Michele Cimrelda

S. West, Cooper,

MD MD

#{149} Brian

Gallbladder in Patients

Index

terms:

Gallbladder,

1 #{149} Gallbladder,

Gallbladder, den, vanices,

US studies, 762.75 1991;

MD

CT studies, MR studies, 762.1214 762.1298 #{149} Gallblad-

T

the

systemic documenting

collateral portal

MATERIALS

AND

of Radiology,

Georgetown

is useful hyper-

in

Fifty consecutive

METHODS

patients

with

a diag-

nosis of portal hypertension based on clinical data (physical examination findings and/or free and wedged hepatic vein pressure measurements) initially exam-

med in our department during a 2-year period were included in our study. All CT examinations were performed with a CT/T 9800 scanner (GE Medical Milwaukee)

by using

a contrast

material-enhanced, dynamic rapid-sequence technique. Scanning parameters included a 2-second scan time, 120 kVp, 200 mA.

A volume

60% iodinated

From the 1989 RSNA scientific assembly. Received sion received November 13; accepted November ment of Radiology, The Johns Hopkins Hospital, © RSNA, 1991

vessels venous

tension and, in some cases, may be the first indication of its presence. Despite the wide variety of collateral pathways that have been described, relatively little attention has been focused on those that reside within the gallbladder wall and pericholecystic bed. The purpose of this study was to review the spectrum of imaging appearances of gallbladder varices in patients with portal vein hypertension.

System, #{149}

179:179-182

Department

S. Hayes,

DO.

MD

angiographic, sonogmaphic, and computed tomographic (CT) appearance of portal venous hypertension and portal vein thrombosis have been well documented in the literature (1-il). More recently, magnetic resonance (MR) imaging and duplex and colon Doppler flow ultrasound (US) have also been used for evaluation of the portal venous systern (12-17). Demonstration of porto-

modt,

From

#{149} Wendelin

HE

lamate

I

C. Honii, MD K. Zeman,

#{149} Robert

Varices: Imaging Findings with Portal Hypertension’

and Radiology

#{149} Steven

M. Silverman,

A retrospective review of the mcdical and imaging records of 50 patients with portal hypertension cxamined in the authors’ department during a 2-year period identified six patients with gallbladder wall vandes. Imaging studies performed in these patients included computed tomography (CT) (four patients), duplex and color Doppler flow (five patients), and magnetic resonance (MR) (four patients). Five of six patients with gallbladder vanices had portal vein thrombosis. Anechoic areas within the gallbladder wall detected with ultrasonography could be distinguished from intramural edema by using duplex on color Doppler flow imaging in all five patients in whom it was used. Contrast material enhancement of these vanices was detected with CT in three patients, two of whom also had adjacent mesentenic collaterals. Gradient-echo MR imaging (fast imaging in steady precession/fast low-angle shot) showed flow-nelated enhancement within the gallbladder wall in two patients. The presence of gallbladder wall vanices may imply the presence of portal vein thrombosis. Since these vanices can be a source of major blood loss, surgeons must be made aware of them when operating on patients with portal hypertension.

762.121

MD

S. Gamra,

#{149} Paul

contrast

meglumine,

St Louis)

University

of 100-150

material

Conray-60;

was

Medical

injected

Center,

mL of

(iotha-

Washington,

at a rate

DC.

of i.2-1.5

mL/sec.

Real-

time, duplex, and color flow sonography was perfomed with an Ubtramark 9 sonographic unit (Advanced Technology Laboratories, Bothell, Wash). MR images were acquired with a Magnetom imager (Siemens, Iselin, NJ) operating at 1.5 T. Spin-echo sequences with a repetition time (TR) of 400 msec and echo time (TE) of i5 msec (400/i5) (Ti) and 2,000/30, 80, 150 (triple-echo T2) were performed in the transaxial and coronal planes with a 256 )( 256 matrix and 8-mm-thick sections. Fast imaging in steady precession (FISP) flow-related sequences with a 45#{176} flip angle and 50/12 were also performed. In two patients, fast low-angle shot (FLASH) sequences with a flip angle of 30#{176} and 30/10 were also performed. Angiography was performed in two patients and

consisted

rior

and

debayed

of injections

inferior portal

into

the

supe-

artery with venous phase filming. were reviewed by three inmesentenic

images dependent observers. A consensus session was subsequently held, and the images were assigned to one of three groups depending on the ease of detection of the gallbladder varices: vanices not seen, vailces adequately seen, and vanices well seen (Table). The final groups were assigned on the basis of agreement between the three reviewers. All

RESULTS Of the 50 cases reviewed, six (12%) were found to have gallbladder wall varices. Although these six patients had documented portal hypertension, five were found to also have portal vein thrombosis. The diagnosis of portal vein thrombosis was made prospectively based on either the absence of flow in or cavernous transformation

Mallinck-

as a monopha-

June 12, 1990; revision requested July 16. Address reprint requests to M.S.W., 600 N Wolfe St. Baltimore, MD 21205.

sic bolus

the

flow-related

al vessels

in the

of the

portal

MR

images,

porta

vein

on

colbater-

hepatis

and

no

portal vein identified with contrastenhanced CT, or lack of flow in the portal vein detected with duplex so-

6; reviDepartAbbreviations:

TE

=

echo

time, TR

-

repeti-

tion time.

179

nogmaphy.

Thrombus

in the

extrahepatic

portal

vein

was portion

identified of the

patients and in both the intraand extrahepatic portions in three patients. Percutaneous liver biopsy results showed that all six patients had cirrhosis, suggesting that the portal vein thrombosis was not acute but secondary to portal yenous hypertension. In addition, all patients had prior evidence of gastrointestinal bleeding: Three had documented esophageal vanices, one had hemobilia, and two had an undetemmined source. The reasons for imaging were deteriorating liver function (three patients), routine follow-up (two patients), and right-upper-quadrant pain (one patient). In three patients the gallbladder vanices were surgically proved. Anechoic areas in the gallbladder wall showed venous flow within them at duplex or color Doppler flow imaging in four patients in whom it was used (Fig 1). In a fifth patient, only thickening of the gallbladder wall was detected on the two-dimensional US images; however, venous flow within the wall could be seen with colon Doppler flow (Fig 2). These anechoic areas appeared serpentine (in

four

in two

patients)

or as a single

demonstrable

venous

1.

flow

in

normal gallbladder wall. Contrast enhancement in the vances was present on CT scans in four of five patients, three of whom also demonstrated contact between adjacent mesentemic collateral vessels and the gallbladder bed. In one patient, collateral vessels could be seen extending from the gallbladder to the anterior abdominal wall (Fig 3a, 3b). In all four patients in whom flow-related MR sequences were used, flowrebated enhancement could be identifled within the gallbladder wall (Fig

Images

of a 12-year-old

US

scan

boy

through

wall (arrows). the gallbladder

Detectability

the

with

chronic

gallbladder

Note-AS = vanices adequately tion not performed. * PVT = portal vein thrombosis, 1 These patients had surgically

hepatitis

serpentine

image

and anechoic

corresponding

hemobilia. areas

within

the

to a demonstrates

Wall Vanices

(y)

1/M/59 2/M/35t 3/Ff771 4/M/7t 5/M/63 6/M/66

active

shows

(b) Color Doppler flow wall vanices (arrows).

of Gallbladder

Patient/Sex/Age

hypo-

echoic band (in one patient) in the gallbladder wall. They could actually be linked to extracholecystic vessels in one case. A random sampling of 10 patients with no known liver or biliamy disease revealed no sonographically

Figure

(a) Transverse gallbladder flow within

Diagnosis

CT

US

MR

Cirrhosis Biliary cirrhosis Pancreas carcinoma Chronic active hepatitis Cirrhosis Cirrhosis

AS AS NS NP AS AS

AS NP WS WS WS AS

NP WS AS AS AS NP

seen.

WS

varices

+ = pnesent. proved gallbladder

well

wall

seen.

NS

varices

not seen.

PVT* + + + + + ...

NP

examina-

vanices.

the

3). Signal

wall echo only two gested only

void

within

the

gallbladder

was also identified with spinTi-weighted sequences, but in two of these patients. Of the angiognaphic studies, one sugportal vein thrombosis, but a diffuse

tangle

of vessels

in the

right upper quadrant was noted and could not confirm gallbladder vances. Although the group assignments represent a subjective assessment, we believed that color Doppler flow was superior to MR and CT in depicting gallbladder wall vamices. 180

#{149} Radiology

DISCUSSION Gallbladder erately unusual

wall vanices manifestation

tal hypertension (12%)

Associated

portal

was present In a previous

gallbladder also

noted

was

not

vanices, that

seen.

First, resent

The

the

presence

in five case

in this

vein

throm-

of six report

et ab (18) portal vein presence and boca-

as well as the disallow us to sugexplanations for

of gallbladder

vein

paof

Rails

and most likely, a portosystemic

cystic

in six

cases

a patent

tion of thrombus, tribution of varices, gest three possible

the

a modof por-

occurred

of 50 consecutive

series. bosis tients.

and

are

branch

vamices.

portal

system to systemic anterior abdominab wall collatemals. Second, they may act as a bypass around a focally

thrombosed the the

portal cystic

extrahepatic vein. vein

Retrograde to gallbladder

segment

of

flow from vanices

to flow across the galldirectly into the hepatic and ultimately into the vein. Third, gallbladder merely represent dilated

veins due to simple back-pressure within the portal venous system. Regardless of their cause, gallbladder wall vanices have received only limited attention in the radiography literature (18-20). This in part stems from their poor visualization on angiographic studies. Although only

two

they may repshunt linking

of the

may give rise bladder bed parenchyma right portal varices may

of our

patients

underwent

angi-

ography, they exemplify the difficulty in confirming the presence of these small vanices. The angiographic detection of portal venous collatemals relies on their indirect opacification during the portal phase of a mesentemic artery injection. Because of their small caliber and the large number of collateral vessels in the porta hepatis and hepatoduodenal ligament, gallbladder varices may be obscured and

April

1991

b. Figure

2.

(a) Contrast-enhanced

axial

C-

CT image

of a 77-year-old woman with adenocarcinoma of the pancreas shows irregular thickening and enhancement in the gallbladder wall (long straight arrows), a markedly dilated common bile duct (short straight arrow) with adjacent collateral vessels (arrowheads), and a mass in the head of the pancreas (curved arrow). (b) Longitudinal sonognam through the gallbladder reveals only thickening of the gallbladder wall (arrows). (c) Color Doppler flow image in the same patient photographed in gray scale shows venous flow within the gallbladder wall, confirming that the gallbladder wall thickening is secondary to vanices (arrows) (cf b).

I .‘,

4t

.

S

O

I

,t

%

b.

c.

Figure 3. (a) Contrast-enhanced axial CT image from a 35-year-old man with primary biliary cirrhosis shows serpentine enhancement within the gallbladder wall and penicholecystic fat (arrows). (b) Image obtained 2 cm cephalad shows irregular enhancement within the gallbladder wall (arrowheads) and adjacent collateral vessels coursing toward the anterior abdominal wall (arrows). (c) Coronal gradientecho MR image of the same patient obtained with 50/12 and 45#{176} flip angle reveals flow-related enhancement in gallbladder wall varices rowheads), cavernous transformation of the portal vein (straight arrows), and vanices within the gastric wall (wavy arrow).

escape

detection. MR imaging all proved capable of depicting gallbladder varices. In this small series,

Us,

angiographic

CT, and

Doppler

US allowed

the

most

by acute

cholecystitis,

hepati-

tis, or ascites (21). The anechoic tend to be more serpentine and occasionally cystic vessels.

be

linked Because

to extracholeincreased ante-

nab flow may be observed bladder wall in patients cholecystitis, Doppler

Volume

flow

179

areas

can

in the gallwith acute

both duplex and color imaging are essential

Number

#{149}

I

confirming

the

diagnosis.

CT showed

appears

The

normal gallbladder wall should demonstrate detectable venous as would be found in vanices.

confi-

dent diagnosis of vanices. A thickened gallbladder wall containing anechoic areas may be seen with vances. This appearance is similar to that

caused

for

enhancement

not flow,

of the

thickened gallbladder wall in four patients. The enhancement pattern differed from that seen in the normal gallbladder or in acute or chronic cholecystitis. Vamices appeared as nodular enhancement within the gallbladder wall due to vessels cross-

ing

perpendicular

Numerous

were also seen bladder in the Normal

within

to the

enhancing

plane.

gallbladder

may

wall,

be

smoother

evidence

band

within

present, lecystitis.

fuse

the

vessels

due

and

the

gallbladder

enhancing

wall

stranding

The

less enhancement and is more random around (especially proved

was

in choto con-

pericholecystic

mesentemic

to inflammation.

entation imaging imaging)

uniform.

as might be expected It is important not with

to show varices

more

of a low-attenuation

latter

tends

than do in its on-

the

gallbladder. MR flow-enhanced capable of depicting

gallfat.

gallbladder vanices but did not add any information to the CT or sonographic findings despite the avail-

seen

ability

vessels

adjacent to the pericholecystic

enhancement

the

scan

small

No

(an-

but

it

The

of coronal

imaging.

radiologist

plays

a major Radiology

role #{149} 181

in distinguishing gallbladder wall vances from other causes of gallbladden wall thickening. In patients with right-upper-quadrant pain and portal hypertension, anechoic or hypoechoic areas in the gallbladder wall at US cannot be assumed to be due to inflammation. In patients with portal hypertension undergoing biliary bypass on cholecystectomy, the surgeon benefits from the preoperative knowledge that significant blood loss may occur from gallbladder varices (22). Similarly, if liver transplantation is considered, the knowledge that gallbladder vanices are present will reduce handling of the gallbladden prior to achieving adequate vascuban control. In conclusion, gallbladder wall varices can mimic a variety of diseases. Their presence may imply portal vein thrombosis. Although this represents only a small series, colon Doppler flow imaging appears to be the most sensitive and specific for the detection of these varices and should be used in patients with known or suspected portal hypertension undergoing examinations of the liven and biliary tree, particularly as a part of preoperative planning. U

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182

#{149} Radiology

April

1991