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Pain in right upper quadrant with fever
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Echogenic area in gallbladder fossa represents gall bladder with multiple small gallstones. Posterior acoustic shadowing is present beneath the gallstones. Thin rim of hypoechoic area between two echogenic lining could represent bile between gall bladder wall and calculi.
Wall-echo-shadow (WES) sign represents well-defined echogenic gall bladder wall (W), echoes (E) from gallstones beneath gall bladder wall, and prominent posterior acoustic shadowing (S). Hypoechoic area beneath echogenic bladder wall and calculi represent interpostioned bile. This sign is sufficient for diagnosis of cholelithiasis.
This sign suggests large gallstone or multiple small stones filling the entire gall bladder lumen. If WES sign is not recognized, and gall bladder may be misinterpreted as a bowel loop.
Pitfalls are calcification of gall bladder wall as in porcelain gallbladder and collapsed gallbladder and portion of duodenum appears echogenic with posterior shadowing.