Gallstones on Ultrasound - Are Gallstones Always Innocent?

1. E. Vranou1, S. Deftereos1, M. Pitiakoudis2, S. Foutzitzi1, P. Prassopoulos1
1Radiology Department, University Hospital, Alexandroupolis, Greece
2Surgery Department, University Hospital, Alexandroupolis, Greece
GALLSTONES ON ULTRASOUND
ARE GALLSTONES ALWAYS INNOCENT ?

2. The most common
reason for
gallbladder disease
is gallstones
…but are gallstones
always innocent?

3. Plain abdominal radiograph
Ultrasound
Computed Tomography (CT)
Magnetic Resonance Cholangio-Pancreatography (MRCP)
Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
Endoscopic Naso-Biliary Drainage (ENBD)
Cholangiopancreatography during operation
Oral cholecystography (history)
Intravenous cholangiography (history)
IMAGING METHODS

4. Non-invasive and painless,
Easily performed : option of performing a bedside
examination and the ability to evaluate adjacent organs
First choice for biliary tract disease, high sensitivity
and accuracy (>95%)
Lack of ionizing radiation
Relatively low cost
IMAGING METHODS
Ultrasonography (US)

5. To underline the possibility
of an occult gallbladder cancer
that may be hidden and/or overlooked
by the presence of
gallstones/cholecystitis.
PURPOSE

6.  The study comprised 886
consecutive patients that were admitted
to the emergency room
with intense Right Upper Quadrant Pain
referred for immediate imaging
evaluation over a period of 24 months
(9th/2007 – 8th/2009)
METHODES & MATERIALS

7.  886 patients
 gallbladder stones 467/886 pts (52,7%)
with (103) or without cholecystitis
 suspicion of coexisted malignancy
26/467 pts
METHODES & MATERIALS

8.  focal gallbladder wall thickening
 intraluminal mass of irregular shape
 presence of “tissue” around
 presence of “tissue” near the gallstones
suspicion of coexisted malignancy
was posed:
METHODES & MATERIALS

9.  focal gallbladder wall thickening
RESULTS

10.  intraluminal mass of irregular shape
RESULTS

11.  intraluminal mass of irregular shape
RESULTS

12.  presence of “tissue” near and/or around
RESULTS

13.  presence of “tissue” near and/or around
RESULTS

14.  886 patients
 gallbladder stones 467/886 pts (52,7%)
with (103) or without cholecystitis
 suspicion of coexisted malignancy
26/467 pts
 presence of cancer 12/26 pts
 the remaining 14/26 cases ?
RESULTS

15. In the remaining 14 cases
final diagnosis was :
 benign polyps (n=3),
 chronic cholecystitis (n=3),
 adenomyosis (n=1),
 mural changes due to cholecystitis (n=7)
RESULTS

16. on the contrary
gallstones and no US malignancy suspicion
n=2
neoplasm on histopathology
RESULTS

17. Ultrasonography in the diagnosis
of occult gallbladder cancer
among patients with gallbladder stones:
overall accuracy 46%
sensitivity 85%,
specificity 97%
positive predictive value of 0,63 and
negative predictive value of 0,99
RESULTS

18. Gallbladder stones
are not always “innocent”
CONCLUSIONS

19.  Gallbladder cancer
may be mimics
gallstones/cholecystitis
 on US
CONCLUSIONS

20. Thorough analysis
of the diagnostic images
is important to detect occult cancer
when it accompanies stones
which may be easily missed.
…should be alert and
analyze “images” in detail…
CONCLUSIONS

21. …keep informed the surgeon in the presence
of suspicious US findings for a more thorough
investigation
and possible operation adjustment, i.e. modified
laparoscopic approach or open technique.