Ultrasound of the Gallbladder - SD

Introduction

Hello, my name is Faye Lang.

I'm a radiologist at the Brigham and Women's Hospital in Boston, Massachusetts,
where I'm professor of radiology at Harvard Medical School.

The purpose of this lecture is to discuss using ultrasound to evaluate the gallbladder.

We're gonna be talking about ultrasound of the gallbladder, a common anatomic area to evaluate.

Let's have a look at it.

Evaluating Gallstones

Gallstones are usually not an issue when they're large and classic and show, as we see here,
a clean acoustic shadow, a dependent position and important the fact that they're mobile.

But sometimes when we're looking at a patient, we don't always get the classic appearance,
or you might be fooled, for example, in this case this looks like it could be a gallstone, but it's not.

That's just some bowel gas.

Seeing that a stone is mobile has important implications to be sure about the diagnosis.

These are gallstones, but you can see how close one image mimics the other.

Also fluid in the right upper quadrant does not equal a gallbladder in all cases.

In this patient, the history reveals there was a cholecystectomy and this is a post-op fluid collection.

What you really wanna look for is make sure there's a wall and the configuration of the gallbladder.

Every gallbladder has this fold in it called a junctional fold.

It's an embryologic result of the development of the gallbladder.

You should look for it in cases where there's any question if you're dealing with the gallbladder.

What I really wanna focus on is not the obvious stones, but the more subtle stones.

Patients who may have acute cholecystitis.

If you're not sure you're seeing the gallbladder, the significance of intraluminal echoes that are not due to calculi.

And the question of polyps, when do you worry? And are you dealing with adenomyosis or possibly cancer?

Acoustic Shadowing in Gallstones

Now we've already mentioned that when you have a gallstone you wanna see shadowing and in this case we see no shadowing here or no significant shadowing, but shadowing here.

And these are gallstones, but it's the same patient.

The question is, why did I not see shadowing over here?

Here's a case with sludge balls and I already mentioned these are gallstones, two different patients, identical scans.

Sludge balls you wouldn't expect shadowing gallstones. You work to see that they do shadow.

And what is the difference then between these two scans? Why do I see acoustic shadowing in the scan on the right?

It has to do with where the ultrasound, where the gallstone is relative to the ultrasound beam.

And if I am not occluding the beam or if I'm at the very edge of the beam, you will not see an acoustic shadow.

Having the stone there at the edge and not occluding the beam is not a good way to go.

What you really wanna do is have a narrow beam with the gallstone at the level where the beam is narrow and that implies you're using a high frequency.

The highest frequency possible transducer that you can use will result in a narrow beam and try to place that stone as you're going through it in the center of the beam to occlude it and create an acoustic shadow.

Here again, we do not see acoustic shadowing and that's because this patient was just turned immediately before this scan was done.

Having a patient hold a position for a few minutes lets the stones settle and aggregate and present as a larger geometric volume to the ultrasound beam and then create an acoustic shadow as we see here with some sludge.

In addition, here's another example where in the classic LPO sagittal position, a shadow is not evident yet.

This same patient in the opposite right side down position, we see a relative mild but definite acoustic shadow over the liver.

Why didn't we see the acoustic shadow in the LPO position?

That's because as we come through the gallbladder, the patient is turned with the right side up, there will be bowel as there often is in the duodenum or the antrum, and that effectively precludes you from seeing a shadow because you're seeing lack of echoes over lack of echoes where there's the gas if you have the patient in the opposite direction.

However, as we see here, the small subtle stones are present. In this case we'll create an acoustic shadow that is visible over the echogenicity of the hepatic parenchyma.

With small stones, these are the problems you don't. Big stones are easy to see, but small stones are very difficult sometimes.

Looking for the acoustic shadow is very important.

To reiterate, use the highest frequency transducer. You can have stones, small stones aggregate.

Think about scanning with the right side down if there's a question to see if you can get shadowing projected over the liver.

Here, for example, is a case this patient actually had two quote normal ultrasound exams but had classic biliary colic when you questioned him.

I might see a little bit of sludge in the gallbladder on this clip, but no definite stones.

It was the history that made me look harder at this patient.

When you're thinking about subtle stones, one of the things you might wanna do is to turn the patient rather rapidly as we see here.

You can see literally at least a hundred stones here, small individual stones that are very, very difficult to see.

That's why he had two prior normal studies.

These are the kind of stones that will cause problems as they pass into the biliary tree.

Look for the rolling stones, and it depends on what you mean by that.

But I'm not talking about this type of rolling stones.

Look for the rolling stones in the gallbladder when you have a, to emphasize clues, important ones to see small stones as to look for the acoustic shadow, scan appropriately to see it with the appropriate transducer.

Look for mobility, turn patients if necessary.

Also if a patient is lying LPO or if there's a question of acute cholecystitis, look very carefully in the neck because that's a difficult area to examine due to the twists and the turns that are anatomically present at the level of the neck.

Diagnosing Acute Cholecystitis

Now let's turn our attention to making the specific diagnosis of acute cholecystitis.

If you took a hundred patients who have gallstones, about a third or so will be a throughout their lifetime.

Many patients will however go on to develop chronic symptoms but nothing too acute, dyspepsia and so forth when they eat perhaps a fatty meal.

The largest way patients go on to develop acute cholecystitis is going from those chronic symptoms to suddenly becoming acutely ill with severe right upper quadrant pain,

relatively few patients go from being asymptomatic to suddenly having acute cholecystitis.

What happens when people have acute cholecystitis?

Typically a stone is moved from the region of the body of the gallbladder and look carefully because if it's impacted in the neck it may be difficult to identify and your eye may just pick these stones up.

Make an effort to look around the curves in the twist in the neck to see if you can see a stone impacted in the neck.

Often people have more than one stone and the question in this case is, is this an impacted stone and that's a free stone or is it two free stones?

It's important to show relative motion between this stone if it's impacted and that stone.

One of the things people often will do is turn the patient a little bit LPO or RPO as in done in this case you can see there's no real change in the position of the stone in the body to the neck in either image.

That is not sufficient in this case to prove whether or not there's impaction because neither stone has moved very well.

You haven't turned the patient sufficiently.

What I suggest you do is take the patient from the supine position, either turn them prone or sit them up into an erect position.

Now clearly there's no question that that stone that's in the neck has not moved, but the one that was in the body has now moved to the fundus clearly showing one is mobile and the other is fixed.

Very important to make that determination.

What criteria do I use to make the specific diagnosis of acute cholecystitis?

The two that I consider the most important or major criteria consist of the presence of stones in association with focal gallbladder tenderness.

Other criteria that have been described and used include looking at the gallbladder size and shape wall changes, perico cystic fluid collections and intraluminal changes.

I consider these minor findings because they're not as specific as the major criteria of stones with focal gallbladder tenderness or a positive Murphy sign.

The problem here is that I can take a picture of all of these criteria except I cannot take a picture of focal gallbladder tenderness a major criterion.

I have to know how to elicit a Murphy sign and various things have been described in the literature.

What I like to do is to look at this in two ways.

One, first I ask the patient to take one finger and show me with one finger where they hurt in their right upper quadrant.

If they rub over their entire right upper quadrant, that is definitely not a Murphy sign.

If they take their finger on the other hand and point to one spot and then I take my transducer and I see that spot corresponds to the gallbladder, that is very suspicious for Murphy's sign.

Then in a more objective manner, I try to take, I take the transducer and I tell the patient I'm gonna push in three spots and they should denote to me which is the most tender.

Let's say the second place I push is over the gallbladder and then they say, that is the area that was most tender, that will in my mind confirm a Murphy sign.

I do two things. One is the patient shows me where they hurt and the second is I try to use the transducer to out in various areas, one of which corresponds to the gallbladder and the patient says yes, that is where the pain is.

Gallbladder Wall Changes

Wall changes are interesting.

Most patients who have acute cholecystitis will have wall changes and some with chronic cholecystitis will have some thickening of their wall.

What I would like to do is not just look at wall changes specifically but to determine if the wall is diffuse or focal thickened.

When it's diffusely thickened, yes it could be due to acute or chronic cholecystitis, but there are a large number of other entities that can cause diffuse wall thickening, including a patient who's not fasting, a patient who has chronic low albumin hepatitis, heart failure, and even HIV with association due to AIDS cholangitis.

If you look at this list often except for the top of that list, acute cholecystitis or chronic cholecystitis often diffuse gallbladder wall thickening is not associated with primary gallbladder disease.

Let's look at a few examples.

Very, very thickened gallbladder with sludge in the lumen, the CT showing the same thing.

Notice how complex fluid on ultrasound is so much more dramatic than it is on the CT scan.

This is the same patient that is acute hepatitis with dramatic diffuse wall thickening.

On the other hand, here's a patient with acute cholecystitis. Very, very similar findings.

This patient, as we can see with a shrunken liver nodular contour ascites has a diffuse wall thickening and that is due to hypoalbuminemia associated with the chronic liver disease.

Sometimes people say ascites causes wall thickening and as you can see in this case a normal thickness to the gallbladder wall in association with ascites, it's really the hypoalbuminemia that commonly occurs with ascites that causes the wall thickening.

It's not ascites per se.

Here is a case where some people might look at this and think the gallbladder wall's diffusely thickened, but if you look at it carefully, it's only the portion of the gallbladder that is in contact with the undersurface of the liver that looks thick.

As a matter of fact, this isn't wall thickening at all. This is a patient who has edema of the gallbladder fossa and this is a person who has acute pancreatitis causing this.

How does this happen?

If you think of either pancreatitis or possibly peptic disease occurring down in this area of the duodenum or head of the pancreas, inflammation can develop and spreads in a retrograde fashion along the hepato duodenal ligament or the course of bile duct and then rests by the area of the gallbladder neck and subsequently dissects into the gallbladder fossa, hence giving you this appearance.

Just be aware that when you have this asymmetric type of thickening just in the undersurface of the liver, that it probably is not gallbladder wall thickening but maybe due to pancreatitis.

Here's just another example of two patients.

Notice the patient with acute hepatitis has diffuse wall thickening all the way around the acute pancreatitis is a nice example with the fatty liver showing the echogenic change in the area of the gallbladder fossa and no thickening on the opposite wall.

Focal gallbladder wall thickening has a long list of differential diagnoses and these different entities often look different one from another, but if you consider polyps, metastases, adenoma, myosis, carcinoma, et cetera, the rest of the list, these are gallbladder conditions even though they look different from one another.

Focal gallbladder wall thickening almost always is due to primary gallbladder disease.

When it's in the context of course of pain and so forth, we might be thinking of severe gallbladder, severe cholecystitis such as a gangrenous gallbladder.

Severe Cholecystitis and Complications

Let's take this case. Is this a good scan?

There is diffuse wall thickening on both sides of the gallbladder.

I'm sure you've already appreciated a stone in the neck, but there's a problem here because the images of the fundus are not good and it's very, very important when you're looking at the gallbladder not to forget the fundus.

The fundus really does deserve our respect and we can see that when somebody has severe acute cholecystitis.

The problem is that the fundus often suffers first and that's because there's a poor blood supply to the fundus of the gallbladder.

We can see the hepatic artery taking off then the cystic artery coming into the neck of the gallbladder and then it peters out by the time we reach the fundus.

The fundus of the gallbladder suffers the ravages of acute cholecystitis initially, and we can see there's some irregular thickening here at the fundus.

When somebody has a gangrenous or perforated gallbladder, severe cholecystitis, the wall changes then particularly involve the fundus with irregular thickening.

You may see intraluminal changes. Sludge is not specific, but if you can see stranding it will suggest that the mucosa of the gallbladder is sloughing in association with necrosis and gangrene of the gallbladder.

Pericystic changes are also often at the fundus if the gallbladder has perforated and has contained abscess or contained air collection.

Here's a nice example where at the fundus compare it to the ct, see the irregular thickening at the fundus.

In both examples, Dr. Netter agrees in his diagram of a gangrenous gallbladder.

Sometimes it's not just the fundus per se but changes around the fundus that are important.

This was a woman who actually had a CT scan, and I'm gonna just show you the CT scan and the CT clearly showed edema of the fat around the fundus of the gallbladder but no stones.

Ultrasound was done and did show clearly stones because ultrasound is better at showing stones than ct.

The question was did the patient have stones? And the answer was yes, but I'm showing you this case to show the pericystic inflammation or the dirty fat that is seen on the CT scan and the corresponding appearance on the ultrasound.

Notice it appears white and echogenic and that is what fat looks like when it's inflamed anywhere in the abdomen.

We can see it around the appendix around diverticulitis.

When you're worried about somebody who has inflammation of the gallbladder look for these changes, look for echogenic material that does not look like bowel, no wall, no compression that signifies dirty fat.

Here is another example of a patient who has a perforated fundus of the gallbladder and on the clip in addition there's a contained fluid collection.

Nice example, but can be difficult if you're not looking at the fundus carefully.

Here's another example. And I have two clips here.

We can see a contained with fluid debris level, abscess at the fundus on the sagittal and also on the transverse scan.

There's sludge in the lumen and now there's a contained fluid debris level at the fundus.

Here's another example where we can see changes and the clip I think will help you.

We can see sludge and there's some stones in the gallbladder, but notice the dirty shadowing at the level of the fundus due to emphysematous cholecystitis see the perforation on the corresponding CT at the level of the fundus and the contained abscess that is seen both on ultrasound over here and on CT over here.

Acalculous Cholecystitis

Acalculous cholecystitis is a very difficult diagnosis to make clinically because they're often intercurrent illnesses.

The ultrasound findings are non-specific because by definition there are no stones.

The patients often are too sick to localize whether or not they have pain over their gallbladder and once gangrene and perforation occur you lose that sonographic Murphy sign.

It's very challenging to make the diagnosis and often when it's clinically a worrisome finding, we will do biliary aspiration and even place a cholecystostomy tube.

One of the things you can look for is evidence of inflammation around the gallbladder pericystic inflammation.

Here's an example, no stones a very sick patient and all that white echogenic material around the neck and in the porta hepatis here corresponds to what we see on the CT scan with that dirty fat.

That is what we have to hang our hat on.

Here coming down the porta hepatis as well along the hepato duodenal ligament, if you have an old scan to compare, you will see that this is now increased in comparison to that old scan.

Also here in the region of Morrison's pouch.

Again, to compare with the ct, we can see the fluid on ct, the fluid on ultrasound, the dirty fat on CT is the white echogenic material on ultrasound and it's, I can't emphasize how important it is to look for inflamed fat on ultrasound.

It doesn't jump out and grab you. You have to seek it out and look carefully for that pericystic inflammation.

Here's just an example at the bedside where we're replacing a cholecystostomy tube in a gallbladder with acalculous cholecystitis.

Non-Visible Gallbladder and Mimics

What if you're having trouble seeing the gallbladder? It's not visible. Well it may be very contracted, it may be filled with stones or sludge. These are much less likely.

Here's a case where we really don't see the gallbladder but we see the telltale so-called WES or wall echo shadow sign The wall is the first line.

The stones that are filling the gallbladder is the second concentric line.

Notice they're rounded and we can clearly see those are stones.

There's a little bit of bile between the wall and the stones.

And then the shadowing.

Most often it's due to a gallbladder filled with stones as we see in this case.

Sometimes again history is very important because this looks like a WES sign, but this is not.

It could be due to a patient whose gallbladder is totally contracted and maybe has some air in the stomach, but this is actually somebody who has no gallbladder and this is just air in the stomach mimicking a WES sign.

History is very, very important.

If you're not sure, you can give the patient some water to see if this indeed is in the stomach as it was in this case.

It's very important when we're looking for the WES sign to contrast it to a single line that we're seeing here with a porcelain gallbladder.

Remember the WES is two concentric white lines, a porcelain gallbladder a single line.

This becomes very important because of the association of a porcelain gallbladder with gallbladder cancer.

If somebody has a porcelain gallbladder, it certainly should be removed.

If somebody has a WES finding, even though there may be many stones, if the patient is asymptomatic, often nothing is done.

Is this one or two lines?

Here I think it clearly looks like a single line, so you might consider a porcelain gallbladder, but now look at the same patient and we can see that there are two lines, not a single line making this actually a WES finding or a gallbladder filled with stones as opposed to a porcelain gallbladder.

What's the difference between here and here?

The difference is two megahertz, five megahertz transducer used here, only a three megahertz used over here.

You must use the highest frequency transducer possible to get adequate resolution to show this because in this case this patient did not need a cholecystectomy.

Whereas if you thought it was a WES, where if you thought it was a porcelain gallbladder, it should be surgically removed.

That's a very important distinction.

Here's a patient with a five megahertz, we still couldn't tell and therefore a CT scan was appropriately done proving a porcelain gallbladder.

Whenever you see a porcelain gallbladder, of course look carefully because most of these are associated with stones and we already mentioned the possibility of cancer.

When we look carefully in this patient, you can see there is a mass adjacent to the gallbladder in the liver and this is what the CT looked like and this person was already being treated for their inoperable gallbladder cancer.

Intraluminal Echoes

Intraluminal echoes can be due to an awful lot of different conditions in addition to stones.

It could have sludge, you might have artifacts milk of calcium, they may look like membranes blood or pus or neoplasm.

Let's briefly touch on these.

Sludge and Related Findings

Typical sludge is homogeneous low level echoes that are due to stasis of bile, bile crystals, calcium bilirubin, cholesterol crystals.

We've already said they're homogeneous, they move slowly and very importantly, sludge does not shadow.

Is this sludge in this case then? Not really.

If you look carefully because as soon as you put a higher frequency transducer on, we can see this is a contracted gallbladder notice the central luminal line of a completely contracted gallbladder with diffusely thickened wall.

Technique is always important and I emphasize over and over use the highest frequency possible to make an appropriate diagnosis.

Not a four, but in this case harmonics with a five made a better diagnosis.

Typical sludge has a fluid debris level as we see here.

If you see what does not look like a fluid debris level, but a rounded grouping of echoes in the lumen, be wary that that may not be sludge.

In this case, that is a blood clot with hemobilia.

Here's another example.

Notice it's not a fluid debris level, it is rounded and here is the hemobilia seen on the CT scan.

This could certainly be a sludge ball, but if you put color on and you show the stalk of a polyp, then it's not a sludge ball.

Sludge balls often are multiple as we see in this example.

Sometimes you'll see what looks like sludge, clearly no argument about that.

But then when you scan the patient from a different position, it's gone.

This actually is an artifact.

What does it do to this is due to a so-called side lobe artifact.

What happens here is if you take the transducer as we often do, scanning the patient in an LPO position, pointing it toward the duodenum, the sound will come in to the patient's gallbladder.

But there will be these problematic side lobes and they are not in the main beam.

If they hit something that's very reflective like bowel gas and the duodenum, they will be returned to the transducer and the transducer only knows it was hit by an echo that took a certain time path to return to the transducer.

It will always put that echo in the main beam.

Depending upon the time it took, that will be the position where it will be.

As you can see here, that side lobe will then be projected in the lumen of the gallbladder as we see here, as that troublesome looking sludge.

Really what you wanna do is not point toward bowel when you're looking, if you're questioning if it's real or artifactual.

If you point it away from the duodenum as we see here, there will no longer be the side lobe artifact.

Another reason that you can get echoes that are pseudo sludge if you will, if you're not occluding the beam, if you have partial volume of duodenum in the beam, that too can be projected in the lumen of the gallbladder as pseudo sludge.

Important reasons.

Patients who have sludge in the gallbladder are typically those we said who have stasis due to not eating or anybody with an obstruction who can't empty their gallbladder because of an obstruction anywhere in the biliary tree from the gallbladder neck down to the distal duct.

If you see what looks like sludge but it is shadowing, well that is possibly an entity called milk of calcium where a patient has prolonged stasis of crystals in their gallbladder and precipitates out this very high level of calcium in the sludge and that can cause shadowing.

But small stones can appear similar however, see on CT the fluid debris level here similar to the ultrasound in this case due to milk of calcium.

Membranes, Blood Clots, and Neoplasms

What happens if you see membranes in the gallbladder lumen?

In this case it's due to sloughing of the mucosa in a patient who has a gangrenous gallbladder because it has infarcted the wall.

Another entity with membranes can be hemobilia where the clot organizes.

As it matures you just like in a ovarian cyst you can see membranes.

Other reasons that you can have echoes in the gallbladder as we see here or another example, a lot of people would look at this and say this is a large polyp or it's a tumor.

But notice importantly there's no vascular flow.

Notice also the wall is intact.

Gallbladder cancer is very aggressive and typically does not respect the wall, the gallbladder.

When we see this mass without echoes in it, we again should think of a blood clot.

This another example of hemobilia CT number greater than 30 confirms hemobilia on the CT scan.

Another example of echoes in the lumen and stones, but this looks more like a heterogeneous mass and look always very carefully is there a liver mass here because as I say, gallbladder cancer typically is very aggressive.

When we look carefully here you can see it broke right through the wall.

That is an important clue that we're dealing then with a gallbladder cancer here.

We can see the same thing on the CT scan. Dr. Netter also shows that aggressiveness of this tumor with gallbladder cancer.

Polypoid Masses and Adenomyosis

Let's just turn our attention for the few last minutes to polypoid masses and then adenomyosis.

We see patients here who have small polypoid masses in the gallbladder is a cholecystectomy indicated.

Not when they look like this.

What do we mean by these benign multiple polyps?

They are multiple and they're each less than five millimeters.

They have a narrow neck, the wall is respected.

If you on the other hand have a single or maybe a cluster of small non-mobile non-shadowing masses, then we get more worried, especially if they're broad-based as we see here.

This is metastatic melanoma and this is a patient who actually at surgery had carcinoma in situ to obviously an important time to diagnose as opposed to when it is spread outside the gallbladder.

Notice base attachments, in both cases they are relatively solitary or just paired as in this case they will be in general greater than 10 millimeters, five to 10 millimeters.

If they're multiple, we tend to wanna watch those.

Typically they don't really grow with time as far as my experience.

Here's a very interesting case.

Clearly this is not hemobilia 'cause we see the blood flowing within this mass.

But notice that the wall is intact and that is a clue that probably it's benign, but the large size greater than 10 suggests it should come out.

This was a benign polyp and this case was lent to me thanks to Bill Middleton.

Polyp can become quite large. What about this case?

Be careful here.

Everybody I think would focus on the stone but look beyond the stone.

Most people with gallbladder cancer have stones.

Don't just see stones and then forget about the rest of the gallbladder wall.

In this case blood flow is seen in this and that becomes worrisome, not surprising, a case of gallbladder cancer.

Another example here are stones and is this study then just complete based on what we see?

No notice we're using a sector scan here.

Sometimes we need more than a single scan transducer to evaluate the entire gallbladder, especially the near field.

Where's the fundus?

The gallbladder fundus deserves our respect.

That sector scan didn't see it. Change your transducer.

Now we're using a curve six and clearly the fundus is not looking healthy.

The curve transducer, the higher frequency, the broader near field all came to our rescue.

The next thing obviously is to put color on seeing flow there is very worrisome for a neoplasm.

Looking further in the porta hepatis we can see that abnormal lymph node there.

Unfortunately it was small cancer but it had already spread and was therefore not a curable entity.

Diagnosing Adenomyosis

Here now three different patients all with the same condition and the condition is adenomyosis. How do we make this diagnosis?

Because if we can make the diagnosis, we do not wanna do a cholecystectomy.

The clues are often intramural cyst typically at the fundus of the gallbladder as we see there.

We can see some here again, focal changes at the fundus with multiple intramural cysts.

There also looking for comet tail artifacts as we see in the patients one and two, due to crystals that become deposited.

Crystals of bile that become deposited within these intraluminal cysts or Rokitansky-Aschoff sinuses known as RIAS.

When we see that combination of focal thickening, particularly at the fundus with cysts and comet tails, we can confidently make the diagnosis of adenomyosis.

Here's Dr. Netter's rendition.

Yes, other areas can be involved, but the fundus is quite typical with these little cavities or cysts that trap cholesterol and bile calcium bilirubin crystals get reverberation between these crystals causing those comet tails.

Look carefully at the fundus.

Here's an example where somebody asked me was that an abnormality?

When quick perusal said it's probably just a reverberation artifact again with a four megahertz sector transducer, but you can't stop there.

When we looked further at this patient changing again to the six curve higher frequency transducer, clearly there was something wrong with this gallbladder.

I suspected it was probably adenomyosis, but it was rather difficult for me to really get an ideal picture.

That patient did go to surgery, was proven to have adenomyosis.

Can we do any better even than I've done here?

Because if possible I'd like to not send the patient to surgery.

Here's an example again, six megahertz curve transducer.

I can't really say for sure if that's adenomyosis.

Can I do better? The answer is yes.

Now I can see the Rokitansky sinuses in a contained mass in the fundus.

How did I do this transducer?

Believe it or not, I used a vaginal probe.

This is the endovaginal probe.

This is eight megahertz, a higher frequency.

I know it sounds funny putting it over the right upper quadrant, but use whatever it takes to get a better picture if possible to avoid doing an unnecessary cholecystectomy.

This is I believe my last case where we can see CT was done.

First the question was, is this a porcelain gallbladder?

If it is, then the gallbladder should be removed because of the worrisome development of cancer.

The ultrasound here we can see the cysts in the focal area of change in the fundus.

We can see the comet tails and those can often be even more dramatically revealed with this so-called twinkle artifact that we get from the irregularity of the crystals that we see in the Rokitansky-Aschoff sinuses, the so-called twinkle artifact and confidently make the diagnosis of adenomyosis and avoid surgery.

This truly is my last case, again, is cholecystectomy indicated.

Notice here comet tails, but not coming from a thickened gallbladder wall.

I suppose this could be air in the lumen of the gallbladder, but the patient was not symptomatic and therefore air and did not have any reason to have air in the gallbladder based on a prior interventional procedure.

ERCP for example.

In this case, these are comet tails coming from the surface of a non thickened gallbladder wall, so-called strawberry gallbladder.

These are just crystals of cholesterol deposition on the surface of the gallbladder analogous to these little deposits on the strawberry of the seeds that we see on the strawberry wall.

That's why this has been called a strawberry gallbladder.

This too does not need to be removed.

This is cholesterolosis as opposed to the adenomyosis that we've already talked about.

Conclusion

I hope you've ended up becoming a little bit wiser, the wise old owl as you've looked hard at the gallbladder here.

I hope this discussion has been helpful to you when evaluating the gallbladder with ultrasound.

Thank you for your attention.