The Common Vein Copyright 2008
Ashley Davidoff MD
Introduction
The normal gallbladder in the fasting state contains about 50-70mls of bile and measures 8-10 cms in length, by 3-4cms in diameter using ultrasound. The volume is determined by using the formula of ellipsoid approximation, – length X width X depth X .5cms.
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Stone Impacted in the Cystic Duct |
| 04766b05b04b.35k.8s gallbladder cystic duct stone impacted obstruction enlarged gallbladder acute calculous cholecystitis Davidoff art copyright 2008 |
The gallbladder contracts following a fatty meal. Patients are therefore required to fast for 4-6hours before the examination, for optimal evaluation. Examples of contracted gallbladders are shown below.
The size of the gallbladder is one of the more important determinants in the evaluation of gallbladder disease, but as you will learn there is not a black and white answer as to whether the gallbladder is enlarged or not. The size of the gallbladder cannot be assessed by clinical examination since the gallbladder lies under the liver and only a small portion of the fundus is exposed. Therefore under normal circumstances it cannot be palpated and is only palpable when it is significantly enlarged. For this reason, assessment of the size of the gallbladder requires the use of an imaging technique. This is best accomplished by ultrasound, since the true long axis and short axis can be defined by the ultrasonographer who is able to angle the transducer along the appropriate axis. The gallbladder is normally positioned at an angle that is off the horizontal, sagittal and coronal planes. The fundus is located relatively inferiorly, while the neck is positioned more medially and superiorly. Thus by the nature of the transverse imaging of CT and usual orthogonal imaging of MRI, the true axis is not routinely defined by these methods. Although nuclear imaging can also assess the size of the gallbladder accurately, other factors such as wall thickness and probe tenderness cannot be evaluated. Thus when assessment of the size of the gallbladder, and associated features of wall thickness and probe tenderness is required, ultrasound becomes the procedure of choice.
 Contracted Gallbladder Following a Fatty Meal |
| Following a fatty meal, the gallbladder in this instance measures 6.5cms by 1.3cms.
25902c.8s gallbladder small normal post fatty meal normal physiology USscan ultrasound copyright 2008 Courtesy Ashley Davidoff MD |
The fundus has the largest diameter, the body the largest volume while the the neck is the smallest part of the gallbladder proper.
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| Image a and b show a transverse CT image revealing a contracted gallbladder with a stomach filled with food (orange). The oral cholecystogram shows a contracted gallbladder following a fatty meal.
46354c01.81s gallbladder function contracted cholecystokinin normal physiology fat digestion size stomach food ingestion stimulated stimulation hormone normal CTscan Courtsy Ashley Davidoff MD radiologists and detectives
Oral Cholecstogram post Fatty MEal 04751 gallbladder contracted gallbladder oral cholecystogram cystic duct normal anatomy oral cholecystogram Davidoff MD |
Image a and b show a transverse CT image revealing a contracted gallbladder with a stomach filled with food (orange). The oral cholecystogram shows a contracted gallbladder following a fatty meal.
46354c01.81s gallbladder function contracted cholecystokinin normal physiology fat digestion size stomach food ingestion stimulated stimulation hormone normal CTscan Courtsy Ashley Davidoff MD radiologists and detectives
04751 gallbladder contracted gallbladder oral cholecystogram cystic duct normal anatomy oral cholecystogram Davidoff MD
Applied Biology
From a practical and clinical standpoint, the clinician who suspects an enlarged gallbladder is really asking whether there is increased pressure in the gallbladder. The imaging technology uses size as an indirect measure of the intraluminal pressure since we would otherwise have to use invasive techniques to assesss the pressure directly. Since there are situations where the gallbladder loses its tone (atonic or hypotonic gallbladder as a result of aging process or diabetes) it can enlarge without the ever important increase in pressure. On the other hand there are situations when the gallbladder wall is fibrotic (chronic cholecystitis) and this results in a small contracted gallbladder which cannot dilate when the luminal pressure rises.
Multiple factor therefore have to be taken into consideration when assessing the size of the gallbladder.
Size Changes
Introduction
The normal gallbladder in the fasting state contains about 50-70mls of bile and measures 8-10 cms in length, by 3-4cms in diameter using ultrasound. Because of its ellipsoid shape the approximation for gallbladder volumecan be estimated by using the formula of length X width X depth X .5cms.
Common Causes
Enlargement is usually caused by obstruction by calculi, which typically become lodged in the neck of the gallbladder in the cystic duct or more distal obstructions, in the common bile duct. Neoplasm of the bile duct, metastases to porta hepatis nodes and pancreatic carcinoma, are not uncommon causes of a distended gallbladder. Clot in the biliary tree may also cause obstruction.
Less commonly, the gallbladder can become distended due to atony. This is commonly seen in diabetic neuropathy but is also caused by aging and cholestasis. Prolonged cholestasis is commonly seen in severely ill ICU patients who have gallbladders that are unstimulated by CCK. Decreased contractility can also result from impaired vagal nerve function, due to iatrogenic or traumatic severing of the vagal innervations to the gallbladder.
An accurate transverse view is taken orthogonal to the long axis of the gallbladder. In this view as shown below the transverse (right side to left side) dimension is larger than the anteroposterior (A-P) dimension. This is normal. Sometimes the normal gallbladder has a larger A-P dimension. It is not usually round. The normal largest dimension in the transverse plane is not usually greater than 4cms.
 The Shape of the Gallbladder in Transverse Section |
| 82428c01.8s gallbladder small normal transverse oval shape normal anatomy USscan ultrasound copyright 2008 Courtesy Ashley DAvidoff MD |
 Shape Reflecting Size |
| 82418.8s 38F normal gallbladder pressure size normal anatomy Courtesy Ashley Davidoff MD copyright 2008 |
The size of the gallbladder is one of the more important determinants in the evaluation of gallbladder disease, but as you will learn there is not always a black and white answer as to whether the gallbladder is enlarged or not.
Normal Fasting Gallbladder
Normal Size of the Fasting Gallbladder on Ultrasound |
| The gallbladder in the fasting state measures 8-10 cms in length and 3-4cms in diameter. In this instance it measures 10 by 3.5cms.
82021.8s gallbladder normal anatomy size shape position character width 3.5cms length = 10cms pear shape pyriform shape fundus body neck fundus anterior neck posterior USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008 pear shape
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The wall is normally 2-3mm thick in the fasting state. It is only about 1mm thick in the neonate.
Wall Thickness by Ultrasound |
| 82427.8s gallbladder wall normal size thickness USscan ultrasound Courtesy Ashley DAvidoff MD Copyright 2008 |
Elongated but not Dilated – The Aging Gallbladder |
| The CT is also from an elderly asymptomatic female (from the perspective of the gallbladder) whose gallbladder measures 3.5cms in the short axis and 11cms in the long axis. The latter measurement is considered abnormal while the former is normal. This zuchini shaped gallbladder is probably normal and reflective of the patients age. An ultrasound would be far more specific, since wall thickness, probe tenderness, and true long axis and short axis measurements could be made.
76764.8s elderly femal gallbladder elongated sausage shape zuchini shape transverse dimension 4.5 cms longitudinal dimension 12.5cms aging gallbladder vs enlarged? CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
The gallbladder contracts following a fatty meal. Patients are therefore required to fast for 4-6hours before the examination, for optimal evaluation. Examples of contracted gallbladders are shown below.
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Contracted Gallbladder Following a Fatty Meal |
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Following a fatty meal, the gallbladder in this instance measures 6.5cms by 1.3cms. 25902c.8s gallbladder small normal post fatty meal normal physiology USscan ultrasound copyright 2008 Courtesy Ashley Davidoff MD |
The fundus has the largest diameter, the body the largest volume while the the neck is the smallest part of the gallbladder proper.
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Conracted Gallbladder Recent Meal in Stomach
Oral Cholecstogram post Fatty MEal
Image a and b show a transverse CT image revealing a contracted gallbladder with a stomach filled with food (orange). The oral cholecystogram shows a contracted gallbladder following a fatty meal.
46354c01.81s gallbladder function contracted cholecystokinin normal physiology fat digestion size stomach food ingestion stimulated stimulation hormone normal CTscan Courtsy Ashley Davidoff MD radiologists and detectives
04751 gallbladder contracted gallbladder oral cholecystogram cystic duct normal anatomy oral cholecystogram Davidoff MD
Zuchini (Italian) Gallbladder |
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The elongated shape of the gallbladder without being wide is remoiniscent of the Italian Zuchini in thi as76764c.81s elderly female gallbladder elongated sausage shape zuchini shape transverse dimension 4.5 cms longitudinal dimension 12.5cms aging gallbladder vs enlarged? food in the body CTscan Courtesy Ashley DAvidoff MD Davidoff art Davidoff photography copyright 2008 |
Duplicated Gallbladder |
| 04750.8s gallbladder duplicated size congenital duplicated duplication OCG oral cholecystogram CourtesyAshley Davidoff MD copyright 2008 |
The large galllbladder is defined as a gallbladder that exceeds 10cms in the long axis and 4cms in the short axis. Although it is not definitive, the transverse measurement of the gallbladder is more specific in the evaluation of size. An elongated gallbladder can be normal, particulalrly in the elderly. The shape of the gallbladder becomes more rotund when it is enlarged. The gallbladder is normally ovoid in shape in the transverse plane. With enlargement it becomes round which is a fairly reliable criterion for a dilated gallbladder.
Prolonged fasting also results in a large gallbaladder. When the transverse diameter exceeds 4cms it is abnormal but included in this differential is the fasting gallbladderlogical
Depending on the clinical presentation of the patient, the gallbladder may be more distended if the patient has not eaten for some time or contracted if he or she has recently eaten.
Gallbladder enlargement is not necessarily abnormal. In aymptomatic patients, enlargement can occur as a normal variant in people with asthenic builds, in older patients and in diabetics (atonic). It is suggestive of cholestasis in patients who are on a prolonged fast, and those on hyperalimentation. An atonic or hypotonic ileus of the gallbladder is seen in patients following abdominal surgery, patients with GI infections, hepatitis, pancreatitis, and bowel ileus, all of which can cause asymptomatic enlargement. In these patients there is no gallbladder tenderness, the wall is normal , but there may be thickened bile (sludge) in the lumen.
Distended Gallbladder |
| 00384 gallbladder pancreas liver anatomy |
Gallbladder Upper limits Normal in Size |
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The 78 year old female is asymptomatic from the perspective of the gallbladder. It measures by CT on this cut 9.5cms in long axis and 3.5cms in short axis. This measurement is upper limitsnormal and probaly reflects age related change. 82156.8 78 year old female patient No gallbladder symptoms gallbladder normal atonic aging CTscan Courtesy Ashley Davidoff copyright 2008 |
Diabetic Arteriopathy – Gallbladder Atony |
| 82719c.8s 68M diabetes peripheral vascular disease diabetic arteriopathy artery small vessel disease gallbladder atonic enlarged vas deferens calcification calcified Courtesy Ashley Davidoff MD copyright 2008 |
Gallbladder enlargement is most often caused by mechanical abnormalities and usually by a stone that is impacted in the infundibulum, cystic duct or common bile duct. (CBD). Cystic duct or infundibular obstruction by a stone is the most common cause. If this results in inflammation then acute cholecystitis results.
Acute Cholecystitis |
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In this artistic rendition, a small stone has become impacted in the infundibulum of the gallbladder, resulting in obstruction and acute cholecystitis. 04766b08.8s gallbladder stones cholelithiasis acute cholecystitis distended enlarged bile ducts Davidoff art copyright 2008 |
Acute Calculous Cholecystitis wit Gallbladder Wall Edema and Hyperemia |
| 72365c01 gallbladder wall fluid in gallbladder fossa positive sonographic Murphy’s sign inflammation mechanical obstruction infection hyperemia hypervascularity dx acute calculous cholecystiis Davidoff MD |
Obstruction by pancreatic cancer, or less commonly an ampullary tumor will result in an enlarged gallbladder. Other causes include sclerosing cholangitis when the common bile duct and less commonly the cystic duct are stenotic.
Acalculous cholecytitis is a relatively common cause of gallbladder dilatation. It is an advanced form of cholestasis where inflammatory changes supervene as a complication of prolonged and advancing cholestasis.
RUQ Pain, Distended Gallbladder, Tumefactive Bile – same patient |
| 77717c01s right upper quadrant pain ICU setting RUQ pain gallbladder distended thick walled sludge cholestasis tumefactive bile fluid in gallbladder fossa small shadowing stones acalculous cholecystitis shape of tumefactive bile in the gallbladder has fetus like formation USscan ultrasound Courtesy Ashley DAvidoff MD copyright 2008 |
Dilated in Acalculous Cholecytitis and Dilated in Fatty Liver |
| 78606c.8s liver normal liver abnormal fatty change 777017 = a = acalculous cholecystitis b= pancreatitis with steatosis hepatization of the gallbladder density of the liver is the same as the bile in the gallbladder CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Acute Pancreatitis |
| 26898c code pancreas + peripancrteatic tissue + fx fluid accumulation + dx acute pancreatitis CT scan C+ code gallbladder |
RUQ Pain, Distended Gallbladder, Indurated Fat – Acalculous Cholecystitis |
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The CT iamges are from a an ICU patient who presented with RUQ pain and fever. The CTscan shows a distended gallbladder, no calcified stones, thickening and hyperemia of the wall, with stranding in the fat surrounding the gallbladder. Although this could still be calculous cholecystitis caused by an impacted stone the clinical setting is more likely to be of an acalcalous nature. Prior to placing a cholecystostomy tube US scan should be performed to exclude calculi. 77717c02s right upper quadrant pain ICU setting RUQ pain gallbladder distended thick walled hyperemic enhancing wall pericholecystic induration dirty fat stranding acalculous cholecystitis Courtesy Ashley DAvidoff MD copyright 2008 |
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RUQ Pain, Distended Gallbladder, Indurated Fat |
| 77717c02s right upper quadrant pain ICU setting RUQ pain gallbladder distended thick walled hyperemic enhancing wall pericholecystic induration dirty fat stranding acalculous cholecystitis Courtesy Ashley DAvidoff MD copyright 2008 |
A biliary stone may also becpome impacted in the common bile duct in which case dilatation of the bile ducts as well as the gallbladder results.
Choledocholithiasis |
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The MRCP performed using T2 weighted FSE technique shows a CBD stone associated with dilatation of the CBD, cystic duct and the gallbladder. 17083c02.3k.8s 82 female presents with obstructive jaundice gallbladder duct enlarged distended distension dilated dilatation choledocholithiasis stone obstruction obstructive jaundice MRI T2 weighted Courtesy Ashley Davidoff MD copyright 2008 |
Gallbladder Distension Associated with Common Bile Duct Stone |
| 17089c01.8s gallbladder enlarged choledocholithiasis bile duct obstructed fluid fluid level MRIscan T2 weighted T1 weighted Courtesy Ashley Davidoff MD copyright 2008 |
 
Courvoisier Gallbladder |
| 78441c01.8s painless jaundice pancreas mass bile ducts intrahepatic dilated extrahepatic gallbladder enlarged distended dilated gallstones cholelithiasis pancreatic duct double duct sign Courvoisier’s CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Courvoisier Gallbladder |
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The patient presented with painless jaundice and a palpable gallbladder. (Courvoisier sign) The epicentre of the collage of images is in image c where the arrow points to a mass in the head of the pancreas that has caused obstruction of the pancreatic duct (seen upstream from the mass in c ), gallbladder distension (a) and bile duct dilatation (a,b, &d) A percutaneous biliary drainage catheter has traversed the obstruction and is in the duodenum that will allow for decompression. (d) 44005c01.8s elderly patient presents with painless jaundice Courvoisier gallbladder distended enlarged dilated pancreatic duct pancreas mass pancreatic carcinoma CTscan percutaneous cholangiogram PTC Courtsy Ashley DAvidoff MD copyright 2008 bile duct |
Courvoisier’s Gallbladder |
| 04655.8s 57 year old female presents with jaundice Courtesy Ashley Davidoff MD gallbladder dilated distended bile duct intrahepatic bile duct ampullary carcinoma imaging radiology CTscan neoplasm malignant primary tumor cancer mechanical Courtesy Ashley DAvidoff MD copyright 2008 |
Ampullary Carcinoma |
| 57 year old female presents with jaundice 04655c02 Courtesy Ashley Davidoff MD code liver fx nodule bile duct intrahepatic bile duct extrahepatic bile duct fx dilated “too many ducts” sign pancreas pancreatic duct fx dilated double duct sign code dx ampullary carcinoma imaging radiology CTscan neoplasm malignant primary tumor cancer mechanical |
Ampullary Carcinoma |
| 57 year old female presents with jaundice 04655c05 Courtesy Ashley Davidoff MD code liver fx nodule bile duct intrahepatic bile duct extrahepatic bile duct fx dilated “too many ducts” sign pancreas pancreatic duct fx dilated double duct sign code dx ampullary carcinoma imaging radiology USscan CTscan grosspathology neoplasm malignant primary tumor cancer mechanical |
Sclerosing Cholangitis |
| 04202 bile duct + sclerosing cholangitis ulcerative colitis gallbladder enlarged obstructed cholestasis |
Sclerosing Cholangitis |
| 27089b gallbladder + fx large + dx sclerosing cholangitis + imaging radiology MRI T2 + MRCP bile duct stenosis |
Sclerosing Cholangitis |
| 25187c.8s 29 female with obstructive jaundice bile ducts thickened heterogeneous ulcerative colitis sclerosing cholangitis gallbladder dilated fluid in gallbladder fossa distended CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
Applied Biology
The small gallbladder usually is of lesser clinical significance than the enlarged gallbladder. The most common cause of a small gallbladder is recent ingestion of a meal. In chronic cholecystitis, the development of fibrosis occasionally results in a chronically contracted gallbladder. In HIV cholangiopathies, significant edema of the wall results in impingement on the lumen and the gallbladder will appear relatively small.
Hypercontractile Gallbladder |
| 82264c01.8s gallbladder hypercontractile contracted predisposition to adenomyomatosis hyperplastic cholesterolosis small stomach filled with fluid and food particles CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Thick Wall Normal Lumen – Hepatitis |
| 48008c01 gallbladder thick wall non distended dx hepatitis USscan Davidoff MD |
Small Contracted Gallbladder Filled with Stones – Chronic Cholecystitis |
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The scout film from an abdominal CT scan of a 96 year old female shows a small contracted gallbladder in the RUQ filled with calcified stones. These findings are consistent with a diagnosis of chronic cholecystitis 82011c.8s 96 year old female small contracted gallbladder filled with stones cholelithiasis calcification calcified chronic cholecystitis CTscan scout film KUB Courtesy Ashley Davidoff MD copyright 2008 |
Small Gallbladder Filled with Stones |
| 02118.8s gallbladder small stone filled contracted chronic cholecytitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Chronic Cholecystitis, Hyperemic Wall, Small Contracted Gallbladder |
| 30701.8s stone cholelithiasis hyperemic wall small contracted chronic cholecytitis stomach gastrostomy redundant mucosa CTscan Courtesy Ashley Davidoff MD copyright 2008 chronic cholecytitis |
Small Contracted Gallbladder with Stone and Thick Wall |
| 81916.8s gallbladder stone cholelithiasis thick wall thickened wall small contracted chronic cholecystitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Edematous Galbladder Wall Due to Venous and Lymphatic Congestion |
| 51 year old male with history of rectal carcinoma with extensive hepatic metastases. (orange) The metastases surround gallbladder and by space occupation result in venous and lymphatic congestion causing a thickened edematous gallbladder wall (orange) with a small lumen (green) Tthe portal triad shows surrounding edema (white arrow). This is called periportal tracking which is another sign of venous and lymphatic engorgement. The metastases are calcified confirming the mucinous nature of the tumor.
calcified metastasis in gallbladder fossa edema of the wall lymphatics contracted gallbladder CTscan copyright 2008 Courtesy Ashley Davidoff MD gallbladder liver portal triad 82313c01.8s |
Animals Aristotle and Shakespeare
There has been much interest in the presence absence and size of the gallbladder in animals It appears that the presence and size mostly relates to diet so that carnivores tend to have larger gallbladders, omnivores intermediate size and herbivores small or even absent gallbladders. (Hobart) The Petromyzon is a sea lamprey that is an eel like jawless fish that parasitises on healthy fish by attaching to them. They are born with a biliary system which subsequently degenerates. In the pigeon the gallbladder also develops and then disappears. In the rat horse, zebra, camels, rhinos, elephants, dolphins, and deer the gallbladder never develops(Mann) (Robinson) Aristotle discussed this in his treatise on animal anatomy in 350BC.
The gallbladder is not usually papable but when enlarged it is felt just below the liver edge in the midclavicular line, below the 9th rib.
Significantly Enlarged Gallbladder that was Clinically Palpable |
| The sagittal image (a) from a CTscan, and the transverse image reveal an enormous ballon like rotund gallbladder that was clinically palpable. This 80 year old female had recently undergone cardiac catherization and had a bleed (arrow) into the right rectus sheath.
82304c01.8s 80f s/p cardiac cath spontaneous anterior wall muscle bleed (arrow) distended gallbladder huge large dilated distended cholestasis CTscan copyright 2008 Courtesy Ashley Davidoff MD |
Courvoisier’s sign is a palpable gallbladder in the presence of obstructive jaundice most commonly caused by pancreatic cancer, but sometimes caused by a cancer at the ampulla..
The close relationship of the gallbladder to the liver, creates a potential pathway for the spread of disease. Thus exension of the inflammatory and infectious process of acute cholecystids will be identified in the liver.
Cholecystitis Complicated by Abscess Formation in the Gallbladder Fossa |
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The artistic rendition shows 2 stones lying free in the lumen and one impacted in the neck of the gallbladder with secondary inflammatory changes in the wall(red) and abscess formation in the gallbladder fossa and extension into the neighbouring liver. 11921.8b05b037.8s gallbladder cystic duct gallstones cholelithiasis stone impacted in the cystic duct distended enlarged hyperemic wall complex fluid in the gallbladder fossa tumefactive bile cholestasis sludge acute cholecytitis abscess formation Davidoff Art copyright 2008 |
Similalrly when gallbladder cancer spreads, its closest neighbour, the liver is invvolved, though sometimes, and usually at a later stage the colon may be involved as well. The reverse is also true when colon carcinoma of the hepatic flexure can spread to the gallbladder.
Direct Invasion into the Liver and Bile Duct Obstruction |
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A gallbladder cancer (orange) has extended from the gallbladder (green) directly into the liver. Associated ductal obstruction is present. 16254c02b.8s gallbladder anterior wall liver invasion space occupatopn obstruction bile ducts aggressive gallbladder carcinoma complicated by direct invasion metastasis liver windows narroe windws tumor settings gallbladder fossa GBF CTscan Courtesy Ashley Davidoff copyright 2008 |
Pear Shaped |
| 47018 gallbladder normal shape pear shaped anatomy nrmal USscan Davidoff MD |
Pear |
| 85370pb01.8s pear fruit food gallbladder shape Davidoff photography Davidoff art Copyright 2008 |
The phrygian cap is a common normal variant of gallbladder shape characterized a fundus that is folded forward. It was first described by Bartel in 1916. The Phrygians were a primitive race that migrated into northern and central Asia Minor in the second millenium BC. The Greeks knew of the cap as an Oriental headgear that was tight fitting and conical in shape and it has been depicted in their art. (Ober WB, Wharton RN On the “phrygian cap.” 255:571-572 New England Journal of Medicine 1956
Phrygians of Northern and Central Asia Minor 1000-2000BC |
| 82407b14.8s gallbladder Phrygian cap freedom liberty shape symbol Davidoff art Copyright 2008
The phrygian cap is a common normal variant of gallbladder shape characterized a fundus that is folded forward. It was first described by Bartel in 1916. The Phrygians were a primitive race that migrated into northern and central Asia Minor in the second millenium BC. The Greeks knew of the cap as an Oriental headgear that was tight fitting and conical in shape and it has been depicted in their art. (Ober WB, Wharton RN On the “phrygian cap.” 255:571-572 New England Journal of Medicine 1956 The cap was a symbol of freedom and the pursuit of liberty. The cap was worn by King Midas who was cursed with donkey ears by Apollo. He used the Phrygian cap to hide his ears. It was subsequently worn by the Trojan hero Paris, was a symbol of freedom in the French and American revolutions, was depicted on coinage in the US and on variety of seals and flags throughout the world. |
The cap was a symbol of freedom and the pursuit of liberty.
The cap was worn by King Midas who was cursed with donkey ears by Apollo. He used the Phrygian cap to hide his ears. It was subsequently worn by the Trojan hero Paris, was a symbol of freedom in the French and American revolutions, was depicted on coinage in the US and on variety of seals and flags throughout the world.
Phrygian cap |
| 45217 gallbladder shape phrygian cap normal anatomy shape USscan Courtesy Ashley Davidoff MD |
 
Phrygian cap |
| 39696 39696b Courtesy Ashley Davidoff MD gallbladder normal anatomy shape phrygian cap |
Reversed Phrygian |
| 82447c01.81s 67 F gallbladder reversed phrygian cap kidney ptotoc prominent artery and veins probable AVM arteriovenous malformation CTscan Corteys Ashley DAvidoff MD copyright 2008 |
Enlarged with Phrygian Cap – Cholestasis |
| 18260.8s gallbladder shape phrygian cap distended enlarged courtesy Ashley Davidoff MD copyright 2008 |
Fundal Fold Phrygian Cap |
| 04487.8s gallbladder fundus fold normal variant anatomy shape OCG Courtesy Ashley DAvidoff MD copyright 2008 |
Fold in the Fundus Phrygian in Green |
| 04487.84s.8s gallbladder fundus fundal fold fold normal variant anatomy shape cystic duct phrygian cap Davidoff art copyright 2008 |
Fold in the Fundus |
| 82698.8s 69F shape fold in the fundus gallbladder normal variant anatomy Courtesy Ashley Davidoff MD copyright 2008 |
“S” shaped Gallbladder |
| 28470 gallbladder normal shape S-shape anatomy USscan Davidoff MD |
Sigmoid Gallbladder |
| 82453c01.8s 88F p/w abdominal pain no known prior study gallbladder shape character sinusoidal shape to “s” shape fluid fluid level milk of contrast bile vicarious excretion anatomy CTscan Courtesy Ashley DAvidoff MD |
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Elongated but not Dilated – The Aging Gallbladder |
| 76764.8s elderly femal gallbladder elongated sausage shape zuchini shape transverse dimension 4.5 cms longitudinal dimension 12.5cms aging gallbladder vs enlarged? CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
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Zuchini Gallbladder |
| 76764c.81s elderly female gallbladder elongated sausage shape zuchini shape transverse dimension 4.5 cms longitudinal dimension 12.5cms aging gallbladder vs enlarged? food in the body CTscan Courtesy Ashley DAvidoff MD Davidoff art Davidoff photography copyright 2008 |
Fold in Fundus Oral Cholecystogram |
| 04407 gallbladder filling defect stones cholelithiasis OCG oral cholecystogram imaging radiology historical |
Figure of 8 Chronic Cholecystitis |
| 04731.8s gallbladder fibrosis across the fundus filling defect chronic cholecystitis OCG historical stricture Courtesy Ashley Davidoff MD copyright 2008 |
Figure of 8 Chronic Cholecystitis |
| 11530.81s gallbladder fibrosis across the fundus filling defect chronic cholecystitis cholelithiasis stone in fundus OCG historical stricture Courtesy Ashley Davidoff MD copyright 2008 |
Chronic Cholecystitis |
| 31285.8s 64 male gallbladder fibrosis across the fundus filling defect chronic cholecystitis cholelithiasis stone in fundus Ctscan figure of eight stricture Courtesy Ashley Davidoff MD copyright 2008 |
Metastasis to Fundus |
| 22705 gallbladder abdomen peritoneum peritoneal cavity fx mass fx calcification fx distortion dx metastatic colon carcinoma large bowel malignant primary compliacated by transperitoneal spread dx metastasis to the gallbladder fundus metastases metastattic fx ascites imaging radiology CTscan C+ CTscan Courtesy Ashley Davidoff MD |
Metastasis to Fundus |
| 22704c01.8s gallbladder abdomen peritoneum peritoneal cavity fx mass fx calcification fx distortion dx metastatic colon carcinoma large bowel malignant primary compliacated by transperitoneal spread dx metastasis to the gallbladder fundus metastases metastattic fx ascites imaging radiology CTscan C+ CTscan Courtesy Ashley Davidoff MD copyright 2008 |
 
Biloculate Carcinoma of the Fundus Mucosal and Submucosal Infiltration |
| 16228c01.8s gallbladder wall submucosal tumor = orange mucosal tumor = pink lumen = green thickened mucosa and submucosa carcinoma of the gallbladder CTscan Courtesy Ashley DAvidoff MD copyright 2008 |
Central Gallbladder Situs Ambiguus |
| In this post mortem specimen of the unfortnate child with asplenia syndrome the gallbladder is noted in the middle of the body. (dark green) This ambiguus position of the gallbladder is coupled in this image with an ambiguus liver that appears to have two large right lobes. The whole entity is combined with other ambiguus anomalies such as bilateral right atria, or bilateral IVC’s for example. Many of these anomalies are incompatible with life.
82222.8s liver gallbladder bilateral right lobe asplenia syndrome Ivemark syndrome central gallbladder situs ambiguus congenital position gross pathology Courtesy Ashley DAvidoff MD copyright 2008 |
 
Floating and Gas Filled |
| 26540 gallbladder + fx filling defects + fx air + fx floating + dx cholelithiasis + imaging radiology CTscan C- |
Air
Emphysematous Cholecystitis |
| 16195c02.8s elderly patient with heart disease and significant atherosclerotic disease gallbladder lumen is filled with air wall linear air collection bubbles of air air fluid level dx emphysematous cholecystitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
 
Emphysematous Cholecystitis |
| 61 year old who presents with abdominal pain, acute inferior myocardial infarction, with a background history of type II diabetes 31093 Courtesy Ashley Davidoff MD code pancreas fx induration dx acute pancreatitis code gall bladder wall fx air dx emphysematous cholecystitis size |
Emphysematous Cholecystitis |
| 61 year old who presents with abdominal pain, acute inferior myocardial infarction, with a background history of type II diabetes
31095c Courtesy Ashley Davidoff MD code pancreas fx induration dx acute pancreatitis code gall bladder wall fx air dx emphysematous cholecystitis size |
Gallstone Ileus |
| 31127c01.8s gallbladder stones air adherent to duodenum small bowel dilatation calcification stone gallstone ileus CTscan Courtesy Ashley DAvidoff copyright 2008 |
 
Obesity and Cholesterol Stone |
| 82205.8s 82206.8s 54 female mildly enlarged non tender gallbladder no abnormality seen on CTscan but large stone seen on USscan consistent with cholesterol stone isodense on CT shadowing on ultrasound atony obese Courtesy Ashley Davidoff MD Copyright 2008 |
Crystalline Floaters |
| 77753c01.8s young female right upperquadrant tenderness RUQ gallbladder echogenic irregular fluid fluid layer conforming to the shape of the gallbladder wall thickened linear echoes floaters crystalline SG less than bile cholesterol crystals specific gravity forces space cholelithiasis stones small acute cholecystitis USscan ultrasound Courtesy Ashley Davidoff MD For Radiologists and Detectives |
Crystalline Floaters |
| 77753c02.8s young female right upperquadrant tenderness RUQ gallbladder echogenic irregular fluid fluid layer conforming to the shape of the gallbladder wall thickened linear echoes floaters crystalline SG less than bile cholesterol crystals specific gravity forces space cholelithiasis stones small acute cholecystitis USscan ultrasound Courtesy Ashley Davidoff MD For Radiologists and Detectives |
 
Tiny Calcified Floaters |
| 45092 45092b02 gallbladder fx cholelithiasiscompletely occupying gallbladder lumen CTscan Courtesy Ashley Davidoff MD |
Tiny Calcified Cholesterol Floaters |
| 25306.8s small cholesterol crystals stones floaters hyperemic wall chronic cholecytitis gas air cholelithiasis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Stones Floating on Surface – Cholesterol Content – Historical Image |
| 04730 gallbladder floating small filling defect cholesterol stones cholelithiasis OCG oral cholecystogram imaging radiology historical |
Fluid
Hepatization of the Gallbladder Steatosis of the Liver |
| Images a and b are from a normal patient. Note the density of the liver and compare to the density of the gallbladder in image b. The patient in c and d has diffuse steatosis and an enlarged liver. Note the difference in the liver density of the two cases and the difference in the relative densities of the gall bladders. The liver is normal in size in case A (a,b) and enlarged in case B (c.d) The patient in c and d is known to abuse both alcohol and drugs. Courtesy Ashley Davidoff MD 37833c code liver gallbladder steatosis fatty liver normal large |
|
Hepatization of the Gallbladder Steatosis of the Liver |
| 78606c.8s liver normal liver abnormal fatty change 777017 = a = acalculous cholecystitis b= pancreatitis with steatosis hepatization of the gallbladder density of the liver is the same as the bile in the gallbladder CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Empyema |
| 48010.800 gallbladder fx thick walled shadowing cholelithiasis complex fluid dx gallbladder empyema |
Black – like Crank Case Oil |
| 26067 bile black crankcase oil dx acalculous cholecystitis body fluid Laboratory Test Courtesy Ashley DAvidoff MD |
Acaclculous Cholecystitis |
| 77680c01.8 right upper quadrant pain RUQ pain ICU setting gallbladder distended sludge cholestasis complex fluid in the gallbladder fossa acalculous cholecystitis USscan Courtesy Ashley Davidoff MD copyright 2008 |
Tumefactive Bile
Acaclculous Cholecystitis |
| 16136c03.8s gallbladder prolonged ICU stay right upper quadrant pain right upper quadrant tenderness cholestasis enlarged tumefactive bile sludge thick walled acalculous cholecystitis percutaneous cholecystostomy ultrasound USscan Courtesy Ashley Davidoff MD copyright 2008 |
|
RUQ Pain, Distended Gallbladder, Tumefactive Bile – same patient |
| 77717c01s right upper quadrant pain ICU setting RUQ pain gallbladder distended thick walled sludge cholestasis tumefactive bile fluid in gallbladder fossa small shadowing stones acalculous cholecystitis shape of tumefactive bile in the gallbladder has fetus like formation USscan ultrasound Courtesy Ashley DAvidoff MD copyright 2008 |
Carcinoma – Local Invasion and Separate Liver Mestastasis |
| 17280c02b01.8s gallbladder liver mass local invasion cholelithiasis metastasis carcinoma primary gallbladder gallbladder fossa Courtesy Ashley Davidoff MD copyright 2008 |
Lumenal Invasion |
| 16254c04.8s gallbladder space occupation gallbladder carcinoma by CT it appears as a low density centrally and enhancing soft tissue peripherally by USscan looks like the whole lumen is filled with soft tissue tumor question of delayed tumor enhancement vs necrosis CTscan USscan ultrasound Courtesy Ashley Davidoff copyright 2008 |
Layering Hyperdense |
| 78352.8s obese female gallbladder layering hyperdense stones cholelithiasis hyperemic wall hyperemic mucosa and submucosa chronic cholecystitis CTscan Courtesy Ashley Davidoff MD copyright 2008 |
 
Calcific Foci in the Wall with Focal Thickening |
| 19701 gallbladder + wall + fx calcification + cholecystoses + hyperplastic cholecystoses cholesterolosis imaging radiology CTscan Aschoff -Rokitansky sinuses hyperplastic cholecystosis hyperplastic cholecystoses adenomyomatosis cholesterolosis |
Echogenic Foci in the Wall with Ringdown Artifact |
| 82101cs 34 female gallbladder adenomyomatosis ring down artifact hyperplastic cholecystoses calcifications stones Aschoff-Rokitansky sinuses USscan ultrasound Courtesy Ashley DAvidoff MD copyright 2008 |
|
Aschoff-Rokitansky Sinuses |
| 16176bs gallbladder outpouchings diverticula prominent Aschoff Rokitansky sinuses thickened wall hyperplastic cholecystosis hyperplastic cholecystoses adenomyomatosis calcifications in wall courtesy Ashley Davidoff MD copyright 2008 |
Dystrophic Calcification – Carcinoma of the Gallbladder Extending into the Gallbladder Fossa |
| 24404c.8s 75 female gallbladder calcification adjacent mass in the liver local invasion into the gallbladder fossa dystrophic calcification probably mucinous adenocarcinoma of the gallbladder carcinoma stones cholelithiasis hydronephrosis |
|
Porcelain Gallbladder |
| 47683c01 gallbladder fx calcification in wall calcified wall dx porcelain gallbladder CTscan Davidoff MD |
Milk of Calcium Bile |
| 16489 gallbladder + milk of calcium bile +liver micronodular cirrhosis imaging radiology CTscan |
Renal Failure |
| 24075 81Y F with LLQ pain s/p cardiac catheterization gallbladder fx fluid -fluid level fx high density sediment fx vicarious excretion of contrast s/p heart catheter kidney fx small left kidney fx enlarged right kidney with hydronephrosis muscle fx hematoma dx pelvic hematoma CTscan Courtesy Ashley Davidoff MD |
Acute Hemorrhagic Cholecystitis |
| 81902s.8b01 elderly man with acuteright upper quadrant pain gallbladder wall mildly distended gallbladder hyperdense irregular wall dx acute hemorrhagic cholecytitis acute on chronic cholecystitis kidney cyst complex calcification grade 3 Bosniak CTscan Courtesy Ashley Davidoff MD copyright 2008 |
Hemorrhagic Cholecystitis |
| 16214c.8s gallbladder distended enlarged containing hyperdense material sludge differential diagnosis tumefactive bile cholestasis dx acute hemorrhagic cholecystitis CT scan USscan Courtesy Ashley Davidoff MD Copyright 200 |
References
Catalano et al MR Imaging of the Gallbladder RadioGraphics 2008;28:135-155
Gallbladder Wall Thickening Web presentation from radiologyassistant.nl 5star
|
T1 |
T2 |
||
| Wall | pre Gad | intermediate | low
wall on liver side may not be appreciated |
| post Gad | uniform enhancement
wall on liver side may not be appreciated |
||
| Lumen (bile) | non fasting | variable depending on concentration | bright |
| fasting | bright, sometimes layering effect is seen | bright | |
| sludge | hyperintensity with layering | iso to mild hyperintensity | |
References
Hsu-Chong et al Floating Gallstones in Bile without Added Contrast AJR 1986
Tera H. Stratification of Human Gallbladder Bile In Vivo Acta Chirg Scan (Suppl) 1960 256: 9-85 (not available Pubmed)
Hawk Practical Physiological Chemistry By Philip Bovier Hawk, Olaf Bergeim Published by Blakiston, 1918
During fasting, bile undergoes a process of concentration. Water is reabsorbed and the concentration of cholesterol and bile salts increases, leading to a shortened T1 relaxation time and, consequently, to bright bile on T1-weighted images. A layering effect is sometimes observed, with concentrated and denser bile in the dependent position.
In the Ivemark syndrome patients are born with an abnormal position of the gallbladder. This occurs with situs inversus but also occurs in rare instances in situs ambiguus states such as asplenia and polysplenia syndromes.
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82222.8s liver gallbladder bilateral right lobe asplenia syndrome Ivemark syndrome central gallbladder situs ambiguus congenital position gross pathology Courtesy Ashley DAvidoff MD copyright 2008
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16228c01.8s gallbladder wall submucosal tumor = orange mucosal tumor = pink lumen = green thickened mucosa and submucosa carcinoma of the gallbladder CTscan Courtesy Ashley DAvidoff MD copyright 2008
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Phrygians of Northern and Central Asia Minor 1000-2000BC
82407b14.8s gallbladder Phrygian cap freedom liberty shape symbol Davidoff art Copyright 2008
The phrygian cap is a common normal variant of gallbladder shape characterized a fundus that is folded forward. It was first described by Bartel in 1916. The Phrygians were a primitive race that migrated into northern and central Asia Minor in the second millenium BC. The Greeks knew of the cap as an Oriental headgear that was tight fitting and conical in shape and it has been depicted in their art. (Ober WB, Wharton RN On the “phrygian cap.” 255:571-572 New England Journal of Medicine 1956
The cap was a symbol of freedom and the pursuit of liberty.
The cap was worn by King Midas who was cursed with donkey ears by Apollo. He used the Phrygian cap to hide his ears. It was subsequently worn by the Trojan hero Paris, was a symbol of freedom in the French and American revolutions, was depicted on coinage in the US and on variety of seals and flags throughout the world.
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Phrygians of Northern and Central Asia Minor 1000-2000BC
82407b14.8s gallbladder Phrygian cap freedom liberty shape symbol Davidoff art Copyright 2008
The phrygian cap is a common normal variant of gallbladder shape characterized a fundus that is folded forward. It was first described by Bartel in 1916. The Phrygians were a primitive race that migrated into northern and central Asia Minor in the second millenium BC. The Greeks knew of the cap as an Oriental headgear that was tight fitting and conical in shape and it has been depicted in their art. (Ober WB, Wharton RN On the “phrygian cap.” 255:571-572 New England Journal of Medicine 1956
The cap was a symbol of freedom and the pursuit of liberty.
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The phrygian cap is a common normal variant of gallbladder shape characterized a fundus that is folded forward. It was first described by Bartel in 1916. The Phrygians were a primitive race that migrated into northern and central Asia Minor in the second millenium BC. The Greeks knew of the cap as an Oriental headgear that was tight fitting and conical in shape and it has been depicted in their art. (Ober WB, Wharton RN On the “phrygian cap.” 255:571-572 New England Journal of Medicine 1956
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47018 gallbladder normal shape pear shaped anatomy nrmal USscan Davidoff MD
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Direct Invasion into the Liver and Bile Duct Obstruction
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Direct Invasion into the Liver and Bile Duct Obstruction
A gallbladder cancer (orange) has extended from the gallbladder (green) directly into the liver. Associated ductal obstruction is present.
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Cholecystitis Complicated by Abscess Formation in the Gallbladder Fossa
The artistic rendition shows 2 stones lying free in the lumen and one impacted in the neck of the gallbladder with secondary inflammatory changes in the wall(red) and abscess formation in the gallbladder fossa and extension into the neighbouring liver.
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Cholecystitis Complicated by Abscess Formation in the Gallbladder Fossa
The artistic rendition shows 2 stones lying free in the lumen and one impacted in the neck of the gallbladder with secondary inflammatory changes in the wall(red) and abscess formation in the gallbladder fossa and extension into the neighbouring liver.
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The artistic rendition shows 2 stones lying free in the lumen and one impacted in the neck of the gallbladder with secondary inflammatory changes in the wall(red) and abscess formation in the gallbladder fossa and extension into the neighbouring liver.
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The artistic rendition shows 2 stones lying free in the lumen and one impacted in the neck of the gallbladder with secondary inflammatory changes in the wall(red) and abscess formation in the gallbladder fossa and extension into the neighbouring liver.
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Significantly Enlarged Gallbladder that was Clinically Palpable
The sagittal image (a) from a CTscan, and the transverse image reveal an enormous ballon like rotund gallbladder that was clinically palpable. This 80 year old female had recently undergone cardiac catherization and had a bleed (arrow) into the right rectus sheath.
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Significantly Enlarged Gallbladder that was Clinically Palpable
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Gallbladder Upper limits Normal in Size
The 78 year old female is asymptomatic from the perspective of the gallbladder. It measures by CT on this cut 9.5cms in long axis and 3.5cms in short axis. This measurement is upper limitsnormal and probaly reflects age related change.
82156.8 78 year old female patient No gallbladder symptoms gallbladder normal atonic aging CTscan Courtesy Ashley Davidoff copyright 2008
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82156.8 78 year old female patient No gallbladder symptoms gallbladder normal atonic aging CTscan Courtesy Ashley Davidoff copyright 2008
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82156.8 78 year old female patient No gallbladder symptoms gallbladder normal atonic aging CTscan Courtesy Ashley Davidoff copyright 2008
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00384 gallbladder pancreas liver anatomy
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Zuchini (Italian) Gallbladder
The elongated shape of the gallbladder without being wide is remoiniscent of the Italian Zuchini
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Contracted Gallbladder Following a Fatty Meal
Following a fatty meal, the gallbladder in this instance measures 6.5cms by 1.3cms.
25902c.8s gallbladder small normal post fatty meal normal physiology USscan ultrasound copyright 2008 Courtesy Ashley Davidoff MD
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Contracted Gallbladder Following a Fatty Meal
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25902c.8s gallbladder small normal post fatty meal normal physiology USscan ultrasound copyright 2008 Courtesy Ashley Davidoff MD
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Elongated but not Dilated – The Aging Gallbladder
The CT is also from an elderly asymptomatic female (from the perspective of the gallbladder) whose gallbladder measures 3.5cms in the short axis and 11cms in the long axis. The latter measurement is considered abnormal while the former is normal. This zuchini shaped gallbladder is probably normal and reflective of the patients age. An ultrasound would be far more specific, since wall thickness, probe tenderness, and true long axis and short axis measurements could be made.
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Elongated but not Dilated – The Aging Gallbladder
The CT is also from an elderly asymptomatic female (from the perspective of the gallbladder) whose gallbladder measures 3.5cms in the short axis and 11cms in the long axis. The latter measurement is considered abnormal while the former is normal. This zuchini shaped gallbladder is probably normal and reflective of the patients age. An ultrasound would be far more specific, since wall thickness, probe tenderness, and true long axis and short axis measurements could be made.
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The gallbladder in the fasting state measures 8-10 cms in length and 3-4cms in diameter. In this instance it measures 10 by 3.5cms.
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Normal Size of the Fasting Gallbladder on Ultrasound
The gallbladder in the fasting state measures 8-10 cms in length and 3-4cms in diameter. In this instance it measures 10 by 3.5cms.
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Conracted Gallbladder Recent Meal in Stomach
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Conracted Gallbladder Recent Meal in Stomach
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Following a fatty meal, the gallbladder in this instance measures 6.5cms by 1.3cms.
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