Gallbladder torsion.

ABSTRACT: Gallbladder torsion is a rare cause of acute surgical abdomen. Early recognition and surgical intervention are important for reducing complications and improving postoperative patient outcomes, but standard imaging and laboratory evaluation typically are indistinguishable from those of acute cholecystitis. This article describes a patient with gangrenous cholecystitis secondary to torsion and summarizes recommendations for evaluation and management.

Simple biliary cysts of the liver can be lined by mucinous epithelium.

AIMS & METHODS: Simple biliary cysts of the liver are described to be lined by biliary epithelium and may be managed nonsurgically or by deroofing only. By contrast, its important differential diagnosis-mucinous cystic neoplasm (MCN)-is at least focally lined by mucinous epithelium, has malignant potential, and therefore should be resected. Following anecdotal observations in routine diagnostic practice, the following case series was assembled to confirm whether simple biliary cysts of the liver can be lined by mucinous epithelium. Detailed clinicoradiological review, including postoperative follow-up, was also completed to assess whether the presence of mucinous epithelium had any associations, including a risk of hepatobiliary neoplasia. RESULTS: Histological review of 21 simple biliary cysts received as surgical specimens over a 3- year period confirmed an absence of ovarian-like stroma in all cases. The lining epithelium of seven cysts showed focal supranuclear/apical mucin, as confirmed histochemically. Cysts with mucinous epithelium were generally larger and more often showed histological evidence of previous haemorrhage than cysts without this epithelium. There were no other statistically-significant differences in clinicoradiological features between cysts with and without mucinous epithelium, including at postoperative radiological follow-up. CONCLUSIONS: Focal mucinous epithelium can be present in at least one-third of surgically-managed, simple biliary cysts of the liver. Such epithelium may be metaplastic and should not be misinterpreted to indicate a diagnosis of MCN but, apart from this, appears to have no clinical significance. Ovarian-like stroma may therefore be the only histological feature that reliably distinguishes MCN from simple biliary cyst.

Accuracy of Endoscopic Transpapillary Gallbladder Drainage with Liquid-Based Cytology for Gallbladder Disease.

INTRODUCTION: Gallbladder carcinoma is often difficult to distinguish from benign gallbladder diseases. While the diagnostic accuracy of endoscopic transpapillary gallbladder drainage (ETGD) has been reported, these results were obtained retrospectively. This prospective study aimed to evaluate the cytological diagnostic accuracy of ETGD in patients with gallbladder disease. METHODS: This single-arm prospective clinical trial included a total of 35 patients scheduled to undergo ETGD between March 2017 and September 2019. A 5F pigtail nasobiliary drainage tube was inserted into the gallbladder, and bile was collected over 5 times; if ETGD failed, a drainage tube was placed into the bile duct. The endpoints were, first, the cytological diagnostic accuracy of ETGD and, second, technical success rates and adverse events. RESULTS: Of the 35 patients, 19 were finally diagnosed with gallbladder cancer. The success rate of ETGD tube insertion was 85.7%, and the morphological pattern of the cystic duct with the angle down and located on the right side had a significantly lower success rate for ETGD than that of other cystic duct patterns (odds ratio, 13.5; 95% confidence interval, 1.7-143.7; p = 0.02). Cytological samples were collected 5 times on median. The sensitivity, specificity, and accuracy in all patients were 78.9%, 100%, and 88.6%, respectively, while those in 30 patients with successful ETGD were 87.5%, 100%, and 93.3%, respectively. Adverse events occurred in 3 patients: mild pancreatitis in 1 patient and obstructive jaundice in 2 patients; all complications were resolved with conservative therapy. DISCUSSION/CONCLUSIONS: Cytology using an ETGD tube is useful in differentiating benign and malignant gallbladder diseases (Clinical Trial Registry No. UMIN000026929).

Gallbladder perforation: A single-center experience in north India and a step-up approach for management.

BACKGROUND: Spontaneous gallbladder perforation (GBP) is an uncommon diagnosis. This study presented the experience of managing spontaneous GBP over nine years at a large, tertiary care university hospital in north India and investigated the outcomes and treatment strategies. METHODS: A retrospective review of prospectively maintained digital database of consecutive patients was performed. All patients received medical and/or surgical treatment for spontaneous GBP in our department between January 2010 and June 2018. RESULTS: We identified 151 patients (81 females and 70 males) with mean age of 53 years. Most common presenting features were pain (96.7%), fever (54.3%) and jaundice (31.1%). Most common cause was gallbladder stones (84.8%) followed by common bile duct stones (30.5%), xanthogranulomatous cholecystitis (17.9%) and malignancy (11.9%). As per Niemeier classification, 8.6% had type 1 GBP (free perforation in peritoneal cavity), 76.2% had type 2 GBP (localized perforation) and 13.2% had type 3 GBP (cholecysto-enteric fistula). About 60% of the perforations were diagnosed preoperatively. Type 1 was more common in patients with diabetes and also had the worst prognosis. Surgery was performed in 109 patients (72.2%). Seven patients (4.6%) had a postoperative morbidity of Clavien-Dindo III or higher. There were three mortalities in patients who underwent surgery. CONCLUSIONS: High index of suspicion is required for preoperative diagnosis of GBP, especially in types 2 and 3. Laparoscopic cholecystectomy can be difficult in these patients and patients may require open or partial cholecystectomy. Early diagnosis and step-up approach for the treatment of GBP is critical.

Dysplasia and carcinoma of the gallbladder: pathological evaluation, sampling, differential diagnosis and clinical implications.

Pathological evaluation of gallbladder neoplasia remains a challenge. A significant proportion of cases presents as clinically and grossly inapparent lesions, and grossing protocols are not well established. Among epithelial alterations, pseudo-pyloric gland metaplasia is ubiquitous and of no apparent consequence, whereas goblet cell metaplasia and a foveolar change in surface cells require closer attention. Low-grade dysplasia is difficult to objectively define and appears to be clinically inconsequential by itself; however, extra sampling is required to exclude the possibility of accompanying more significant lesions. For high-grade dysplasia ('high-grade BilIN', also known as 'carcinoma in situ'), a complete sampling is necessary to rule out invasion. Designating in-situ or minimally invasive carcinomas limited to muscularis or above as early gallbladder carcinoma (EGBC) helps to alleviate the major geographical differences (West/East) in the criteria for 'invasiveness' to assign a case to pTis or pT1. Total sampling is crucial in proper diagnosis of such cases. A subset of invasive GBCs (5-10%) arise from the intracholecystic neoplasm (ICN, 'adenoma-carcinoma sequence') category. Approximately two-thirds of ICNs have invasive carcinoma. However, this propensity differs by subtype. True 'pyloric gland adenomas' (> 1 cm) are uncommon and scarcely associated with invasive carcinoma. A distinct subtype of ICN composed of tubular, non-mucinous MUC6+ glands [intracholecystic tubular non-mucinous neoplasm (ICTN)] forms a localised pedunculated polyp. Although it is morphologically complex and high-grade, it appears to be invasion-resistant. Some of the invasive carcinoma types in the gallbladder have been better characterised recently with adenosquamous, neuroendocrine, poorly cohesive and mucinous carcinomas often being more advanced and aggressive.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis.

BACKGROUND: Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS: FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS: During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS: In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Clinical value of diffusion-weighted MRI for differentiation between benign and malignant gallbladder disease: a systematic review and meta-analysis.

BACKGROUND: Radiological differentiation between benign and malignant gallbladder disease is important but remains challenging. Furthermore, the clinical value of diffusion-weighted imaging (DWI) remains unclear. PURPOSE: To determine the value of DWI in discriminating benign from malignant gallbladder disease by conducting a systematic review and meta-analysis. MATERIAL AND METHODS: The literature was systematically searched. Studies analyzing diagnostic value of DWI in gallbladder disease with histopathology or follow-up as reference standard were included. Study selection and data extraction were done by two reviewers independently. Methodological quality was assessed using the QUADAS-2 tool. Sensitivity and specificity were calculated and displayed in a forest plot. A sensitivity analysis was performed in case of outliers. Pooled sensitivity and specificity of DWI were plotted on a hierarchical summary receiver operating characteristic curve. If available, the added value of DWI to conventional magnetic resonance imaging (MRI) sequences was analyzed. RESULTS: Out of 2456 articles, eight studies fulfilled the inclusion criteria; 592 patients with 221 malignant lesions were included. Pooled sensitivity and specificity rates were 0.87 and 0.84, respectively. In two studies, diagnostic accuracy rates improved after adding DWI to conventional MRI (64% and 75% for conventional MRI vs. 89% and 94% after combining conventional MRI with DWI). In another study, the area under the curve increased from 0.92 to 0.95. CONCLUSION: DWI appears to be an accurate imaging technique in discriminating benign from malignant gallbladder disease. To achieve optimal patient care, it should be part of multiparametric MRI and should be combined with other imaging modalities.

[Gallbladder polyps: modern approaches to diagnostics and treatment].

Gallbladder polyps are an elevation of the mucous membrane that protrudes into the lumen of the gallbladder cavity. Their prevalence in the general population varies from 0.3 to 13.8%. According to the modern classification, polyps of the gallbladder are divided into benign non-tumor, benign tumor and malignant tumor polyps. A review of modern literature presents cohort and randomized controlled trials, including those summarized in meta-analyzes and systematic reviews, suggesting that the dominant form of polypoid formations of the gallbladder are cholesterol pseudo-polyps with no malignant potential associated with impaired cholesterol metabolism, often combined with gallbladder cholesterosis, metabolic syndrome and cardiovascular morbidity. Evidence is building up on the effectiveness of ursodeoxycholic acid for controlling components of the metabolic syndrome and cardiovascular risks. Ursodeoxycholic acid preparations may become promising for the management of cholesterol polyps.

Gallbladder and Biliary Disease in Pregnancy.

Diseases of the gallbladder and biliary tract are extremely common in developed nations. Because of the physiology of pregnancy, their incidence increases during gestation. This article represents a review of the existing literature on the entire spectrum of biliary disease. The physiology, clinical presentation, and diagnostic evaluation of a variety of conditions are reviewed. Historical and contemporary data regarding pregnancy implications and treatment options are discussed.

Gallbladder tuberculosis in a dialysis patient: a case-report.

BACKGROUND: The diagnosis of gallbladder tuberculosis remains elusive even to the most experienced clinicians. Our aim is to describe our experience of this rare disease, and to raise awareness of the increasing likelihood of tuberculosis in chronic kidney disease (CKD) patient. CASE PRESENTATION: We report a rare case of gallbladder tuberculosis in a chronic kidney disease patient on hemodialysis. This combination is rarely reported in literature. No signs of abdominal tuberculosis were observed besides a clinical profile consistent with CKD in our patient. The clinical signs of uremia masks those of abdominal tuberculosis and render the pre-operative diagnosis of tuberculosis more difficult. CONCLUSIONS: The clinical signs of uremia conceal those of abdominal tuberculosis. The diagnosis of tuberculosis in CKD patients hinges mainly on a high index of suspicion, perioperative findings and histological examination.

Gallbladder torsion: a cholecystectomy that cannot be delayed.

Gallbladder torsion is a rare entity, where the gallbladder twisted around its mesentery. Unfortunately, the diagnosis is rarely done preoperatively. This paper aims, through a case report, to describe the risk factors and the radiological criteria used to diagnose gallbladder torsion, in order to avoid a rapidly unfavourable evolution and the need to proceed to emergency cholecystectomy.

[Surgical treatment of gallbladder polyps]. / Khirurgicheskoe lechenie polipov zhelchnogo puzyrya.

OBJECTIVE: To study the incidence of gallbladder polyps and the possibilities of modern methods of diagnosis and surgical treatment of this disease. MATERIAL AND METHODS: There were 42 laparoscopic cholecystectomies in patients with diagnosed gallbladder polyps. The polyps were diagnosed preoperatively. Intraoperative diagnosis during surgery for gallstone disease was observed in 3 cases. A comparative analysis of preoperative examination did not reveal any advantages of certain diagnostic approach. RESULTS: Hyperplastic polyp was the most common type (n=20, 47.6%), adenomatous polyps occurred in 19 (45.3%) cases, cholesteric polyps - in 3 (7.1%) patients. All patients had signs of chronic inflammation of the gallbladder wall with its infiltration by lymphocytes and histiocytes. CONCLUSION: Further studies with clear criteria for the diagnosis of gallbladder polyps including ones for determining true polyps, precancerous and malignant polyps are required.

Quantitative contrast-enhanced US helps differentiating neoplastic vs non-neoplastic gallbladder polyps.

OBJECTIVES: To differentiate between large (≥ 1 cm in diameter) gallbladder (GB) non-neoplastic and neoplastic polyps using quantitative analysis of contrast-enhanced ultrasound (CEUS) findings. METHODS: From September 2017 to May 2018, 29 patients (10 males; median age, 63 years) with GB polyps of ≥ 1 cm in diameter who were undergoing cholecystectomy were consecutively enrolled. All patients underwent preoperative conventional US and CEUS examinations. Quantitative analysis of CEUS findings using time-intensity curves between the two groups was independently performed by two radiologists. The interobserver agreement for the quantitative analysis of the CEUS results was measured using the intraclass correlation coefficient. Receiver operating characteristic analysis was performed to evaluate the diagnostic performance of CEUS examination. RESULTS: After the cholecystectomy, the patients were classified into the non-neoplastic polyp group (n = 12) and the neoplastic polyp group (n = 17) according to the pathological results. The interobserver agreement for quantitative assessment between the two radiologists was near perfect to substantial. Quantitative assessment of the CEUS findings revealed that the rise time, mean transit time, time to peak, and fall time of non-neoplastic GB polyps were significantly shorter than those of neoplastic polyps (p < 0.001, p = 0.008, p = 0.013, and p = 0.002, respectively). The sensitivity and specificity of the quantitative CEUS parameters for the differentiation between the two groups were 76.5-100% and 75%, respectively, with an area under the curve of 0.765-0.887. CONCLUSIONS: Quantitative analysis of CEUS findings could be valuable in differentiating GB neoplastic polyps from non-neoplastic polyps. KEY POINTS: • Quantitative analysis of CEUS findings could be valuable in differentiating gallbladder neoplastic polyps from non-neoplastic polyps. • Quantitative analysis of CEUS findings in gallbladder polyps provides cut-off values for differentiation between neoplastic polyps and non-neoplastic polyps with near-perfect to substantial interobserver agreement.

Feasibility study for rapid near-infrared spectroscopic identification of different gallbladder diseases by direct analysis of bile juice.

A whole-sample-covering near-infrared (NIR) spectroscopy scheme has been adopted for the simple drop-and-dry measurement of raw bile juice for the identification of gallbladder (GB) diseases of stone, polyp, and cancer. For reproducible measurement, a non-NIR absorbing polytetrafluoroethylene (PTFE) providing a hydrophobic surface was chosen as a substrate to form bile juice droplets of a consistent shape. To ensure representative spectroscopic sampling, NIR radiation illuminated the whole area of the dried sample for spectral acquisition. The NIR band shapes and relative band intensities of GB cancer differed moderately from those of GB stone and GB polyp. The composition of GB cancer samples was presumed to be dissimilar from other sample compositions. Differentiation between GB polyp and GB stone, however, was less facile; nevertheless, in the case of GB polyp samples, the obtained NIR features were informative in the identification of various pathological conditions such as adenomyomatosis (abnormal growth of epidermal tissue) and hepatitis B. To elucidate the NIR features of bile juice samples, separate NIR spectra of major bile constituents such as conjugated bile salts, lecithin, cholesterol, and albumin were analyzed. The demonstrated NIR spectroscopy scheme requiring no sample pretreatment or separation of bile juice could be useful for fast bile juice-based screening of GB diseases, especially the identification of early GB cancer.

A Duplicated Gallbladder in a Patient Presenting with Acute Cholangitis. A Case Study and a Literature Review.

Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a simple hepatobiliary surgical procedure. The case report of a 63-year-old woman who presented with cholangitis and underwent a successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Using ERCP, MRCP and 3D reconstructions the two cystic ducts with one common bile duct were identified. A review of the literature in referral of this variant, its anatomical classifications and significance to clinical and surgical practice is included. In conclusion, gallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder when evaluating radiologic studies. In case of surgery, preoperative diagnosis is essential to prevent possible biliary injuries or reoperation if accessory gallbladder has been overlooked during initial surgery. Laparoscopic cholecystectomy remains feasible for intervention can be safely done and awareness is necessary to avoid complications or multiple procedures.

Magnetic resonance cholangiopancreatography with GRASE sequence at 3.0T: does it improve image quality and acquisition time as compared with 3D TSE?

OBJECTIVES: The current study evaluated the clinical usefulness of the gradient and spin-echo (GRASE) sequence with single breath-hold in 3.0 T magnetic resonance cholangiopancreatography (MRCP). We compared the acquisition time and image quality between GRASE and breath navigator-triggered 3D turbo spin echo (3D TSE). METHODS: We examined 54 consecutive patients who underwent MRCP with GRASE and 3D TSE. We compared the image acquisition time and contrast-to-noise ratio (CNR) between the common bile duct (CBD) and liver. Overall image quality, blurring, motion artifacts and CBD visibility were scored on a 4-point scale by two radiologists. Paired t-tests were used to compare the variables. RESULTS: The mean image acquisition time was 95 % shorter with the GRASE than with 3D TSE (GRASE: 20 s; 3D TSE: 6 min 27 s). The CNR of GRASE was significantly higher than that of 3D TSE (GRASE: 25.4 ± 13.9 vs. 3D TSE: 18.2 ± 9.6, p < 0.01). All qualitative scores for GRASE were significantly better than those for 3D TSE. CONCLUSIONS: 3.0 T MRCP with GRASE sequence with single breath-hold significantly improved the CNR of CBD with a 95 % shorter acquisition time compared with conventional 3D MRCP with 3D TSE. KEY POINTS: • MRCP acquisition time was 95% shorter with GRASE than with 3D TSE. • Overall image quality of GRASE was significantly better than 3D TSE. • Pancreaticobiliary tree visibility with GRASE was better than that with 3D TSE.

Multivisceral IgG4-related disease presenting as recurrent massive gastrointestinal bleeding: a case report and literature review.

BACKGROUND: IgG4-related disease (IgG4-RD) is a newly recognized autoimmune systemic disorder characterized by elevated levels of serum IgG4 and abundant infiltration of IgG4-positive plasmacytes in the affected organs. The liver, biliary system and pancreas are the most commonly affected organs. However, involvement of the digestive tract is very rare. To date, only a few cases of isolated gastric IgG4-RD have been reported. CASE PRESENTATION: We present a case of IgG4-RD of the liver, gallbladder, pancreas and duodenum, which was clinically misinterpreted and thereafter over-treated. A 52-year-old male presented with obstructive jaundice for 3 years, melena for 5 months and hematemesis for 10 days. Three years prior, the patient had undergone biopsies of pancreatic lesions, liver lesions, cholecystectomy and choledochojejunostomy. Histopathology showed chronic inflammatory changes. Endoscopy at admission revealed a duodenal ulcer with active bleeding. Despite medical management, the patient presented with repeated gastrointestinal bleeding. Upon evaluation, serum IgG4 levels were found to be elevated. Histopathology of the duodenal ulcer biopsy and repeated examination of the gallbladder and pancreatic and liver biopsies confirmed IgG4 positive plasma cell infiltration. A definitive diagnosis of IgG4-RD was made and steroid administration was initiated. At last follow up, 11 months to-the-day after initiating steroid treatment, the patient was asymptomatic. CONCLUSIONS: Notably, IgG4-RD of multiple digestive organs is still very rare. As a systemic disease, it is characterized by the infiltration of IgG4-bearing plasma cells and raised IgG4 levels. Histopathology findings remain the diagnostic gold standard for this disorder.

Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of localized gallbladder lesions.

BACKGROUND AND AIM: Differential diagnosis of localized gallbladder lesions is challenging. The aim of the present study was to evaluate the utility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for diagnosis of localized gallbladder lesions. METHODS: One hundred and twenty-five patients with localized gallbladder lesions were evaluated by CH-EUS between March 2007 and February 2014. This was a single-center retrospective study. Utilities of fundamental B-mode EUS (FB-EUS) and CH-EUS in the differentiation of gallbladder lesions and sludge plug were initially compared. Thereafter, these two examinations were compared with respect to their accuracy in the diagnosis of malignant lesions. Five reviewers blinded to the clinicopathological results evaluated microcirculation patterns in the vascular and perfusion images. RESULTS: In the differentiation between gallbladder lesions and sludge plug, FB-EUS had a sensitivity, specificity, and accuracy of 82%, 100%, and 95%, respectively, whereas CH-EUS had a sensitivity, specificity, and accuracy of 100%, 99%, and 99%, respectively. FB-EUS-based diagnosis of carcinomas based on tumor size and/or shape had a sensitivity, specificity, and accuracy of 61-87%, 71-88%, and 74-86%, respectively. Additional information regarding irregular vessel patterns in the vascular image and/or heterogeneous enhancement in the perfusion image on CH-EUS increased the sensitivity, specificity, and accuracy for the diagnosis of carcinomas to 90%, 98%, and 96%, respectively. There was a significant difference between FB-EUS and CH-EUS in terms of carcinoma diagnosis. CONCLUSION: CH-EUS was useful for the evaluation of localized gallbladder lesions.

Contrast-enhanced ultrasound complements two-dimensional ultrasonography in diagnosing gallbladder diseases in dogs.

Gall-bladder diseases are common in dogs and two-dimensional ultrasonography is a current standard method for diagnosis and treatment planning. However, findings from this modality can be nonspecific. The aim of this retrospective, case series study was to describe conventional and contrast-enhanced ultrasound (using SonoVue® ) findings in a group of dogs with histologically confirmed gall bladder disease. A total of 65 dogs were included. Branchlike, heterogeneous, and homogeneous contrast enhancement of echogenic intraluminal mass-forming lesions was a contrast-enhanced ultrasound characteristic of polypoid lesions due to cystic mucosal hyperplasia of the gallbladder and/or tumor, which had different wash-in and washout characteristics. In dogs with mobile or immobile biliary sludge or mucocele, the echogenic intraluminal masses remained unenhanced. A double rim mark or enhancement defect in the gallbladder wall was a characteristic of edema or necrosis/rupture of the wall, respectively. Conventional ultrasonography correctly identified biliary sludge or mucocele in 36/37 dogs, cholecystitis/edema in 44/47 dogs, necrosis/rupture in 19/25 dogs, and gallbladder neoplasia in three of three dogs with these pathologies. It falsely identified biliary sludge or mucocele in eight of 28 dogs, cholecystitis/edema in three of 15 dogs, necrosis/rupture in 13/37 dogs, and gall-bladder neoplasia in 20/59 dogs that did not have these pathologies. Contrast-enhanced ultrasound correctly identified cholecystitis/edema in 42/47 dogs, but falsely identified cholecystitis/edema in three of 18 dogs. It correctly identified necrosis/rupture, benign polypoid lesions, and gallbladder neoplasia in all dogs with no false-positive results. Findings supported contrast-enhanced ultrasound as a complement to conventional ultrasonography for dogs with suspected gallbladder pathologies such as edema, necrosis, and rupture.