Gallbladder Wall Thickening: Not Always Acute Chotecystitis

Gallbladder Wall Thickening: Not Always Acute Cholecystitis…

Denis Ostick, MD, James Longenbach, MD, and Max Cooper, MD RDMS

Case

A 58-year-old male with a past medical history of COPD, hypertension, congestive heart failure with EF 20%, AICD, and atrial fibrillation presented to the Emergency Department with a chief complaint of near syncope, chest pain, and abdominal pain. The patient was at his cardiology appointment when he felt lightheaded, became diaphoretic, and had epigastric pain and nausea. These symptoms resolved on their own, but his cardiologist sent him to the ER via EMS for evaluation.

Review of systems was positive for left sided chest pain and two months of abdominal pain with nausea and vomiting. The abdominal pain was associated with eating. Previous GI workup with upper endoscopy was unremarkable besides reflux esophagitis. Physical exam was notable for lungs with rales bilaterally. Cardiovascular exam was tachycardic, with normal heart sounds. His abdomen was mildly tender in the epigastric region. The patient had no allergies and took atorvastatin, albuterol, apixaban, carvedilol, furosemide, metformin, and omeprazole.

Notable lab work included a non-detectable initial troponin, BNP 3988, non-elevated white blood cell count, bilirubin 2.7, AST 15, ALT 16, and lactate of 2.3. CT of the abdomen showed a markedly distended IVC and hepatic veins consistent with right heart failure. Abdominal ultrasound showed gallbladder sludge with pericholecystic fluid, diffuse “top-normal” gallbladder wall thickening, and no stones.

Surgery was consulted for potential acalculous cholecystitis given the physical exam and ultrasound findings. They evaluated the patient at bedside and believed the thickened gallbladder wall was secondary to the patient’s heart failure. His right sided heart failure likely led to liver congestion and stretching of Glisson’s capsule which resulted in his pain. They recommended CTA abdomen and HIDA scan to rule out acute acalculous cholecystitis or mesenteric ischemia.

Discussion

Diffuse gallbladder wall thickening seen on ultrasound (>3 mm) is commonly thought to be due to cholecystitis. Given it is a necessary finding in those with acute cholecystitis, it is within reason to obtain a surgicalconsult in the ED. However, in this case, the ultrasound finding is due to gallbladder wall edema. Therefore, multiple processes can create this ultrasonographic and CT finding. There is still a differential to consider when a thickened gallbladder is encountered.

Primary gallbladder inflammation seen in acute, chronic, and acalculous cholecystitis is the classic culprit.2 Other primary gallbladder diseases such as gallbladder carcinoma or adenomyomatosis could also confuse the ultrasonographer.1 As was in our case above, gallbladder thickening can also be attributed to a secondary process. Factors leading to gallbladder wall edema include elevated portal venous pressure, systemic venous pressure, or Figure 1. Gallbladder wall thickening of 0.46cm decreased intravascular osmotic pressure.1 Therefore, pathologic conditions like cirrhosis, hepatitis, and congestive right heart failure can be attributed to the finding.1 In our patient’s case, it was likely secondary to his heart failure with EF of 20%. Gallbladder wall thickness may return to within normal limits with time or adequate control of the primary etiology.

It is important to always combine imaging and lab findings with the clinical picture to determine the most appropriate diagnosis. When it comes to the RUQ ultrasound, remember that the differential for gallbladder wall thickening is broader than just cholecystitis. You may save your patient an unneeded trip to the OR.

References

1. van Breda Vriesman, A. C., Engelbrecht, M. R., Smithuis, R. H., & Puylaert, J. B. (2007). Diffuse gallbladder wall thickening: Differential diagnosis. American Journal of Roentgenology, 188(2), 495–501. https:// doi.org/10.2214/ajr.05.1712.

2. Runner, G. J., Corwin, M. T., Siewert, B., & Eisenberg, R. L. (2014). Gallbladder wall thickening. American Journal of Roentgenology, 202(1). https://doi.org/10.2214/ajr.12.10386.