Cholelithiasis – the role of ultrasound

11th December, NIA Diagnostic Imaging

biliary colic

Gallstones are commonly encountered in clinical practice, with a prevalence of approximately 10-15% in adults. They represent one of the most frequent causes of gastrointestinal dysfunction worldwide, contributing to both chronic and episodic pain syndromes (Jones et al., 2025). While many cases remain asymptomatic, gallstones can lead to significant morbidity when complications arise, making timely diagnosis essential for effective management.

What are gallstones?
Gallstones are crystallised concretions that form within the gallbladder from components of bile which are primarily cholesterol, bilirubin and calcium salts. They result from impaired gallbladder contractility, bile stasis
and excess cholesterol or bile salts (Jones et al., 2025).

What are the symptoms and risk factors?
Patients with gallstones may remain asymptomatic and only detected incidentally during imaging procedures. When symptomatic, the classic presentation is biliary colic, resulting from transient obstruction of the cystic duct.

Symptoms
● Intermittent right upper quadrant or epigastric pain, often triggered by fatty or greasy meals
● Nausea and vomiting
● Abdominal bloating
Risk factors
● Female sex
● Middle age (40–60 years)
● Obesity or rapid weight loss
● Pregnancy or oestrogen therapy
● Hyperlipidaemia
● Diabetes mellitus
● Family history of gallstones
(Jones et al., 2025)

What are the complications?
Untreated gallstones can cause a variety of complications due to obstruction, inflammation or infection of the biliary system. Prompt diagnosis is critical in preventing severe outcomes.
● Biliary colic
● Acute cholecystitis
● Choledocholithiasis
● Acute cholangitis
● Gallstone pancreatitis
(Evanson et al., 2025; Jones et al., 2025).

What is the role of ultrasound?

Ultrasound is the first-line imaging modality for the evaluation of suspected gallstones and biliary pathology. It is a useful imaging procedure for the detection of gallstones and evaluation of its mobility. On ultrasound, gallstones are characteristically echogenic and demonstrate posterior acoustic shadowing as seen in Figure 1 (Murphy et al., 2020). The ultrasound procedure also enables dynamic examination of gallstones where mobile stones will collect in the gallbladder’s dependent portion while impacted stones remain static (Evanson et al., 2025).

Advantages of ultrasound

Safe
Non-invasive
No ionising radiation
Readily available
Enable dynamic real-time imaging

Figure 1: Ultrasound image of the gallbladder with a gallstone, demonstrating the typical appearance of echogenic structure with posterior acoustic shadowing (arrow) (Murphy et al., 2020)

What is the treatment? Prompt diagnosis and treatment and management are critical to prevent severe outcomes. For symptomatic cases, laparoscopic cholecystectomy is standard treatment for recurrent or complicated gallstone disease which involves removal of the gallbladder (Jones et al., 2025).

At NIA Diagnostic Imaging, we perform comprehensive upper abdominal ultrasound examinations for patients with suspected gallstones or biliary pathology. Prompt and accurate ultrasound diagnosis facilitates timely referral and surgical management, improving patient outcomes.

References

Evanson DJ, Elcic L, Uyeda JW and Zufiqar M (2025) ‘Imaging of gallstones and complications’, Current problems in diagnostic radiology, 54(3): 392-403. https://doi.org/10.1067/j.cpradiol.2024.12.007

Jones MW, Weir CB and Marietta M (2025) Gallstones (cholelithiasis), StatPearls, accessed 14 October 2025, https://www.ncbi.nlm.nih.gov/books/NBK459370/

Murphy MC, Gibney B, Gillespie C, Hynes J and Bolster F (2020) ‘Gallstones top to toe: what the radiologist needs to know’, Insights into Imaging, 11(13). https://doi.org/10.1186/s13244-019-0825- 4

PFO Closure

Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991–

A multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.

Results:

Primary end point was 5.5% in the closure group as compared with 6.8% in the medical-therapy group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P = 0.37)

Conclusion:

“In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure

with a device did not offer a greater benefit than medical therapy alone for the

prevention of recurrent stroke or TIA”

2 Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017; 377: 1022–

A multicenter, randomised, open-label trial ,randomly assigned patients 18 to 60 years of age who had a patent foramen ovale (PFO) and had had a cryptogenic ischemic stroke to undergo closure of the PFO (PFO closure group) or to receive medical therapy alone (aspirin, warfarin, clopidogrel, or aspirin combined with extended-release dipyridamole; medical-therapy group). The primary efficacy end point was a composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomisation.

Results:

Recurrent ischemic stroke occurred in 18 patients in the PFO closure group and in 28 patients in the medical-therapy group, resulting in rates of 0.58 events per 100 patient-years and 1.07 events per 100 patient years, respectively (hazard ratio 0.55; 0.31 – 0.999; P = 0.046)

Conclusion:

“Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up.”

Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083–

A prospective, multicenter, randomised, event-driven trial, randomly assigned patients to medical therapy alone (anti-platelet or warfarin therapy) or closure of the patent foramen ovale.

Results:

9 patients in the closure group and 16 in the medical-therapy group had a recurrence of stroke (hazard ratio with closure, 0.49; 0.22 – 1.11; P = 0.08). The primary analysis of the intentionto- treat cohort showed a nominal 51% hazard rate reduction with closure, but the reduction did not reach significance.

Conclusions:

” …there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischaemic stroke.”

Sondergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377: 1033–

Multinational trial involving patients with a PFO who had had a cryptogenic stroke, randomly assigned patients to undergo PFO closure plus antiplatelet therapy or to receive antiplatelet therapy alone.

Results:

During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 0.09 to 0.62; P=0.002).

Conclusions:

“Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation.”

Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377: 1011–

In a multicenter, randomised, open-label trial patients 16-60 years of age who had had a recent stroke attributed to PFO, to transcatheter PFO closure plus long-term antiplatelet therapy, antiplatelet therapy alone or oral anticoagulation.

Results:

No stroke occurred among patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet- only group (hazard ratio, 0.03; 0 to 0.26; P<0.001). Large number of patients discontinued anti-coagulation in the anti-coagulant group and statistical significance was not analysed because the study was not adequately powered to compare outcomes.

Conclusion:

“Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation.”

Lee PH, Song J-K, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO Trial. J Am Coll Cardiol 2018; 71: 2335–

Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group.

Results:

No events occurred in the PFO closure group. 12.9% of patients in the medication group had an event (p= 0.023).

Conclusion:

“PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence”