What is the recommended management for a patient with a contracted gallbladder on ultrasound (US), possibly indicating chronic gallbladder disease?

Management of Contracted Gallbladder on Ultrasound

A contracted gallbladder on ultrasound in a fasting patient warrants evaluation for chronic cholecystitis and should proceed to elective cholecystectomy if the patient is symptomatic with biliary-type pain, after confirming the diagnosis and excluding common bile duct stones. 1

Initial Diagnostic Confirmation

Verify patient fasting status - A contracted gallbladder may be a normal physiologic finding in non-fasting patients, but in fasting patients it suggests pathology such as chronic cholecystitis. 1

Assess for gallstones on ultrasound - Gallstones are present in the majority of chronic cholecystitis cases (75-93% depending on acuity). 2 The classic ultrasound appearance shows:

• High-amplitude echoes in the gallbladder bed with strong acoustic shadowing 3
• However, this "WES triad" (wall-echo-shadow) does not reliably predict gallbladder wall thickness or the degree of contraction 3
• Gallbladder volume may be normal or even increased despite the contracted appearance 3

Evaluate for chronic cholecystitis features:

• Thickened gallbladder wall (present in only 18% of chronic cases, compared to 80% in acute) 2
• Presence of gallstones (93% of chronic cholecystitis cases) 2
• Absence of pericholecystic fluid (typically absent in chronic disease) 1

Risk Stratification for Common Bile Duct Stones

Before proceeding to cholecystectomy, stratify the risk of choledocholithiasis using clinical and laboratory parameters: 4

High-risk patients (require preoperative ERCP):

• Evidence of common bile duct stone on ultrasound 4
• Ascending cholangitis 4

Moderate-risk patients (require additional imaging before surgery):

• Total bilirubin > 4 mg/dL, OR 4
• Common bile duct diameter > 6 mm with bilirubin 1.8-4 mg/dL 4
• Abnormal liver biochemical tests other than bilirubin 4
• Age > 55 years 4
• Clinical gallstone pancreatitis 4

Low-risk patients (proceed directly to surgery):

• No predictors present 4

Additional Imaging for Moderate-Risk Patients

For moderate-risk patients, obtain one of the following before surgery: 4

• MRCP (sensitivity 93%, specificity 96%) 4
• Endoscopic ultrasound (sensitivity 95%, specificity 97%) 4
• These tests reduce unnecessary ERCP by 30-75% 4
• Choice depends on local availability, expertise, and acceptable delay to surgery 4

Functional Assessment if Diagnosis Unclear

If ultrasound findings are equivocal and the patient has typical biliary pain:

• Consider Tc-99m cholescintigraphy with gallbladder ejection fraction measurement 1
• Ejection fraction < 30-38% suggests functional gallbladder disorder or chronic cholecystitis 1
• This is particularly useful when anatomic imaging alone cannot establish the diagnosis 1

Definitive Management

Proceed to elective laparoscopic cholecystectomy for symptomatic patients with confirmed chronic cholecystitis. 5

Surgical considerations for contracted gallbladder:

• The contracted gallbladder predisposes to higher risk of biliary or vasculobiliary injury due to unclear anatomy from chronic inflammation and fibrosis 6
• Strongly consider intraoperative laparoscopic ultrasound - this significantly improves visualization of anatomical conditions and reduces operating time compared to visual evaluation alone 6
• Combination of fundus-first approach and subtotal cholecystectomy with laparoscopic ultrasound navigation is effective for the shrunken gallbladder 6

Medical Management Alternative

For patients with radiolucent stones who are poor surgical candidates:

• Ursodiol 8-10 mg/kg/day in 2-3 divided doses can be considered for stone dissolution 7
• Monitor with ultrasound at 6-month intervals 7
• Partial dissolution within 6 months indicates > 70% chance of complete dissolution; within 12 months indicates 40% probability 7
• Stone recurrence occurs in 30-50% of patients within 2-5 years after dissolution 7

Watchful Waiting Considerations

For asymptomatic or minimally symptomatic patients:

• Complications of asymptomatic gallstone disease occur at < 1% per year 5
• Development of moderate-to-severe symptoms occurs at 2-6% per year, with cumulative rate of 7-27% over 5 years 7
• Surgical mortality varies significantly by age, sex, and comorbidities (ranging from 0.54 per 1,000 operations in low-risk young women to > 100 per 1,000 in high-risk elderly men with common duct exploration) 7

Common pitfalls to avoid:

• Do not assume a contracted gallbladder always indicates a small, stone-filled organ - the volume may be normal or increased 3
• Do not proceed to cholecystectomy without assessing common bile duct stone risk, as unrecognized choledocholithiasis increases morbidity 4
• Do not rely on ultrasound sensitivity alone for chronic cholecystitis (ranges 26-100%) - clinical correlation is essential 1