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Adjacent to interlobar fissure, 4 x 10 cm, GB wall < 3mm, Phrygian cap (fundal fold), fast 4-8 hours before scan to ensure adequate GB distension


75% cholesterol, 25% pigment, symptomatic 1% per year, sensitivity 95%;

Mobile, echogenic, dependent or floating intraluminal structures that cast acoustic shadow, stones < 3 mm may not cast a shadow.

DDx: Polyp (non-mobile), Sludge ball (mobile w/o shadow)

GB completely filled w/ stones may resemble gas-filled loop of bowel - echogenic shadowing structure → differentiate by:

!! stones produce a clean shadow, while gas produces a dirty shadow

WES (Wall-Echo-Shadow) complex

3 arc shaped lines

Stone can float in very concentrated bile (cholesterol)


Calcium bilirubinate granules and cholesterol crystals. Mobile, non-shadowing reflectors in the dependent portion of GB forms bile-sludge level or sludge balls, early stage of stones. May be a cause of pancreatitis.

Acute Cholecystitis

Positive Predictive Value of Gallstone and Positive sonographic Murphy’s sign is 92%; NPV is 95%

  1. Gallstones

  2. GB wall thickening > 3 mm

  3. Pericholecystic fluid

  4. Sonongraphic Murphy’s sign

  5. GB enlargement

5% acalculous cholecystitis (likely ischemic in very sick patients)

Emphysematous cholecystitis

Ischemic, older men, DM, infection w/ gas forming organisms, Perforation likely. Very bright reflections from gas in the wall of non-dependent portion of GB w/ dirty acoustic shadowing and ring-down artifact from gas

GB Carcinoma

Chronic irritation from stones. Most common sono appearance is soft tissue mass centered in GB fossa (w/ or w/o stone). Mmay also present as irregular, asymmetric, eccentric, focal or diffuse GB wall thickening, or polypoid mass

DDx: Tumefactive sludge, inflammatory GB wall thickening, Polyps, Mets (melanoma), Adenomyomatosis


Cholesterol polyps: enlarged papillary fronds filled w/ lipid-laden macrophages, ball on the wall sign, < 5 mm, lack of shadow , non-mobile; lesions > 5 mm should be monitored, > 10 mm should be removed. Cholesterolosis: Strawberry GB

DDx: much less common are Adenomas, Papillomas, Leiomyomas, Lipomas, Neuromas; Mets (melanoma)


Mucosal hyperplasia and thickening of the muscular layer of the GB, mucosal herniation into the muscular layer - Rokitansky-Aschoff sinuses contain cholesterol crystals producing comet-tail artifacts along the near wall.

Biliary causes of GB wall thickening > 3 mm

Non-biliary causes of GB wall thickening > 3 mm

Porcelain GB

Calcified wall from chronic GB inflammation. Increased risk for GB carcinoma 20-60%. Prophylactic cholecystectomy. Echogenic arc w/ dense posterior shadowing. Search for malignancy.

DDx: entirely stone filled GB (WES complex), Emphysematous cholecystitis