DAFTAR PUSTAKA USG KOLELITHIASIS

1. Ultrasound of the gallbladderSamir Haffar M.D.Assistant Professor of

Gastroenterology
2. Ultrasound of the gallbladder Normal GB ultrasound Congenital
abnormalities GB stones & sludge Acute cholecystitis & its complications
Chronic cholecystitis Polyps & adenomyomatosis GB carcinoma
Miscellaneous: volvulus nonvisualization
3. Normal GB ultrasound
4. Anatomy of the gallbladderSherlock S & Dooley J. Diseases of the liver and
biliary system.Blackwell Science, Oxford, UK, 11th edition, 2002.
5. Normal ultrasound of gallbladderMinimum 6 hours of fastingSubcostal or
intercostal scanningSupine LLD Prone ErectGB wall 3 mm Anterior
wallLong-axisPerpendicularTransverse diameter < 4 cmRumack CM et al. Diagnostic
Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.FBN
6. Gallbladder foldsAbraham D et al. Emergency medicine sonography:
Pocket guide.Jones & Bartlett Publishers, Boston, MA, USA, 1st edition,
2010.Longitudinal view of gallbladderHartmans pouchPhrygian cap
7. Gallbladder foldsPhrygian cap (fundus over body)Fold between neck &
bodySigmoid GB (multiple folds)
8. Acoustic shadow from a GB foldPart of a fold within gallbladder producing
an acoustic shadowWhen only part of fold is visualized, it may mimic a polyp or a
stoneMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
9. Edge refraction shadowMcGahan J et al. Diagnostic ultrasound, Informa
Healthcare, 2nd edition, 2008.Shadow near neck of GB on longitudinal
sectionAbsence of visible stone at origin of shadowScanning in different positions
10. Proximal cystic ductLongitudinal view of GB neck & proximal cystic
ductSerrated appearance of cystic duct secondary to valves of HeisterOccasionally
identified on sonographyMcGahan J et al. Diagnostic ultrasound, Informa Healthcare,
2nd edition, 2008.
11. Distal cystic ductNormal distal cystic duct entering the CBD
posteriorlyParulekar SG. Ultrasound Quarterly 2002 ; 18 : 187 202.
12. Congenital abnormalities
13. Congenital abnormalities of the gallbladder Agenesis of gallbladder
Confirmation with other tests Anomalous GB location Abnormal locations
Duplication of gallbladder One or two cystic ducts Septated gallbladder Honeycomb
appearance Gallbladder diverticulum Any location in gallbladderMcGahan J et al.
Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
14. Congenital anomalies of the gallbladderYamada T et all. Textbook of
gastroenterology.Wiley-Blackwell, Oxford, UK, 5th edition, 2009.Septated
GBDuplicated GB Diverticulum
15. Agenesis of gallbladder1 in 6,000 live births fewer than 300 reported
casesWaller AH et al. Clin Gastroenterol Hepatol 2008 ; 6 : 38. First described by
Lemery in 1701 Failure of cystic bud to develop in fourth week of life Associated
with chromosomal abnormalities Symptoms attributed to biliary dyskinesia US
diagnosis: absence of gallbladder HIDA scan: acute cholecystitisDiagnosis usually
obtained after surgical exploration
16. Agenesis of gallbladderWaller AH et al. Clin Gastroenterol Hepatol 2008 ;
6 : 38.HIDA scanUptake by liverExcretion into CBD & bowelNo visualization of
gallbladderMRI & MRCPNo visualization of normal orectopic GBNormal biliary tree

17. Anomalous location of gallbladderRare Reported only in isolated case

reportsMost common locations Left side (posterior to left lobe) Intrahepatic
Suprahepatic (right lobe & diaphragm) Retrohepatic (posterior to right
lobe)Intrahepatic GBMay preclude Lap surgeryMcGahan J et al. Diagnostic
ultrasound, Informa Healthcare, 2nd edition, 2008.
18. Duplication of gallbladderOne in 3000 to 4000 GB2 gallbladders adjacent
to each other with 2 separate cystic ductsAfter meals, both gallbladders showed
normal emptyingwww.ultrasound-images.com/gall-bladder.htm
19. Multi-septate gallbladderCongenital origin Very rare Entire GB or part
of lumen Chambers communicate by orifices Isolated or coexist with other
anomalies Symptoms of recurrent cholecystitis Multiple linear fine echogenic
septationsOriented horizontally or verticallyKapoor V et al. J Ultrasound Med 2002 ;
21 : 677 680.
20. True diverticulum of gallbladderExtreme rarityOccurs anywhere in
GBUsually singleVaries greatly in sizeMcGahan J et al. Diagnostic ultrasound,
Informa Healthcare, 2nd edition, 2008.
21. Gallbladder stones & sludge
22. US of gallbladder stoneGold standard for diagnosis of cholelithasis3
sonographic criteria Echogenic focus Cast acoustic shadow Seek gravitational
dependenceStones < 2 3 mm may be difficult to visualizeGore RM et al.
Gastroenterol Clin N Am 2010 ; 39 : 265 287.
23. Shadow of gallbladder stone* Gore RM et al. Gastroenterol Clin N Am
2010 ; 39 : 265 287.** Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 413.3 patterns
of shadowing* Clean shadow Solitary stone Confluent shadowing Multiple small
stones Wall-Echo-Shadow (WES) GB filled with gallstones** Soft pigment stones
may not shadow
24. Confluent shadowing of GB stonesMultiple small stones gravel abut each
other with confluent ASMural thickening of gallbladder
25. Acoustic shadow of a gallbladder stoneTime gain compensationtoo
highTime gain compensationis lowerBates J A. Abdominal Ultrasound: How, why and
when.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
26. Stone smallerthan the beamShadowing of the stonesShadowBates J A.
Abdominal Ultrasound: How, why and when.Churchill Livingstone, Edinburg, UK,
2nd edition, 2004Stone occupieswidth of the beamLarge stoneoutside focal zoneLarge
stonejust out of beamNo shadow
27. Floating stonesBates J A. Abdominal Ultrasound: How, Why and
When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Floating stones just
below anterior gallbladder wall
28. Tissue harmonic imaging & gallstonesLongitudinal ultrasoundNormal
gallbladderRubens D. Radiol Clin North Am 2004 ; 42 : 257 78.Harmonic
imagingMultiple small stones
29. Correct & incorrect positions for prone scanningDemonstrates
gravitational dependence of stoneCorrect: transducer as vertically as possible to image
anterior GB wallIncorrect: most dependent anterior part of GB not well
examinedHough DM et al. J Ultrasound Med 2000 ; 19 : 633 638.
30. Pitfalls in diagnosis of GB stoneResidue in bowel indenting posterior wall
of GBmimics gallstonesMcGahan J et al. Diagnostic ultrasound, Informa Healthcare,
2nd edition, 2008.
31. Dependent debris in the gallbladder Sludge Pseudosludge Blood Pus
Milk of calcium bileMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd

edition, 2008.
32. Biliary sludgePrevalence unknown in general population Predisposing
factors PregnancyRapid weight loss & prolonged fastingLong-term TPNCeftriaxone
Prolonged octreotide ttBone marrow transplantation Evolution (3 years) 50% resolve
spontaneously20% persist asymptomatically5 15 % develop gallstones10 15 %
become symptomatic Complications Biliary colic, AAC, pancreatitis
33. Biliary sludgeAlso known as biliary sandLow-amplitude nonshadowing
echoes in dependent portion of GBGore RM et al. Gastroenterol Clin N Am 2010 ;
39 : 265 287.Occasionally, sludge can be highly echogenic
34. PseudosludgeMcGahan J et al. Diagnostic ultrasound, Informa Healthcare,
2nd edition, 2008.Most commonly along posterior surface of gallbladderProduced by
sidelobe artifactsDisappear in different positions & when central portion of GB
scanned
35. Aggregated sludge Sludge ballMcGahan J et al. Diagnostic ultrasound,
Informa Healthcare, 2nd edition, 2008.Change in appearance or disappearance on
follow-upDifferentiates sludge ball from a stone or neoplasmNonshadowing mobile
echogenic structures
36. Aggregated sludge Tumefactive sludgeGB with tumor-like
sludgeRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd
edition, 2005.Potential mobility of sludgeNormal gallbladder wallNo vascularity
detected on Doppler USFollow-up
37. Biliary sludge"hepatization" of gallbladderRumack CM, Wilson SR, &
Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA,
3rd edition, 2005.GB entirely filled with sludge isoechoic to adjacent liverRecognized
by identifying normal GB wall
38. Blood in the gallbladderClinical history very useful for
diagnosisSonographic findings Echogenic or mixed echogenicity Fluid with lowlevel internal echoes Retractile May be mobileRumack CM et al. Diagnostic
Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.Angled edges of
clotQuite typical of blood clots
39. Milk of calcium bile (limey bile)Diagnosis can be confirmed by abdominal
radiography or CTHigh-attenuation material withindependent portion of GBHighly
echogenic material independent portion of GB with ASRumack CM et al. Diagnostic
Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
40. Milk of calcium bile (limey bile)Abdominal radiography
41. Acute cholecystitis & its complications
42. Causes of right upper quadrant pain Peptic ulcer disease Pancreatitis
Hepatitis Appendicitis Hepatic congestion from right-sided heart failure
Perihepatitis (Fitz-Hugh-Curtis syndrome) Right lower lobe pneumonia Right-sided
pyelonephritis Nephro-ureterolithiasis
43. Diagnostic standard for acute cholecystitisTokyo guidelines 2007Hirota M
et al. J Hepatobiliary Pancreat Surg 2007 ; 14 : 78 82 .Three categories of diagnostic
findingsOne criterion from each category must be fulfilled(1) Murphy sign or
pain/tenderness in RUQ or RUQ mass(2) Fever, leukocytosis, or elevated CRP(3)
Confirmation by US or HIDA scan
44. Acute cholecystitis HIDA scanHigher accuracy than
ultrasonographyTalley NJ et al. Practical gastroenterology & hepatology: Liver &
biliary disease.Wiley Blackwell, Oxford, UK, First edition, 2010.Tracer in GBTracer
in CBDTracer in small bowelGBCBDSmallbowelNormal HIDA scanNon-filling of
GBTracer in CBDTracer in small bowelCBDSmallbowelAcute cholecystitis

45. Sonographic findings in acute cholecystitis Impacted stone in cystic duct

or GB neck Positive sonographic Murphys sign Thickening of GB wall (>3 mm)
Distention of GB lumen (> 4 cm) Pericholecystic fluid collections (frequent)
Hyperemic GB wall on color Doppler (supportive test)None of above signs
pathognomonicCombination of multiple signs make correct diagnosisRumack CM et
al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
46. Acute cholecystitisCaused by gallstones in more than 90% of casesLarge
obstructing stone within GB neckThick hypoechoic gallbladder wallPositive
sonographic Murphy signRalls PW et al. Gastroenterol Clin N Am 2002 ; 31 : 801
825.
47. Negative sonographic Murphys sign Patients who received pain medicine
or steroids Para or quadriplegic patients Patients not able to give reliable history or
pain response Denervated GB: DM gangrenous cholecystitis Gallbladder
ruptureCareful attention to clinical status importantwhen assessing for sonographic
Murphy s signRubens DJ. Ultrasound Clin 2007 ; 2 : 391 413.
48. Gallbladder wall thickening Generalized edematous states CHF Renal
failureEnd-stage cirrhosisHypoalbuminemia Inflammatory conditions Primary Acute
cholecystitisChronic cholecystitisCholangitisSecondary Acute hepatitisPerforated
DUPancreatitisDiverticulitis/colitis Neoplastic conditions Adenocarcinoma
Metastases Miscellaneous Adenomyomatosis VaricesRumack CM et al. Diagnostic
Ultrasound. Elsevier-Mosby, St. Louis, USA, 3rd edition, 2005.
49. Diffuse gallbladder wall thickeningMcGahan J et al. Diagnostic
ultrasound, Informa Healthcare, 2nd edition, 2008.Three echo patterns (not
specific) Uniformly echogenic pattern Central hypoechoic zone & 2 peripheral
echogenic layers Striated pattern
50. Gallbladder wall thickeningUniformly echogenic patternEchogenic
thickening of the wall in chronic cholecystitisMcGahan J et al. Diagnostic ultrasound,
Informa Healthcare, 2nd edition, 2008.
51. Gallbladder wall thickeningCentral hypoechoic zone separated by two
echogenic layersGallbladder wall thickening due to ascites
52. Gallbladder wall thickeningStriated patternRubens DJ. Ultrasound Clin
2007 ; 2 : 391 413.Striated wall with alternating echogenic & hypoechoic
layersStriated wall in setting of acute cholecystitis: gangrenous cholecystitisStriated
wall without evidence of acute cholecystitis: non specific
53. Gallbladder wall thickeningRubens DJ et al.Ultrasound Clin 2007 ; 2 : 391
413.GallstonesFocal GB wall thickening (7 mm)Free air with reverberation
shadowsPericholecystic fluid (arrows)Free air (arrowheads)Extraluminal air (paired
arrowheads)Peptic ulcer perforation
54. Gallbladder wall thickeningRubens DJ et al.Ultrasound Clin 2007 ; 2 : 391
413.Focal pyelonephritisHeterogeneous decreasedattenuation area typicalof focal
pyelonephritisGB wall thickening 3-cm echogenic massin lower pole of rt kidney
55. Pericholecystic fluidTwo specific patternsType I Thin anechoic crescentshaped collectionadjacent to gallbladder wallNonspecific findingType II Round or
irregularly shaped collection withthick walls, septations, or internal debrisAssociated
with GB perforation & abscessTeefey SA et al. J Ultrasound Med 1991 ; 10 : 603
6.Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 413.
56. Acute cholecystitisHyperemic GB wallMcGahan J et al. Diagnostic
ultrasound, Informa Healthcare, 2nd edition, 2008.Color Doppler
sonographyIncreased vascularity in GB wallSupportive test
57. Acute acalculous cholecystitis (AAC)5 15% of acute cholecystitis

Critically ill patients Major surgerySevere traumaSepsisTotal parenteral

nutritionDiabetesAtherosclerotic diseaseHIV infection Nonhospitalized patients
Elderly male with atherosclerosisHIDA scan & sampling of luminal contentshelp to
establish the diagnosis
58. Acute acalculous cholecystitis (AAC)Difficult to diagnose clinically & on
imagingMarked GB mural thickeningHypoechoic regions within wallGore RM et al.
Gastroenterol Clin N Am 2010 ; 39 : 265 287.Marked GB mural thickeningwith
hypo & hyperenhancing areas
59. Complications of acute cholecystitis Suppurative cholecystitis
(empyema) Gangrenous cholecystitis Up to 20% Emphysematous cholecystitis 1 %
Hemorrhagic cholecystitis Rare Gallbladder perforation 5 10%
60. Suppurative cholecystitis (Empyema)Patients very ill with fever & acute
painFine echoes caused by pus in bilePericholecystic GB collection (leakage)US used
to guide drainage before surgeryBates J A. Abdominal Ultrasound: How, why and
when.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Large GB full of pus &
stones
61. Gangrenous cholecystitisNo specific diagnostic US findings Striated
thickening of GB wall Intraluminal membranes (5%) Marked asymmetry of GB
wall Echogenic debris within GB Pericholecystic fluid collections US Murphys
sign negative in 70%Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265
287.Mucosal sloughingEchogenic debris within GB
62. Gangrenous cholecystitisMucosal sloughingRubens D J. Ultrasound Clin
2007 ; 2 : 391 413.Longitudinal US of gallbladderIntraluminal membranes
associated gallbladder gangreneStone impacted in gallbladder neck
63. Emphysematous cholecystitisPrompt surgical intervention required
Organisms Clostridium welchii & Escherichia coli Characteristics Male
preponderance (70%)Frequent occurrence in diabetic (50%)Lack of gallstones in up
to one thirdHigher risk of gangrene & perforation Three stages Stage 1: Gas in GB
lumenStage 2: Gas in GB wallStage 3: Gas in pericholecystic tissuesBennett GL et al.
Radiol Clin N Am 2003 ; 41 : 1203 1216.Appearance depends on amount of gas
present
64. Emphysematous cholecystitisAssociated with DM & atherosclerotic
diseaseIntraluminal & intramural gas bubblesDebris within necrotic GBHigher
sensitivity of CTfor the diagnosisDiagnosis should be confirmed by abdominal
radiography or CTGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 287.
65. Emphysematous cholecystitisSmall amount of gasSupine positionPresence
of echoes anteriorlyCould be in the lumen or the wallRubens D J. Ultrasound Clin
2007 ; 2 : 391 413.Upright positionGas moves & breaks into bubblesDistinguishing
it from calcium
66. Emphysematous cholecystitisLarge amount of gasAbsence of a normal
gallbladder is a clueGas in GB completely obscures the lumen (dirty shadow)Bates J
A. Abdominal Ultrasound: How, Why and When.Churchill Livingstone, Edinburg,
UK, 2nd edition, 2004Location of GB fossa essential to avoid mistaking this for
bowel gas
67. Emphysematous cholecystitisAbdominal radiographyIntraluminal &
intramural gas bubblesBates J A. Abdominal Ultrasound: How, Why and
When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004
68. Gallbladder perforation5 10 % of patients with acute cholecystitisSmall
defect in GB wall: not always seenDeflation of the gallbladderPericholecystic fluid
collectionPericholecystic abscessRumack CM, Wilson SR, & Charboneau JW.

Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition,

2005.Disruption of GB wall
69. GB perforation Pericholecystic abscessRumack CM, Wilson SR, &
Charboneau JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA,
3rd edition, 2005.Abscess (internal strands typical of abscess)Echogenic inflamed
fatSmall amount of ascites
70. Hemorrhagic cholecystitisRare Atherosclerosis High mortality
rateBennett GL et al. Radiol Clin N Am 2003 ; 41 : 1203 1216.Echogenic material
with higherechogenicity than sludgeIncreased density of bile
71. Hemorrhagic cholecystitisDifferential diagnosis Blood in gallbladder
NeoplasmAneurysmsTraumaAnticoagulationEctopic pancreasEctopic gastric mucosa
High-density bile Recently administered IV contrastMilk of calcium bileBennett GL
et al. Radiol Clin N Am 2003 ; 41 : 1203 1216.
72. Chronic cholecystitis
73. Forms of chronic cholecystitis Traditional chronic cholecystitisThick
gallbladder wall with gallstones Wall-Echo-Shadow complex (WES)Double arcshadow sign Porcelain gallbladderHigh incidence of GB carcinoma (10 30%)
Xanthogranulomatous cholecystitis (XGC)Difficult to distinguish from
adenomyomatosis &gallbladder carcinoma
74. Chronic cholecystitisBates J A. Abdominal Ultrasound: How, Why and
When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004Thick gallbladder
wallSmall gallbladder stone with posterior ASBouts of acute cholecystitis may
complicate chronic cholecystitis
75. Wall-Echo-Shadow complex (WES)Contracted gallbladder filled with
stones2 parallel arcuate hyperechoic linesSeparated by thin hypoechoic spaceDistal
acoustic shadowingMcGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd
edition, 2008.Differentiation from air or calcification in GB wallNormal GB wall not
seen; only bright echo & AS seen
76. Porcelain gallbladderCalcified wall with acoustic shadowMistaken for
stone within GB lumenNo GB wall visibleRumack CM, Wilson SR, & Charboneau
JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition,
2005.Dense calcification in GB fundus
77. Porcelain gallbladder Mild calcificationRickes S et al. N Engl J Med,
2002 ; 346 : e4.Computed tomographyGallstonesCalcification of GB
wallUltrasonographyGallstones (one in cystic duct)leading to GB enlargement (5
cm)Calcification of GB wall
78. Porcelain gallbladderAbdominal radiography
79. Xanthogranulomatous cholecystitis (XGC)2% of cholecystectomy
specimensCompressed lumenMultiple large mural nodulesseparated by enhancing
marginsStone not visualizedCompressed lumenMultiple hypoechoic mural
nodulesWall markedly thickenedAdjacent stoneRubens D J. Ultrasound Clin 2007 ;
2 : 391 413.
80. GB polyps & adenomyomatosis
81. Classification of gallbladder polyps3 7% of subjects undergoing
USGallahan WC et al. Gastroenterol Clin N Am 2010 ; 39 : 359
367.NeoplasticAdenomas (4%) 5 20 mm, solitaryMiscellaneous Leiomyomas,
lipomas,neurofibromas, carcinoidsNon-neoplasticCholesterol polyp (60%) < 10
mmAdenomyomatosis (25%) Usually fundusInflammatory (10%) < 10 mm
82. Risk of malignancy in GB polyps Size Small polyp not necessarily
benignSessile polyps 10 mm quite aggressive 10 mm suspicious> 18 mm usually

invasive malignancy Patient age > 50 Concurrent gall stones Diagnosis of

PSCTalley NJ et al. Practical gastroenterology & hepatology: Liver & biliary
disease.Wiley Blackwell, Oxford, UK, First edition, 2010.
83. Cholesterol polyp & cholesterolosisLamina propria infiltrated with lipidladen foamy macrophagesCholesterol polypCholesterolosis strawberry gallbladder
84. Cholesterol polyp & cholesterolosisCholesterol polypCholesterolosis
strawberry gallbladderJohnson CD et al. Mayo Clinic gastrointestinal imaging
review.Mayo Clinic Scientific Press, Rochester, USA, 2005.
85. Gallbladder polypsGallahan WC et al. Gastroenterol Clin N Am 2010 ;
39 : 359 367.Sessile polypPedunculated polyp
86. Gallbladder polypAny sizePSCCholelithiasisSessileLap surgeryTalley NJ
et al. Practical gastroenterology & hepatology: Liver & biliary disease.Wiley
Blackwell, Oxford, UK, First edition, 2010.> 18 mmStaging &Open surgery< 10
mmSymptomsYesImaging: US or EUSEvery 6 monthsNon10 18 mmNo consensus
guidelines to guide treatmentManagement should be individualized
87. Variable ScoreTumor maximum size (mm) Value in mmEUS in
gallbladder polypRetrospective study of 70 surgical cases - Multivariate
analysisSadamoto Y et al. Endoscopy 2002 ; 34 : 959 965.Scores 12: neoplastic
polypSen: 78% Sp: 83% Accuracy: 83 %Internal echo
patternHeterogeneousHomogeneous40Hyperechoic spottingSingle 1 5 mm
hyperechoic spotMultiple hyperechoic 1 3 mm spotsPresence: 5Absence: 0
88. EUS in gallbladder polyp11 mm in diameter (11)Homogenous
(0)Hyperechoic spots ( 5)Cholesterol polyp GB adenoma9 mm in diameter
(9)Heterogeneous (4)Hyperechoic spots (0)Sadamoto Y et al. Endoscopy 2002 ; 34 :
959 965.Score: 6 Score: 13
89. Adenomyomatosis (Rokitansky-Aschoff sinuses)8% of patients
undergoing cholecystectomyFundicMost
frequentAdenomyomaSegmentalHourglassDiffuseExcessive proliferation of surface
epitheliumwhich can invaginate into muscularis
90. Diffuse adenomyomatosis of gallbladderThickened GB wallComet-tail
artifacts in GB wallComet-tail or ring-down
artifact
91. Diffuse adenomyomatosis of gallbladderThick gallbladder wallEchogenic
intramural fociring-down
artifactsMultiple high signal intensitystructures within
GB wallstring of pearls appearanceGore RM et al. Gastroenterol Clin N Am 2010 ;
39 : 265 287.
92. Segmental adenomyomatosisRumack CM, Wilson SR, & Charboneau JW.
Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition,
2005.Masslike areas obliterating lumenCystic spaces suggest diagnosisMultiple
echogenic fociCrystals in sinuses suggest dg
93. Fundal adenomyomatosisHypoechoic mass-likeFundal
adenomyomaRumack CM et al. Diagnostic Ultrasound. Elsevier-Mosby, St. Louis,
USA, 3rd edition, 2005.Thickened GB wall with smallRokitansky-Aschoff sinus at
fundus
94. Gallbladder carcinoma
95. US of gallbladder carcinoma3 major patterns of presentationGore RM et
al. Gastroenterol Clin N Am 2010 ; 39 : 265 287. Polypoid GB mass25% of
carcinoma > 1 cm Broad based Role of EUS Mural thickeningLeast common
Focal or diffuse IrregularMost difficult to diagnose Gallbladder fossa massMost
common Replacing GB Invading adjacent liver
96. Gallbladder carcinoma Mural thickeningMarked mural thickening of the

neck of gallbladderGore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 287.

97. Gallbladder carcinoma Polypoid massEnhancing mass in GB
fundusRubens DJ et al. Ultrasound Clin 2007 ; 2 : 391 413.Gore RM et al.
Gastroenterol Clin N Am 2010 ; 39 : 265 287.2-cm polypoid mass in GB
fundusInternal vascularityVillous adenoma with foci of CIS
98. Gallbladder carcinoma Gallbladder fossa massMass occupying GB
fossaCoronal reformatted CT scanRubens DJ et al. Ultrasound Clin 2007 ; 2 : 391
413.Gore RM et al. Gastroenterol Clin N Am 2010 ; 39 : 265 287.Immobile
gallstonesHeterogeneous mass in GB fossaSome vascularity on color DopplerColor
Doppler US
99. Malignant tumors of gallbladder Most frequent Adenocarcinoma
Unusual histologic variants Papillary adenocarcinomaMucinous
adenocarcinomaSignet ring celltype Unusual malignancies Squamous cell
carcinomaCarcinosarcomaSmall cell carcinomaLymphomaMetastasisKim MJ et al.
AJR 2006 ; 187 : 473 480.Radiologic findings overlap with ordinary GB carcinoma
100. Signet ring cell carcinoma of gallbladderKim MJ et al. AJR 2006 ; 187 :
473 480.Target-like wall thickening ofgallbladderTargetlike wall thickening of
GBEnhancement of gallbladder fundusMassive necrotic LN along portahepatis &
hepatoduodenal ligament
101. Miscellaneous: volvulus nonvisualization
102. Volvulus of gallbladderMobile GB with long suspensory mesentery Rare
acute entity Symptoms of acute cholecystitis Often seen in elderly females US
findings:Massively distended & inflamed GBUnusual location of gallbladderUnusual
horizontal long axis in left to right directionRumack CM, Wilson SR, & Charboneau
JW. Diagnostic Ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition,
2005.
103. Volvulus of gallbladder
104. Nonvisualization of gallbladder Previous cholecystectomy Chronic
cholecystitis Contracted GB: postprandial cystic fibrosis Porcelain gallbladder
with shadowing Air-filled GB or emphysematous cholecystitis Agenesis of
gallbladder Ectopic location Tumefactive sludge GB carcinoma completely filling
gallbladderRumack CM, Wilson SR, & Charboneau JW. Diagnostic
ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
105. Micro-gallbladder in cystic fibrosisBates J A. Abdominal Ultrasound:
How, Why and When.Churchill Livingstone, Edinburg, UK, 2nd edition, 2004