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Ultrasound in the examination of the gallbladder - A holistic approach: Grey scale, Doppler, CEUS, elastography, and 3D
Abstract and Figures
Ultrasonography (US) is the essential imaging method in gallbladder examination being the most widespread and inexpensive technique. The method is indicated both in congenital and acquired disorders, inflammatory, tumoral, or degenerative pathology. Besides the basic technique (grey scale US), new sophisticated techniques exist: DopplerUS, i.v. contrast enhanced harmonic examination, tridimensional US, elastography. Each technique provides specific information, while their combination helps, in most cases, to establish the accurate non-invasive diagnosis. However, the US findings should be correlated with the patient’s clinical exam and other imaging methods. This paper is a synthesis of literature combined with our own experience, aiming to present the US features of gallbladder pathology and the correlations within the clinical picture and other imaging methods. Relevant images for this integrative approach are presented. The final conclusion is the necessity for a correlation of all clinical and imaging data in order to obtain an accurate diagnosis.
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... First, an optimal examination window is selected, the whole GB being visualized. The "real-time" examination is multidirectional and assesses the aspect and size of the GB, wall thickness, content, pain at transducer palpation (US Murphy's sign) [4]. Secondly, the selection of the region of interest (ROI) is performed. ...
... In the venous phase the wall seems to "melt" into the echogenic mass of the liver parenchyma [5]. Subsequently, an extensive examination of the liver is recommended, based on the patient's complaints and the clinical features [4]. A recording in "wmw" format is obtained. ...
... Irreversible inflammation of the gall bladder wall, often associated with biliary lithiasis might lead to two entities: the porcelain gallbladder (diffuse or localized calcification of the wall) and xantogranulomatous cholecystitis [4]. CEUS will evidence hyper loading at the wall level in the arterial phase, without significant clearance of the CA in the late phase [4,5]. ...
Gallbaldder disorders represent a prevalent pathology encounterd in daily practice, both in emergency and ambulatory settings. Transabdominal ultrasound has a high accuracy for the diagnosis of gallstones and acute cholecystitis. Contrast enhanced ultrasound (CEUS) can depict and characterized the vascular pattern in cases of inflammatory or malignant processes. In an emergency situation such as acute cholecystitis in patients with comorbidities, CEUS can acurate identify a gangrenous cholecystitis; subsequently the medical management can rely on this technique. The differential diagnosis of benign vs malignant pathology, in cases of segmental or diffuse wall thickening, can also benefit from CEUS. In this paper we aimed to discuss and to illustrate the role of CEUS in gallbladder pathology.
... Ultrasound elastography may reveal increased stiffness in large and superficially located GBC (Badea et al. 2014), whereas benign GBPs are characterized by low stiffness (Teber et al. 2014). However, elastographic US techniques need to be evaluated prospectively in larger cohorts. ...
... High-resolution US (Joo et al. 2013Bang et al. 2014;Kim et al. 2015;Lee et al. 2017;Dong et al. 2020b) or EUS (Kim et al. 2003;Tanaka et al. 2021) is superior to standard abdominal US in evaluating the integrity and layering of the GB wall. GB wall vascularity can be assessed using CDI (Hirooka et al. 1996;Pradhan et al. 2002;Badea et al. 2014), CEUS and CEH-EUS (Cornell and Clarke 1959;Numata et al. 2007;Liu et al. 2012;Xu et al. 2014;Badea et al. 2014;Bang et al. 2014;Imazu et al. 2014;Chen et al. 2017;Tang et al. 2015;Wang et al. 2016;Cheng et al. 2018;Kamata et al. 2018;Kong et al. 2018;Serra et al. 2018;Sidhu et al. 2018;Yuan et al. 2018;Zhang et al. 2018;Zhuang et al. 2018;Dong et al. 2020b;Gupta et al. 2020aGupta et al. , 2020bKin et al. 2020;Kumar et al. 2020;Liang and Jing 2020; (Fig. 6). Tumefactive sludge is easily differentiated from solid GB wall lesions Kamata et al. 2018;Serra et al. 2018;Kumar et al. 2020). ...
... High-resolution US (Joo et al. 2013Bang et al. 2014;Kim et al. 2015;Lee et al. 2017;Dong et al. 2020b) or EUS (Kim et al. 2003;Tanaka et al. 2021) is superior to standard abdominal US in evaluating the integrity and layering of the GB wall. GB wall vascularity can be assessed using CDI (Hirooka et al. 1996;Pradhan et al. 2002;Badea et al. 2014), CEUS and CEH-EUS (Cornell and Clarke 1959;Numata et al. 2007;Liu et al. 2012;Xu et al. 2014;Badea et al. 2014;Bang et al. 2014;Imazu et al. 2014;Chen et al. 2017;Tang et al. 2015;Wang et al. 2016;Cheng et al. 2018;Kamata et al. 2018;Kong et al. 2018;Serra et al. 2018;Sidhu et al. 2018;Yuan et al. 2018;Zhang et al. 2018;Zhuang et al. 2018;Dong et al. 2020b;Gupta et al. 2020aGupta et al. , 2020bKin et al. 2020;Kumar et al. 2020;Liang and Jing 2020; (Fig. 6). Tumefactive sludge is easily differentiated from solid GB wall lesions Kamata et al. 2018;Serra et al. 2018;Kumar et al. 2020). ...
The World Federation of Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings with a series of position papers to give advice on characterization and management. The biliary system (gallbladder and biliary tree) is the third most frequent site for incidental findings. This first part of the position paper on incidental findings of the biliary system is related to general aspects, gallbladder polyps and other incidental findings of the gallbladder wall. Available evidence on prevalence, diagnostic work-up, malignancy risk, follow-up and treatment is summarized with a special focus on ultrasound techniques. Multiparametric ultrasound features of gallbladder polyps and other incidentally detected gallbladder wall pathologies are described, and their inclusion in assessment of malignancy risk and decision- making on further management is suggested.
... Furthermore, optimization of this technique was achieved by constructing high-resolution broadband transducers with 3D and 4D options for organ imaging. This diagnostic arsenal was further enriched with endoscopic, laparoscopic and contrast-enhanced ultrasound (CEUS), as well as elastography and automatic organ segmentation, which was achieved using a special algorithm (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11) . Ultrasonography has long been a method allowing for precise cytological diagnosis of lesions by means of transabdominal and endoscopic ultrasound-guided fine needle aspiration biopsy (12)(13)(14) . ...
... This is important due to the management strategy in gallbladder polyps. Resection is recommended for polyps ≥10 mm as they significantly increase the risk of dysplasia or cancer (2)(3)(4)20,21) . An enlarged image allows tracking the polyp's behavior over time with greater precision. ...
... The degree of vascularization of lesions detected in the gallbladder and its walls should be assessed in various pathologies during each examination. Color Doppler should be set at slow blood flow, i.e. 2-10 cm/s (2) . ...
Although transabdominal imaging of the gallbladder has become a gold standard, new light should be shed on some aspects, which will prove useful in everyday practice. Therefore, based on our own experience and the available literature, we would like to draw attention to those elements of gallbladder ultrasound imaging which may increase its diagnostic efficacy. The paper draws attention to the difficulty in assessing certain anatomical structures, such as the inferior wall, the bottom and the region of the neck of the gallbladder, and offers ways to improve their imaging. We also emphasized the negative effects of duodenal and transverse colon (along with their contents) adhesion to the bottom of the gallbladder on the correct diagnosis. Due to the importance of size in the management strategy for detected gallbladder polyps, we suggest their measurement on an image enlarged with the zoom function. This technique also allows for an accurate assessment of the shape and echostructure of these lesions. An enlarged image of a polyp makes it possible to trace its behavior in time. We also remind that the hepatic wall of the gallbladder is the only site allowing for a reliable wall thickness measurement. We also pointed to the importance of changing patient‘s position when assessing the mobility and the nature of lesions. Altering patient‘s position during examination may help detect anomalies in the form of a floating gallbladder, which may promote its torsion. Finally, pathologies whose diagnosis may be facilitated by color-coded blood flow imaging are also presented. The issues discussed in this paper are only a fraction of problems faced by an ultrasound operator in the field of gallbladder diagnostic imaging. However, the proposed ultrasound approaches should help solve some of these problems in everyday practice.
Gallbladder diseases are very common, and their diagnosis is based on clinical–laboratory evaluation and imaging techniques. Considering the different imaging diagnostic tools, ultrasound (US) has the advantage of high accuracy combined with easy availability. Therefore, when a gallbladder disease is suspected, US can readily assist the clinician in the medical office or the emergency department. The high performance of US in the diagnosis of gallbladder diseases is mainly related to its anatomic location. The most frequent gallbladder pathological condition is gallstones disease, easily diagnosed via US examination. Acute cholecystitis (AC), a possible complication of gallstone disease, can be readily recognized due to its specific sonographic features. Additionally, a number of benign, borderline or malignant gallbladder lesions may be detected via US evaluation. The combined use of standard B-mode US and additional sonographic techniques, such as contrast-enhanced ultrasonography (CEUS), may provide a more detailed study of gallbladder lesions. Multiparametric US (combination of multiple sonographic tools) can improve the diagnostic yield during gallbladder examination.
Objective:
To study the utility of 2D shear wave elastography (SWE) and ascertain cut-off values of shear wave elasticity (SWe) to differentiate benign and malignant thickening of the gallbladder wall.
Methods:
This study was a prospective study of patients with symptomatic gallstone disease (GSD, n = 51) and gallbladder cancer (GBC, n = 46) and controls without any biliary disease (n = 46). All the participants underwent 2D USG and SWE of the gallbladder. Grey-scale ultrasound and SWE were done in the different regions in the gallbladder.
Results:
The median age of the patients with GSD was 49 years (interquartile range [IQR]: 33-55), GBC was 55 years (IQR: 46-65), and controls was 37 years (IQR: 27-48.25). In patients with GBC, asymmetrical mural thickening was the predominant imaging pattern (n = 24, 52.2%). The mean SWe of the abnormal area in GBC (34.99 ± 17.77 kPa [n = 46]) was significantly higher than that of the uninvolved region (18.27 ± 8.12 kPa [n = 35]; P < .01). The mean SWe of the uninvolved region in GBC (18.27 ± 8.12 kPa [n = 35]) was also significantly higher (P < .01) than that of GSD (12.27 ± 4.13 kPa [n = 51]) and controls (10.52 ± 3.75 kPa [n = 46]). On ROC analysis, AUC of 0.927, at a cut-off of 20 kPa, sensitivity was 91.3%, specificity was 83.5%, positive likelihood ratio was 5.54, and negative likelihood ratio was 0.10 to diagnose GBC.
Conclusion:
The 2D SWE is a reliable adjunctive tool to grey-scale USG in differentiating the malignant from benign gallbladder wall and may help to pick up early malignancy in GSD.
Objectives
This study aimed to determine ultrasonic image characteristics that enable differentiation between cholesterol and adenomatous polyps and to assess the diagnostic efficacy of combining conventional ultrasound (CUS) with contrast‐enhanced ultrasound (CEUS).
Methods
Eighty‐nine patients with gallbladder polyps of 1–2 cm in diameter were enrolled and examined by CUS and CEUS before cholecystectomy. The appearances on CUS and CEUS were recorded and analyzed. The receiver operating characteristic (ROC) curve was used to calculate the optimal size threshold for distinguishing cholesterol from adenomatous polyps. A logistic regression analysis was performed to identify diagnostic variables. ROC analysis was performed to evaluate the diagnostic efficacy of the size, the independent variables, and the combined factors.
Results
There were differences in size, number, vascularity on CUS and intralesional vascular shape, wash‐out, and area under the curve on CEUS between the two groups (P < .05). ROC analysis indicated that a maximum diameter of 1.45 cm was the optimal threshold for the prediction of adenomatous polyps. The logistic regression analysis proved that the single polyp, presence of vascularity, and intralesional linear vessels were associated with adenomatous polyps (P < .05). ROC analysis showed that the area under the ROC curve, sensitivity, and specificity for the combination of the three independent variables were 0.858, 87.3%, and 67.6%. The number combined with intralesional vascular shape had the highest diagnostic sensitivity of 91.2%.
Conclusions
The combination of CUS and CEUS demonstrated great significance in the differential diagnosis of cholesterol and adenomatous polyps.
Abstract
Introduction
Gallbladder adenoma (GA) is a precancerous neoplasm and needs surgical resection. It is difficult to differentiate adenoma from other gallbladder polyps using imaging examinations. The aim of present systematic review and meta-analysis was to evaluate the diagnostic accuracy of contrast-enhanced ultrasound in the diagnosis of gallbladder adenoma.
Methods
The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until end of 30/06/2019. The search included published literature in the English language in MEDLINE via PubMed, EMBASE via Ovid, The Cochrane Library, and Trip databases. For literature published in other languages, national databases (Magiran and SID), KoreaMed, and LILACS were searched. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology.
Results
Overall, 868 patients were studied in the 10 studies chosen for inclusion. Of these 10 studies, 5 (50%) were retrospective and 5 (50%) were prospective. The total prevalence of gallbladder adenoma in 10 studies was 16% (95% CI 13%, 18%). The sensitivity and specificity of contrast-enhanced ultrasound were 0.846 (95% CI 0.818–0.871) and 0.870 (95% CI: 0.844–0.894), respectively. The diagnostic odds ratio was 40.807 (95% CI 18.838–88.393).
Conclusion
CEUS is a reliable, non-invasive, and no-radiation-exposure imaging modality with a high sensitivity and specificity for detection of gallbladder adenoma. Nonetheless, it should be applied cautiously, and large scale, well-designed trials are necessary to assess its clinical value.
Ultrasound (US) is a cost-effective and noninvasive procedure without radiation exposure, with real-time evaluation and high spatial resolution. Although it is useful for the detection of gallbladder (GB) polyps, including gallbladder cancer, adenoma, and benign polyps, conventional US is insufficient for differential diagnosis because it is not capable of evaluating hemodynamic information, unlike computed tomography or magnetic resonance imaging. With recent technological advances in US equipment and contrast agents, Doppler imaging and contrast-enhanced ultrasonography (CEUS) are being used to characterize GB polyps, and several reports on evaluation of the vascularity of GB polyp have been published. In this review, we aimed to report the latest developments in the hemodynamic diagnosis of GB polyps based on previous reports, with an emphasis on CEUS, and to evaluate the efficacy for differential diagnosis. The information in this article is expected to enable early diagnosis and prompt surgical treatment for gallbladder cancer.
Aim:
To investigate the value of contrast enhanced ultrasound with high resolution linear transducers (HF-CEUS) for differential diagnosis of focal fundal gallbladder (GB) wall thickening.
Methods:
A total of 32 patients with incidentally detected focal fundal GB wall thickening were included. After conventional B mode ultrasound (BMUS) examinations, HF-CEUS were performed with a 7.5-12 MHz 9L4 linear transducer (S2000 HELX OXANA unit, Siemens). Two radiologists independently reviewed the HF-CEUS enhancement patterns to determine the differential features between malignancy and benignity with a five-point confidence scale. The diagnostic accuracy of BMUS and HF-CEUS for GB wall thickening was compared. The final gold standard was surgery with histological examination.
Results:
Final diagnoses included GB adenocarcinoma (n = 16), adenomyomatosis (n = 12), Xanthogranulomatous (n = 2) and cholecystitis (n = 2). HF-CEUS features associated with GB adenocarcinoma including arterial phase inhomogeneous hyperenhancement, venous phase hypoenhancement and disruption of GB wall layer structure (P < 0.05). Two small (5 mm) liver metastasis were confirmed by HF-CEUS during the late phase liver sweep as hypoenhanced lesions. Nonenhanced Rokitansky-Aschoff sinuses were clearly observed in 83.3% focal adenomyomatosis. Overall sensitivity, specificity and accuracy for differentiation between malignant and benign focal fundal GB wall thickening of HF-CEUS and BMUS were 84.3% vs 53.1%, 90.6% vs 59.3% and 87.5% vs 56.2% (P < 0.005).
Conclusions:
CEUS performed with high frequency linear transducers could be a useful alternative in the differential diagnosis of focal fundal GB wall thickening on conventional ultrasound.
New 3-dimensional (3D) US technology brings the ability to accurately reproduce almost any view of the anatomy with precision. This article reviews the advances in 3D US and details the clinical applications for which it is most beneficial.
The size and number of gallbladder polyps are used to differentiate between benign and malignant lesions before surgery and to determine whether surgery is necessary for the lesion. Since 1987, laparoscopic cholecystectomy has been widely used as the management method of choice for gallbladder lesions. The results of a clinicopathologic study of polypoid lesions of the gallbladder. based completely on laparoscopically resected gallbladder tissue, have not yet been evaluated fully. Data from 123 patients with polypoid lesions of the gallbladder treated by laparoscopic cholecystectomy were reviewed retrospectively. The gallbladders were classified into four histologic groups. Clinical features, maximal diameter, and the number of lesions were compared among the groups. The mean age of patients with adenoma and cancer was significantly greater than that of patients with cholesterol polyps and other lesions. More women than men had a neoplasm (adenoma and cancer), Patients in the neoplasm group tended to have a single lesion. The mean maximal diameter of neoplasms was significantly larger than that of lesions in the nonneoplasm group. All seven malignant lesions that were detected measured at least 1.5 cm, Univariate analysis showed that polypoid lesions of the gallbladder with neoplastic lesions correlated significantly with age, sex, size, and number of the lesions. Univariate analysis also showed that malignancy in polypoid lesions of the gallbladder correlated significantly with age, size, and number of the lesions. Multivariate logistic regression analysis showed that the age of the patient and the size of the lesion (greater than or equal to1.0cm) are two independent factors in predicting neoplastic lesions in polypoid lesions of the gallbladder. The size of the lesion (greater than or equal to1.5cm) is the only independent factor in predicting malignancy in the polypoid lesions of the gallbladder as shown by multivariate logistic regression analysis. Laparoscopic cholecystectomy is a safe and feasible method fur gallbladder polypoid lesions. Neoplastic change in polypoid lesions of the gallbladder should be considered when a patient older than 50 years of age has a polypoid lesion larger than 1.0 cm, Cancer should be suspected when a polypoid lesion of the gallbladder is larger than 1.5 cm, and an aggressive surgical approach is warranted so that early gallbladder cancer can be detected and patients can have an increased chance of cure.
Benign neoplasms of the gallbladder occur so rarely that even in a large surgical practice one encounters few of them; for this reason all studies of these growths have been based on only a few cases. We wish to present a clinical and pathologic study of the benign tumors of the gallbladder encountered at operation at the Mayo Clinic from Jan. 1, 1906, to Dec. 31, 1938, inclusive. The group comprises 45 gallbladders containing one or more polypi, 103 containing adenomyoma and 2 containing fibroma. All the specimens except 3 were obtained by cholecystectomy; 3 were taken for biopsy—2 of the 3 at cholecystostomy and 1 at gastric resection for carcinoma of the stomach. Papilloma of the gallbladder, as has been pointed out by MacCarty,¹ by Phillips,² and by Graham, Cole, Copher and Moore,³ is not a true neoplasm and hence was not included in this study.
Background and Methods.
The Southern Surgeons Club conducted a prospective study of 1518 patients who underwent laparoscopic cholecystectomy for treatment of gallbladder disease in order to evaluate the safety of this procedure.
Results.
Seven hundred fifty-eight operations (49.9 percent) were performed at academic hospitals, and 760 (50.1 percent) at private hospitals. In 72 patients (4.7 percent) the operation was converted to conventional open cholecystectomy; the most common reason for the change was the inability to identify the anatomy of the gallbladder as a result of inflammation in the region of this organ.
Conclusions.
The results of laparoscopic cholecystectomy compare favorably with those of conventional cholecystectomy with respect to mortality, complications, and length of hospital stay. A slightly higher incidence of biliary injury with the laparoscopic procedure is probably offset by the low incidence of other complications. (N Engl J Med 1991;324:1073–8.)
Background:
The purpose of this study was to estimate the sensitivity and specificity of diagnostic tests for gallstones and acute cholecystitis.Methods:
All English-language articles published from 1966 through 1992 about tests used in the diagnosis of biliary tract disease were identified through MEDLINE. From 1614 titles, 666 abstracts were examined and 322 articles were read to identify 61 articles with information about sensitivity and specificity. Application of exclusion criteria based on clinical and methodologic criteria left 30 articles for analysis. Cluster-sampling methods were adapted to obtain combined estimates of sensitivities and specificities. Adjustments were made to estimates that were biased because the gold standard was applied preferentially to patients with positive test results.Results:
Ultrasound has the best unadjusted sensitivity (0.97; 95% confidence interval, 0.95 to 0.99) and specificity (0.95; 95% confidence interval, 0.88 to 1.00) for evaluating patients with suspected gallstones. Adjusted values are 0.84 (0.76 to 0.92) and 0.99 (0.97 to 1.00), respectively. Adjusted and unadjusted results for oral cholecystogram were lower. Radionuclide scanning has the best sensitivity (0.97; 95% confidence interval, 0.96 to 0.98) and specificity (0.90; 95% confidence interval, 0.86 to 0.95) for evaluating patients with suspected acute cholecystitis; test performance is unaffected by delayed imaging. Unadjusted sensitivity and specificity of ultrasound in evaluating patients with suspected acute cholecystitis are 0.94 (0.92 to 0.96) and 0.78 (0.61 to 0.96); adjusted values are 0.88 (0.74 to 1.00) and 0.80 (0.62 to 0.98).Conclusions:
Ultrasound is superior to oral cholecystogram for diagnosing cholelithiasis, and radionuclide scanning is the test of choice for acute cholecystitis. However, sensitivities and specificities are somewhat lower than commonly reported. We recommend estimates that are midway between the adjusted and unadjusted values.(Arch Intern Med. 1994;154:2573-2581)
