What is a contracted gallbladder?

Contracted Gallbladder: Definition and Clinical Significance

A contracted gallbladder is a gallbladder that appears small and collapsed on imaging, which can be either a normal physiological state following gallbladder emptying or a pathological finding associated with certain disease processes.

Normal Contracted Gallbladder

• A normal gallbladder can appear contracted on imaging after:
  • Recent meal (physiological contraction due to cholecystokinin release)
  • Prolonged fasting
  • Normal gallbladder emptying in response to fatty foods

Pathological Contracted Gallbladder

A contracted gallbladder can be associated with several pathological conditions:

1. Chronic Cholecystitis

• Chronic inflammation leads to fibrosis and scarring of the gallbladder wall
• Results in a small, contracted, and sometimes calcified gallbladder
• Often associated with recurrent episodes of biliary colic 1

2. Complicated Cholecystitis

• In complicated cholecystitis (emphysematous, hemorrhagic, gangrenous, or perforated), the gallbladder may appear contracted or distended 1
• Pericholecystic fluid may be variably present
• Intraluminal debris, membranes, or gas in the gallbladder wall may be visible on imaging

3. Difficult Gallbladder Surgery

• A contracted gallbladder is considered a risk factor for conversion from laparoscopic to open cholecystectomy 1
• Identified as one of the predictors of difficult cholecystectomy, along with male sex, age > 60 years, obesity, cirrhosis, and previous upper abdominal surgery 1

4. Functional Gallbladder Disorder

• Abnormal gallbladder contraction can be assessed using cholecystokinin-cholescintigraphy (CCK-CS)
• A gallbladder ejection fraction (GBEF) below 38% is considered abnormal 1
• May indicate functional gallbladder disorder in the appropriate clinical setting

Imaging Findings

Ultrasound

• First-line imaging modality for gallbladder assessment
• A contracted gallbladder appears small with thickened walls
• May be difficult to visualize completely
• Important to differentiate from other conditions like scleroatrophic cholecystitis or Mirizzi syndrome 1

CT Scan

• Can confirm or refute the diagnosis of acute cholecystitis in equivocal cases
• May reveal complications such as gangrene, gas formation, hemorrhage, or perforation 1

HIDA Scan

• Gold standard for diagnosing acute cholecystitis
• Sensitivity of 86.7-89.3% and specificity of 66.8-79% 2
• Non-visualization of the gallbladder suggests cystic duct obstruction

Clinical Implications

1. Surgical Considerations:

   • A contracted gallbladder may necessitate alternative surgical approaches during cholecystectomy
   • May require subtotal cholecystectomy or "fundus-first" technique if the critical view of safety cannot be achieved 1
   • Associated with higher risk of conversion to open surgery 1

2. Diagnostic Challenges:

   • May be difficult to distinguish from other gallbladder pathologies on imaging
   • Could mask underlying conditions like choledocholithiasis or biliary dyskinesia 3

3. Management Implications:

   • In cases where a contracted gallbladder is found during attempted cholecystectomy for acute cholecystitis, subtotal cholecystectomy may be safer than complete cholecystectomy 1
   • Laparoscopic or open subtotal cholecystectomy is recommended in situations where anatomic identification is difficult and risk of iatrogenic injuries is high 1

Conclusion

A contracted gallbladder can represent either a normal physiological state or a pathological condition. When found in the context of gallbladder disease, it may indicate chronic inflammation, functional disorder, or complicate surgical management. Appropriate imaging and clinical correlation are essential for proper diagnosis and management planning.