverse US scan shows a severe thickening of the gallbladder wall, microabscesses, and gallstone in a patient with acute cholecystitis (demonstrated after surgery). Page 5 of 14

6 Fig. 3: Transverse US scans of a patient with cirrhosis, multifocal hepatocarcinoma, and ascites, shows gallstone in fundus and thickening of the gallbladder wall secundary to ascites. Fig. 4: Transverse US scan shows a 12mm thickening of the gallbladder in a patient with chronic liver disease. Page 6 of 14

7 Fig. 5: Transverse US shows gallstones and posterior shadowing, with thickened gallbladder wall, secondary to ascites. Page 7 of 14

8 Fig. 6: Axial CT scan shows gallbladder wall thickening and pericholecystic inflammation in a patient with acute cholecystitis. However, no gallstones are visible. Page 8 of 14

9 Fig. 7: Transverse US scan shows diffuse gallbladder wall thickening in a patient with acute hepatitis. Page 9 of 14

10 Fig. 8: Coronal MPR CT scan shows gallbladder wall thickening and no visible pericholecystic inflammation in a patient with heart failure. Page 10 of 14

11 Fig. 9: Transverse US scans of a patient with gallbladder carcinoma. Notice the focal and irregular wall thickening with high doppler signal. Fig. 10: Axial CT scans in a patient with gallbladder carcinoma. Notice the diffuse gallbladder wall thickening and the intrahepatic biliary dilation. Page 11 of 14

12 Fig. 11: Axial CT scan shows diffuse gallbladder wall thickening in a patient with Acute Myeloid Leukemia. Page 12 of 14

13 Imaging findings OR Procedure details A Siemens ACUSON Ultrasound system and a General Electric LightSpeed 64 Slice CT were used to perform the exams. Conclusion Wall thickening of the gallbladder is not an accurate sign for the appropriate diagnosis of acute cholecystitis and is present in other diseases. It should be complemented with other signs for the correct diagnosis of acute cholecystitis, such as impacted gallstones or other cause of gallbladder neck obstruction and positive Murphy's sign (which are known as major signs), considering the diffuse thickening of the gallbladder wall a secondary sign. It is important for radiologists to know the most common differential diagnosis in order to prevent misdiagnosis and unnecessary surgical interventions. References 1. Aydin C, Altaca G, Berber O, Tekin K, Kara M, Titiz I. Prognostic parameters for the prediction of acute gangrenous cholecystitis. J Hepatobiliary Pancreat Surg 2006; 13: Teefey A, Dahiya N, Middleton W, Bajaj S, Dahiya N, Ylagan L, Hildebolt C. Acute Cholecystitis: Do Sonographic Findings and WBC Count Predict Gangrenous Changes?. AJR 2013; 200: Levy A, Murakata L,Rohrmann C. Gallbladder Carcinoma: Radiologic-Pathologic Correlation. RadioGraphics 2001; 21: Page 13 of 14

14 4. Bortoff G, Chen M, Ott D, Wolfman N, Routh W. Gallbladder Stones: Imaging and Intervention. RadioGraphics 2000; 20: Levy A, Murakata L, Abbott R, Rohrmann C. Benign Tumors and Tumorlike Lesions of the Gallbladder and Extrahepatic Bile Ducts: Radiologic-Pathologic Correlation. RadioGraphics 2002; 22: Rosenthal S, Cox G, Wetzel L, Batnitzky S. Pitfalls and Differential Diagnosis in Biliary Sonography. RadioGraphics 1990; 10: Rumack C, Wilson S, Charboneau J, Johnson J. Diagnostic Ultrasound Edition 3. Elsevier Health Sciences 2004; ISBN: Personal Information Page 14 of 14