BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2008; VOL. 16(2) : 51-55

Sonographic Evaluation of Gall Bladder in Acute Hepatitis BANAJABA1, SHIBENDU MAJUMDER2, SALAHUDDIN AL-AZAD3, MUSHTAQUE AHMED JALALI4 Abstract: Ultrasound is a popular modality for evaluating jaundice patient primarily for identification of type of jaundice whether medical or surgical. Sonographic changes of gall bladder are usual in different surgical conditions. Gall bladder changes also occur in medical jaundice or hepatitis which may be confused with surgical conditions. Objective of this study is to show the possibility of gall bladder involvement and to evaluate its diagnostic accuracy in different stages of acute hepatitis. Fifty clinically and biochemically diagnosed cases of acute hepatitis who suffered for less than 6 months were included in this study except the postcholecystectomy patients and patients with gall stone disease. All subjects were examined early in the morning after 12 hours of fasting. The patients were evaluated sonographically, biochemically and clinically at weekly intervals. Abnormal sonographic patterns were observed in 45(90%) patients with acute viral hepatitis and included thickened gall bladder wall and presence of sludge within the lumen of gallbladder and volume shrinkage of gallbladder among which gallbladder wall thickening was the most common. Sonographic changes of gall bladder was not related to the etiological agent of acute hepatitis and found in all types of acute viral hepatitis available among the study group. Introduction: Viral hepatitis is almost always caused by the specific hepatitis virus, hepatitis due to other virus accounts for only 1-2% of cases. Causes of viral hepatitis included Hepatitis A, B, C, D & E virus, cytomegalo virus, Epstainbar virus and yellow fever virus.

Acute viral hepatitis can be caused by any of the hepatotopic virus, other conditions include carrier state, chronic hepatitis and fulminant hepatitis. Symptomatic, biochemical or serologic evidence of continuing inflammatory hepatic disease for more than 6 months without steady improvement means chronic hepatitis. Diagnosis of acute hepatitis is made by liver function tests and serological studies .In acute viral hepatitis, ultrasound examination reveals pathologic changes of other organ specially gall bladder along with liver. Changes of gall bladder in acute hepatitis include thickening of wall, abnormal content of gallbladder and volume shrinkage1. Maresca et. al. showed the abnormal findings of gall bladder in acute hepatitis and included: 1. Increased wall thickness with evidence of three layers 2. Decreased volume of gall bladder 3. Both increased wall thickness and decreased volume 4. Abnormal gall bladder content2. There are different nonsurgical causes of gall bladder wall thickening3. In a retrospective study thickening of gall bladder wall was found in 22 patients without any gall bladder disease, among which there were patients of alcoholic liver disease (11), hepatitis (3), sepsis (2), renal failure (2), primary biliary cirrhosis (1), right congestive heart failure (1) and disseminated brucellosis (1). All except three patients were hypoalbuminaemic. In our country, ultrasound is a popular modality for evaluating jaundice patients. So, this study has been conducted to show the gall bladder

1. M.O, Department of Radiology and Imaging, Shaheed Suhrawardy Medical College & Hospital, Dhaka, 2. Assistant Professor, Department of Radiology and Imaging, Shaheed Suhrawardy Medical College & Hospital, Dhaka, 3. Associate Professor, Department of Radiology and Imaging, BSMMU, Dhaka, 4. MO, Department of Radiology and Imaging, National Institute of Cancer Research and Hospital, Dhaka.

Sonographic Evaluation of Gall Bladder in Acute Hepatitis

Banajaba et al

abnormalities in acute hepatitis, their incidence and time to time change with the patient’s recovery.

(standard deviation). Paired t test was done for serial changes in gall bladder wall thickness. Chisquare test and correlation coefficient were used for statistical evaluation of the data obtained.

Materials and Methods: This prospective study was carried out in the department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University (BSMMU) with the cooperation of gastroenterology and hepatology department of BSMMU during the period from July 2005 to June 2006. Patients having hepatitis for less than 6 months and those with clinically & biochemically diagnosed as an acute hepatitis case were included. Patients with history of cholecystectomy & with gall stones were excluded from the study. Following evaluation of 68 patients with suspected acute viral hepatitis, the clinical diagnosis was confirmed based on the laboratory findings. Eighteen patients were excluded from the study because they were lost in the follow up. Thirty (group 1) out of 50 patients were evaluated and studied with ultrasound within a week from the onset of symptom and/ or jaundice, the other 20 patients(group 2) were studied with ultrasound at a later phase of illness. All subjects were examined early in the morning after 12 hours of fasting by longitudinal, transverse and subcostal scan. All the patients were evaluated weekly intervals clinically, sonographically and biochemically up to recovery. All the data were analyzed by appropriate statistical method. Mean of the measurements were calculated and expressed as mean ± SD

Observations and Results: Thirty patients were studied within one weeks of onset of symptoms (group1), twenty patients entered the study 8-14 days after the onset of symptoms(group2). There was 34 men and 16 women in the study. The age was between 15 years to 50 years. Most of them were between 25 years to 35 years. Etiological factors included Hepatitis A virus in 36, Hepatitis B virus in 9 and Hepatitis E virus in 5 patients. Abnormal sonographic pattern in patients of acute hepatitis included thickened gallbladder wall and presence of sludge within the lumen of gall bladder and volume shrinkage of gall bladder. The most common abnormality was wall thickening, which was (8.07± 2.08)mm in 28 (93.3%) patients within 0 to 7 days of illness,(5.16±1.62)mm in 40 (80%) patients within 8 to 14 days of illness,(3.62± 1.07)mm in 25 (50%) patients within 15 to 21 days of illness. Gall bladder wall thickness in different weeks is shown in table I. By ‘t’ test it was observed that the mean gall bladder wall thickness was more in group 1 i.e. within 1st week of hepatitis than in group 2 which was statistically significant (p‹ 0.001). The mean gall bladder wall thickness was 8.07mm in group 1 and 4.95 mm in group 2.Serological tests were done (anti HAV IgM, HBsAg, AntiHCV, AntiHEVIgM) for the confirmation of type of virus. Gall bladder

Table-I

Mean Median

Gallbladder wall thickening within 7 days(in mm) 8.07

Gallbladder wall thickening within 8 to 14 days(in mm) 5.16

Gallbladder wall thickening within 15 to 21 days(in mm) 3.62

8.0

5.00

3.50

2.08

5

1.07

Minimum

3

2

2

Maximum

14

8

6

Standard deviation(SD)

52

Bangladesh Journal of Radiology and Imaging

wall thickening was seen in all patients irrespective of type of jaundice. Chi-square test was done to study any relation between the type of viral agent with the gall bladder wall thickness. It was observed that chi-square value =1.30 & p=0.52 in the 1st week, chi-square value = 0.56,p =0.76 in the 2nd week and chi-square value =0.31 & p=0.86 in the 3rd week. The degree of thickness of gall bladder wall was not related to etiological agent causing hepatitis. It was observed that gall bladder wall thickness, gall bladder sludge as well as volume shrinkage were more frequent in the 1st than the 2nd group (p‹0.001). On follow up, the patients were evaluated at weekly intervals due to the rapid clinical and sonographic resolution. It was observed that a time dependent normalization of sonographic pattern occurred along with clinical and biochemical resolution. Complete resolution of sonographic pattern was observed in 8 patients after 28 days. The remaining patients had complete normalization before this. Discussion: Ultrasonography is a popular method of evaluating acute hepatitis. Clinically, biochemically and serologically diagnosed 50 cases were included in this study. S.bilirubin, alanin transaminase (ALT) level were measured. According to the study of Sharma et.al. (1991) Hepatitis A virus infection (HAV) was diagnosed by the demonstration IgMcAb and HBsAg. A diagnosis of non-A non-B hepatitis was made by exclusion of HAV and HBV infection. In this study abnormal sonographic pattern of gallbladder was studied in AVH (acute viral hepatitis) and abnormal sonographic pattern included• Increased gall bladder wall thickness (›3mm) • Abnormal content of gallbladder & • Volume shrinkage of gallbladder Maresca et. al.(1982) studied the sonographic alteration of gallbladder in patients with acute viral hepatitis in different phases of the disease and found similar findings2. In that study 26 (group 1) out of the 61 patients evaluated with ultrasound within a week from the onset of symptom and/or 53

Vol. 16(2) : July 2008

jaundice, the other 35 patients (group 2) were studied at a later phase. Subsequent serial examinations were performed for all patients every 7-10 days until recovery. During this period serum level of alanine transferase (ALT), bilirubin, alkaline phosphatase and albumin for all subjects also were determined. In this study 30 (group 1) out of the 50 patients evaluated and studied with ultrasound within a week from the onset of symptom/jaundice, the other 20 patients (group 2) were studied with ultrasound after the end of one week because they visited the physician at a later phase of illness. In normal fasting subjects the gallbladder wall appears as a thin echogenic line, thickness not exceeding 3 mm. Dharma et. Al. included 31 patients and 23 healthy control. A in normal subjects, the gallbladder wall measurement ranged from 1 to 3 mm with a mean value of 2.0(±0.06) mm4. Another study showed that sonography can be used to reliably measure the thickness of gall bladder wall and walls thicker than 3.5 mm would indicate disease5. An increased thickness of gall bladder wall has been observed in different physiological and pathological conditions and therefore cannot be regarded as a specific finding6.In conditions like after a meal or pharmacological stimulation (cholecystokinin) or protracted total parenteral feeding, gallbladder wall thickness may be increased. Furthermore, thickening of gallbladder wall may be observed in disease of the gallbladder (acute and chronic cholecystitis, neoplasm, adenomyometosis) and of biliary tree (obstructive jaundice), as well as in disease not affecting the biliary system(ascitis, hypoalbuminaemia, heart failure, cirrhosis). In this study, gallbladder was considered to be thickened in fasting subjects whenever its width exceed 3 mm. Pathophysiology of the gall bladder wall thickness during acute viral hepatitis is not clear. Hypoalbuminaemia, local extension of the hepatic inflammatory process, and elevated portal pressure all could be reflected in oedema of gall bladder wall7. A direct invasion of the gall bladder by the hepatitis virus has been documented8. They reported viral antigen was

Sonographic Evaluation of Gall Bladder in Acute Hepatitis

Banajaba et al

demonstrated in most epithelial cell of the gall bladder wall of a patient of acute hepatitis caused by HAV. They suggested that acute cholecystitis may be part of the spectrum of HAV infection.

dl in the 2nd week and 3.10±1.32 mg/dl in the 3rd week.

In this study abnormal sonographic patterns of gall bladder were found in 45(90%) of patients with AVH. The most common abnormality was increased gall bladder wall thickness which was found in 93.3% of patients in the 1st week, 80% of patients in the 2nd week and 50% of patients in the 3rd week. In the first week the thickness of the gall bladder wall was 8.07±2.08 mm, in the 2nd week it was 5.16±1.62 mm and in 3rd week it was 3.62±1.07 mm, with the progress of clinical symptoms the patients showed gradually decreasing gall bladder wall thickness. The thickened wall appeared to be three layers of the gall bladder wall with a middle hypoechoic rim. This wide middle rim seemed to be characteristic and the main cause of the increased wall thickness, probably as a result of submucosal oedema. Contraction of the size of gall bladder was found less frequently. It was present in the 35% of patients in the 1st week, 12% patients in the 2nd week and 2% of patients in the 3rd week of illness. Luminal sludge was frequently found. It was present in 33.33% in the 1st week, 10% of patients in the 2nd week and 2% of the 3rd week of illness. It was shown that all the abnormalities are more frequent among those patients who were examined within 7days after the onset of symptoms than those who were examined 8-14 days after the onset of symptoms (P