ArticlePublisher preview availableLiterature Review

A comprehensive exploration of gallbladder health: from common to rare imaging findings

July 2024
Abdominal Radiology 50(1):131-151

Authors:

University of São Paulo

This comprehensive review explores a wide range of imaging findings associated with the gallbladder (GB), from anatomic variants to rare diseases. Through an in-depth review of diagnostic modalities including ultrasound, magnetic resonance cholangiopancreatography, CT, and MRI, we aim to highlight the crucial role of imaging techniques in diagnosing GB disorders, as congenital anomalies, inflammatory diseases, neoplasms, and surgical complications. Employing a detailed analysis and comparison of imaging findings across various modalities, this review seeks to improve diagnostic accuracy for GB-related pathologies, facilitating optimal patient management. Graphical abstract

Anatomical Variants and Malformations. Gallbladder Agenesis:a Axial T2-weighted MR image shows an empty gallbladder fossa (white circle), and b coronal T2-weighted MR image demonstrates the absence of the gallbladder and cystic duct. c MRCP image with normal appearance of the intra and extrahepatic biliary ducts and no gallbladder visualized. Gallbladder Hypoplasia:d Axial T2-weighted MR image showing a shrunken gallbladder (white arrow), e axial diffusion-weighted image demonstrating the small gallbladder size (white arrow), and f axial T1-weighted MR image post-contrast depicting the hypoplastic gallbladder with reduced volume (white circle). Intrahepatic Gallbladder:g Axial CT scan with intravenous contrast showing the gallbladder in an intrahepatic position (white arrow), encased within the liver parenchyma, with h sagittal reformatting and i coronal reformatting further demonstrating the gallbladder’s abnormal location, fully surrounded by hepatic tissue

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Anatomical Variants and Malformations. Gallbladder Duplication:a Axial T2-weighted MR image and b Axial T1-weighted MR image post-contrast revealing two elongated saccular structures at the gallbladder fossa (white arrow), indicative of duplicated gallbladders. c MRCP demonstrating the presence of a double gallbladder, with both sharing a single cystic duct. d Ultrasound image showing a gallstone within one of the duplicated gallbladders (white arrow). Multiseptate Gallbladder:e Axial and f Coronal T2-weighted MRI images demonstrating the gallbladder divided into multiple compartments by thin septa, presenting a honeycomb appearance and a faintly bosselated external surface (white circle). g Axial portal venous phase post-contrast MR image revealing non-enhancing septa within the gallbladder. h MRCP showing thin septa within the gallbladder, some of which may be complete. Gallbladder Diverticulum:i Coronal and j Axial T2-weighted MRI images revealing a focal outpouching arising from the medial wall of the gallbladder (white arrow), without evidence of gallstones or features of bile stasis. k Axial portal venous phase post-contrast MR image demonstrating enhancement of the septa within the diverticulum (white arrow)

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Phrygian Cap:a Axial CT image demonstrating the folded fundus of the gallbladder representing the Phrygian cap (white arrow). b Axial and c Coronal T2-weighted MR images showing a septum or fold within the gallbladder between the fundus and the body. d Axial portal venous phase post-contrast MR image depicting enhancement of the septum or fold. Lymphangioma of the Gallbladder:e–g CT scan with intravenous contrast demonstrating a cystic mass adjacent to the gallbladder (white arrow). The mass lacks solid components and appears to insinuate itself between the liver and the gallbladder

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Acute Acalculous Cholecystitis:a-d Axial CT scan displaying gallbladder distention with dense content in an ICU patient. Acalculous Phrygian Cap Cholecystitis:e and f Axial and coronal T2-weighted MR images depicting the gallbladder with the morphology of a Phrygian cap. g On the coronal portal venous phase post-contrast MR image, the Phrygian cap is abnormally distended with a thickened wall, accompanied by surrounding inflammatory fat stranding (white arrow). The proximal gallbladder appears normal, with no surrounding inflammatory change

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Xanthogranulomatous Cholecystitis:a and b MRI images depicting diffuse gallbladder thickening, heterogeneous enhancement of the wall, and infiltration into the pericholecystic fat and adjacent liver (white circle). Gangrenous Cholecystitis:c Axial T2-weighted MRI and d MRCP revealing wall thicirregularity (white arrow) consistent to detachment of the mucous layer. e Axial MRI post-contrast showing an over-distended gallbladder with absence of mural enhancement. f Diffusion-weighted trace image indicating wall diffusion restriction. Hemorrhagic Cholecystitis:g Non-contrast CT scan revealing high-attenuating gallbladder content as well as high-attenuating adjacent fluid suggesting hemorrhage. h and i During arterial phase CT scans, active contrast agent extravasation indicating ongoing bleeding (white arrow)

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Vol.:(0123456789)

Abdominal Radiology (2025) 50:131–151

https://doi.org/10.1007/s00261-024-04431-4

SPECIAL SECTION: EDITOR’S INVITE

A comprehensive exploration ofgallbladder health: fromcommon

torare imaging ﬁndings

ViviannedePaulaReisGuimarães1 · JoaoMiranda2,3 · CássiaTamuraSttefanoGuimarães1 ·

HiltonLeãoFilho1 · RobertoBlasbalg1 · DanielLahan‑Martins1,4 · FernandaGarozzoVelloni1

Received: 10 April 2024 / Revised: 28 May 2024 / Accepted: 30 May 2024 / Published online: 2 July 2024

Abstract

This comprehensive review explores a wide range of imaging ﬁndings associated with the gallbladder (GB), from anatomic

variants to rare diseases. Through an in-depth review of diagnostic modalities including ultrasound, magnetic resonance

cholangiopancreatography, CT, and MRI, we aim to highlight the crucial role of imaging techniques in diagnosing GB

disorders, as congenital anomalies, inﬂammatory diseases, neoplasms, and surgical complications. Employing a detailed

analysis and comparison of imaging ﬁndings across various modalities, this review seeks to improve diagnostic accuracy

for GB-related pathologies, facilitating optimal patient management.

Graphical abstract

Keywords Gallbladder· Anatomy· Inﬂammation· Neoplasm

Vivianne de Paula Reis Guimarães and Joao Miranda equally

contributed to this study.

Extended author information available on the last page of the article

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

ResearchGate has not been able to resolve any citations for this publication.

Multiseptate gallbladder in an asymptomatic child: Case report and review of the literature

Article

Full-text available

Jan 2024

Multiseptated gallbladder also known as “Honeycomb gallbladder” is a rare condition that was first described by Tandon in 1963. It is described as a congenital anomaly in most of the cases. It may be asymptomatic or may lead symptoms. We present the case of a multiseptate gallbladder in a 5 year old girl who was admitted for managament of acute appendicitis.

Agenesis of gallbladder—an unexpected absence in laparoscopy

Article

Full-text available

Apr 2023

Gallbladder agenesis is a very rare condition, majority of which are normally diagnosed intraoperatively because of low index of suspicion and high rate of false positive results for cholecystitis on ultrasound imaging. We present a case of a 25-year-old man who presented with a right upper quadrant pain, whose ultrasound suggests a contracted gallbladder with gallstones. He was treated as an acute on chronic cholecystitis and booked for laparoscopic cholecystectomy. Intraoperatively, there was no gallbladder to be seen and decision was made to abandon procedure and avoid further exploration. Post-operative magnetic resonance cholangiopancreatography confirmed the congenital agenesis of gallbladder. It is important to have awareness of this condition, and possible further imaging modalities should be used if the ultrasound suggests a shrunken or contracted gallbladder that is not easily visible to avoid the risk of undergoing an unwarranted surgery.

Cholecysto-hepatic fistula in type III gallbladder perforation: A rare etiology of liver abscess; case report

Article

Full-text available

Mar 2023

Introduction and importance: Gallbladder perforation (GBP) with cholecystohepatic fistula is an extremely rare complication of acute and/or chronic gallbladder diseases. Niemeier classified GBP into three types each characterized by specific signs and symptoms. Radiological investigations such as abdominal ultrasonography (USG) and computed tomography (CT) are crucial to evaluate and diagnosing GBP, while fistulae are usually identified intraoperatively. Case presentation: A 77-year-old female patient, with a background medical history of multiple comorbidities, presented to our hospital with a one-week history of abdominal pain. Laboratory investigations showed abnormal values. The abdominal CT scan revealed a mildly enlarged liver, distended gallbladder, and liver abscess. Then, ultrasound-guided aspiration was done, and the clinical picture was consistent with calcular cholecystitis complicated with liver abscess. So, laparoscopic cholecystectomy was decided and the intraoperatively detected fistula was excised. The resected perforated gallbladder was sent for histopathological studies. The postoperative period was uneventful. Clinical discussion: GBP is an unusual entity that is categorized into three types. It is considered a gallbladder complication and surgical emergency. The clinical features of GBP are non-specific and radiological tools aid in diagnosis demonstration. In the presented case of type III GBP, cholecystohepatic fistula was detected and excised intraoperatively. Conclusion: Due to the rare entity of type III GBP in association with liver abscess, we report the case of a 77-year-old female with right lower quadrant pain, found to be caused by type III GBP with cholecystohepatic fistula and liver abscess.

Complications Related to Transarterial Treatment of Hepatocellular Carcinoma: A Comprehensive Review

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Jan 2023

Currently, various types of transarterial treatments are performed for hepatocellular carcinoma from the early to advanced stages. Its indications and efficacy have been widely investigated. However, procedure-related complications have not been updated in the literature, although new types of transarterial treatments, such as drug-eluting bead transarterial chemoembolization and transarterial radioembolization, are common in daily practice. Herein, a comprehensive literature review was carried out, and complications were organized according to the organs affected and treatment modalities.

Multiseptate gallbladder presenting with biliary colic

Article

Full-text available

Sep 2022

Common diagnoses associated with right upper quadrant and epigastric pain include cholecystitis, peptic ulcer disease (PUD), biliary colic, gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). Multiseptate gallbladder is a rare congenital anomaly that can cause symptoms of biliary colic, however it may present with atypical symptoms, which can prolong definitive diagnosis and treatment. We present a case of multiseptate gallbladder in a 21-year-old female who initially presented with GERD and IBS. After multiple failed treatment regimens for IBS, she ultimately was found to have multiseptate gallbladder and was successfully treated with cholecystectomy.

The Clinical Significance of Hemorrhagic Cholecystitis

Article

Full-text available

Apr 2022

Background: Hemorrhagic cholecystitis (HC) is a rare complication of acute cholecystitis. HC is difficult to diagnose pre-operatively and previous case reports suggest a strong association with anticoagulation and an increased morbidity. The purpose of the study is to determine the clinical presentation and outcomes of patients with HC in a large cohort of patients. Method: A retrospective review of HC patients diagnosed following review of the clinical and pathological database between January 1, 2000 - June 30, 2021 at two hospitals. A search of the histopathology database, patient medical records, laboratory results, and imaging was conducted. Results: Thirty-five patients were diagnosed on the histopathology report from approximately 6458 patients who had cholecystectomies. Thirty-one had emergency presentation and four patients (11.4%) had elective surgery. Twenty-one patients (60%) were female and 15 patients (40%) were male. The median age was 51 years. All patients had laparoscopic cholecystectomy, four patients were converted to open and five patients required postoperative endoscopic retrograde cholangiopancreatography. Two patients (5.7%) were on anticoagulation therapy. Twenty-three (65.7%) had ultrasound, 12 patients (34.2%) had computed tomography, three patients (8.5%) had magnetic resonance cholangiopancreatography, and one patient with a pre-operative diagnosis of HC. Conclusion: HC is a rare form of acute cholecystitis. Anticoagulation only accounts for a small fraction of these patients. Pre-operative diagnosis of HC is not often made. Patients were treated with cholecystectomies and made a full recovery with no complications. Our study seems to show HC is a histological diagnosis with no clinical consequences for the patients.

Synchronous gallbladder metastasis originating from residual gastric cancer: a case report and the review of literature

Article

Full-text available

Dec 2022

Background Gastric cancer rarely metastasizes to the gallbladder. Furthermore, there has never been a case report of simultaneous gallbladder metastasis from residual gastric cancer. Here, we report a case of synchronous gallbladder metastasis originating from a residual gastric cancer. Case presentation A 67-year-old man underwent a follow-up upper endoscopy 18 months after a partial gastrectomy for gastric cancer; an ulcerative lesion was found in the remnant stomach at the gastrojejunal anastomosis. A biopsy revealed gastric signet-ring cell carcinoma (SRCC). A full-body examination revealed no abnormalities other than gallstones in the gallbladder. With a diagnosis of residual gastric cancer (cT2N0M0 cStage I), the patient underwent open total gastrectomy and cholecystectomy. Macroscopic findings of the resected specimen revealed thickening of the gallbladder wall; however, no obvious neoplastic lesions were found on the mucosal surface of the gallbladder. The pathological findings showed that the SRCC had invaded the submucosa of the gastrojejunostomy site with a high degree of lymphatic invasion and lymph node metastases. SRCCs were also found in the lymphatic vessels of the gallbladder wall. These findings suggested the possibility of gallbladder metastasis through lymphatic vessels. The patient and his family members refused postoperative chemotherapy. Ten months after the operation, the patient experienced respiratory failure due to lymphangitis carcinomatosa and died. Conclusions At present, it is difficult to determine whether resection of the gallbladder contributes to an improved prognosis of gastric cancer patients. However, reports in such cases demonstrate that gallbladder metastasis could be a poor predictor of prognosis for gastric cancer.

Biliary Disorders, Anomalies, and Malignancies in Children

Article

Mar 2024
RADIOGRAPHICS

Biliary abnormalities in children are uncommon, and the spectrum of biliary disorders is broader than in adult patients. Unlike in adults, biliary disorders in children are rarely neoplastic and are more commonly rhabdomyosarcoma rather than cholangiocarcinoma. Pediatric biliary disorders may be embryologic or congenital, such as anatomic gallbladder anomalies, anomalous pancreaticobiliary tracts, various cholestatic processes, congenital cystic lesions, or genetic conditions. They may also be benign, such as biliary filling anomalies, biliary motility disorders, and biliary inflammatory and infectious disorders. Distinguishing these entities with a single imaging modality is challenging. US is the primary imaging modality for initial evaluation of biliary abnormalities in children, due to its wide availability, lack of ionizing radiation, and low cost and because it requires no sedation. Other examinations such as MRI, CT, and nuclear medicine examinations may provide anatomic and functional information to narrow the diagnosis further. Hepatobiliary-specific contrast material with MRI can provide better assessment of biliary anatomy on delayed images than can traditional MRI contrast material. MR cholangiopancreatography (MRCP) allows visualization of the intra- and extrahepatic biliary ducts, which may not be possible with endoscopic retrograde cholangiopancreatography (ERCP). Suspected biliary atresia requires multiple modalities for diagnosis and timely treatment. Determining the type of choledochal cyst calls for a combination of initial US and MRCP. Many benign and malignant biliary masses require biopsy for definitive diagnosis. Knowledge of the imaging appearances of different pediatric biliary abnormalities is necessary for appropriate imaging workup, providing a diagnosis or differential diagnosis, and guiding appropriate management. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Imaging Features of Premalignant Biliary Lesions and Predisposing Conditions with Pathologic Correlation

Article

Aug 2022

Biliary malignancies include those arising from the intrahepatic and extrahepatic bile ducts as well as the gallbladder and hepatopancreatic ampulla of Vater. The majority of intrahepatic and extrahepatic malignancies are cholangiocarcinomas (CCAs). They arise owing to a complex interplay between the patient-specific genetic background and multiple risk factors and may occur in the liver (intrahepatic CCA), hilum (perihilar CCA), or extrahepatic bile ducts (distal CCA). Biliary-type adenocarcinoma constitutes the most common histologic type of ampullary and gallbladder malignancies. Its prognosis is poor and surgical resection is considered curative, so early detection is key, with multimodality imaging playing a central role in making the diagnosis. There are several risk factors for biliary malignancy as well as predisposing conditions that increase the risk; this review highlights the pertinent imaging features of these entities with histopathologic correlation. The predisposing factors are broken down into three major categories: (a) congenital malformations such as choledochal cyst and pancreaticobiliary maljunction; (b) infectious or inflammatory conditions such as parasitic infections, hepatolithiasis, primary sclerosing cholangitis, and porcelain gallbladder; and (c) preinvasive epithelial neoplasms such as biliary intraepithelial neoplasm, intraductal papillary neoplasm of the bile duct, intra-ampullary papillary tubular neoplasm, and intracholecystic papillary neoplasm of the gallbladder. Recognizing the baseline features of these premalignant biliary entities and changes in their appearance over time that indicate the advent of malignancy in high-risk patients can lead to early diagnosis and potentially curative management. An invited commentary by Volpacchio is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations

Article

Jul 2022

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.

A comprehensive exploration of gallbladder health: from common to rare imaging findings

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