Gallbladder cholesterolosis and adenomyomatosis (CEUS)

Case contributed by Bruno Di Muzio


Chronic HBV, for HCC screening.

Patient Data

Age: 50 years
Gender: Male

The liver has homogeneous echotexture and smooth contour.

Within segment III a round hypoechoic lesion is identified measuring 1.6 x 1.4 cm.  There is subtle posterior enhancement.  Peripheral vascularity on color Doppler.  The remainder of the liver is normal.

The portal vein is patent and has anterograde flow. 

Multiple polyps noted within the gallbladder, the largest measuring 9 mm in the region of the neck. The fundus of the gallbladder is filled with heterogeneous, echogenic material. This is well-circumscribed but appears separate from the gallbladder wall.  Bright echogenic foci are seen around the periphery, possibly representing small stones.  Difficult to ascertain whether there is maybe some peripheral color flow. No fluid in the gallbladder fossa. No biliary tree dilatation.

Spleen normal size.  No ascites.


- Indeterminate liver lesion in segment III

- Possible gallbladder fundal cholesterolosis and a mixture of sludge and stones. Also, a few polyps (up to 11mm). 

Recommendation: CEUS to asses both the liver lesion and assure no underlying mass within the gallbladder fundus.  

Liver CEUS


Gallbladder:  0.3 ml IV Definity. No contrast enhancement within the lesion in the gallbladder fundus.  Findings are consistent with a sludge ball. Background cholestorolosis with small polyps. 

Segment III liver: 0.3 ml IV Definity.   Nodular peripheral enhancement during the arterial phase with rapid centripetal filling in. The lesion becomes rapidly isodense to the liver parenchyma with no washout.  Findings consistent with a hemangioma.


Hepatic hemangioma.

Small gallstones and a large sludge ball. 9 mm polyp in the gallbladder neck which will require ongoing surveillance.

Case Discussion

This case illustrates how difficult it can be to assess the gallbladder when there is anatomical distortion due to cholesterolosis/adenomyomatosis and sludge. It is difficult to ascertain if the 11 polyp at the fundus was part of the wall hypertrophy distortion or a true polyp.

CEUS has a well-established use for the assessment of focal liver lesions and, similar to this case, to differentiate gallbladder sludge from a mass. This study reassured no evidence of sizable suspicious lesions in the gallbladder.

6 months follow-up scan (not shown) showed stability of the findings but given stated 11 mm polyp, which was stable, the surgical review recommended removal of the gallbladder. The risk of underlying malignancy was discussed (see guidelines for gallbladder polyp management), the patient was offered cholecystectomy: 

Macroscopy: Labeled "gallbladder". Gallbladder, 78 x 30 x 23 mm the cystic duct is clamped. A cystic duct node is not identified. The serosal surface is smooth. The gallbladder wall is tan, up to 3 mm in thickness. The mucosa is green, velvety, with frequent yellow speckling, forming polyps, up to 4 mm in diameter. Within the lumen, innumerable yellow fragments of debris from similar polyps.

Microscopy: Gallbladder shows smooth muscle hypertrophy and fibrosis and Rokitansky Aschoff sinus formation. Patchy chronic inflammation. A cholesterol polyp is seen with subepithelial foamy macrophage deep to the surface epithelium. No malignancy. 

Conclusion: Gallbladder–chronic cholecystitischolesterolosis, cholesterol polyp.

Please note that in this case, the sonographic features are those of likely multiple cholesterol polyps (cholesterolosis) and possible adenomyomatosis (further characterized on histology).

Adenomyomatosis: mucosal hyperplasia with growth toward the muscular layer - thickened muscular layer. Cholesterol accumulation is intraluminal (within the Rokitansky-Aschoff sinuses), therefore, lined by mucosal epithelium. 

Cholesterolosis: mucosal hyperplasia with the accumulation of cholesterol esters and triglycerides in the lamina propria macrophages - appearance is known as “strawberry gallbladder".

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