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sv 4v01 0012 Mp 233 Wednesday Apr 17 12:23 PM SV-Ab Image (v. 21, #1) 00124v03

Abdom Imaging 21:233–237 (1996)

AbdominalImaging

q Springer-Verlag New York Inc. 1996

Color Doppler imaging of the gallbladder wall in acute cholecystitis:sonographic–pathologic correlation

V. L. Schiller,1 R. R. Turner,2 D. A. Sarti1

1Tower Imaging, St. John’s Hospital and Health Center, 1328 22nd Street, Santa Monica, CA 90404, and Department of RadiologicalSciences, UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90024, USA2Department of Pathology, St. John’s Hospital and Health Center, 1328 22nd Street, Santa Monica, CA 90404, USA

Received: 3 February 1995/Accepted: 24 March 1995

AbstractBackground: The purpose of this study was to evaluatethe usefulness of color Doppler imaging (CDI) in sus-pected cases of acute cholecystitis.Methods: Twenty-two patients suspected of havingacute cholecystitis were prospectively evaluated over a12-month period using gray-scale and color Dopplertechnique. Gallbladder wall thickness was greater than2 mm in all patients included in the study. Pathologiccorrelation was obtained in 17 patients, with clinical orsonographic follow-up in five for a period of 6–12months. CDI was considered positive only if the mid tofundal wall demonstrated flow. Sonographic Murphy’ssign and laboratory values were recorded.Results: Eight patients had acute cholecystitis. All hadpositive color Doppler flow. Wall thickness in these pa-tients ranged between 4 and 10 mm. Three patients withnecrotizing acute cholecystitis had no flow within 6–8-mm walls. Six patients with pathologically provenchronic cholecystitis had no evidence of increased flowwithin thickened walls. Five patients with presumedchronic cholecystitis (thickened wall without increasedcolor flow) were treated medically, and their symptomsresolved. CDI was more sensitive in predicting acutecholecystitis than was the sonographic Murphy’s signand/or laboratory values.Conclusion: CDI demonstrates hyperemic changes inthickened gallbladder walls and is an important adjunctin the diagnosis of acute cholecystitis.

Key words: Ultrasonography—Color Doppler sonog-raphy—Acute cholecystitis, gallbladder.

Correspondence to: V. L. Schiller

The gray-scale examination and clinical findings inacute cholecystitis are well described. Gallbladder (GB)wall thickening, distention of the lumen, localized fluidin the gallbladder fossa, and the sonographic Murphy’ssign are sensitive and specific signs upon which to makethe sonographic diagnosis [1–7]. However, the diag-nosis is not always clear-cut, especially in the elderlypopulation.

This prospective study was designed to evaluate theutility of color Doppler imaging (CDI) in suspectedcases of acute cholecystitis. We hypothesized that wecould detect increased flow within the gallbladder wallin cases of acute cholecystitis. By identifying abnormalflow, we could increase our confidence in the diagnosis,especially in difficult cases where the GB wall is mildlythickened and the clinical signs are subtle.

Subjects and Methods

Forty patients were prospectively evaluated to exclude or confirm theclinical diagnosis of acute cholecystitis. Twenty-two patients with GBwalls greater than 3 mm comprised the study group. Twelve patientswere female, 10 were male; age ranged from 32 to 89 years old (mean-68 years old). Five patients were younger than 50 years old. Referralswere obtained from the emergency room of a medium-sized com-munity hospital or directly from the physician’s office with the clinicalquery ‘‘rule-out acute cholecystitis.’’

Sonograms were performed on ATL Ultramark 9 HDI and ATLUltramark 9 HDI ESP (extended signal processing software) units(ATL, Bothell, WA). Transducers, 3.5–5 MHz, were used for gray-scale and CDI. CDI parameters were optimized for low velocity andlow flow states. Duplex Doppler was performed when flow could beobtained to document the presence of arterial flow.

Ten normal volunteers were examined at the outset of the study.GB wall thickness was less than 3 mm in each. Flow from the cysticartery could be documented using color and Duplex Doppler imagingin all individuals in the lower one-third of the gallbladder. This ob-servation established the baseline normal exam.


V. L. Schiller et al.: CDI of gallbladder in acute cholecystitis234

After gray-scale assessment of wall thickness, lumen distention,the presence and number of stones, pericholecystic fluid, the intrahe-patic biliary tree, and the extrahepatic common bile duct was per-formed, CDI was obtained. Flow was considered abnormal if detectedin the distal two-thirds of the gallbladder. Findings were qualitativelygraded as mild, moderate, or marked. If the amount of color flow inthe mid to distal wall approximated the normal baseline flow in thelower one-third, it was graded as moderate. Only a few color pixels,often in a discontinuous segment of 2–3 mm in the mid to distal one-third of the gallbladder wall, was graded as mild; marked flow wasevident, often as a continuous vessel in the mid to distal wall.

The GB wall was considered abnormally thickened if greater than3 mm. Four patients with ascites, hypoalbuminemia due to liver dis-ease, renal failure, or congestive heart failure were excluded from thestudy. White blood cell count, alkaline phosphatase, amylase, SGOT,SGPT, and GGT values were recorded when available in all patients.The sonographic Murphy’s sign was recorded as present or absent inall patients. Gentle compression with the transducer was applied overthe gallbladder and compared with other regions of the right upperquadrant and epigastrium. The sign was considered present if tender-ness was considered maximal over the sonographic localized gall-bladder.

Seventeen of the 24 patients with clinically suspected acute cho-lecystitis went to surgery within 48 h of the initial ultrasound. Twopatients who had cholecystectomy performed after 48 h were excludedfrom the study. Surgery was not performed in five patients; clinicalor sonographic 6–12-month follow-up was obtained in these patients.Surgeon’s operative notes and gross description of the gallbladderwere reviewed. Slides were reviewed with the pathologist at the timeof each case; results were subdivided into acute cholecystitis (char-acterized as pattern of transmural leukocytic infiltration, vascular con-gestion, possibly fibrin within intact vessels, and general preservationof mucosa and mucosal folds), acute necrotizing cholecystitis (fibri-noid necrosis of vessels and segments of GB wall, frank abscess for-mation, large patches of mucosa denuded), and chronic cholecystitis(mild wall thickening with scattered leukocytes, intact columnar epi-thelium, sometimes increased subepithelial and subserosal fibrous tis-sue) groups.

Results

Abnormal increased color Doppler flow was detected inthe distal two-thirds of the GB wall of all (eight) patientswith pathologically proven acute cholecystitis (Fig. 1).CDI was graded as moderate in two, marked in six.There was no evidence of increased color Doppler flowwithin the GB wall in 14 patients with thickened gall-bladder walls. Six of the 14 had pathologically provenchronic cholecystitis (Fig. 2). Three of the 14 had path-ologically proven necrotizing acute cholecysititis (Fig.3). Five remaining patients without increased flow werepresumed to have cholecystitis based on clinical assess-ment and did not have surgery. All three patients withnecrotizing acute cholecystitis without increased flowdemonstrated engorged vessels filled with pus or fibri-nous exudate.

Wall thickness varied between 4 and 10 mm in eightpatients with acute cholecystitis (median-7 mm). Wallthickness ranged between 6 and 9 mm in three patientswith necrotizing cholecystitis (median-8 mm). Elevenpatients with chronic cholecystitis had wall thickness of

4–6 mm (median-4 mm). There is considerable overlapin the wall thickness measurements obtained in acutecholecystitis and acute necrotizing cholecystitis.

Gallbladder lumen distention was considered pres-ent if both walls were concaved outward. Distention waspresent in five of eight cases of acute cholecystitis; threecases had contracted gallbladders. Distention was pres-ent in two of three cases of necrotizing cholecystitis, inone of six patients with surgically proven chronic cho-lecystitis, and in none of the patients with chronic cho-lecystitis who did not go to surgery.

Gallstones were present in all cases. Pericholecysticfluid representing perforation, choledocholithiasis, andcentral biliary dilatation were not present in any patientin the series.

The sonographic Murphy’s sign was a useful dis-criminating feature among the various patient subsets.In patients with acute cholecystitis, the sonographicMurphy’s sign was present in six out of eight. The son-ographic Murphy’s sign was present in one of three pa-tients with acute necrotizing cholecystitis. One out ofsix patients with pathologically proven chronic chole-cystitis had a positive Murphy’s sign. Patients with clin-ically presumed chronic cholecystitis had positive find-ings in one out of five.

Laboratory tests were normal initially in three ofeight patients with acute cholecystitis. All of these pa-tients were over 70 years of age. Leukocytosis was pres-ent in five patients with acute cholecystitis. Only amildly elevated white blood cell count was recorded inone of three patients with acute necrotizing cholecysti-tis. Two of six patients with pathology proven chroniccholecystitis had leukocytosis. Sonographic Murphy’ssign and leukocytosis was present in five of eight pa-tients with acute cholecystitis and in one of three pa-tients with necrotizing acute cholecystitis. Fever waspresent in three of eight patients with acute cholecysti-tis. Elevated liver function tests (LFTs) and/or leuko-cytosis were recorded in all patients with chronic cho-lecystitis who went to surgery; the tests were negativein three of five patients with chronic cholecystitis fol-lowed clinically.

Discussion

Early evidence suggests that color Doppler holds greatpromise in the evaluation of inflammatory disorders.Vasodilatation and increased flow, which occur as com-ponents of the inflammatory process, have been de-tected in many settings using this technique [8–12].Color Doppler is an important adjunct in the diagnosisof scrotal inflammatory disorders such as epididymitis,epididymo-orchitis, and orchitis [10]. An increased mu-ral blood flow can be identified in gastrointestinal in-flammatory conditions [11, 12]. This study was de-


V. L. Schiller et al.: CDI of gallbladder in acute cholecystitis 235

Fig. 1. A Abnormal increased color Doppler flow within 4-mm-thickgallbladder wall in a patient with acute cholecystitis. B Photomicro-graph of the same patient demonstrates dense inflammation charac-teristic of acute cholecystitis, with foci of hemorrhage into the wall.

Fig. 2. A Mildly thickened gallbladder wall in an acutely symptomaticpatient with chronic cholecystitis. (No evidence of increased color

flow). B Photomicrograph of the same patient demonstrates mildchronic inflammation with patent vessels.

Fig. 3. A Markedly thickened gallbladder wall without increased flowin a patient with necrotizing acute cholecystitis. B Photomicrographof the same patient demonstrates destruction and fibrinous necrosis ofvessel wall, organizing clots, and dense inflammation.


V. L. Schiller et al.: CDI of gallbladder in acute cholecystitis236

signed to assess whether color Doppler coulddemonstrate inflammation of the GB wall in suspectedcases of acute cholecystitis.

Our results show that color Doppler can detect in-creased flow within an inflamed GB wall. All patientswith pathologically proven acute cholecystitis had ab-normal increased flow in the distal two-thirds of the GBwall. Patients with chronic cholecystitis did not haveincreased flow. We have found, as have others, that hy-peremic vessels in a thickened GB wall are sensitivelyidentified with the color Doppler technique and are notapparent when using gray-scale imaging alone [8, 9].Although color Doppler is not essential in making thediagnosis of acute cholecystitis in all cases, it can be areliable additional sign.

CDI played an integral role in making the sono-graphic diagnosis in several difficult cases. In our pop-ulation, elderly patients with acute cholecystitis may ex-hibit only vague, nonspecific abdominal pain with orwithout abnormal laboratory values. This older subsetcan have a more cryptic presentation than the classicclinical picture of a middle-aged obese female. The el-derly may not manifest a subtle sonographic Murphy’ssign. And the GB wall may be only mildly thickened,suggestive of either chronic or acute underlying pathol-ogy. The addition of CDI has proven helpful in selectedcases in distinguishing between early acute cholecystitisand chronic cholecystitis, thereby increasing confidencein the diagnosis.

There was no evidence of abnormal increased colorDoppler flow in patients with necrotizing acute cholecys-titis. Pathologically, most of the vessels in the markedlythickened walls were engorged with pus or fibrinous ex-udate. Presumably, flow is significantly decreased or im-peded altogether within these congested vessels, account-ing for the absence of color Doppler findings.

In addition, the sonographic Murphy’s sign may beabsent in these patients due to the fact that the nervesinnervating the GB wall have been destroyed by under-lying inflammation [4]. The lack of increased flow anda relatively asymptomatic patient might create a con-fusing clinical picture. Nevertheless, the diagnosis ofgangrenous cholecystitis was suggested in all cases.

Although increased GB wall color Doppler flow isan abnormal and important indicator of underlying dis-ease, lack of increased flow does not exclude the sub-type of necrotizing cholecystitis. In these patients, theGB wall is usually markedly thickened; in addition,gallbladder distention may be present. We carefully as-sessed the sonographic Murphy’s sign because it is oftennegative in patients with gangrenous cholecystitis [4].Our laboratory relies on the established signs of a mark-edly thickened GB wall, GB distention, pericholecysticfluid collections, and the sonographic Murphy’s sign todistinguish cases of necrotizing acute cholecystitis fromchronic cholecystitis or other causes.

Gray-scale morphology of the GB wall is still thecardinal method of establishing the sonographic diag-nosis of acute cholecystitis. Abnormal GB wall thick-ness is seen in acute and chronic cholecystitis, liver fail-ure, congestive heart failure, renal disease, hepatitis,HIV-related infection, and interferon therapy [13–17].GB wall thickness greater than 3 mm is abnormal whennoninflammatory secondary causes are excluded. Stri-ations may represent edema within the wall, often in thesetting of acute inflammation [5]. And the presence ofpericholecystic fluid collections is quite sensitive in pre-dicting perforation of the GB wall [18].

Recently, one group has suggested that increasedflow is nonspecific and of little value in the diagnosisof acute cholecystitis [19]. In that study, nearly all thepatients who ultimately had a cholecystectomy weretreated with antibiotics for at least 1 week prior to sur-gery. We postulate that this delay alters the underlyingpathologic appearance of the GB wall. Anecdotally, twopatients removed from this study had early acute cho-lecystitis diagnosed by sonographic, color Doppler,clinical, and laboratory abnormalities. They weretreated with antibiotics for 1 week prior to surgery. Thepathologic diagnosis was chronic cholecystitis. Al-though these two cases may have been misdiagnosedfrom the outset, we believe that the underlying pathol-ogy can change significantly with 1 week of intravenousantibiotic therapy.

Color Doppler sonography can detect increased ar-terial flow within the thickened GB wall. Abnormal ar-terial flow confirms that inflammation is ongoing; as aresult, the presence of increased flow is a useful adjunctin the diagnosis of acute cholecystitis. More work isneeded to determine whether or not this technique isuseful in patients with early acute cholecystitis who donot have thickened GB walls. In the proper clinical set-ting, color Doppler can supplement gray-scale findingsand increase confidence in the diagnosis of acute cho-lecystitis.

References

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