CHOLELITHIASIS (GALL STONE) Highly echo reflective originating from anterior surface of the calculus with prominent posterior acoustic shadow. Multiple small stones show echogenic foci with nonshadowing. Sludge balls (tumefactive biliary sludge) can appear as mobile masses within gallbladder lumen without posterior acoustic shadowing. Material includes parasites; blood clots aggregated pus, sludge and contrast material. Wall-echo-shadow (WES triad) or the double arc shadow sign: two parallel, curved, echogenic lines separated by a thin anechoic space with distal acoustic shadowing. ACUTE CHOLECYSTITIS Primary signs: gall stones, focally tender gall bladder (sonographic Murphy’s sign) and impacted gall stone. Secondary signs: gall bladder dilatation, sludge and diffuse wall thickening (>3mm). Doppler shows increased color flow in the gall bladder wall. Emphysematous cholecystitis- diabetic, M: F= 7:3 If gas is intraluminal, image consists of prominent nondependent hyperechoic focus with an associated ring down or comet-tail artifact. Intramural gas has a semicircular or arc-like configuration. Large gas is present; appearance may simulate calcification in the gall bladder wall or gallbladder filled with stones. Gangrenous cholecystitis Marked irregularity or asymmetric thickening of gall bladder wall with multiple striations due to ulceration, hemorrhage, necrosis and microabscesses. Gall bladder perforation Acute, resulting in generalized peritonitis. Subacute, resulting in a pericholecystic abscess-complex echogenic pericholecystic fluid collection with septations, or encompass gall bladder resulting nonvisible gall bladder. Thick, hypoechoic gall bladder wall and cholelithiasis color Doppler shows acute pericholecystic inflammation by demonstrating an echogenic pericholecystic mass contains internal vascularity. Chronic, resulting in an internal biliary fistula. ACACULOUS CHOLECYSTITIS Gall bladder wall thickening (in the absence of hypoalbuminemia, ascites, congestive heart failure), pericholecystic fluid or subserosal edema, intraluminal or intramural gas, or sloughed mucosal membranes. CHRONIC CHOLECYSTITIS Gall bladder wall thickening, contracted gall bladder after nil by mouth (2days) with or without multiple small stones SLUDGE Low to mid-level echoes. PERICHOLECYSTIC FLUID Anechoic or complex fluid collection adjacent to or surrounding the gall bladder. WALL CHANGES Diffuse wall thickening: relatively hypoechoic region between two echogenic lines. Thickened wall may have striated or layered appearance. Causes: acute cholecystitis, hepatic dysfunction (associated with alcoholism, hypoalbuminemia, ascites, and hepatitis), congestive heart failure, renal disease, AIDS, and sepsis. Unusual leukemic infiltration, interleukin 2 chemotherapy and gall bladder varices. Focal wall thickening suggests primary gall bladder disease. Causes: gall bladder carcinoma, metastatic nodules, polyps, papillary adenomas, adenomyomatosis and tumefactive sludge. GALL BLADDER POLYPS (ADENOMATOUS AND CHOLESTEROL) Cholesterol polyps show aggregation of echogenic spots. Adenomyomatosis show echogenic or anechoic foci visible within thickened gall bladder wall. GALL BLADDER CARCINOMA Intraluminal mass, asymmetric wall thickening, mass replacing the gall bladder, gall bladder wall calcification, cholelithiasis, liver metastases, adenopathy, and bile duct dilatation. GALL BLADDER METASTASIS Small area of wall irregularity is present with wide base of mass due to melanoma, GI cancer, breast cancer, carcinoid tumor and lymphoma. HEMOBILIA Heterogeneously echogenic material almost completely fills the gall bladder lumen. MILK OF CALCIUM BILE OR LIMLY BILE Both an echogenic flat fluid-fluid level and convex shadowing meniscus pattern. PARASITIC INFESTATION Nonshadowing intracystic wormlike structure may be mobile which is linear ( 4 to 7 cm) or coiled. INTRAHEPATIC BILIARY CALCULI This condition a variety of names, including Oriental cholangiohepatitis, intrahepatic pigment stone disease, and biliary obstruction syndrome of the Chinese. It occurs with recurrent pyogenic cholangitis (RPC). Moderate echogenicity and lack acoustic shadowing. SCLEROSING AND AIDS CHOLANGITIS Minimal luminal bile duct dilatation. Smooth or irregular wall thickening of the intrahepatic bile ducts. CYSTADENOMA (BENIGN) – middle aged women Cystic masses with multiple septae and papillary excrescences may be unilocular, calcified or multiple. CYSTADENOCARCINOMA (MALIGNANT) Cystic masses with multiple septae and papillary excrescences may be unilocular, calcified or multiple.