Cystitis is usually treated and cured by surgery to

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cystitis is usually treated and cured by surgery to remove the gallbladder (cholecystectomy) [ 7 ]. Common sonographic findings include gallbladder wall thickening ( Figure 7.17 ), pericholecystic fluid ( Figure 7.18 ), or multiple findings ( Figure 7.19 ). Keep in mind that the presence of ascites can lead to sonographic findings of pericholecystic fluid as well as a thickened gallblad- der wall ( Figure 7.20 ). Ralls et al. demonstrated that finding gallstones and a sonographic Murphy sign on bedside ultrasound had a positive predictive value of 92.2% for diagnosing cholecystitis [ 1 ]. Negative findings (no stones, no sono- graphic Murphy) were associated with a negative predictive value of 95.2%. This is important because it gives literature support to the goal-directed study idea and removes some of the diagnostic insensitivity of the common bile duct and anterior gallbladder wall signs. A more recent study by Summers Figure 7.16 Wall-echo-shadow (WES) sign. The anterior wall of the gallbladder (and leading edge of gallstones) is noted with small arrows. 162 Diagnostic ultrasound Gallbladder ultrasound
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Figure 7.17 Thickened gallbladder wall (measured between arrows) within liver (L). Figure 7.18 Pericholecystic fluid (arrow) visible behind gallbladder. Figure 7.19 Acute cholecystitis. Note liver (L), gallbladder (G) with thickened wall (arrows), stones (S), and pericholecystic fluid (*). Diagnostic ultrasound 163 Gallbladder ultrasound
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and colleagues demonstrated emergency department ultrasound to have similar test characteristics to radiology department sonography for the detec- tion of acute cholecystitis [ 8 ]. Chronic cholelithiasis is usually accompanied with chronic cholecystitis. The wall of the gallbladder may become thickened and fibrotic, which may prevent the gallbladder from contracting and expanding normally. There are many common variants and additional abnormalities that may be visualized during an ultrasound examination of the gallbladder – most of which are beyond the scope of this text. One abnormality that deserves mention is biliary sludge ( Figure 7.21 ). Biliary sludge may be detected as a dependent layer of variable non-shadowing echogenicity in the gallbladder. It is frequently detected in states associated with biliary stasis, such as limited oral intake. It has also been known to cause biliary obstruction and cholecystitis. Acute acalculous cholecystitis Acute acalculous cholecystitis is the presence of an inflamed gallbladder in the absence of a gallstone obstructing the cystic or common bile duct. It typically occurs in the setting of a critically ill patient (e.g., severe burns, trauma, lengthy postoperative care, prolonged intensive care) and accounts for 5% of cholecystectomies. Because abdominal pain, fever, and leukocytosis are relatively common in these patients, the physician must have a high index of suspicion to make the diagnosis. The etiology is believed to have an ischemic basis, and a gangrenous gallbladder may result. This condition has an increased rate of complications and mortality [ 7 ].
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