van Breda Vriesman et al.

H e p a t o b i l i a r y I m ag i n g • P i c t o r i a l E s s ay
Diffuse Gallbladder Wall
Thickening

Diffuse Gallbladder Wall Thickening:

Differential Diagnosis
Adriaan C. van Breda Vriesman1 OBJECTIVE. The objective of our study was to review and illustrate the various clinical
Marc R. Engelbrecht2 entities that may cause diffuse thickening of the gallbladder wall on diagnostic imaging studies.
Robin H. M. Smithuis1 CONCLUSION. Diffuse gallbladder wall thickening may be caused by a wide range of
Julien B. C. M. Puylaert3 gallbladder diseases and extracholecystic pathologic conditions. In most cases its cause can be
determined by correlation of the clinical presentation and associated imaging findings.
van Breda Vriesman AC, Engelbrecht MR,
Smithuis RHM, Puylaert JBCM hickening of the gallbladder wall is ing [2], or CT may be used as an adjunct to an

T
American Journal of Roentgenology 2007.188:495-501.

a relatively frequent finding on di- inconclusive sonography examination or for

Keywords: abdominal imaging, acute abdomen,
adenomyomatosis, cholecystitis, CT, gallbladder
carcinoma, gallbladder disease, gallbladder thickening,
sonography
DOI:10.2214/AJR.05.1712
Received September 26, 2005; accepted after revision
November 12, 2005.
1Department
of Radiology, Rijnland Hospital, Simon
Smitweg 1, PO Box 4220, NL-2350 CC Leiderdorp,
The Netherlands. Address correspondence to
A. C. van Breda Vriesman (adriaanbreda@hotmail.com).
2Department
of Radiology, UMC Radboud, Nijmegen,
The Netherlands.
3Department of Radiology, MCH Westeinde Hospital,
The Hague, The Netherlands.
AJR 2007; 188:495–501
0361–803X/07/1882–495
© American Roentgen Ray Society
agnostic imaging studies. Histori-
cally, a thick-walled gallbladder
has been regarded as proof of primary gallblad-
der disease, and it is a well-known hallmark
feature of acute cholecystitis. The finding it-
self, however, is nonspecific and can also be
found in a variety of conditions unrelated to in-
trinsic gallbladder disease. Diffuse gallbladder
wall thickening may produce a diagnostic
problem because it occurs in symptomatic and
asymptomatic patients and in patients with and
those without an indication for cholecystec-
tomy. Misinterpretation of the cause of this im-
aging finding can lead to an unnecessary
cholecystectomy in patients without intrinsic
gallbladder disease and, conversely, misdiag-
nosis in patients who do require a cholecystec-
tomy may result in delayed treatment with in-
creased morbidity. In this essay, we discuss and
illustrate the various causes of a thickened gall-
bladder wall because knowledge of its differ-
ential diagnosis is essential for the correct in-
terpretation of this finding.
Normal and Thickened Gallbladder
Sonography, CT, and MRI all allow direct
visualization of the normal and thickened
gallbladder wall. Traditionally, sonography is
used as the initial imaging technique for eval-
uating patients with suspected gallbladder
disease because of its high sensitivity in the
detection of gallbladder stones, its real-time
character, and its speed and portability [1].
However, CT has become popular for evalu-
ating the acute abdomen and often is the first
technique to show gallbladder wall thicken-
staging of disease. The potential value of MRI
in the evaluation of gallbladder disease has
been shown [3], but it still plays little role.
The normal gallbladder wall appears as a
pencil-thin echogenic line on sonography
(Fig. 1) and is usually visible on CT as a thin
rim of soft-tissue density that enhances after
contrast injection (Fig. 2). The thickness of the
gallbladder wall depends on the degree of gall-
bladder distention, and pseudothickening can
occur in the postprandial state (Fig. 1). A
thickened gallbladder wall measures more than
3 mm, typically has a layered appearance at
sonography [1], and frequently contains a hy-
podense layer of subserosal edema that mimics
pericholecystic fluid at CT [2] (Fig. 3).
Primary Gallbladder Disease
Acute Cholecystitis
Acute cholecystitis is the fourth most
common cause of hospital admissions for
patients presenting with an acute abdomen
[4], and it is the prime diagnostic concern
when a thick-walled gallbladder is found at
imaging. This feature, however, is not
pathognomonic, and additional imaging
signs should be present to support the diag-
nosis of acute calculous cholecystitis, such
as an obstructing gallstone (Fig. 4), hydropic
dilatation of the gallbladder (Figs. 4 and 5),
a positive sonographic “Murphy’s” sign (i.e.,
pain elicited by pressure over the sonograph-
ically located gallbladder), pericholecystic
fat inflammation or fluid (Figs. 4 and 5), and
hyperemia of the gallbladder wall at power
Doppler imaging (Fig. 6).

AJR:188, February 2007 495


Acute acalculous cholecystitis mainly oc-
curs in critically ill patients presumably be-
cause of increased bile viscosity from fasting
and taking medication that causes cholestasis.
The imaging features are those of acute chole-
cystitis except for the absence of stones and
the presence, usually, of gallbladder sludge
(Fig. 6). Because gallbladder abnormalities
are frequently found secondary to systemic
disease in critically ill patients, as we discuss
later in this article, acalculous cholecystitis
can be difficult to diagnose [5]. In these pa-
tients, a percutaneous cholecystostomy can
be both diagnostic and therapeutic.
Chronic Cholecystitis
“Chronic cholecystitis” is a term used clini-
cally to refer to symptomatic gallbladder
stones that cause transient obstruction that
leads to low-grade inflammation with fibrosis
[1]. Correlation of the imaging finding of a
American Journal of Roentgenology 2007.188:495-501.
stone-containing, slightly thick-walled gall-
bladder (Fig. 7) with clinical history is critical.
Xanthogranulomatous cholecystitis is an
unusual variant of chronic cholecystitis that is
characterized by a lipid-laden inflammatory
process comparable to xanthogranulomatous
pyelonephritis. Imaging studies show marked
gallbladder wall thickening, with the wall of-
ten containing nodules that are hypoechoic at
sonography and hypoattenuating at CT
(Fig. 8); these nodules are abscesses or foci of
xanthogranulomatous inflammation. These
features overlap with those of gallbladder car-
cinoma, often making preoperative distinc-
tion between these entities impossible [6].
A porcelain gallbladder is a rare disorder in
which chronic cholecystitis produces mural
calcification (Fig. 9). In these patients, a pro-
phylactic cholecystectomy has been advo-
cated because porcelain gallbladder has been
associated with gallbladder carcinoma [4];
however, this association appears to be weak.
Gallbladder Carcinoma
Gallbladder carcinoma is the fifth most com-
mon malignancy of the gastrointestinal tract
and is found incidentally in 1–3% of cholecys-
tectomy specimens [4]. It is often detected at a
late stage of the disease because of the lack of
early or specific symptoms. Gallbladder carci-
noma has various imaging appearances, rang-
ing from a polypoid intraluminal lesion to an
infiltrating mass replacing the gallbladder, and
it may also present as diffuse mural thickening
(Fig. 10). Associated findings such as invasion
of adjacent structures, secondary bile duct dila-
tation, and liver or nodal metastases may help in
496
van Breda Vriesman et al.
differentiating it from acute or xanthogranulo-
matous cholecystitis [2, 4].
Adenomyomatosis
Adenomyomatosis of the gallbladder is
characterized by epithelial proliferation, mus-
cular hypertrophia, and intramural diverticula
(Rokitansky-Aschoff sinuses), which may
segmentally or diffusely involve of the gall-
bladder. It is a benign condition that requires
no specific treatment and occurs as an inci-
dental finding in up to 9% of cholecystectomy
specimens [6]. The sonographic finding of
cholesterol crystals, shown as comet-tail re-
verberation artifacts (Fig. 11) within a thick-
ened wall of the gallbladder strongly suggests
this diagnosis. Air may produce a similar ar-
tifact; however, patients with emphysematous
cholecystitis are usually ill in contrast to those
with adenomyomatosis. MRI may be able to
differentiate adenomyomatosis from gall-
bladder carcinoma by depicting Rokitansky-
Aschoff sinuses [7].
Secondary Gallbladder Involvement
Diffuse thickening of the gallbladder wall
may occur in patients who do not have a pri-
mary gallbladder disease, but in whom the
gallbladder is secondarily involved in an ex-
trinsic pathologic condition. In these patients,
a cholecystectomy is unwarranted, and gall-
bladder wall thickening will usually return to
normal after correction of its extrinsic cause.
Systemic Diseases
Systemic diseases, such as liver dysfunc-
tion, heart failure, or kidney failure, may lead
to diffuse gallbladder thickening [1, 2]. The
exact pathophysiologic mechanism leading to
edema of the gallbladder wall in these diverse
conditions is uncertain, but it is likely due to
elevated portal venous pressure, elevated sys-
temic venous pressure, decreased intravascu-
lar osmotic pressure, or a combination of
these factors. Liver cirrhosis (Fig. 12), hepa-
titis (Fig. 13), and congestive right heart fail-
ure (Fig. 14) are relatively frequent causes.
Hypoproteinemia has also been reported as a
cause of extrinsic gallbladder disease, but this
finding has been disputed [8].
Extracholecystic Inflammation
Extracholecystic inflammation may sec-
ondarily involve the gallbladder, thereby
causing wall thickening due to the direct
spread of the primary inflammation or, less
frequently, due to an immunologic reaction
[8]. Theoretically, gallbladder wall thicken-
ing may be caused by any inflammation that
extends to the region of the gallbladder, but
only a few entities are regularly encountered,
including hepatitis, pancreatitis (Fig. 15), and
pyelonephritis. Gallbladder wall thickening
has also been reported in patients with infec-
tious mononucleosis [9] and in patients with
AIDS due to opportunistic infections or sec-
ondary neoplastic infiltration [2].
Conclusion
Diffuse gallbladder wall thickening can
result from a broad spectrum of pathologic
conditions, including surgical and nonsurgi-
cal diseases. Although, at times, a definite
imaging diagnosis may be impossible, the
cause of gallbladder wall thickening can be
determined in most cases by correlation of
the clinical presentation and associated im-
aging findings.
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7. Yoshimitsu K, Honda H, Jimi M, et al. MR diagno-
sis of adenomyomatosis of the gallbladder and dif-
ferentiation from gallbladder carcinoma: impor-
tance of showing Rokitansky-Aschoff sinuses. AJR
1999; 172:1535–1540
8. Kaftori JK, Pery M, Green J, Gaitini D. Thickness
of the gallbladder wall in patients with hypoalbu-
minemia: a sonographic study of patients on peri-
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AJR:188, February 2007
 Diffuse Gallbladder Wall Thickening

A B C
Fig. 1—35-year-old healthy male volunteer with normal gallbladder. Fig. 2—52-year-old man with normal gallbladder.
A, Longitudinal sonogram of gallbladder, obtained after patient fasted for 12 hours, shows wall (arrow) as pencil- Contrast-enhanced CT scan shows gallbladder wall as
thin echogenic line. thin rim of enhancing soft-tissue density (arrowhead)
B, Longitudinal sonogram in postprandial state shows pseudothickening of gallbladder wall (arrow) due to surrounded by normal hypoattenuating fat.
physiologic contraction.
American Journal of Roentgenology 2007.188:495-501.

Fig. 3—59-year-old woman with diffuse gallbladder

wall thickening from acute cholecystitis.
A, Longitudinal sonogram shows layered appearance of
thickened gallbladder wall, with relatively hypoechoic
region (arrowhead) between echogenic lines.
B, Contrast-enhanced CT scan shows thick-walled
gallbladder contains hypodense outer layer (arrow)
that corresponds to subserosal edema, which may
simulate pericholecystic fluid.
A B

AJR:188, February 2007 497

 van Breda Vriesman et al.

Fig. 4—43-year-old woman with acute calculous

cholecystitis.
A and B, Contrast-enhanced CT scans show distended
gallbladder (arrowheads, A) with slightly thickened
wall and subtle regional fat stranding (asterisk, A).
Impacted, obstructing stone (arrow, B) is seen in neck
of gallbladder.

A B
American Journal of Roentgenology 2007.188:495-501.

Fig. 5—62-year-old man with acute calculous

cholecystitis.
A, Transverse sonogram at spot of maximum
tenderness shows noncompressible hydropically
distended thick-walled gallbladder (arrowheads) and
intraluminal stone and sludge or debris.
B, Contrast-enhanced CT scan depicts extensive
fat inflammation (arrowheads) surrounding
gallbladder (arrow).

A B

A B C
Fig. 6—74-year-old man with acute acalculous cholecystitis.
A, Longitudinal sonogram at spot of maximum tenderness shows mural thickening of gallbladder (arrow), which is completely filled with sludge (asterisk) without any stones.
B, Power Doppler sonogram shows hypervascularity of gallbladder wall (arrowhead) as sign supporting diagnosis of inflammation.
C, Contrast-enhanced CT scan depicts thick-walled gallbladder (arrow) filled with dense sludge (asterisk).

498 AJR:188, February 2007

 Diffuse Gallbladder Wall Thickening

Fig. 7—49-year-old woman with chronic cholecystitis. Longitudinal sonogram of gallbladder shows slight wall
thickening (arrow) and intraluminal nonobstructing stone. This patient had fasted overnight, so wall thickening
does not represent physiologic contraction. Correlation of these findings with her clinical history of recurrent
coliclike right upper quadrant pain due to transient gallbladder obstruction is essential for diagnosis.
American Journal of Roentgenology 2007.188:495-501.

A B C
Fig. 8—71-year-old man with xanthogranulomatous cholecystitis.
A, Transverse sonogram of gallbladder shows marked wall thickening with intramural hypoechoic nodules (arrowheads) and intraluminal stone (arrow).
B and C, Contrast-enhanced CT scans show deformed and thickened gallbladder wall (arrow, B) containing hypoattenuating nodules (arrowheads, C) that correspond to
hypoechoic lesions, representing abscesses or foci of inflammation. Lumen contains several stones (arrow, C).

A B C
Fig. 9—56-year-old man with porcelain gallbladder.
A, Conventional abdominal radiograph depicts diffusely calcified gallbladder wall (arrowhead).
B, Transverse sonogram of gallbladder shows calcification of anterior wall (arrowhead) with acoustic shadowing.
C, Contrast-enhanced CT scan depicts circumferential calcification of gallbladder wall (arrow).

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 van Breda Vriesman et al.

A B C
Fig. 10—79-year-old man with gallbladder carcinoma. Fig. 11—39-year-old woman with adenomyomatosis
A, Longitudinal sonogram of gallbladder shows marked generalized wall thickening (arrowheads), replacing of gallbladder. Longitudinal sonogram of gallbladder
gallbladder lumen. Multiple gallbladder stones (arrow) indicate probable location of filled lumen. shows mural thickening with calcifications and
B, Contrast-enhanced CT scan depicts thick-walled gallbladder (arrowhead) with local infiltration of mass in stones, with characteristic comet-tail reverberation
American Journal of Roentgenology 2007.188:495-501.

adjacent liver (arrow). In absence of associated findings such as local invasion or metastases, it may not be artifact (arrowhead) emanating from anterior wall.
possible to differentiate carcinoma from xanthogranulomatous cholecystitis. Note that gallstones are occult at CT. This is due to small cholesterol crystals within
Rokitansky-Aschoff sinuses.

Fig. 12—56-year-old man

with liver cirrhosis.
A, Longitudinal
sonogram of gallbladder
depicts wall thickening
(arrow) surrounded by
ascites. Note irregular
cirrhotic liver
parenchyma. Secondary
gallbladder wall
thickening in patients
with liver cirrhosis is
presumably due to
elevated portal venous
pressure and decreased
intravascular osmotic
pressure.
B, Contrast-enhanced CT
scan shows wall of
gallbladder (arrow)
appears nearly normal
because subserosal
edema cannot be well
differentiated from
surrounding ascites at CT.
A B

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 Diffuse Gallbladder Wall Thickening

A B C
Fig. 13—75-year-old man with drug-induced hepatitis.
A, Longitudinal sonogram of nondistended gallbladder shows diffuse wall thickening (arrow) and incidental cholelithiasis, which may be confusing.
B and C, MR images were obtained to evaluate bile ducts because of abnormal liver function tests. Axial SPIR (spectral presaturation by inversion recovery) T2-weighted
image (B) shows small amount of ascites (arrowhead, B), which indicates that thickened gallbladder wall (arrow, B) probably has extrinsic systemic cause. Mural thickening
American Journal of Roentgenology 2007.188:495-501.

of gallbladder (arrowhead, C) is also shown on oblique HASTE image (C) from MR cholangiography; this study excludes choledocholithiasis.

Fig. 14—74-year-old man with congestive right heart

failure.
A, Longitudinal sonogram of stone-free painless
gallbladder depicts diffuse wall thickening (arrow).
B, Transverse sonographic view through liver shows
large-caliber hepatic veins (arrowheads) and inferior
vena cava as supporting evidence of right heart failure.
A B

Fig. 15—56-year-old man with pancreatitis. Contrast-enhanced CT scan shows

peripancreatic inflammatory changes (arrowheads) and thickening of wall of
gallbladder (arrow), which is secondarily involved in pancreatic inflammation.

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