G a s t r o i n t e s t i n a l I m a g i n g • R ev i ew

Smith et al.
Imaging of Gallbladder Inflammatory Disease

Gastrointestinal Imaging
Review

Cross-Sectional Imaging of
Acute and Chronic Gallbladder
Inflammatory Disease
Ethan A. Smith1 OBJECTIVE. The purpose of this article is to provide a comprehensive review of the
Jonathan R. Dillman1 clinical and cross-sectional imaging features of a variety of acute and chronic gallbladder
Khaled M. Elsayes1 inflammatory diseases.
Christine O. Menias 2 CONCLUSION. Inflammatory gallbladder diseases are a common source of abdominal
Ronald O. Bude1 pain and cause considerable morbidity and mortality. Although acute uncomplicated cholecys-
titis and chronic cholecystitis are frequently encountered, numerous other gallbladder inflam-
Smith EA, Dillman JR, Elsayes KM, Menias CO, matory conditions may also occur that can be readily diagnosed by cross-sectional imaging.
American Journal of Roentgenology 2009.192:188-196.

Bude RO

A
cute and chronic inflammatory
gallbladder diseases are a com-
mon cause of upper abdominal
pain. Although many of these
conditions may cause significant morbidity
and mortality if left untreated, the prognosis
is generally excellent with prompt diagnosis
and management. Imaging often plays an im-
portant role in the evaluation of patients with
suspected gallbladder inflammatory disease.
In this article, we provide a comprehensive,
contemporary review of the pertinent clini-
cal and cross-sectional imaging features of
numerous acute and chronic gallbladder in-
flammatory conditions.
Acute Uncomplicated Cholecystitis
Acute cholecystitis is the most frequent
acute inflammatory condition of the gallblad-
Keywords: acute cholecystitis, chronic cholecystitis,
der. Approximately 90–95% of cases occur in
complicated cholecystitis, cross-sectional imaging
the setting of cystic duct or gallbladder neck
DOI:10.2214/AJR.07.3803 obstruction related to cholelithiasis [1]. This
condition characteristically affects middle-
Received February 7, 2008; accepted after revision aged women, often those who are obese. Clin-
July 23, 2008.
ical findings may include acute persistent right
1
Department of Radiology, University of Michigan Health upper quadrant abdominal pain, fever, nausea
System, 1500 E Medical Center Dr., Ann Arbor, MI and emesis, and focal tenderness directly
48109-5030. Address correspondence to E. A. Smith overlying the gallbladder. The patient may
(ethans@med.umich.edu). have a positive “Murphy sign,” defined as in-
2
Department of Radiology, Mallinckrodt Institute of
spiratory arrest on firm palpation along the
Radiology, St. Louis, MO. right upper quadrant costal margin. Labora-
tory findings in this setting may be normal or
AJR 2009; 192:188–196
abnormal and are often nonspecific. Serum
0361–803X/09/1921–188 liver transaminase, alkaline phosphatase,
and bilirubin levels may be abnormally ele-
© American Roentgen Ray Society vated, suggesting a hepatobiliary abnormal-
ity. Leukocytosis (often with a left shift) may
or may not be present.
Sonography is generally the preferred ini-
tial imaging technique when acute cholecys-
titis is clinically suspected. The sensitivity of
sonography for this condition ranges from
80% to 100% and specificity ranges from
60% to 100% [2–4]. Imaging findings may
include cholelithiasis, gallbladder wall thick-
ening (> 3–5 mm), pericholecystic fluid, and
the presence of a positive sonographic Mur-
phy sign (Fig. 1A). Less-specific imaging
findings include abnormally increased gall-
bladder distention and echogenic bile (sludge).
A gallstone may or may not be visualized
within the gallbladder neck or cystic duct [1].
Ralls et al. [5] noted that accuracy in diag-
nosing acute cholecystitis increased when us-
ing a combination of findings including
cholelithiasis, gallbladder wall thickening,
and a positive sonographic Murphy sign. For
example, they found that in a population of
patients with suspected acute cholecystitis,
gallstones alone had a positive predictive
value of 88%. When patients had a combina-
tion of gallstones and a positive sonographic
Murphy sign, the positive predictive value in-
creased to 92%. In patients with gallstones,
gallbladder wall thickening, and a positive
sonographic Murphy sign, the positive pre-
dictive value was 94%.
CT is commonly used in the evaluation of
abdominal pain when other diagnoses in ad-
dition to acute cholecystitis are being consid-
ered [6]. Gallbladder wall thickening (> 3–5
mm), mural or mucosal hyperenhancement,

188 AJR:192, January 2009

 Imaging of Gallbladder Inflammatory Disease

A B C
Fig. 1—85-year-old woman with right upper quadrant abdominal pain, leukocytosis, and fever.
A, Longitudinal sonogram shows multiple shadowing gallstones and mild wall thickening. There was positive sonographic “Murphy sign.”
B, Axial contrast-enhanced CT image shows gallbladder wall thickening (arrow) and pericholecystic soft-tissue stranding in fat (arrowhead). This image also shows that
gallstones are not always detected with CT.
C, Patient was not surgical candidate due to multiple comorbidities, so cholecystostomy tube was placed. Catheter injection under fluoroscopy 4 weeks later shows
multiple filling defects within gallbladder, consistent with gallstones. Gallstone is seen lodged in gallbladder neck (arrow).

pericholecystic fluid and adjacent soft-tissue show an impacted stone (a hypointense filling all cases of acute cholecystitis [6, 15]. Dis-
American Journal of Roentgenology 2009.192:188-196.

inflammatory stranding, abnormally increas­
ed gallbladder distention, and cholelithiasis
may be observed on CT in the setting of
acute cholecystitis [7] (Fig. 1B). Gallstones
on CT, if visualized, may appear as hyperat-
tenuating (calcified) or hypoattenuating
(gas-containing) filling defects within the
gallbladder lumen [8]. Liver parenchyma ad-
jacent to the gallbladder fossa may also hy-
perenhance because of reactive hyperemia,
particularly during arterial phase imaging,
giving rise to what is known as a transient
hepatic attenuation difference [8, 9]. CT is
also particularly useful for detecting the
complications of acute cholecystitis.
MRI is playing an increasing role in the
evaluation of acute abdominal pain, particu-
larly for pediatric and pregnant patients. Ac-
cording to Altun et al. [10], MRI has sensi-
tivity of 95% and specificity of 69% for the
detection of acute cholecystitis. Imaging
findings are similar to those observed on
sonography and CT, including gallbladder
wall thickening, mural or mucosal hyperen-
hancement, pericholecystic fluid and adja-
cent soft-tissue inflammatory changes, ab-
normally increased gallbladder distention,
and cholelithiasis (hypointense intraluminal
foci on T2-weighted imaging sequences).
Gallbladder wall thickening may be seen on
fat-suppressed T1- and T2-weighted images
as well as on contrast-enhanced fat-sup-
pressed T1-weighted images [11]. Hyperen-
hancement of adjacent liver parenchyma on
contrast-enhanced fat-saturated T1-weighted
images may be noted, similar to CT [10].
MR cholangiopancreatography (MRCP) may
defect surrounded by hyperintense bile) in
the gallbladder neck or cystic duct [11].
Management of acute uncomplicated chole­
cystitis may vary depending on the clinical sit-
uation and institution. Many consider acute
gallbladder inflammation to be a relative con-
traindication to cholecystectomy [12]. In this
situation, acute cholecystitis may be treated ini-
tially with inpatient hospital admission and ad-
ministration of broad-spectrum IV antimicro-
bial therapy. Nonemergent cholecystectomy
then follows after the acute inflammation has
subsided. A recent study by Stevens et al. [12],
however, has shown that immediate cholecys-
tectomy may be as safe as delayed surgical in-
tervention. On occasion, when medical man-
agement fails or surgery is contraindicated,
acute cholecystitis may be treated with percuta-
neous catheter drainage to decrease intraluminal
pressure and decrease the risk of gallbladder
perforation [13] (Fig. 1C). When bile aspirated
from the gallbladder is cultured, specimens are
positive for an infectious agent in only 16–49%
of patients [14]. Sosna et al. [14] found clinical
improvement in 52% of patients treated with
percutaneous aspiration or cholecystostomy
tube placement.
Acute Complicated Cholecystitis
Gangrenous Cholecystitis and
Gallbladder Perforation
Gangrenous change may occur in the set-
ting of advanced acute cholecystitis and is
associated with increased patient morbidity
and mortality [15]. Therefore, prompt diag-
nosis and treatment of this condition are cru-
cial. Gangrenous change occurs in 2–29% of
tinguishing acute uncomplicated cholecysti-
tis from gangrenous cholecystitis can be
clinically difficult and is important because
medical and surgical management of these
entities may differ. Although patients with
gangrenous cholecystitis are typically more
acutely ill at the time of presentation, this
may not always be the case. According to a
study by Fagan et al. [15], the only statisti-
cally significant predictors of gangrenous
change in the setting of acute cholecystitis
were a history of diabetes mellitus and a
WBC greater than 15,000 cells/mL at the
time of initial presentation. Gangrenous
cholecystitis is thought to occur as a result of
abnormally increased gallbladder distention
and subsequent ischemic mural necrosis
caused by vascular compromise.
Imaging plays an important role in the dis-
crimination of acute uncomplicated chole-
cystitis from gangrenous cholecystitis. Many
imaging features of gangrenous cholecystitis
overlap with those of acute uncomplicated
cho­lecystitis on sonography. Sonographic
find­ings suggesting gangrenous change in-
clude floating intraluminal membranes (rep-
resenting sloughed mucosa), echogenic shad-
owing foci consistent with gas within the
gallbladder wall or lumen, frank disruption
of the gallbladder wall, and pericholecystic
abscess formation [16]. Teefey et al. [17] re-
ported that a specific sign supporting the
diagnosis of gangrenous cholecystitis is gall-
bladder wall striation, or the presence of al-
ternating mural hyperechoic and hypoechoic
linear areas, which can be seen in up to 40%
of patients.

AJR:192, January 2009 189

 Smith et al.

Evaluation of gangrenous cholecystitis with

CT may also be of diagnostic utility. Bennet
et al. [6] found that CT was highly specific for
gangrenous cholecystitis (96%), although sen-
sitivity was poor (29%). Specific findings that
suggest gangrenous cholecystitis include foci
of gas within the gallbladder wall, lack of
gallbladder wall enhancement (focal or dif-
fuse), intraluminal membranes, and peri­
cholecystic abscess formation. Additional CT
findings that suggest gangrenous cholecystitis
include mural striation and adjacent hepatic
parenchyma hyperenhancement [6, 8]. A B
Abnormally hyperintense areas of fat-sup- Fig. 2—76-year-old man with history of repaired abdominal aortic aneurysm and recent diagnosis of acute
pressed T1-weighted and T2-weighted signal uncomplicated cholecystitis by sonography and hepatobiliary scintigraphy. Patient was subsequently managed
within and adjacent to the gallbladder wall conservatively without cholecystectomy but developed worsening abdominal pain and fever a few days later.
A, Follow-up sonogram through gallbladder and hepatorenal fossa shows heterogeneous mass containing
on MRI suggest possible perforation in the multiple echogenic shadowing foci.
setting of acute cholecystitis. Causes for such B, Axial contrast-enhanced CT image shows indistinct gallbladder wall (arrow), pericholecystic and
areas of signal abnormality include gallblad- hepatorenal fossa fluid, and gallstones outside of gallbladder (arrowheads), confirming gallbladder perforation.
der wall ulceration, intramural hemorrhage,
mural necrosis, and abscess formation. Lack Complications are more frequent in patients typically affects elderly men, often in the set-
American Journal of Roentgenology 2009.192:188-196.

of gallbladder wall enhancement on contrast-
enhanced fat-suppressed T1-weighted imag-
es also suggests gangrenous change [11].
An important complication of gangrenous
cholecystitis is gallbladder perforation. Gall-
bladder perforation is caused by transmural
necrosis in the setting of acute cholecystitis.
Acute uncomplicated cholecystitis will eventu-
ally progress to perforation in 2–11% of cases,
with a reported mortality rate of up to 60%
[18]. On occasion, patients may experience sig-
nificant pain relief on perforation. Perforation
has been classified into three types. Type I per-
foration involves free spill of gallbladder in-
traluminal contents into the peritoneal cavity,
whereas type II perforation is a more subacute
process that is contained by an adjacent ab-
scess. Type III perforation is a chronic process
with the formation of a cholecystoenteric fistula
[1, 18, 19]. The most common site of perfora-
tion is the gallbladder fundus.
Small areas of gallbladder perforation may
be difficult to detect on imaging. A focal de-
fect in the gallbladder wall may be visualized
on sonography, CT, or MRI. An extraluminal
gallstone is a specific imaging finding that in-
dicates perforation (Fig. 2). More often, find-
ings of perforation are nonspecific and include
pericholecystic fluid, gallbladder lumen col-
lapse, and pericholecystic abscess [1, 20].
The treatment of gangrenous cholecystitis,
with or without perforation, generally re-
quires prompt surgical intervention with
cholecystectomy and debridement. IV anti-
microbial therapy is also required. Percuta-
neous catheter drainage may be used in pa-
tients for whom surgery is not appropriate.
with gangrenous cholecystitis and the prog- ting of underlying diabetes mellitus or some
nosis is poorer than with acute uncomplicated other debilitating disease [1, 11, 22]. Al-
cholecystitis [21]. though patients with emphysematous cho­
lecystitis may present clinically in a manner
Emphysematous Cholecystitis similar to those with acute uncomplicated
Emphysematous cholecystitis is defined as cholecystitis, individuals with diabetic neu-
the presence of gas within the gallbladder ropathy may not experience typical right up-
wall or lumen in the setting of acute cholecys- per quadrant pain [1].
titis without demonstrable abnormal fistulous Emphysematous cholecystitis may be di-
communication between the gallbladder and agnosed initially using abdominal radiogra-
the gastrointestinal tract. This condition is phy. Radiographs that reveal curvilinear lu-
thought to be secondary to underlying vascu- cencies within the gallbladder wall or an
lar insufficiency and ischemia of the gallblad- air–fluid level within the gallbladder lumen
der wall [1, 22]. As a consequence, gas-form- are specific for this entity in the setting of
ing bacteria are able to proliferate within the suspected cholecystitis (Fig. 3A). Gill et al.
gallbladder wall or lumen. Implicated bacte- [22] found that the sensitivity of abdominal
rial organisms include Clostridium species, radiography is low. As a result, sonography is
Escherichia coli, Staphylococcus aureus, and frequently the initial imaging technique for
Streptococcus species [1, 22]. This condition diagnosing this condition. Sonography findings
A B
Fig. 3—62-year-old man with emphysematous cholecystitis.
A, Abdominal radiograph shows curvilinear lucencies in right upper quadrant in expected location of
gallbladder (arrows).
B, Longitudinal sonogram shows echogenic gas in gallbladder wall (arrowheads). This sonographic appearance
may be difficult to distinguish from gallbladder wall calcification without correlative radiography.

190 AJR:192, January 2009

 Imaging of Gallbladder Inflammatory Disease
may be similar to those seen in acute uncom-
plicated cholecystitis. In addition, curvilinear
or punctate hyperechoic foci, often with re-
verberation artifact (also known as ring-
down artifact) are present, corresponding to
foci of gas within the gallbladder wall or lumen
[1, 22, 23] (Fig. 3B).
CT is considered the most sensitive and spe-
cific imaging technique for the diagnosis of
emphysematous cholecystitis [22]. CT shows
low-attenuation foci consistent with gas within
the gallbladder wall or lumen (Fig. 4). Addi-
tional findings may be similar to those observed
in acute uncomplicated cholecystitis. On MRI,
areas of signal void within the gallbladder wall
or lumen may be observed, corresponding to
foci of intramural or intraluminal gas [11].
Complications of emphysematous cholecys-
titis include gangrenous change, perforation,
and pericholecystic abscess formation [24].
Both peritonitis and sepsis may also occur.
American Journal of Roentgenology 2009.192:188-196.
Garcia-Sancho Tellez et al. [24] reported a
mortality rate of up to 25% in the setting of
emphysematous cholecystitis. In general, the
management of emphysematous cholecystitis
involves emergent cholecystectomy and IV an-
timicrobial therapy. Percutaneous cholecystos-
tomy tube placement may be performed in pa-
tients who are not surgical candidates [21].
Suppurative Cholecystitis
Suppurative cholecystitis (gallbladder em-
pyema) may occur as a complication of acute
cholecystitis. This condition results when puru-
lent material fills and distends the gallbladder
lumen. Patients with suppurative cholecystitis
may experience symptoms similar to those ex-
perienced by patients with acute uncomplicated
cholecystitis, including fever, chills, rigors, and
right upper quadrant pain. Signs of sepsis may
or may not be present [25].
On sonography and CT, imaging findings of
suppurative cholecystitis are nonspecific and
similar to those seen in acute uncomplicated
cholecystitis. Echogenic (at sonography) or high-
attenuation (at CT) material consistent with pus
is identified within the distended gallbladder lu-
men and is indistinguishable from sludge. MRI
is sometimes helpful in distinguishing pus from
sludge using heavily T2-weighted sequences,
which may show a fluid–fluid level with depen-
dent layering of purulent bile [11].
Treatment options for suppurative cholecys-
titis include both emergent cholecystectomy
and percutaneous catheter drainage. The rate
of conversion of laparoscopic cholecystectomy
to an open procedure is greater than that ob-
served in cases of uncomplicated acute chole-
AJR:192, January 2009 191
A B
Fig. 4 —76-year-old man with history of type 2 diabetes mellitus and new right upper quadrant pain.
A, Axial contrast-enhanced CT image shows inflammatory stranding involving fat adjacent to gallbladder (arrow).
B, Contrast-enhanced CT through mid gallbladder shows gas within gallbladder lumen, consistent with
emphysematous cholecystitis (arrow).
cystitis [21]. Patients with this condition are
also treated with IV antimicrobial therapy.
Hemorrhagic Cholecystitis
Hemorrhage into the gallbladder wall and
lumen may be observed in the setting of acute
calculous or acalculous cholecystitis [11].
Hemorrhagic cholecystitis may present clini-
cally with acute onset of biliary colic, jaun-
dice, melena, and hematemesis [1]. Hemor-
rhagic cholecystitis must be differentiated
from other causes of gallbladder hemorrhage,
such as trauma, neoplasm, and coagulopathy
(often related to anticoagulation therapy).
Hemorrhagic cholecystitis typically pres-
ents on sonography and CT with imaging
findings suggestive of acute cholecystitis. In
addition, sonography may show echogenic or
heterogeneous material within the gallblad-
der wall or lumen because of hemorrhage.
On CT, high-attenuation blood products are
present within the gallbladder wall or lumen
[1, 26] (Fig. 5). On occasion, intraluminal
hemorrhage may be difficult to distinguish
from sludge. MRI can be quite specific in
the diagnosis of this condition. Subacute
blood products are generally hyperintense on
both T1-weighted and T2-weighted images
because of the presence of extracellular
methemoglobin [11].
Complications of hemorrhagic cholecystitis
include gallbladder wall perforation and asso-
ciated potentially catastrophic hemoperitone-
um [27]. Treatment typically involves chole-
cystectomy and IV antimicrobial therapy [28].
Acalculous Cholecystitis
Acalculous cholecystitis is most often ob-
served in the critically ill population, in-
cluding postoperative and trauma patients in
Fig. 5—62-year-old woman with right upper quadrant
pain. Axial unenhanced CT image through level of
mid gallbladder shows abnormal high-attenuation
material within abnormally distended gallbladder
lumen. At surgery, imaging findings were confirmed
to represent hemorrhagic cholecystitis.
an ICU setting as well as those patients re-
ceiving total parenteral nutrition [29]. This
condition is thought to be caused by a gradu-
al increase in bile viscosity that leads to
eventual functional obstruction of the cystic
duct [30]. The clinical diagnosis of acute
acalculous cholecystitis frequently is diffi-
cult because affected patients often have
multiple medical comorbidities as well as
numerous other complicating issues such as
mechanical respiration, sedation, and post-
operative pain.
Sonography and CT are commonly used
imaging techniques in the evaluation of acal-
culous cholecystitis. Mirvis et al. [30] deter-
mined that sonography had sensitivity of
92% and specificity of 96% for the diagnosis
of this condition. Common sonographic find-
ings include abnormally increased gallblad-
der distention, gallbladder wall thickening
(> 3–5 mm), pericholecystic fluid (in the ab-
sence of ascites), and sludge (in the absence
 Smith et al.

A B C
Fig. 6—37-year-old pregnant women who presented to emergency department with new right upper quadrant abdominal pain.
A, Longitudinal sonogram shows gallbladder distention, wall thickening (arrow), and pericholecystic fluid (arrowheads).
B, Transverse sonogram also reveals wall thickening (arrow), pericholecystic fluid (arrowheads), and echogenic bile (sludge). No gallstones were visualized.
C, Axial contrast-enhanced CT image shows peripheral wedged-shaped areas of low attenuation in right hepatic lobe and spleen (arrowheads), consistent with infarcts.
On basis of clinical history, imaging findings, and laboratory blood testing, patient was diagnosed with acalculous cholecystitis in setting of underlying hemolysis,
elevated liver enzymes, and low platelet count syndrome.

of cholelithiasis) (Fig. 6). CT may reveal cholecystitis and infection with Helicobacter
similar imaging findings as well as peri­ pylori [33].
American Journal of Roentgenology 2009.192:188-196.

cholecystic inflammatory stranding with ad-
jacent liver hyperemia [30].
MRI is not commonly performed in pa-
tients with acalculous cholecystitis because,
at least in part, of the difficulty in perform-
ing MRI studies in critically ill patients.
When MRI is performed, findings suggestive
of acalculous cholecystitis are similar to
those seen on sonography and CT, including
abnormally increased gallbladder distention,
gallbladder wall thickening, and adjacent
inflammatory changes in the absence of
cholelithiasis [11].
Complications of acute acalculous chole-
cystitis include gangrenous change, perfo-
ration, and pericholecystic abscess [29]. Un-
complicated cases may be treated with
cholecystectomy if there are no surgical con-
traindications and IV antimicrobial therapy.
Frequently, critically ill patients with acalcu-
lous cholecystitis are managed conservative-
ly with either gallbladder aspiration or chole-
cystostomy tube placement in addition to IV
antimicrobial therapy [14, 30, 31].
Chronic Cholecystitis
Chronic cholecystitis is a common inflam-
matory condition that affects the gallbladder.
This condition almost always arises in the
setting of cholelithiasis. Patients may have a
history of recurrent acute cholecystitis or bil-
iary colic, although some patients may be
asymptomatic [32]. Microscopically, there is
evidence of chronic inflammation within the
gallbladder wall. Gallbladder dysmotility
may also be present. Recent studies have also
raised a possible connection between chronic
The most commonly observed cross-sec-
tional imaging findings in the setting of
chronic cholecystitis are cholelithiasis and
gallbladder wall thickening (Fig. 7). The gall-
bladder may appear contracted or distended,
and pericholecystic inflammation is usually
absent [34]. Hepatobiliary scintigraphy may
be required to distinguish acute from chronic
cholecystitis and to evaluate gallbladder dys-
motility by calculation of the gallbladder
ejection fraction in response to exogenous
cholecystokinin administration [35]. Uncom­
plicated chronic cholecystitis is generally
managed with elective cholecystectomy.
Possible complications related to chronic
cholecystitis include acute cholecystitis and
gallbladder carcinoma. An uncommon com-
plication is the formation of a biliary–enteric
fistula. This can lead to passage of gallstones
into the small bowel with resultant obstruc-
tion, also known as gallstone ileus. Typically,
the gallstones lodge in the terminal ileum
near the ileocecal valve; however, gallstones
may be found anywhere throughout the small
bowel and occasionally within the colon in
this disorder [36]. Rarely, an ectopic gall-
stone will migrate proximally and cause gas-
tric outlet obstruction [37]. Radiographically,
the diagnosis can be made by identifying the
Rigler’s radiographic triad, which includes
pneumobilia, an ectopic gallstone, and evi-
dence of bowel obstruction (Fig. 8). This
combination of imaging findings, however, is
seen in a minority of patients with gallstone
ileus [36]. Gallstone ileus carries a high
mortality rate (20–40%) and is treated surgi-
cally [36, 38].
Fig. 7—80-year-old woman with intermittent right
upper quadrant abdominal pain, proven to represent
chronic cholecystitis after cholecystectomy. Axial
contrast-enhanced CT image shows gallbladder wall
thickening and adjacent hepatic hyperenhancement,
prospectively thought to represent acute
cholecystitis. Subsequent hepatobiliary scintigraphy
(hepatoiminodiacetic scan) was negative for acute
cholecystitis, as the gallbladder filled with radiotracer.
Xanthogranulomatous Cholecystitis
Xanthogranulomatous cholecystitis is a
rare gallbladder inflammatory disorder char-
acterized by abnormal intramural nodules
[39, 40]. These nodules are thought to form
when the Rokitansky–Aschoff sinuses be-
come occluded and rupture. Bile then ex-
travasates into the gallbladder wall causing
an inflammatory reaction, characterized by
the presence of histiocytes, multinucleated
giant cells, and fibroblasts. Superimposed in-
fection is also frequently present. This condi-
tion is most commonly observed in elderly
patients, although a wide range of ages has
been observed [41].
Cholelithiasis and gallbladder wall thick-
ening are the most common findings on

192 AJR:192, January 2009

 Imaging of Gallbladder Inflammatory Disease

A B C
Fig. 8—82-year-old woman with biliary–enteric fistula and gallstone ileus. (Courtesy of Ravi Kaza, Ann Arbor, MI)
A, CT scout image shows multiple abnormally dilated loops of small bowel, suspicious for small-bowel obstruction.
B, Axial contrast-enhanced CT image shows gas within gallbladder (arrow), diffuse gallbladder wall thickening (arrowheads), and pericholecystic fluid. Multiple
abnormally dilated fluid-filled loops of small bowel are also seen.
American Journal of Roentgenology 2009.192:188-196.

C, Axial contrast-enhanced CT image inferior in relation to B shows dilated loops of small bowel (arrowheads) and round, lamellated structure within small-bowel loop
(arrow), proven to represent ectopic gallstone.

sonography and CT in patients with xan-

thogranulomatous cholecystitis. Mural thick-
ening may be focal or diffuse. Pericholecystic
inflammatory changes may also be present.
Intramural hypoechoic (on sonography) or
hypoattenuating (on CT) nodules or bands
may suggest the specific diagnosis of xan-
thogranulomatous cholecystitis [40]. The
diagnosis is rarely made before surgery and
histopathologic evaluation of the gallbladder
[39–41] (Fig. 9). On occasion, xanthogranu-
lomatous cholecystitis may mimic gallbladder
carcinoma on cross-sectional imaging [39].
Complications attributed to xanthogranu-
lomatous cholecystitis include gallbladder
perforation, hepatic abscess, biliary ductal
stricture with or without biliary obstruction,
ascending cholangitis, and biliary fistula
[41]. Patients with xanthogranulomatous
cholecystitis also may be at increased risk of
gallbladder malignancy [39, 41]. Treatment
is typically elective open cholecystectomy
because laparoscopic cholecystectomy is of-
ten unsuccessful due to adhesions and adja-
cent fibrosis.
Mirizzi Syndrome
Mirizzi syndrome may occur as an acute
presentation of cholelithiasis or in the setting
of acute cholecystitis. The condition occurs
when an impacted gallstone in the gallbladder
neck or cystic duct causes biliary tree obstruc-
tion and cholestasis. Cholestasis is the result
of either direct compression of the adjacent
A B
Fig. 9—Two patients with xanthogranulomatous cholecystitis.
A, In 27-year-old woman with intermittent right upper quadrant abdominal pain, longitudinal sonogram
shows cholelithiasis and equivocal gallbladder wall thickening. Although patient was thought to have chronic
cholecystitis and underwent elective cholecystectomy, lipid-laden macrophages were identified within
gallbladder wall, confirming diagnosis of xanthogranulomatous cholecystitis.
B, In 73-year-old woman who also presented with right upper quadrant pain, coronal contrast-enhanced CT
image shows irregular gallbladder wall thickening and multiple low-attenuation mural nodules (arrowheads).
This patient was found to have xanthogranulomatous cholecystitis at histopathology.
common hepatic duct or secondary local in- or cystic duct and dilatation of the common
flammation causing bile duct wall edema and hepatic duct and the more proximal intrahe-
fibrosis. Patients may or may not experience patic bile ducts (Fig. 10). Additional findings
right upper quadrant abdominal pain, fever, may include normal caliber of the common
and leukocytosis [1, 6, 42]. Mirizzi syndrome bile duct, pericholecystic and peribiliary
most commonly presents with a relatively ductal inflammatory changes, and gallblad-
acute onset of obstructive jaundice. Differen- der wall thickening [1, 42, 43]. MRI and
tiation of this condition from other causes of MRCP are useful for visualizing a dilated
obstructive jaundice is critical to direct proper common hepatic duct and a normal-caliber
medical and surgical management. more distal common bile duct. Imaging, par-
Sonography and CT findings observed in ticularly MRI and MRCP, can help distin-
Mirizzi syndrome include the presence of a guish Mirizzi syndrome from other causes of
gallstone located within the gallbladder neck obstructive jaundice such as pancreatic or

AJR:192, January 2009 193

 Smith et al.

A B C

Complications of gallbladder volvulus re-

late primarily to vascular compromise and
resultant ischemia. As a result, both gangre-
nous change and perforation may occur.
Emergent cholecystectomy is the preferred
treatment [45].
American Journal of Roentgenology 2009.192:188-196.

Acute Hepatitis-Related
Gallbladder Changes
Inflammatory changes involving the gall-
bladder may be observed in patients with
clinical and laboratory findings of acute hep-
D E atitis, regardless of the underlying cause.
Fig. 10—Two patients with Mirizzi syndrome.
Such gallbladder changes are most common-
A, In 86-year-old man with right upper quadrant pain and new-onset obstructive jaundice (total bilirubin = 3.8 ly thought to be reactive because of adjacent
mg/dL), axial contrast-enhanced CT image shows moderate intrahepatic biliary dilatation (arrowheads). hepatic inflammation. Maresca et al. [46]
B, Axial contrast-enhanced CT image slightly inferior to A shows gallbladder wall thickening, pericholecystic identified gallbladder abnormalities on
stranding, and abnormal gallbladder distention.
C, Coronal reformatted CT image confirms presence of large gallstone in gallbladder neck (arrow). sonography in 51% of consecutive patients
D, In 68-year-old woman also with Mirizzi syndrome, coronal T2-weighted image shows large hypointense presenting with a clinical and laboratory di-
gallstone in gallbladder neck (arrow). A few small, nonobstructing stones are also present more distally in agnosis of acute hepatitis. Their study also
common bile duct (arrowhead).
E, ERCP performed on same patient as in D shows extrinsic compression on common hepatic duct (arrow) by found a direct correlation between the timing
large gallstone within gallbladder neck. Intrahepatic biliary dilatation (arrowheads) is also present. of onset of symptoms and imaging findings.
Eighty-one percent of patients imaged within
biliary neoplasms and sclerosing cholangitis [11, 44]. This condition may also be observed 7 days of onset of clinical symptoms had ab-
as well as numerous additional benign and when there has been significant patient normal gallbladder findings on sonography,
malignant biliary narrowing causes [11]. weight loss with resultant loss of perichole- whereas only 28% of patients imaged at
Traditionally, the treatment for Mirizzi cystic fat. On torsion, gallbladder venous greater than 7 days had sonographic abnor-
syndrome has been surgery. In the past, this drainage becomes obstructed and ischemia malities. A direct correlation has also been
specific diagnosis may not have been clear ensues. Torsion may be complete (> 180°) or reported between the level of elevation of se-
prior to the time of surgical intervention. incomplete (< 180°). The majority of patients rum liver transaminases and the degree of
More recently, however, endoscopic diagno- with this condition are elderly women [44]. gallbladder wall thickening on sonography
sis and treatment with ERCP has been used. Imaging findings compatible with gallblad- [46, 47].
Recognition of related complications, such as der torsion on sonography and CT include ab- Sonography findings observed in the set-
biliary fistula formation, biliary tract stric- normal orientation of the gallbladder, abrupt ting of acute hepatitis include marked gall-
ture, and gallbladder perforation, are of clini- tapering of the cystic duct, pericholecystic bladder wall thickening, gallbladder contrac-
cal importance because they may require an inflammatory changes, and abnormally in- tion, and echogenic bile [47] (Fig. 12). The
alteration in the treatment approach [42]. creased luminal distention [44] (Fig. 11). gallbladder wall may also show three distinct
Cholelithiasis may be absent. MRCP can be layers with central hypoechogenicity [46].
Gallbladder Volvulus useful in the diagnosis of this condition, The adjacent liver may show findings sug-
Gallbladder volvulus is a rare condition in showing abnormal twisting or tapering of the gestive of diffuse edema, including hy-
which variation in normal mesenteric anato- cystic duct and an abnormally distended poechoic parenchyma with prominent echo-
my allows the gallbladder to twist on itself gallbladder [11]. genic portal triads (the so-called starry-sky

194 AJR:192, January 2009

 Imaging of Gallbladder Inflammatory Disease

Fig. 11—100-year-old man with surgically proven

gallbladder torsion.
A, Abdominal radiograph shows masslike opacity in
right upper quadrant with mass effect on adjacent
colon (arrowheads).
B, Longitudinal sonogram is nonspecific, showing
abnormally increased gallbladder distention and
pericholecystic fluid (arrows).

A B

Fig. 12—Two patients with acute hepatitis-related

gallbladder changes.
A and B, 6-year-old girl with new abdominal pain
and jaundice. Laboratory evaluation was consistent
American Journal of Roentgenology 2009.192:188-196.

with acute hepatitis (aspartate aminotransaminase

[AST] = 2,205 IU/L, alanine aminotransaminase
[ALT] = 2,622 IU/L, total bilirubin = 15.8 mg/dL), later
determined to be due to Epstein-Barr virus infection.
Transverse (A) and longitudinal (B) sonograms
show marked gallbladder wall thickening (arrows)
and gallbladder contraction. Visualized portal
triads within liver on transverse image (A) appear
echogenic, suggesting hepatic edema.
C and D, 39-year-old woman with acetaminophen-
related acute fulminant hepatitis (AST = 5,147
IU/L, ALT = 3,596 IU/L, total bilirubin = 3.5 mg/dL). A B
Transverse (C) and longitudinal (D) sonograms
show marked gallbladder wall thickening and
pericholecystic fluid thought to be reactive in cause.

appearance), although this appearance is un-

common. CT may show diffuse gallbladder
wall thickening.
Treatment is generally directed at the un-
derlying cause of the acute hepatocellular in-
jury. Of interest, Juttner et al. [47] described a
correlation between the normalization of the
patient’s clinical and laboratory parameters
and the resolution of gallbladder abnormali-
ties on sonography.
Summary
Numerous acute and chronic inflammatory
conditions may affect the gallbladder. A vari-
ety of related complications with significant
morbidity and mortality can result. Prompt
diagnosis of gallbladder inflammatory disease
is important because treatment frequently re-
quires surgery, percutaneous and endoscopic
interventions, and IV antimicrobial therapy.
Multiple cross-sectional imaging techniques
C D
including sonography, CT, and MRI may all
play important roles in the diagnosis of gall-
bladder inflammatory diseases.
References
1. Bennett GL, Balthazar EJ. Ultrasound and CT
evaluation of emergent gallbladder pathology. Ra-
diol Clin North Am 2003; 41:1203–1216
2. van Breda Vriesman AC, Engelbrecht MR, Smith-
uis RHM, Puylaert JBCM. Diffuse gallbladder
wall thickening: differential diagnosis. AJR 2007;
188:495–501
3. Harvey RT, Miller WT. Acute biliary disease: ini-
tial CT and follow-up US versus initial US and
follow-up CT. Radiology 1999; 213:831–836
4. Rumack CM, Wilson SR, Charboneau JW, John-
son JA. Diagnostic ultrasound, 3rd ed., vol. 1. St.
Louis, MO: Elsevier Mosby, 2005:197–201
5. Ralls PW, Colletti 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
6. Bennet GL, Rusinek H, Lisi V, et al. CT findings
in acute gangrenous cholecystitis. AJR 2002; 178:

AJR:192, January 2009 195


275–281
7. Fidler J, Paulson EK, Layfield L. CT evaluation of
acute cholecystitis: findings and usefulness of di-
agnosis. AJR 1996; 166:1085–1088
8. Grand D, Horton KM, Fishman EK. CT of the
gallbladder: spectrum of disease. AJR 2004; 183:
163–170
9. Yamashita K, Lin MI, Hirose Y, et al. CT finding
of transient focal increased attenuation of the liver
adjacent to the gallbladder in acute cholecystitis.
AJR 1995; 164:343–346
10. Altun E, Semelka RC, Elias J, et al. Acute cholecys-
titis: MR findings and differentiation from chron-
ic cholecystitis. Radiology 2007; 244:174–183
11. Watanabe Y, Nagayama M, Okumura A, et al. MR
imaging of acute biliary disorders. RadioGraph-
ics 2007; 27:477–495
12. Stevens KA, Chi A, Lucas LC, Porter JM, Wil-
liams MD. Immediate laparoscopic cholecystec-
tomy for acute cholecystitis: no need to wait. Am J
Surg 2006; 192:756–761
American Journal of Roentgenology 2009.192:188-196.
13. Weiss CA 3rd, Lakshman TV, Schwartz RW. Cur-
rent diagnosis and treatment of cholecystitis. Curr
Surg 2002; 59:51–54
14. Sosna J, Kruskal JB, Copel L, Goldberg SN, Kane
RA. US-guided percutaneous cholecystostomy:
features predicting culture-positive bile and clini-
cal outcome. Radiology 2004; 230:785–791
15. Fagan SP, Awad SS, Rahwan K, et al. Prognostic
factors for the development of gangrenous chole-
cystitis. Am Surg 2003; 186:481–485
16. Jeffrey RB, Liang FC, Wong W, Callen PW. Gan-
grenous cholecystitis: diagnosis by ultrasound.
Radiology 1983; 148:219–221
17. Teefey SA, Baron RL, Radke HM, Bigler SA.
Gangrenous cholecystitis: new observations on
sonography. J Ultrasound Med 1991; 134:191–194
18. Derici H, Kara C, Bozdag AD, Nazli O, Tugrul T,
Akca E. Diagnosis and treatment of gallbladder
perforation. World J Gastroenterol 2006; 12:
7832–7836
19. Niemeier OW. Acute free perforation of the gall-
bladder. Ann Surg 1934; 99:922–924
20. Madrazo BL, Francis I, Hricak H, Sandler MA,
Hudak S, Gitschlag K. Sonographic findings in
gallbladder perforation. AJR 1982; 139:491–496
21. Borzellino G, Sauderland S, Minicozzi AM, et al.
196 AJR:192, January 2009
Smith et al.
Laparoscopic cholecystectomy for severe acute
cholecystitis: a meta-analysis of results. Surg En-
dosc 2008; 22:8–15
22. Gill KS, Chapman AH, Weston MJ. The changing
face of emphysematous cholecystitis. Br J Radiol
1997; 70:986–991
23. Parulekar SG. Sonographic findings in acute em-
physematous cholecystitis. Radiology 1982; 145:
117–119
24. Garcia-Sancho Tellez L, Rodriguez-Montes JA,
Fernandez de Lis S, Garcia-Sancho Martin L.
Acute emphysematous cholecystitis. report of
twenty cases. Hepatogastroenterology 1999; 46:
2144–2148
25. Kane RA. Ultrasonographic diagnosis of gangre-
nous cholecystitis and empyema of the gallblad-
der. Radiology 1980; 134:191–194
26. Jenkins M, Golding RH, Cooperberg PL. Sonog-
raphy and computed tomography of hemorrhagic
cholecystitis. AJR 1983; 40:1197–1198
27. Demir MK, Kilicoglu G, Akinci O. Perforated
hemorrhagic cholecystitis: MR imaging features.
Clin Radiol 2006; 61:899–901
28. Merrell S, Schneider PD. Hemobilia: evolution of
current diagnosis and treatment. West J Med 1991;
155:621–625
29. Orlando R, Gleason E, Drezner DA. Acute acalcu-
lous cholecystitis in the critically ill patient. Am J
Surg 1983; 145:472–476
30. Mirvis SE, Vanright JR, Nelson AW, et al. The
diagnosis of acute acalculous cholecystitis: a com-
parison of sonography, scintigraphy, and CT. AJR
1986; 147:1171–1175
31. McGahan JP, Walter JP. Diagnostic percutaneous
aspiration of the gallbladder. Radiology 1985;
155:619–622
32. Raptopoulos V, Compton CC, Doherty P, et al.
Chronic acalculous gallbladder disease: multiim-
aging evaluation with clinical–pathologic correla-
tion. AJR 1986; 147:721–724
33. Chen DF, Hu L, Yi P, Liu W, Fang DC, Cao H. H.
pylori are associated with chronic cholecystitis.
World J Gastroenterol 2007; 13:1119–1122
34. Yun EJ, Cho SG, Park S, et al. Chronic gallblad-
der carcinoma and chronic cholecystitis: differen-
tiation with two-phase spiral CT. Abdom Imaging
2004; 29:102–108
35. DiBaise JK, Oleynikov D. Does gallbladder ejec-
tion fraction predict outcome after cholecystecto-
my for suspected acalculous gallbladder dysfunc-
tion? A systematic review. Am J Gastroenterol
2003; 98:2605–2611
36. Bruljevac M, Busic Z, Cabrijan Z. Sonographic
diagnosis of gallstone ileus. J Ultrasound Med
2004; 23:1395–1398
37. Bhama JK, Ogren JW, Lee T, Fisher WE.
Bouveret’s syndrome. Surgery 2002; 132:104–105
38. Lassandro F, Romano S, Ragozzino A, et al. Role
of helical CT in diagnosis of gallstone ileus and
related conditions. AJR 2005; 185:1159–1165
39. Chun KA, Ha HK, Yu ES, et al. Xanthogranu-
lomatous cholecystitis: CT features with emphasis
on differentiation from gallbladder carcinoma.
Radiology 1997; 203:93–97
40. Parra JA, Acinas O, Bueno J, Güezmes A, Fernán-
dez MA, Fariñas MC. Xanthogranulomatous
cholecystitis: clinical, sonographic, and CT find-
ings in 26 patients. AJR 2000; 174:979–983
41. Roberts KM, Parsons MA. Xanthogranulomatous
cholecystitis: clinicopathological study of 13 cas-
es. J Clin Pathol 1987; 40:412–417
42. Abou-Saif A, Al-Kawas F. Complications of gall-
stone disease: Mirizzi syndrome, cholecystocho-
ledochal fistula, and gallstone ileus. Am J Gastro-
enterol 2002; 97:249–254
43. Becker CD, Hassler H, Terrier F. Preoperative di-
agnosis of the Mirizzi syndrome: limitations of
sonography and computed tomography. AJR 1984;
143:591–596
44. Quinn SF, Fazzio F, Jones E. Torsion of the gall-
bladder: findings on CT and sonography and the
role of percutaneous cholecystostomy. AJR 1987;
148:881–882
45. Nguyen T, Geraci A, Bauer JJ. Laparoscopic
cholecystectomy for gallbladder volvulus. Surg
Endosc 1995; 9:519–521
46. Maresca G, De Gaetano AM, Mirk P, Cuada R,
Federico G, Colagrande C. Sonographic patterns
of the gallbladder wall in acute viral hepatitis. J
Clin Ultrasound 1984; 12:141–146
47. Juttner HU, Ralls PW, Quainn MF, Jenney JM.
Thickening of the gallbladder wall in acute hepa-
titis: ultrasound demonstration. Radiology 1982;
142:465–466