Diffuse gallbladder wall edema . Beyond cholecystitis
Poster No.:
C-2360
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
D. Durany Lara, J. ARCE, C. Sanchez; Badalona/ES
Keywords:
Biliary Tract / Gallbladder, Liver, Abdomen, MR, CT, Ultrasound,
Cholangiography, Education, Edema, Inflammation, Pathology
DOI:
10.1594/ecr2014/C-2360
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Page 1 of 11
Learning objectives
Diffuse gallbladder wall thickening can result from a broad spectrum of pathologic
conditions, including surgical and nonsurgical diseases. Diffuse gallbladder wall edema
is usually a non surgical condition.
Characterization and diferentiation of gallbladder wall edema from other types of mural
thickening with the other radiological findings allow a more specific and limited differential
diagnosis.
Background
Thickening of gallbladder disease is one of the most common signs and a valuable proof
of primary gallbladder disease. However, it is nonspecific and it can be present in a
great variety of illnesses unrelated to intrinsic gallbladder disease. In acute cholecystitis
it's common to findgallbladder distention, wall thickening,mucosal hyperenhancement,
pericholecystic fat stranding or fluid, and gallstones.
Diffuse thickening of the gallbladder wall may occur in patients without a primary
gallbladder disease; in whom the gallbladder is involved due to a secondarily pathologic
condition or extrabiliary inflamation.
In patients with secondary conditions causing gallbladder wall thickening, a surgical
treatment is unwarranted and it will usually return to normal condition after correction of
its extrinsic cause.
Fig 1. and 2.
The most common secondarily conditions causing gallbladder wall edema are hepatic
disfunction, heart and kidney failure, venoocclusive intrahepatic disease and capillary
hyperpermeability. The ethiological mecanism of these conditions might be due to
elevated systemic venous pressure, elevated portal venous pressure, decreased
intravascular osmotic pressure.
The most common extra-biliary inflamatory conditions are hepatitis (there is a correlation
between moderate-severe inflamatory activity and gallbladder wall edema in chronic
hepatitis B patients), pancreatitis, pyelonephritis, HIV and infectious mononucleosis.
Page 2 of 11
Fig 3.
Fig 4.
TABLE 1.
Images for this section:
Fig. 1: Fig 1 and 2. 33-year-old woman with medical treatment reaction (gold salts)
involving liver and gallbladder. Axial T2-weighted MR image and fat-saturated T2weighted image at the initial MR showing periportal and gallbladder wall edema. Same
images after resolution of clinical scenario showing absence of periportal and gallbladder
edema. MR cholangiography evolution between the initial examination depicting difuse
enlargement of gallbladder wall consisting of edema and follow up after resolution of
symptoms and overall illness (3 months).
Page 3 of 11
Fig. 2: Fig 1 and 2. 33-year-old woman with medical treatment reaction (gold salts)
involving liver and gallbladder. Axial T2-weighted MR image and fat-saturated T2weighted image at the initial MR showing periportal and gallbladder wall edema. Same
images after resolution of clinical scenario showing absence of periportal and gallbladder
edema. MR cholangiography evolution between the initial examination depicting difuse
enlargement of gallbladder wall consisting of edema and follow up after resolution of
symptoms and overall illness (3 months).
Page 4 of 11
Fig. 3: Fig 3. 33-year-old woman with medical treatment reaction (gold salts) involving
liver and gallbladder. Abdominal CT and axial T2-weighted MR images and fat-saturated
T2-weighted images with MR cholangiography at the initial MR showing moderate
hepatomegaly and diffuse periportal edema. The gallbladder wall is smoothly and
diffusely thickened (edema) without gallstones and no changes in pericholecystic fat.
Page 5 of 11
Fig. 4: Fig 4. 35-year-old woman with abdominal pain, fever and progesive alteration in
blood tests. Coronal T2-weighted images show hepatomegaly with diffuse hiperintensity
of gallbladder wall without changes in pericholecystic fat and absence of biliar duct
dilatation, periportal edema and intraabdominal free liquid. Follow up showed persistance
of described findings and hepatic biopsy was done. The final diagnosis was acute
hepatitis due to sepsis.
Page 6 of 11
Table 1: ETIOLOGY OF GALLBLADDER WALL THICKENING (EDEMA).
Page 7 of 11
Findings and procedure details
Abdominal ultrasound should serve as the initial imaging technique to evaluate patients
with suspected gallbladder disease, followed by CT (MDCT) as a first aproach or used
secondarily with an inconclusive sonography examination. MRI has a potential value in
the evaluation of gallbladder disease when there is no certain diagnosis after US and
CT.Magnetic resonance (MR) imaging has assumed an increasing role as an adjunct
modality for gallbladder imaging, primarily in patients who are incompletely assessed
with US.
Beyond the commonly known radiological features of gallbladder wall thickening in
ultrasound and CT, MRI allows better depiction of the gallbladder wall and surrounding
structures. Pericholecystic fluid collections and edema of the surrounding liver tissue may
also be found. Periportal hyperintensity, although a nonspecific finding, may be observed
on T2-weighted images.
Fig. 5.
Hepatomegaly, periportal edema, intraabdominal fluid, adenopathies, intrahepatic
vessels diameter and normal bile ducts are examples of additional information that may
be useful in assessing the etiopathology of gallbladder wall edema.
In venoocclusive disease there is hepatomegaly, narrow hepatic veins, periportal cuffing,
gallbladder wall thickening with marked hyperintensity on T2 weighted images and ascitis.
As it is said before, in venoocclusive disease there is narrowing of hepatic veins but in
capillary hyperpermeability there is also narrowing of intrahepatic vena cava.
Fig 6.
Images for this section:
Page 8 of 11
Fig. 5: Fig 5. 47-year-old man with abdominal pain, jaundice and cholestasis in blood test.
Policystic liver and kidney disease was depicted in US with mild thickening of gallbladder
wall. Axial T2-weighted images show hyperintensity of periportal tissue and enlargement
of gallbladder wall without other signs of intrinsic gallbladder involvement. Final diagnosis
was achieved by hepatic biopsy with the result of acute autoimmune hepatitis.
Fig. 6: Fig 6. 18-year-old boy with anaplastic lymphoma (treatment with methotrexate)
with abdominal pain and alteration in liver enzymes in blood tests. Axial T2weighted images show hepatoesplenomegaly with small quantity of intraabdominal fluid.
Hiperintensity of periportal space and diffuse and homogeneous gallbladder edema
was also depicted. There was an intrahepatic vena cava almost collapsed, filiform
and suprahepatic veins were not visible. The diagnose of venoocclusive disease was
proposed.
Page 9 of 11
Conclusion
Clinical presentation in association with several image findings determines in most cases
the origin of the pathologic gallbladder condition. MRI is a highly valuable technique that
depicts gallbladder and surrounding structures allowing better diagnosis of the ethiology
of the disease.
Take home messages:
•
•
Gallbladder wall edema is not necessarily a synonim of acute cholecystitis.
There are some radiological findings that must be taken into account
when trying to propose a diagnose in patients with wall gallbladder edema
(hepatomegaly, periportal edema, free intrabdominal liquid, caliber of hepatic
veins).
Personal information
[email protected]
References
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