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Year : 1999  |  Volume : 9  |  Issue : 1  |  Page : 9-11
Sonographic sub-types of cholesterol gallstones among Indian patients : An initial experience

1 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi-110029, India
2 Department of Gastroentrology, All India Institute of Medical Sciences, New Delhi-110029, India

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Objectives : To study the ultrasound morphology of cholesterol calculi in Indian patients. Material and Methods : Twenty-seven patients of solitary gall stones were subjected to ultrasound. The sonographic morphology was categorized into five patterns. Stones obtained at surgery were subjected to estimation of cholesterol content. Results : All the stones showed cholesterol content of more than 70 gm %, hence were labeled as cholesterol calculi. Five sonographic patterns were documented (full moon 25.9%, half moon 25.9%, crescent 22.2%, comet tail 11.1%, no distinct pattern 14.8%). Conclusion : Cholesterol gallstones exhibit a heterogeneous sonographic appearance and fall into five distinct sub-types. Classification of patients into these sub-types may have a bearing on management.

Keywords: Gallstones, Cholesterol stones, Ultrasound morphology, Ultrasound sub-types

How to cite this article:
Paul SB, Berry M, Tandon RK. Sonographic sub-types of cholesterol gallstones among Indian patients : An initial experience. Indian J Radiol Imaging 1999;9:9-11

How to cite this URL:
Paul SB, Berry M, Tandon RK. Sonographic sub-types of cholesterol gallstones among Indian patients : An initial experience. Indian J Radiol Imaging [serial online] 1999 [cited 2020 Sep 26];9:9-11. Available from:
Gall stone disease is a relatively common problem in our country particularly in North India. It is estimated that more than sixty percent of these patients have cholesterol stones [1]. US is the modality of choice for diagnosing gall stones. A gall stone on US presents as an echogenic lesion in the dependent part of the gall bladder lumen, moving with change in the position of the patient and exhibiting posterior acoustic shadowing [2],[3].

The variable response of cholesterol calculi to oral dissolution drugs and extra-corporeal shock wave lithotripsy is well known [4],[5],[6]. This is due to differences in their density, composition and distribution of non-cholesterol constituents. Since US images also depend on the composition of the object, it is logical to postulate that different gallstones may have different sonographic characteristics when studied in finer detail. Indeed, Japanese workers have described sub-types of cholesterol stones on ultrasound [7],[8]. The present study was undertaken to evaluate the detailed ultrasonographic morphology of cholesterol gallstones among Indian patients.

   Materials & Methods Top


Twenty-seven symptomatic patients with solitary gallstones attending the out-patient clinics were subjected to US a week prior to surgery (laparoscopic or open cholecystectomy). Ultrasound was performed in the fasting state using a 3.5 MHz transducer (ATL, Ultramark 9 HDI, USA). An attempt was made to profile the calculus fully and delineate the acoustic shadowing clearly. Adapting the classification of Tsuchiya et al [7] and based on our pilot experience, the sonographic morphology of the stones was categorized into five sub-types, namely: (i) full moon, (ii) half moon (iii) crescent (iv) comet tail (v) others. The schematic drawings of the first four subtypes are shown in [Figure - 1]. The sonographic echopattern and the shadowing of the fifth subtype of 'others' showed bizarre appearances and could not be classified into any of the other four well-defined categories.

Chemical analysis of stones

Calculi of these patients obtained at surgery were subjected to biochemical analysis to estimate their cholesterol content. A stone with a cholesterol content of more than 70 gm percent was classified as a cholesterol calculus.

   Results Top

The average age of the patients was 38.7 years (range 22-74 years) with a man: woman ratio of 2:7. On analysis, all the 27 gallstones were proven to be cholesterol calculi.

The prevalence of the various sonographic sub-types is depicted in the Table. Full moon, half moon and crescent varieties were commonly encountered, while the comet tail pattern was seen relatively less frequently. Representative ultrasound pictures of different types of stones are shown in [Figure - 2].

   Discussion Top

It is evident from this study that cholesterol gallstones do not exhibit a uniform sonographic appearance, but have a variety of distinct patterns. The traditional description of a gallstone is that of an echogenic focus with posterior acoustic shadowing [2],[3]. The character of the shadowing helps us categorize cholesterol stones into distinct sub-types. Tsuchiya et al [7] described three sub-types of sonographic morphology (namely comet, half moon and crescent). Other workers have described two additional sonographic patterns, namely sonolucent and irregular [8],[9]. The description of these patterns is akin to our classification of full moon and others, respectively.

In the present study, full moon, half moon and crescent varieties were almost equally common, while the comet tail pattern was much less frequently documented. There is evidence that the comet tail variety of cholesterol stones is more susceptible to oral dissolution drugs and extracorporeal shock wave lithotripsy [7],[9]. Further investigations are required to confirm whether patients harboring other types of stones (these instances are more common), are less likely to be benefited from these modalities of treatment. This issue needs to be settled through a well-designed clinical trial and our observations from this initial study could form the basis for further evaluation.

   References Top

1.Tandon RK. Studies on pathogenesis of gall stones in India. Ann Nat Acad Med Sci (India) 1989; 25: 213-222.   Back to cited text no. 1    
2.Leopold GR, Amberg J, Gosink B, Mittelstaedt C. Gray scale ultrasonic cholecystography: a comparison with conventional radiographic techniques. Radiology 1976; 121: 445-448.   Back to cited text no. 2    
3.Arnon S, Rosenquist CJ. Gray scale cholecystosonography: an evaluation of accuracy. Am J Roengenol 1976; 127: 817-818.   Back to cited text no. 3  [PUBMED]  
4.Gleeson D, Ruppin DC, Saunders A, Murphy GM, Dowling RH. Final outcome of ursodeoxycholic acid treatment in 126 patients with radiolucent gallstones. Quartly J Med ( New series ) 1990; 76: 711-729.   Back to cited text no. 4  [PUBMED]  
5.Shoenfield LJ, Marks JW. Oral and contact dissolution of gallstones. Am J Surg 1993; 165: 427-430.   Back to cited text no. 5    
6.Shoenfield LJ, Berci G, Carnivale RL, et al. The effect of ursodiol on efficacy and safety of extracroporeal shock wave lithotripsy of gallstones: The Dornier national biliary lithotripsy study. N Engl J Med 1990; 323: 1239-1245.   Back to cited text no. 6    
7.Tsuchiya Y, Saito H, Saito N, et al. Sonographic patterns of radiolucent gall bladder stones for predicting successful shock wave lithotripsy. J. Gastroenterol Hepatol 1995; 10: 426-431.   Back to cited text no. 7    
8.Agarwal R. Sonographic assessment of gallstone disease. Indian J Radiol Imag 1996; 7: 37-44.   Back to cited text no. 8    
9.Ono Y, Ogawa M, Yamamoto Y, et al. A study of usefulness of echopatterns in dissolution therapy of gallstones. Ultrasonics International 1995; 1: 22-27.   Back to cited text no. 9    

Correspondence Address:
Manorama Berry
Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi-110029
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Source of Support: None, Conflict of Interest: None

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[Figure - 1], [Figure - 2]


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