Written by Chris Thom
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In this dual-site retrospective study, the authors found that gallbladder wall changes associated with cholecystitis progress dynamically and may not be present on initial ED POCUS.
The gallbladder wall changes with time
This retrospective study evaluated gallbladder wall changes (GWC) on patients with suspected cholecystitis at two medical centers. GWC was defined as gallbladder wall thickening or pericholecystic fluid. Patients who received POCUS by credentialed ED physicians formed the population for the study, and they were divided into three cohorts: those with baseline GWC on POCUS, those with dynamic GWC, and those with no GWC on POCUS or follow-up imaging. Dynamic GWC was defined as no GWC on initial POCUS, followed by later development of GWC on subsequent imaging.
352 patients were included, 100 (28.4%) with baseline GWC on POCUS and 252 (71.6%) without initial GWC. Among the 252 patients without initial GWC, 49 (19.4%) developed it during the hospitalization. These 49 were considered to have dynamic GWC. Patients without initial GWC, but with gallstones and a positive sonographic Murphy’s sign, had a high risk of developing dynamic GWC. For 89.4% of patients in the dynamic GWC group, these changes were identified within 24 hours.
How will this change my practice?
This study provides a helpful data point by establishing the dynamic changes that can be seen on ultrasound in cholecystitis. If the gallbladder wall is initially normal, but suspicion for acute cholecystitis remains high, repeat POCUS may be warranted. In addition, if subsequent radiology imaging is performed and GWC is present then, it does not necessarily indicate an error in the POCUS interpretation, as the changes may have developed in the interval between imaging studies.
POCUS pro-tips and clips
My preference for gallbladder imaging is almost always through the ribs, about halfway between the mix-axillary and mid-clavicular lines. Yes, you’ll have to navigate the rib shadows, but this will place the ultrasound probe in close proximity to the gallbladder neck. This area is the most likely to harbor the obstructing stones and is often poorly imaged from a purely subcostal approach. Another helpful trick is to have the patient do a large inspiratory breath hold, which can sometimes move the gallbladder caudal to a point where it can be more easily imaged.
Source
Evolution of Secondary Findings in Acute Cholecystitis: A Temporal Analysis from Point-of-Care Ultrasound to Subsequent Imaging. J Emerg Med. 2025 Nov;78:266-274. doi: 10.1016/j.jemermed.2025.03.020. Epub 2025 Mar 26. PMID: 41016303.
