Society of Radiologists in Ultrasound Consensus Conference Recommendations for Incidental Gallbladder Polyp Management: Interreader Agreement Among 10 Radiologists.

BACKGROUND. The 2022 Society of Radiologists in Ultrasound (SRU) consensus conference recommendations for small gallbladder polyps support management that is less aggressive than earlier approaches and may help standardize evaluation of polyps by radiologists. OBJECTIVE. The purpose of the present study was to assess the interreader agreement of radiologists in applying SRU recommendations for management of incidental gallbladder polyps on ultrasound. METHODS. This retrospective study included 105 patients (75 women and 30 men; median age, 51 years) with a gallbladder polyp on ultrasound (without features highly suspicious for invasive or malignant tumor) who underwent cholecystectomy between January 1, 2003, and January 1, 2021. Ten abdominal radiologists independently reviewed ultrasound examinations and, using the SRU recommendations, assessed one polyp per patient to assign risk category (extremely low risk, low risk, or indeterminate risk) and make a possible recommendation for surgical consultation. Five radiologists were considered less experienced (< 5 years of experience), and five were considered more experienced (≥ 5 years of experience). Interreader agreement was evaluated. Polyps were classified pathologically as nonneoplastic or neoplastic. RESULTS. For risk category assignments, interreader agreement was substantial among all readers (k = 0.710), less-experienced readers (k = 0.705), and more-experienced readers (k = 0.692). For surgical consultation recommendations, inter-reader agreement was substantial among all readers (k = 0.795) and more-experienced readers (k = 0.740) and was almost perfect among less-experienced readers (k = 0.811). Of 10 readers, a median of 5.0 (IQR, 2.0-8.0), 4.0 (IQR, 2.0-7.0), and 0.0 (IQR, 0.0-0.0) readers classified polyps as extremely low risk, low risk, and indeterminate risk, respectively. Across readers, the percentage of polyps classified as extremely low risk ranged from 32% to 72%; as low risk, from 24% to 65%; and as indeterminate risk, from 0% to 8%. Of 10 readers, a median of zero change to 0 (IQR, 0.0-1.0) readers recommended surgical consultation; the percentage of polyps receiving a recommendation for surgical consultation ranged from 4% to 22%. Of a total of 105 polyps, 102 were nonneo-plastic and three were neoplastic (all benign). Based on readers' most common assessments for nonneoplastic polyps, the risk category was extremely low risk for 53 polyps, low risk for 48 polyps, and indeterminate risk for one polyp; surgical consultation was recommended for 16 polyps. CONCLUSION. Ten abdominal radiologists showed substantial agreement for polyp risk categorizations and surgical consultation recommendations, although areas of reader variability were identified. CLINICAL IMPACT. The findings support the overall reproducibility of the SRU recommendations, while indicating opportunity for improvement.

The value of CT radiomics combined with deep transfer learning in predicting the nature of gallbladder polypoid lesions.

BACKGROUND: Computed tomography (CT) radiomics combined with deep transfer learning was used to identify cholesterol and adenomatous gallbladder polyps that have not been well evaluated before surgery. PURPOSE: To investigate the potential of various machine learning models, incorporating radiomics and deep transfer learning, in predicting the nature of cholesterol and adenomatous gallbladder polyps. MATERIAL AND METHODS: A retrospective analysis was conducted on clinical and imaging data from 100 patients with cholesterol or adenomatous polyps confirmed by surgery and pathology at our hospital between September 2015 and February 2023. Preoperative contrast-enhanced CT radiomics combined with deep learning features were utilized, and t-tests and least absolute shrinkage and selection operator (LASSO) cross-validation were employed for feature selection. Subsequently, 11 machine learning algorithms were utilized to construct prediction models, and the area under the ROC curve (AUC), accuracy, and F1 measure were used to assess model performance, which was validated in a validation group. RESULTS: The Logistic algorithm demonstrated the most effective prediction in identifying polyp properties based on 10 radiomics combined with deep learning features, achieving the highest AUC (0.85 in the validation group, 95% confidence interval = 0.68-1.0). In addition, the accuracy (0.83 in the validation group) and F1 measure (0.76 in the validation group) also indicated strong performance. CONCLUSION: The machine learning radiomics combined with deep learning model based on enhanced CT proves valuable in predicting the characteristics of cholesterol and adenomatous gallbladder polyps. This approach provides a more reliable basis for preoperative diagnosis and treatment of these conditions.

Mitchell-Riley syndrome iPSCs exhibit reduced pancreatic endoderm differentiation due to a mutation in RFX6.

Mitchell-Riley syndrome (MRS) is caused by recessive mutations in the regulatory factor X6 gene (RFX6) and is characterised by pancreatic hypoplasia and neonatal diabetes. To determine why individuals with MRS specifically lack pancreatic endocrine cells, we micro-CT imaged a 12-week-old foetus homozygous for the nonsense mutation RFX6 c.1129C>T, which revealed loss of the pancreas body and tail. From this foetus, we derived iPSCs and show that differentiation of these cells in vitro proceeds normally until generation of pancreatic endoderm, which is significantly reduced. We additionally generated an RFX6HA reporter allele by gene targeting in wild-type H9 cells to precisely define RFX6 expression and in parallel performed in situ hybridisation for RFX6 in the dorsal pancreatic bud of a Carnegie stage 14 human embryo. Both in vitro and in vivo, we find that RFX6 specifically labels a subset of PDX1-expressing pancreatic endoderm. In summary, RFX6 is essential for efficient differentiation of pancreatic endoderm, and its absence in individuals with MRS specifically impairs formation of endocrine cells of the pancreas head and tail.

Occult pancreaticobiliary reflux is a pathogenic factor of some benign biliary diseases and gallbladder cancer.

BACKGROUND: Pancreaticobiliary maljunction (PBM) is a well-known high-risk factor for biliary malignant tumors because of constant pancreaticobiliary reflux (PBR). However, the impact of occult pancreaticobiliary reflux (OPR), which is characterized by high bile amylase levels in individuals with anatomically normal pancreaticobiliary junction, on biliary diseases remains unclear. The aim of this study was to assess the correlation between OPR and biliary diseases. METHODS: We enrolled 94 consecutive patients with normal pancreaticobiliary junction and primary biliary diseases confirmed by magnetic resonance cholangiopancreatography. We prospectively collected patients' bile samples and measured bile amylase levels. We investigated the incidence of OPR and the difference in bile amylase levels among these patients and assessed the correlation between high bile amylase levels (HBAL) and benign or malignant biliary diseases, as well as the OPR risk factors. RESULTS: The incidence of OPR was 36.6% in patients with benign biliary diseases, 26.7% in those with cholangiocarcinoma and 62.5% in those with gallbladder cancer. The median bile amylase level tended to be higher in patients with gallbladder cancer than in those with benign biliary diseases, but there was no significant difference (165.5 IU/L vs. 23.0 IU/L, P = 0.212). The prevalence of an HBAL with bile amylase levels of 1000-7500 IU/L was similar in patients with gallbladder cancer and benign biliary diseases. However, the incidence of HBAL with bile amylase levels greater than 7500 IU/L was significantly higher in patients with gallbladder cancer than in those with benign biliary diseases (37.5% vs. 4.2%, P = 0.012). Multivariate logistic regression analysis revealed that choledocholithiasis was an independent risk factor for OPR. CONCLUSIONS: OPR can occur in benign and malignant biliary diseases, and it may be a pathogenic factor for some benign biliary diseases and a high-risk factor for gallbladder cancer. There is a correlation between choledocholithiasis and OPR.

Increased radiographic opacity in the region of the gallbladder can be identified in dogs with large amounts of gallbladder sediment, sludge balls, and gallbladder mucocele.

Increased soft-tissue opacity in the region of the canine gallbladder is incidentally detected on radiographs. We hypothesized that there is a difference in the detection of gallbladder sediment on radiographs depending on the amount or mobility of the sediment. In this retrospective and analytical study, we aimed to assess the ultrasonographic features of gallbladder sediment that were detected radiographically. We also aimed to assess the differences in the detection of increased opacity of the gallbladder between radiographic views. We included 223 dogs that underwent thoracic radiography, abdominal radiography, and gallbladder ultrasonography. Ultrasonographic images of the gallbladder were divided into five groups: group 1, gravity-dependent sediment occupying < 50% of the gallbladder; group 2, gravity-dependent sediment occupying ≥50%; group 3, sediment attached to the gallbladder wall; group 4, sludge ball; and group 5, gallbladder mucocele. Dogs showing increased opacity on subjective assessment of any radiographic view were recorded, and the sensitivity of radiographic views for detecting gallbladder sediment was analyzed. Of 168 dogs with gallbladder sediment, 37 had increased opacity on at least one radiographic projection. The frequency was compared as a percentage within each category, and Group 4 was the highest percentage with increased radiographic gallbladder opacity, followed by Groups 2 and 5. The sensitivity for detecting increased opacity was highest in the thoracic ventrodorsal view. Thus, in dogs with increased gallbladder opacity on radiographs, large amounts of gallbladder sediment, sludge balls, and gallbladder mucocele should be considered differential diagnoses. In addition, the thoracic ventrodorsal view is recommended to evaluate gallbladder opacity.

Ultrasonographic Appearance of Gallbladder Neoplasia in 14 Dogs and 1 Cat.

Ultrasonography is the most commonly used diagnostic imaging tool for gallbladder disease in veterinary medicine. Primary gallbladder neoplasia is an uncommon finding with variable prognosis for which no studies have been published describing their ultrasonographic appearance and diagnosis. This retrospective, multicenter, case series study examines the ultrasonographic appearance of gallbladder neoplasia with histologically or cytologically confirmed diagnoses. A total of 14 dogs and 1 cat were analyzed. All discrete masses were sessile in shape and varied in size, echogenicity, location, and gallbladder wall thickening. All studies with images showing Doppler interrogation exhibited vascularity. Cholecystoliths were an uncommon finding, being present in only one case in this study, unlike in humans. The final diagnosis of the gallbladder neoplasia was neuroendocrine carcinoma (8), leiomyoma (3), lymphoma (1), gastrointestinal stromal tumor (1), extrahepatic cholangiocellular carcinoma (1), and adenoma (1). Findings from this study indicate that primary gallbladder neoplasms have variable sonographic appearances and cytologic and histologic diagnoses.

Intracholecystic papillary neoplasm: potential differential diagnosis before a gallbladder polyp.

Intracholecystic papillary neoplasia (IPN) is a rare entity rarely described in the literature, of incidental anatomopathological diagnosis in a cholecystectomy specimen that presents a premalignant behavior, with progression to carcinoma in more than 50% of cases. In the absence of an invasive component, clinical follow-up is recommended, without associating another surgical gesture, with a 5-year prognosis (90% survival). We present a case of a patient with an incidental diagnosis of NPIC after laparoscopic cholecystectomy due to presenting a gallbladder polyp.

Cholecystogastric fistula diagnosed by endoscopic ultrasonography.

A case of a patient with symptoms of gastric obstruction secondary to cholecystogastric fistula is presented and a brief review of the literature is done.

Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations.

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.

Longitudinal Ultrasound Assessment of Changes in Size and Number of Incidentally Detected Gallbladder Polyps.

BACKGROUND. Previous European multisociety guidelines recommend routine follow-up imaging of gallbladder polyps (including polyps < 6 mm in patients without risk factors) and cholecystectomy for polyp size changes of 2 mm or more. OBJECTIVE. The purpose of this study was to assess longitudinal changes in the number and size of gallbladder polyps on serial ultrasound examinations. METHODS. This retrospective study included patients who underwent at least one ultrasound examination between January 1, 2010, and December 31, 2020 (as part of a hepatocellular carcinoma screening and surveillance program) that showed a gallbladder polyp. Number of polyps and size of largest polyp were recorded based primarily on review of examination reports. Longitudinal changes on serial examinations were summarized. Pathologic findings from cholecystectomy were reviewed. RESULTS. Among 9683 patients, 759 (8%) had at least one ultrasound examination showing a polyp. Of these, 434 patients (248 men, 186 women; mean age, 50.6 years) had multiple examinations (range, 2-19 examinations; mean, 4.8 examinations per patient; mean interval between first and last examinations, 3.6 ± 3.1 [SD] years; maximum interval, 11.0 years). Among these 434 patients, 257 had one polyp, 40 had two polyps, and 137 had more than two polyps. Polyp size was 6 mm or less in 368 patients, 7-9 mm in 52 patients, and 10 mm or more in 14 patients. Number of polyps increased in 9% of patients, decreased in 14%, both increased and decreased on serial examinations in 22%, and showed no change in 55%. Polyp size increased in 10% of patients, decreased in 16%, both increased and decreased on serial examinations in 18%, and showed no change in 56%. In 9% of patients, gallbladder polyps were not detected on follow-up imaging; in 6% of patients, gallbladder polyps were not detected on a follow-up examination but were then detected on later studies. No gallbladder carcinoma was identified in 19 patients who underwent cholecystectomy. CONCLUSION. Gallbladder polyps fluctuate in size, number, and visibility over serial examinations. Using a 2-mm threshold for growth, 10% increased in size. No carcinoma was identified. CLINICAL IMPACT. European multisociety guidelines that propose surveillance of essentially all polyps and a 2-mm size change as the basis for cholecystectomy are likely too conservative for clinical application.

Value of contrast-enhanced ultrasound in diagnosis and differential diagnosis of polypoid lesions of gallbladder ≥ 1 cm.

OBJECTIVES: To evaluate the usefulness of Contrast-enhanced ultrasound (CEUS) in the diagnosis and differential diagnosis of Polypoid lesions of gallbladder (PLGs) ≥ 1 cm. METHODS: A prospective analysis was performed on 180 patients with PLGs ≥ 1 cm. 175 cases were confirmed by pathological diagnosis and the remaining were confirmed by other imaging findings. The characteristics of lesions on conventional Ultrasonography (US) and CEUS were recorded. RESULTS: Significant differences were observed in enhancement patterns between benign and malignant PLGs during both arterial (P < 0.001) and venous phases (P < 0.001). The malignant lesions typically yielded a "fast-in and fast-out" enhancement pattern. There was no significant difference in Arrival time (AT) between malignant and benign PLGs. If we consider wash-out time ≤ 40 s as a diagnostic standard for malignant lesions, the sensitivity, specificity, and accuracy were 88.24%, 85.62%, and 86.11%, respectively. Destruction of the Gallbladder (GB) wall was a particularly important indication of malignant PLGs, and the sensitivity, specificity, and accuracy were 93.33%, 92.12%, and 92.22%, respectively. The accuracy of CEUS in the diagnosis of PLGs, as well as malignant and benign lesions, was 92.22%, 92.47%, and 91.17%, respectively. CONCLUSIONS: The "fast-in and fast-out" enhancement pattern, hyper-enhancement in comparison to the GB wall in the arterial phase, wash-out time ≤ 40 s, GB wall destruction, and hepatic parenchymal infiltration are the characteristic findings of malignant PLGs. Besides, CEUS provides a valuable reference to classify some of the benign lesions.

Association of gallbladder diseases with risk of gastrointestinal polyps.

BACKGROUND: It has not yet been determined whether gastroscopy and colonoscopy screening help patients with gallbladder diseases. We aim to retrospectively investigate the relationship between gallbladder diseases and gastrointestinal polyps in order to provide a theoretical basis for the early screening of gastrointestinal polyps in patients with gallbladder disease. METHODS: This is a retrospective cross-sectional study involving 1662 patients who underwent gastroscopy, colonoscopy, and abdominal ultrasound as part of their health check-up from January 2015 to July 2020. We also compared the patients with and without gallbladder diseases to determine the prevalence of gastrointestinal polyps. RESULTS: Patients with gallbladder polyps had greater odds of having colorectal polyps (adjusted odds ratio (OR)=1.77, 95% confidence interval [Cl]: 1.23 to 2.54, p=0.002) and gastric plus colorectal polyps (adjusted OR=2.94, 95%Cl: 1.62 to 5.32, p<0.001) than those without. Patients with multiple gallbladder polyps had greater odds of having colorectal polyps (adjusted OR=2.33, 95% CI: 1.33 to 4.07, p=0.003) and gastric plus colorectal polyps (adjusted OR=3.95, 95% CI: 1.72 to 9.11, p=0.001), and patients with gallbladder polyps had greater odds of having left-colon polyps (adjusted OR=1.90, 95% CI: 1.25 to 2.88, p=0.003) and colorectal adenoma (adjusted OR=1.78, 95% CI: 1.19 to 2.66, p=0.005). We also noted that women with gallbladder polyps had a higher prevalence of colorectal polyps (OR=2.13, 95% CI: 1.20 to 3.77, p=0.010) and gastric plus colorectal polyps (OR=3.69, 95% CI: 1.58 to 8.62, p=0.003). However, no positive correlation was observed between gallbladder stones and gastrointestinal polyps. CONCLUSIONS: Gallbladder polyps are significant indicators of colorectal and gastric plus colorectal polyps. Hence, gastroscopy and colonoscopy screening should be performed for patients with gallbladder polyps, particularly female patients and those with multiple gallbladder polyps.

A nomogram-based model and ultrasonic radiomic features for gallbladder polyp classification.

BACKGROUND AND AIM: Gallbladder polyps (GBPs) are relatively common. Many studies have attempted to distinguish between benign and neoplastic GBPs to identify early-stage gallbladder carcinoma. We have established an accurate neoplastic predictive model and evaluated the effectiveness of radiomics in predicting malignancy in patients with GBPs. METHODS: A total of 503 patients confirmed through postoperative pathology were included in this retrospective study. Clinical information and ultrasonographic findings were retrospectively analyzed. The model was constructed from independent risk factors using Spearman correlation and logistic regression analysis of a training cohort of 250 GBP patients, and its efficacy was verified using an internal validation group of 253 consecutive patients through the receiver operating characteristic curve (ROC). The area of GBPs was delimited manually, and the texture features of ultrasound images were analyzed using correlation and ROC analysis. RESULTS: Independent predictors, including age, gallstones, carcinoembryonic antigen, polyp size, and sessile shape, were incorporated into the nomogram model for the neoplastic potential of GBPs. Compared with other proposed prediction methods, the established nomogram model showed good discrimination ability in the training group (area under the curve [AUC]: 0.865) and validation group (AUC: 0.845). Regarding ultrasonic radiomics, the minimum caliper diameter was identified as the only independent predictor (AUC: 0.841). CONCLUSIONS: Our preoperative nomogram model can successfully evaluate the neoplastic potential of GBPs using simple clinical data, and our study verified the use of radiomics in GBP identification, which may be valuable for avoiding unnecessary surgery in patients.

Value of prediction model in distinguishing gallbladder adenoma from cholesterol polyp.

BACKGROUND AND AIM: Gallbladder adenomatous polyp is a pre-cancerous neoplasm, and it is difficult to classify from cholesterol polyps before cholecystectomy. The study aimed to clarify the risk characteristics of gallbladder adenomas and establish a prediction model to differentiate gallbladder adenomas from cholesterol polyp lesions. METHODS: From May 2019 to December 2021, the patients underwent cholecystectomy in the Shanghai Eastern Hepatobiliary Surgery Hospital were retrospectively reviewed. According to the permanent pathology test, the patients were divided into adenomas and cholesterol polyps groups. All the included cases received ultrasound equipment examinations before cholecystectomy and their clinical information were completely recorded. Then the patients' baseline characteristics and ultrasound imaging variables were analyzed by logistic regression. Finally, a predictive model for gallbladder adenomas will be established and assessed based on the independent risk factors. RESULTS: A total of 423 cases including 296 cholesterol polyps and 127 gallbladder adenomas were analyzed in detail. Multivariate logistic regression analysis revealed that solitary polyp lesion (OR = 2.954, 95% CI 1.759-4.960, P < 0.001), the maximal diameter of lesions (OR = 1.244, 95% CI 1.169-1.324, P < 0.001), and irregular shape of polyp lesions (OR = 5.549, 95% CI 1.979-15.560, P = 0.001) were the independent predictive factors of gallbladder adenomas. According to the results, regression equation of logit(P) = -3.828 + 1.083*number of gallbladder polyps lesions (GPLs) + 0.218*diameter of GPLs + 1.714*shape of GPLs was established. Area under the curve (AUC) was 0.828 (95% CI 0.782-0.874, P < 0.001). When logit P > 0.204, the sensitivity of estimating adenoma was 79.5%, the specificity of recognizing adenoma was 70.6%, and the whole correct ratio was 73.3%. While the AUC of diameter (10 mm) being a predictive factor in this study was only 0.790 (95% CI 0.741-0.839, P < 0.001). And the sensitivity and specificity of 10 mm as the optimal diagnostic cutoff value to diagnose adenomas were 74.8% and 65.9%, respectively. CONCLUSIONS: The risk factors of solitary polyp lesion, larger diameter, and irregular morphology feature of polyp lesions were significantly related to gallbladder adenomas. And the predictive model established in the study can effectively identify adenomas from cholesterol polyps and help patients to select the optimal treatment protocol.

Feasibility of transgastric endoscopic gallbladder-preserving surgery for benign gallbladder diseases (with video).

BACKGROUND: With the increasing realization of the importance of gallbladder function, choledochoscopic gallbladder-preserving surgery has been advocated for benign gallbladder diseases. However, limited information is available regarding the use of endoscopic gallbladder-preserving surgery (EGPS) for patients with benign gallbladder diseases. The aim of this study was to evaluate the feasibility of EGPS for benign gallbladder diseases. METHODS: Between June 2020 and January 2021, 22 patients with gallbladder stones and/or gallbladder polyps were treated with EGPS. The main outcome measures included the rate of complications, residual gallbladder stones, and gallbladder stone recurrence. RESULTS: In this study, transgastric EGPS was successfully performed in 22 patients (13 female, 9 male) with benign gallbladder diseases, and included 8 cases of multiple gallstones, 4 cases of gallbladder polyps with gallstones, 6 cases of multiple gallbladder polyps, 2 cases of single gallstone, and 2 case of singe gallbladder polyp. The median time of transgastric EGPS was 118 min. During hospitalization, 4 patients suffered localized peritonitis (4/22, 18.2%), and these patients successfully recovered after conservative medical treatment. None of the patients experienced massive bleeding, delayed bleeding, diffuse peritonitis, or any other serious complications. During the median follow-up of 4 months, 1 patient suffered residual gallstone, while no gallstone recurrence or deaths related to transgastric EGPS occurred in any patients. CONCLUSIONS: Transgastric EGPS appears to be a feasible treatment method in selected patients with benign gallbladder diseases. However, as it is a new technique, further studies are needed to explore the long-term effectiveness of transgastric EGPS.

Laparoscopic cholecystectomy for left-sided gallbladder.

PURPOSE: Left-sided gallbladder (LSGB) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament without situs inversus. We retrospectively analyzed 13 patients diagnosed with LSGB in a single center to confirm the safety of laparoscopic cholecystectomy (LC) and reviewed the anatomical implications in those patients. METHODS: Of the 4910 patients who underwent LC for the treatment of gallbladder disease between August 2007 and December 2019, 13 (0.26%) were diagnosed as having LSGB. We retrospectively analyzed these 13 patients for general characteristics, perioperative outcomes, and other variations through the perioperative imaging workups. RESULTS: All patients underwent LC for gallbladder disease. In all cases, the gallbladder was located on the left side of the falciform ligament. The operation was successfully performed with standard four-trocar technique, confirming "critical view of safety (CVS)" as usual without two cases (15.4%). In one case, which had an intraoperative complication and needed choledochojejunostomy because of common bile duct injury, there was an associated variation with early common bile duct bifurcation. The other patient underwent an open conversion technique because of severe fibrosis in the Calot's triangle. Furthermore, on postoperative computed tomography, abnormal intrahepatic portal venous branching was found in all cases. CONCLUSIONS: Although LSGB is usually encountered by chance during surgery, it can be successfully managed through LC with CVS. However, surgeons who find LSGB have to make efforts to be aware of the high risk of bile duct injury and possibility of associated anomalies.

Improved Detection of Gallbladder Perforation Using Ultrasound Small Vessel Slow Flow "Perfusion" Imaging.

Gallbladder (GB) perforation is a potentially fatal cause of acute abdomen. Higher morbidity and mortality are associated with this entity due to delayed diagnosis and treatment. Ultrasound with color/power Doppler and contrast sonography can detect wall discontinuity; however, sometimes it can be subtle or unavailable. Small vessel slow flow "perfusion" imaging allows improved microvascular perfusion detection using different filters, which result in increased spatial resolution and vessel visualization. Noncontrast perfusion imaging was of immense clinical value in the diagnosis of GB perforation in the six cases presented here. To the best of our knowledge, this is the first case report describing efficacy of noncontrast "perfusion" imaging in detection of GB perforation.

Prevalence of gallbladder sludge and associated abnormalities in cats undergoing abdominal ultrasound.

The significance of gallbladder sludge in cats remains largely unknown and has been speculated to be a pathologic finding in cats. The objectives of this retrospective, observational study were to determine the prevalence of gallbladder sludge in the population of cats presenting for abdominal ultrasound; to describe clinical signs, laboratory findings and certain abdominal ultrasound abnormalities; and to compare these findings to cats without gallbladder sludge. One hundred and ninety-two cats were included. Medical records were searched for cats with an abdominal ultrasound performed between October 2014-2015. Signalment, clinical signs, complete blood count, biochemical findings, presence or absence of gallbladder sludge, and hepatobiliary and pancreatic ultrasound findings were recorded. Gallbladder sludge was present in 44% of cats that underwent an abdominal ultrasound. There was no significant difference in age, sex, presenting clinical signs or clinicopathologic variables between the two groups. Gallbladder wall thickening significantly increased the odds of detecting gallbladder sludge (OR-3.7 95% CI 1.4 - 10.0). Gallbladder sludge was not associated with other ultrasonographic abnormalities of the liver, gallbladder, bile duct or pancreas. Gallbladder sludge is common in cats undergoing abdominal ultrasound and appears to be a non-specific finding. The clinical significance of concurrent gallbladder sludge and gallbladder wall thickening present on ultrasound in cats remains to be determined.

Gallbladder torsion in pregnancy: a case report and literature review.

Gallbladder torsion is a rare disease that requires immediate surgical intervention to avoid maternal and/or foetal sepsis and death. However, preoperative diagnosis is challenging because the disease has no specific symptoms. A 37-year-old pregnant woman at 34 weeks of gestation presented with severe epigastric pain. Ultrasonography and computed tomography scan findings showed a distended gallbladder without stones, floating from the hepatic bed, and laboratory examination demonstrated normal liver function; therefore, we made a diagnosis of gallbladder torsion and performed a caesarean section and an open cholecystectomy under general anaesthesia. This is the first report wherein gallbladder torsion in pregnancy was diagnosed preoperatively. Gallbladder torsion should be considered as a differential diagnosis in case of such imaging findings.

Gallbladder Polyp: Review and Proposed Algorithm for Management.

Gall bladder polyp is a lesion which is often an incidentally reported finding on ultrasonography. Such patients may or may not have symptoms of gall bladder disease. Although majority of polyps are cholesterol polyps, some are malignant. The challenge is early detection of malignant polyp and cholecystectomy before it becomes invasive or if invasive to carry out adequately wide surgical excision; while avoiding surgery in asymptomatic patients with benign disease. Following are the characteristics suggestive of malignancy in polyp: - size more than 10 mm, solitary lesions, increase in size over time, adenomatous polyps, sessile lesions and associated gallbladder wall thickening. Incidence of malignancy is higher in patients with Indian ethnicity, age more than 50 years, associated primary sclerosing cholangitis or gall stone disease. Pre-operative tissue diagnosis is difficult to obtain and review ultrasonography, contrast enhanced CT scan, endo sonography and a regular follow-up can help the surgeon take the appropriate decision.