What is the significance of a contracted gallbladder?

Significance of a Contracted Gallbladder

A contracted gallbladder on imaging is a nonspecific finding that can be seen in both normal physiological states and pathological conditions such as chronic cholecystitis, but alone is not diagnostic of any specific disease. 1

Normal Physiology vs. Pathology

• A contracted gallbladder is a normal physiological finding after meals when the gallbladder has emptied its contents in response to cholecystokinin (CCK) released following food intake 1
• In the fasting state, the gallbladder normally stores and concentrates bile; after eating, it contracts to release bile into the duodenum 2
• When seen in a fasting patient, a contracted gallbladder may indicate underlying pathology such as chronic cholecystitis 1

Diagnostic Considerations

• On ultrasound, which is the first-line imaging modality for right upper quadrant pain, a contracted gallbladder may be observed in patients with chronic cholecystitis, but this finding alone is insufficient for diagnosis 1
• The diagnosis of chronic cholecystitis is difficult on anatomic imaging, with the gallbladder potentially appearing either contracted or distended 1
• Pericholecystic fluid is usually absent in chronic cholecystitis, unlike in acute cholecystitis 1
• A contracted gallbladder may also be seen in complicated cholecystitis (emphysematous, hemorrhagic, gangrenous, or perforated), though these conditions can also present with a distended gallbladder 1

Clinical Correlation

• The appearance of a contracted gallbladder must be correlated with clinical symptoms and other imaging findings 1
• In patients with biliary-type pain and a contracted gallbladder, functional gallbladder disorder should be considered after structural causes have been excluded 3
• Functional assessment of gallbladder contractility can be performed using cholecystokinin-cholescintigraphy (CCK-CS), which measures the gallbladder ejection fraction 1
• An abnormal gallbladder ejection fraction (<38%) in a patient with typical biliary pain may suggest functional gallbladder disorder 1

Differential Diagnosis

• A contracted gallbladder in a symptomatic patient may represent:
  • Normal postprandial state (if patient has recently eaten) 2
  • Chronic cholecystitis 1
  • Functional gallbladder disorder 3
  • Early stage of acute cholecystitis (before distension occurs) 4
  • Gallbladder cancer (rare but important consideration, especially in patients >70 years) 1

Clinical Pitfalls and Caveats

• The finding of a contracted gallbladder should never be interpreted in isolation but always in the context of clinical presentation and other imaging findings 1
• Avoid overdiagnosis of pathology when a contracted gallbladder may simply represent normal postprandial state 2
• In patients with right upper quadrant pain and a contracted gallbladder on ultrasound, consider additional imaging such as cholescintigraphy if clinical suspicion for biliary pathology remains high 1
• Remember that a contracted gallbladder does not exclude the presence of gallstones, which may still be visible within the contracted lumen 1
• In patients with risk factors for gallbladder cancer (e.g., porcelain gallbladder, age >70), a contracted gallbladder should prompt consideration of further evaluation 1

Management Implications

• A contracted gallbladder as an isolated finding does not warrant specific treatment 1
• Management should be guided by associated symptoms and other clinical/imaging findings 1
• In patients with typical biliary pain and a contracted gallbladder with no other findings, functional evaluation with CCK-CS may be considered 1
• Cholecystectomy should only be considered when the patient has severe symptoms, meets required criteria for gallbladder disease, and other diagnoses are excluded 3