Wall-echo-shadow sign

Case contributed by Dr Rahul Chivate


Pain in right upper quadrant with fever

Patient Data

Age: 45 years
Gender: Female

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.


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.

Case Discussion

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.

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