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3 Imaging ofCommon Biliary Tract Diseases
Mobility is demonstrated by a change in position; CT shows
an increase in density, and MRI shows a signal change of
short T1 and short T2.
3.3.2 Chronic Cholecystitis
Chronic cholecystitis occurs after recurrent episodes of acute
cholecystitis. It can also be initiated chronically, without a
history of acute cholecystitis, and more often with gallstones.
The clinical manifestations of chronic cholecystitis are similar to those of cholelithiasis: they are episodic, occurring
after ingestion of fatty food; some may be asymptomatic.
The most important sonographic sign is abdominal pain with
deep palpation and a positive Murphy’s sign.
3.3.2.1 CT Features
The main feature in the setting of chronic cholecystitis is
gallbladder wall thickening. When the wall thickness of a
well-lled gallbladder exceeds 3mm, it is abnormal; the
density of gallbladder wall thickening is higher in chronic
cholecystitis as opposed to the condition in acute cholecystitis. Calcication of the gallbladder wall is a typical change
of chronic cholecystitis. The gallbladder may appear distended or contracted in the setting of chronic cholecystitis.
The former represents gallbladder effusion, and the latter
represents progressive brosis and contraction of the gallbladder. Stones can be seen in the gallbladder (Figs.3.13
and 3.14).
43
Fig. 3.14 Chronic cholecystitis and gallbladder full of stones, multiple
small calculi are seen in the gallbladder lumen, gallbladder wall slightly
thickened
Fig. 3.13 Chronic cholecystitis, contracted gallbladder, rough and
slightly thickened gallbladder wall, multiple calculi within the
gallbladder
Fig. 3.15 CT ndings of porcelain gallbladder: the gallbladder wall
showing a ring-shaped shadow with increased density
Porcelain gallbladder (Fig. 3.15), a rare presentation of
chronic cholecystitis, is characterized by a calcied wall of
the gallbladder (Kane etal. 1984) and accounts for 0.06% to
0.08% of cholecystectomy specimens (Varadarajulu and
Zakko 2012); it can be divided into two types according to
the extent of calcication: selective mucosal calcication
and diffuse intramural calcication. Calcication can be
localized or distributed throughout the gallbladder. This condition occurs predominantly in male patients (5 times more
than female patients), with the average age of onset being 54.
44
ab
Fig. 3.16 MRI ndings of chronic cholecystitis. (a) Obviously thickened gallbladder wall, and stones are manifested as a short and round-like
voids on short T2in the gallbladder lumen. (b) The gallbladder wall was thickened and roughened in the coronal position
X. Quan et al.
Since the risk for malignancy ranges from 5% to 22%
(Stephen and Berger 2001), prophylactic cholecystectomy is
suggested for both symptomatic and asymptomatic patients
once porcelain gallbladder is diagnosed.
CT has high accuracy in diagnosing porcelain gallblad-
der, showing the diffuse or localized arc of a calcied wall.
sediment- like stones. The CT value of iso-density is approximately 0–25 HU, and the stone position could be changed
with a change in patient position, which is different from that
of gallbladder space occupying. Low-density stones (CT
value <0 HU), also known as cholesterol stones, present as a
lucent lling defect with a density lower than the surrounding bile. Ring-shaped stones are characterized by a lower
3.3.2.2 MRI Features
The MRI presentation of chronic cholecystitis is mainly
characterized by gallstones and gallbladder wall thickening.
However, MRI is less sensitive in detecting calcication of
the gallbladder wall than CT (Fig.3.16).
density center and a slightly higher density around the circumference. They are easily displayed by CT.Tiny stones as
small as 1–2mm in diameter are described as “sediment-like
stones.” They are usually deposited in the walls of the gallbladder along with the direction of gravity when the patient
takes a supine position. However, it should be noted that a
few sediment-like stones can also be suspended in the ante-
3.3.3 Gallstones
rior wall of the gallbladder due to the increase of bile
viscosity. The diagnostic sensitivity of CT in detecting gall-
The clinical symptoms of gallstones are related to the location, size, and complication of stones. Based on their composition, gallstones can be divided into the following ve types:
stones ranges between 75% and 85% for stones ≥5 mm
(Grand etal. 2004), and the enhanced CT is of little help. The
main cause of missed diagnosis is iso-dense stones, which
present the same radiographic density as bile, and sometimes
• High-density stones
• Slightly high-density stones
gas in the colon and duodenum may interfere with the detection of gallstones.
• Iso-density stones
• Low-density stones
• Ring-shaped stones (Figs.3.17 and 3.18)
3.3.3.2 MRI Features
On T2 WI, the gallbladder shows high-signal, and it reveals
low-signal lling defects within the gallbladder, which
3.3.3.1 CT Features
High-density and slightly high-density stones are mostly
pigment stones, and the remainder are mixed stones, with CT
value >25 HU.They are easily detected on plain CT scan,
and gallstones in the gallbladder may be single or a collection of multiple stones, round-, polygonal-shaped, or
means gallstones usually present as low- or medium signal
lling defects; on T1WI, stones appear hypointense and they
can also be recognized as high or mixed signals. There is no
enhancement of calculi during enhanced scanning, which
may be related to the lipid component or calcication of
stones (Figs.3.19 and 3.20).
ab
3 Imaging ofCommon Biliary Tract Diseases
c
45
Fig. 3.17 Multiple gallbladder stones with chronic cholecystitis. (a)
Plain CT shows that the gallbladder is lled with multiple small highdensity stones and the gallbladder wall is rough and thickened. (b) No
Fig. 3.18 CT plain scan shows the calculi of iso- or lower-density
within low-density bile
obvious enhancement is found in the calculi at the arterial stage of
enhanced scanning; (c) No obvious enhancement is found at the portal
vein stage of enhanced scanning
Fig. 3.19 Stones appear to have signicantly low signal in the background of high signal bile on T2WI
46
X. Quan et al.
3.3.4 Gallbladder Cancer
Gallbladder cancer is the most common malignancy of the
biliary tract, which accounts for 80% to 95% of biliary tract
cancers (Hundal and Shaffer 2014; Lazcano-Ponce et al.
2001). It markedly predominates in females aged
50–60years, with a male-to-female ratio of 1:3 (Hundal and
Shaffer 2014). The incidence of gallbladder cancer is associated with factors such as cholelithiasis, cholecystitis
(especially porcelain gallbladder), pancreaticobiliary
maljunction anomalies (the junction of the pancreatic duct
and common bile duct occurs at a distance >15mm from the
papilla of Vater, causing biliary pancreatic reux, and thus
resulting in gallbladder cancer), Gardner syndrome, and
chronic idiopathic colitis.
Approximately 60% of gallbladder cancers originate in
the gallbladder fundus, 30% in the body, and 10% in the
neck (Albores-Saavedra 1986). The most common metastatic pattern of gallbladder cancer is a direct invasion to
adjacent organs such as the liver, stomach, duodenum,
colon, and sometimes liver curvature, and it can also metastasize through the abundant lymphatic vessels. The spread
of gallbladder cancer along the neck of the gallbladder or
metastasis via hematogenous dissemination is extremely
rare. Patterns of spread are independent of the pathological
type of the tumor. Gallbladder cancer is a highly lethal disease with early metastasis and exceptionally poor
prognosis.
Persistent right upper quadrant pain occurs in advanced
stages of gallbladder cancer, accompanied by obvious
cachexia, jaundice, involuntary weight loss, ascites, cystic
duct obstruction, enlarged gallbladder, or a palpable mass in
the right upper quadrant of the abdomen in the presence of
local metastasis to the liver or adjacent structures.
3.3.4.1 CT Features
On CT imaging, they can present as three types (Figs.3.21,
3.22, and 3.23):
Gallbladder Wall Thickening: 20%–30% In general, nor-
mal gallbladder wall thickness is reported to be less than
3mm, and wall thickening caused by gallbladder cancer has
a width greater than 5mm, which can be divided into two
types: focal and diffuse thickening. The lesion of focal gallbladder wall thickening is inltrative growth, which is characterized by focal, asymmetric, or eccentric thickening, with
uneven inner margin; diffuse thickening is characterized by
uneven thickening of part or entire walls, with few
homogenous, smooth inner and outer walls. Contrastenhanced CT shows obvious enhancement of the thickened
wall and an uneven low-density edematous zone in the surrounding area. When the hepatic parenchyma is invaded, a
low-density lesion adjacent to it can be observed.
Nodular Type: 15%–25% Nodular or cauliower-like
mass lesions on the gallbladder wall protrude into the lumen.
Contrast-enhanced scanning shows obvious enhancement of
the tumor nodules, and invasion of the hepatic parenchyma is
rare.
Mass Occupying Lesion: 40%–65% Imaging ndings
reveal a mass replacing the healthy gallbladder. On the plain
scan, the density of the lesion is lower than that of adjacent
liver parenchyma. Calcication is common. Contrastenhanced scanning shows heterogeneous peripheral enhancement and non-enhancement of a necrotic area in the center
(Deshmukh etal. 2013).
3.3.4.2 MRI Features
According to the MRI features (Fig.3.24), two types can be
divided. One is normal disappearance of the gallbladder,
where a mass replaces the normal gallbladder; the other is
the existence of the outline of the gallbladder, in which nodules and masses can be seen. It can also be manifested as a
focal or diffuse thickening of the gallbladder wall. The signal
intensity of the tumor tissue appears slightly or obviously
lower than the surrounding liver parenchyma on T1W1 and
slightly or obviously higher on T2W1, and its signal intensity is heterogeneous. The lesion gave a moderately or obviously heterogeneous enhancement after administration of
Gd-DTPA.Other MRI features of gallbladder cancer include:
Fig. 3.20 The short T2 signal inside the gallbladder is a huge stone
that almost lls the gallbladder lumen
• Tumor invasion to the liver, invasion of the liver and intrahepatic metastases has been reported in 85% of the gallbladder cancer patients by the time of treatment, and it
has the same signal intensity as the primary lesion.
3 Imaging ofCommon Biliary Tract Diseases
47
a
b
c
Fig. 3.21 Diffuse gallbladder wall thickening. (a) Plain CT scan show-
ing diffuse mural thickening of the gallbladder wall with varying thickness; (b) The gallbladder wall was signicantly enhanced during the
• About 50%–100% of patients diagnosed with gallbladder
cancer may present concurrent stones (Yee etal. 2002).
Gallstones that produce no signal in the gallbladder or
within the mass can be observed, and iso-density stones
that cannot be found by CT plain scan can also be detected.
The presence of gallstones in a large gallbladder mass with
an unclear origin can help diagnose gallbladder cancer.
• Obstructive gallbladder dilatation, which is caused by
direct tumor invasion of the bile duct or extrinsic compression by lymph node metastases.
• Lymph node metastases: Cancer frequently spreads to the
porta hepatis, the head of the pancreas, and peripheral
lymphatics of the abdominal aorta.
arterial phase; (c) The enhancement degree of the portal vein in
enhanced scan did not diminish, and the gallbladder shape was slightly
irregular
The presence of adipose tissue between the tumor and
surrounding tissue often indicates that the tumor has not
invaded surrounding tissue.
3.3.4.3 MRCP Features
The presence of a large gallbladder mass in the area of the
gallbladder, abnormal-shaped gallbladder, irregular and
small gallbladder lumen with a gallbladder lling detect,
interruption of the upper common bile duct, and dilatation
of the proximal portion of the bile duct (Munir et al.
2004).
48
ab
X. Quan et al.
c
Fig. 3.22 Nodular gallbladder carcinoma. (a) Plain scan shows a nod-
ular, slightly low-density mass protruding into the gallbladder cavity;
(b) Contrast-enhanced scanning shows obvious enhancement of the
3.3.5 Other Gallbladder Tumors
lesion in the arterial phase; (c) Contrast-enhanced scanning demonstrates further heterogeneous enhancement in the portal venous phase
texture. The clinical features of gallbladder leiomyosarcoma
are non-specic, often associated with gallstones and chole-
Nonepithelial neoplasms comprise 5%–10% of all gallbladder neoplasms, including:
cystitis; a mass in the right upper quadrant of the abdomen is
a common physical sign of gallbladder leiomyosarcoma.
These swellings have an uneven surface. They are hard and
• Leiomyosarcoma that develops in muscle tissue
• Lymphoma that arises from lymphoid tissue
• Fibrosarcoma that derives from brous connective tissue
• Liposarcoma that develops in fat tissue
• Neurobrosarcoma that originates in nerves
• Angiosarcoma that develops in the inner lining of blood
rm and cause tenderness (Paasch etal. 2020; Savlania etal.
2012). CT shows thickening of the gallbladder wall and
masses in the gallbladder wall and lumen. On the plain scan,
the density of the lesion is lower than that of adjacent liver
parenchyma. The contrast-enhanced scan shows a heterogeneous enhancement pattern with gallstone images.
vessels
• Carcinoid that originates from neuroendocrine cells
• Other rare tumors such as carcinosarcoma and
osteosarcoma
3.3.5.2 Rhabdomyosarcoma oftheGallbladder
Rhabdomyosarcoma (RMS) of the gallbladder is a rare
entity, which is pathologically classied into two major subtypes: the embryonal rhabdomyosarcoma (ERMS) and the
3.3.5.1 Leiomyosarcoma oftheGallbladder
Leiomyosarcoma of the gallbladder is a rare disease, more
common in females or late-middle-aged individuals. It usually arises from the fundus and body of the gallbladder. The
tumor is large, with an inltrating growth pattern and hard
alveolar rhabdomyosarcoma (ARMS). RMS occurs mostly
in the pediatric population aged from 16months to 11years.
Its clinical presentation includes abdominal pain, jaundice,
and abdominal mass (al-Jaberi etal. 1994). CT shows a mass
in the gallbladder wall or lumen. On the plain scan, the den-
3 Imaging ofCommon Biliary Tract Diseases
49
a
b
c
Fig. 3.23 Mass occupying lesion of the gallbladder cancer. (a) The
normal form of gallbladder disappeared in the plain scan, showing a
heterogeneous soft tissue density shadow; (b) Contrast-enhanced CT
shows obvious enhancement at the edge of the mass and non-enhanced
sity of the mass is lower than that of adjacent liver parenchyma, and lower density necrotic areas can be observed;
dilation of the intrahepatic bile duct reveals heterogenous
enhancement in an enhanced scan.
3.3.5.3 Primary Gallbladder Lymphoma
Primary Gallbladder Lymphoma (PGBL) is exceedingly
rare. PGBL is dened as extranodal lymphoma arising and
conned to gallbladder without obvious peripheral lymphadenopathy, hepatosplenomegaly, systemic supercial or
mediastinal lymphadenopathy, peripheral blood or bone
marrow changes. CT shows a gallbladder mass with a clear
boundary and intact capsule, most of which are not associated with gallstones or chronic cholecystitis (Batur and Odev
2014).
3.3.5.4 Gallbladder Fibrosarcoma
Gallbladder brosarcoma is a rare entity and most common
in elderly females. It usually arises from the fundus and body
cystic necrosis in the center; (c) Contrast-enhanced CT shows more
obvious enhancement at the edge of the mass in the portal venous
phase, with an irregular edge of the mass, the boundary between the
mass and surrounding structures is not clear
of the gallbladder, rarely in the neck region (Willén 1982).
The mean size of brosarcomas ranges from 2 to 10cm in
diameter. CT shows a low-density mass in the gallbladder.
3.3.5.5 Carcinosarcoma, Primary Osteosarcoma,
Liposarcoma, andAngiosarcoma
ofGallbladder
Carcinoids of the gallbladder are extremely rare, and they
often develop large polyps with necrosis. Pathologically, carcinosarcoma of the gallbladder comprises both epithelial and
mesenchymal components within the same tissue. The most
common epithelial components are adenocarcinoma,
whereas in the mesenchymal component, rhabdomyosarcoma occurs the most, occasionally admixed with chondroid
and osteoid tissues and calcication. CT shows a solid mass
with heterogeneous density and irregular calcication.
Primary osteosarcoma of the gallbladder affects predominantly middle-aged and elderly patients, and its pathological
features include a tumor composed of highly atypical fusi-
50
ab
X. Quan et al.
c
Fig. 3.24 MRI features of gallbladder cancer. (a) T2WI showed that
the normal morphology of the gallbladder disappeared, and there were
multiple, rounded long T2 signal of cystoid degeneration and necrosis,
and irregular and slightly shorter T2 signal in the center; (b) Contrast-
form to round cells, and bones and osteoid tissue, associated
with a large number of chondrocyte-like giant cell tumors. It
enhanced MRI showed no obvious enhancement of the peripheral
necrotic area in the arterial phase; (c) In the delayed phases, areas of
necrosis were still non-enhancing, and the enhancement degree of the
parenchymal areas increased
yellow- colored nodules of varying sizes between the apparently thickened gallbladder wall (Goodman and Ishak 1981).
is a highly malignant tumor with poor prognosis.
Preoperative imaging diagnosis of the above-mentioned
tumors is difcult due to the lack of specicity of clinical
imaging ndings.
3.3.6.1 CT Features
Distended gallbladder, diffuse, or focal wall thickening
(Chun etal. 1997), contracted but not obliterated gallbladder
lumen, the presence of single or multiple intramural
hypodense nodules. Pathologically, lipid, or cholesterol con-
3.3.6 Xanthogranulomatous Cholecystitis
tents of xanthogranulomatous nodules are high. The CT
value of the nodules ranges from 15 to 30 HU.Some of the
Xanthogranulomatous cholecystitis (XGC) was rst named
by Mccoy in 1976. XGC affects predominantly female
patients aged mostly from 60 to 70 years (Solmaz Tuncer
etal. 2012). Patients usually have symptoms such as right
upper quadrant abdominal pain, nausea, vomiting, jaundice,
and positive Murphy’s sign. Pathologically, XGC is characterized by proliferative brosis and accumulation of lipidladen macrophages and inammatory cells in the regions of
destructive inammation. There are single or multiple
nodules are characterized by the presence of multiple intra-
mural nodules, presenting a palisade arrangement (Fig.3.25).
Xanthogranulomatous cholecystitis is often associated
with cholelithiasis and (or) choledocholithiasis. Fat strands,
blurring of the interface between the gallbladder and adjacent tissues and organs, no lymph node enlargement
(Fig.3.26).
After enhancement, the thickened gallbladder wall shows
mild-to-moderate enhancement, while the yellow-colored
ab
3 Imaging ofCommon Biliary Tract Diseases
Fig. 3.25 Xanthogranulomatous cholecystitis. (a) Multiple intramural hypodense nodules; (b) Presenting a palisade change
ab
51
c
Fig. 3.26 Xanthogranulomatous cholecystitis associated with cholelithiasis. (a) Multiple stones in the body of gallbladder; (b) Multiple low-
density nodules in the gallbladder wall; (c) Blurring fat stranding on the gallbladder fossa
52
ab
X. Quan et al.
c
Fig. 3.27 Xanthogranulomatous cholecystitis. (a) Plain scanning shows the irregular shape of the gallbladder, with hypodense nodular shadows;
(b, c) Contrast-enhanced scanning shows palisade patterning of the gallbladder wall, and the hypodense nodules integrated
nodules show no enhancement or slight marginal enhancement. The yellow nodule structures can be located between
the walls or protrude to the submucous or serous membrane.
When a number of hypo-attenuated intramural nodules are
close to each other, they can be fused, resulting in separation
of the thickened gallbladder wall. Sometimes, the muscular
layer and mucous membrane (CT density appears linear
hyperdense) can be pushed into the gallbladder lumen by
yellowish intermural nodules (Fig.3.27).
T2WI (Shuto etal. 2004). In diffuse thickening of the gallbladder wall, the mucosa and serous membrane of the gallbladder show relatively hypointense signals, and the
intramural nodules produce a hyperintense signal.
Hypointense signal separation is observed between hyperintense signal nodules in typical cases (Fig. 3.28). A “hamburger sign”: The enhancement of serosal and mucosal
surfaces is more obvious, but that of the muscle layer is relatively weak (Fig.3.29).
3.3.6.2 MRI Features
CT and MRI imaging ndings of xanthogranulomatous cho-
3.3.7 Gallbladder Adenomyomatosis
lecystitis are similar, including diffuse gallbladder wall
thickening, intramural hypodense nodules, isointense or
slightly hypointense signals on T1WI, and hyperintense on
Gallbladder Adenomyomatosis (GA) is a non-neoplastic,
non-inammatory benign condition characterized by hyper-