Diagnostic ultrasound ( PDFDrive )

198 PART II Abdominal and Pelvic Sonography
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FIG. 6.40 Acute Cholecystitis: Complications. (A)-(C) Early perforation and sequelae. (A) The gallbladder is tense with thickened walls
and sludge and a stone. There is poor deinition of its near wall (arrow) with adjacent heterogeneity of the hepatic parenchyma. (B) Contrast-enhanced
scan demonstrates a defect (arrow) in the gallbladder wall. The patient was treated with antibiotics. (C) Three-month follow-up scan in the now
asymptomatic patient shows a localized luid collection (*) between the wall of the gallbladder and liver parenchyma. (D) Gangrenous cholecystitis.
Sloughed membranes (short arrow) appear as linear intraluminal echoes. (E) Perforation, shown as disruption of the gallbladder wall (arrow) with
a subhepatic abscess (short arrows). (F) Perforation into the liver. There is a large defect (arrow) in the wall of the gallbladder with an adjacent
hepatic abscess. See also Video 6.11. (G)-(I) Emphysematous cholecystitis. (G) Sagittal sonogram of the gallbladder with a focus of intraluminal
air appearing as a bright echogenic focus (arrow) with dirty shadowing. (H) Gallbladder that is illed with air (arrow). The gallbladder is not actually
visualized, and knowledge of the location of the gallbladder fossa is essential to avoid mistaking this for bowel gas. (I) Corresponding CT scan
shows air in the gallbladder wall and lumen.
Gallbladder wall thickening has many causes. he appearance
of the gallbladder wall in acute cholecystitis is nonspeciic, but
marked thickening of the wall with visible stratiication, as seen
in generalized edematous states, is usually not present (Fig. 6.41).
Multiple focal, noncontiguous, hypoechoic pockets of edema
luid within the thickened wall are typically observed. he
inlamed gallbladder is oten signiicantly distended, unless its
wall is perforated. Gallstones, including the obstructing stone,
and sludge are usually identiied. A thin rim of luid, representing
edema, is oten seen around much of the organ.
A sonographic Murphy sign is maximal tenderness over the
gallbladder when the probe is used to compress the RUQ. It is