a) Differential diagnosis of diffuse thickening of the gallbladder wall :

1. Common diseases :
• Acute calculous cholecystitis • Chronic cholecystitis • Hyperplastic changes in the gallbladder wall ( adenomyomatosis )
• Thickening of the gallbladder wall due to systemic diseases:o Chronic heart failure (CHF)o Kidney failureo Cirrhosis of the livero Hypoalbuminemia

2. Less common diseases :
• Acute acalculous cholecystitis
• Acute pancreatitis • Acute hepatitis • Acute gastric and/or duodenal ulcer with perforation • Gallbladder carcinoma • Lymphoma • AIDS-associated cholangiopathy
• Varicose veins of the gallbladder

3. Rare but important diseases :
• Xanthogranulomatous cholecystitis • Dengue fever

b) Important information :

1. Differential diagnosis :
• Clinical data are needed for differential diagnosis • The presence of symptoms of sepsis and pain in the right upper quadrant of the abdomen speaks in favor of acute cholecystitis • An important criterion for making a diagnosis is the presence of symptoms of a systemic disease: CHF, renal failure, hypoalbuminemia
• On the wall of the gallbladder affects the presence of diseases of the hepatobiliary zone: acute hepatitis or pancreatitis, cirrhosis • The presence of a confirmed malignant disease

2. Additional data :
• Fever, leukocytosis, liver function tests

3. Common diseases :

• Acute calculous cholecystitis :
o Symptoms: right upper quadrant pain, fever, positive Murphio sign Acute secondary inflammation of the gallbladder (GB) due to obstruction by a cystic duct stone Gallstones fixed in the bladder necko Diffuse thickening of the GB wall (>3 mm):- Layered appearance: alternation of light and dark layers in the thickened wall of the gallbladder- Symptom “halo”, enlightenment of the wall of the gallbladder: sonolucent
middle layer due to
edema cholecystitis: Asymmetric wall thickening Severe wall heterogeneity
Intraluminal constriction
– GA perforation: GA
wall defect
Perivesical abscess or extracavitary calculi
– Emphysematous cholecystitis: Gas in the wall/lumen of the GA – Empyema of the GA:
Intraluminal echoes, purulent exudate/areas of necrosis

• Chronic cholecystitis :
o In most cases, there are no symptoms Diffuse thickening of the gallbladder wall: – Average thickness – 5 mm – Indistinct / uneven contour Wrinkled gallbladder: – In severe cases, the lumen of the gallbladder can be obliterated
o Virtually all cases have stones in the gallbladder

• Hyperplastic changes in the wall of the gallbladder ( adenomyomatosis ) :
o Adenomyomatosis of the gallbladder o No
clinical symptoms, usually an incidental finding during ultrasound Focal or diffuse thickening of the wall of the gallbladder Small echogenic foci in the wall of the gallbladder with the effect of a “comet tail”
o Presence of cystic cavities in the wall of the gallbladder fundamental adenomyomatosis : uniform thickening or focal mass in the fundus of the gallbladder ± hourglass-shaped “signal rattling” artifact of the gallbladder : narrowing of the middle third of the gallbladder

• Gallbladder wall thickening in systemic disease :
o Clinical
findings are key to explaining gallbladder wall thickening Imaging of thickened wall is nonspecific.
with increased echogenicity of the renal parenchyma
– Cirrhosis of the liver: large-nodular structure of the liver, uneven / lumpy contour of the liver, signs of portal hypertension (for example, ascites, splenomegaly, varicose veins) – Hypoalbuminemia : presence of ascites, diffuse thickening of the intestinal wall

4. Less common diseases :

• Acute acalculous cholecystitis :
o Usually occurs in critically ill patients (eg, as a result of major surgery, severe trauma, sepsis, etc.) o Ultrasound findings are similar to those of acute calculous cholecystitis, except for the absence of a fixed gallstone bladder: Thickening of the gallbladder wall: echogenicity is reduced, the wall is layered
– Stretching of the gallbladder: the contents are often represented by sludge
– Positive ultrasound Murphy’s sign – Fluid in the perivesical space

• Acute pancreatitis :
o Spread of inflammation on the bed of the gallbladder Nonspecific thickening of the wall of the gallbladder Diffuse/focal decrease in the echogenicity of the edematous pancreas

• Acute hepatitis :
o History of the disease: general malaise, vomiting, abnormal liver function tests in the direction of inflammatory changes
o Hepatomegaly with a diffuse decrease in echogenicity
o Starry sky symptom: increased echogenicity of the walls of the portal tracts, relative to the hypoechoic liver parenchyma
o Hypo- / anechoic periportal space
o Less distended gallbladder, unlike acute cholecystitis

• Acute gastric and/or duodenal ulcer with perforation :
o Perforated duodenal ulcer leads to reflex sympathetic thickening of the gallbladder wall o Presence of free gas in the abdominal cavity

• Carcinoma of the gallbladder :
o Asymmetric or irregular thickening of the gallbladder wallo Mass replacing the gallbladder with signs of local tumor extensiono Presence of gallbladder calculio Invasion of adjacent structures (eg, liver, duodenum)o Metastases in regional lymph nodes and liver

• Lymphoma :
o Gallbladder is rarely affected by lymphoma metastasiso Nonspecific diffuse thickening of the gallbladder wall Presence of intra -abdominal lymphomatous lymph nodes

• AIDS-associated cholangiopathy :
o Focal inflammatory lesions of the biliary tract due to AIDS-associated opportunistic infections, leading to narrowing / obstruction of the ducts or cholecystitis Diffuse thickening of the wall of the biliary tract Thickening / inflammation of the walls of the biliary tract: – Periductal areas of increased / decreased echogenicity
o Local narrowing or expansion of the bile ducts

• Gallbladder varicose veins :
o Usually due to portal hypertension or cavernous transformation of the main trunk of the portal veino Tubular structures in the gallbladder wall to varicose veins are easily confirmed by color/power Doppler ultrasound or pulsed wave Doppler .

• Xanthogranulomatous cholecystitis :
o Rare form of chronic cholecystitis Diffuse irregular thickening of the gallbladder wall, similar to an infiltrative growth pattern, may mimic gallbladder carcinoma

• Dengue fever :
o Rash, fever, headache, joint pain, history of visit to an endemic areao Thickening of the gallbladder wall due to acute viral liver injury leading to liver failure

4. Alternative differential diagnosis :
• Etiology of gallbladder wall thickening:o Inflammatory processes: – Acute calculous cholecystitis – Acute acalculous cholecystitis
– Chronic cholecystitis – AIDS-associated cholangiopathy
– Secondary lesion: acute hepatitis, acute gastric and / or duodenal ulcer with perforation, pancreatitis
o Systemic diseases: – CHF – Renal failure – Liver cirrhosis – Hypoalbuminemia
o Tumor infiltration: – Carcinoma of the pancreas – Leukemic / lymphomatous infiltration