Case Report

A 53-year-old woman, previously healthy, with no relevant past medical history, no regular medication and no known drug allergies, presented with a 3-month history of abdominal pain and unintentional weight loss with no other relevant complaints. Laboratory workup revealed a cholestatic pattern with markedly elevated alkaline phosphatase (550 U/L) and gamma-glutamyl transferase (430 U/L), alongside a significantly raised CA 19-9 (>12,000 U/mL).

B-mode ultrasound revealed multiple hepatic nodular lesions, predominantly in the left segments, several with central anechoic content (Figure 1A). On CEUS, all lesions demonstrated homogeneous arterial hyperenhancement followed by early portal-phase washout (Figure 1B), becoming progressively hypoechoic relative to the surrounding parenchyma, with marked and persistent washout on the late phase (Figure 1C). Gallbladder wall thickening was additionally identified (Figure 1D).

Figure 1A. Multiple hepatic nodular lesions, predominantly in the left segments, several with central anechoic content.

Figure 1B. Lesions with early portal-phase washout.

Figure 1C. Lesions with persistent washout on the late phase.

Figure 1D. Gallbladder wall thickening.

Based on the clinical presentation and ultrasound findings, what is the most likely diagnosis?

Submeter

Upper endoscopy and total colonoscopy were unremarkable. Abdominal CT and MRI demonstrated diffuse hepatic lesions but were inconclusive regarding the primary tumour site. Given the diagnostic uncertainty, a percutaneous ultrasound-guided liver biopsy was performed.

Two hours post-biopsy, the patient developed diffuse abdominal pain and haemodynamic instability. Bedside ultrasound demonstrated a peri-hepatic fluid collection (Figure 2A), and urgent contrast-enhanced CT confirmed a subcapsular haematoma along the anterior aspect of hepatic segments 4/5 (Figure 2B). The patient was managed conservatively.

Figure 2A. Subcapsular liver haematoma on US-imaging.

Figure 2B. Subcapsular liver haematoma on CT-imaging.

Histology confirmed a poorly differentiated adenocarcinoma consistent with a biliary tract/gallbladder primary. First-line systemic therapy with cisplatin and gemcitabine was initiated.

Discussion

This case illustrates an advanced gallbladder carcinoma — a rare but aggressive malignancy, often diagnosed at an advanced stage due to its insidious clinical course. The combination of cholestatic liver enzymes, markedly elevated CA 19-9, and diffuse hepatic lesions in a middle-aged woman without a gastrointestinal primary should always prompt consideration of biliary tract malignancy.

The CEUS pattern was pivotal for lesion characterization. Homogeneous arterial hyperenhancement followed by early portal-phase washout and marked, persistent late-phase washout is the hallmark of hepatic metastases, as defined by WFUMB/EFSUMB guidelines. This distinguishes metastatic disease from hepatocellular carcinoma — which typically demonstrates late, less pronounced washout — and from intrahepatic cholangiocarcinoma, which shows peripheral progressive rim-like enhancement. Gallbladder wall thickening on B-mode was the critical finding directing identification of the primary site.

CT and MRI, despite demonstrating diffuse hepatic disease, failed to characterize the primary tumour conclusively, underscoring the complementary role of ultrasound and CEUS in this setting. Percutaneous ultrasound-guided liver biopsy provided the essential histological diagnosis, confirming poorly differentiated adenocarcinoma of biliary origin. However, the procedure was complicated by a clinically significant subcapsular haematoma. In fact, haemorrhagic complications occur in 0.5–1% of percutaneous liver biopsies and, while most resolve conservatively, close clinical and imaging surveillance is mandatory.

References

1. Dietrich CF, Nolsøe CP, Barr RG, Berzigotti A, Burns PN, Cantisani V, et al. Guidelines and good clinical practice recommendations for contrast-enhanced ultrasound (CEUS) in the liver—update 2020 WFUMB in cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultrasound Med Biol. 2020;46(10):2579–2604. doi:10.1016/j.ultrasmedbio.2020.04.030
2. Möller K, Stock B, Ignee A, Safai Zadeh E, De Molo C, Serra C, et al. Comments and illustrations of the WFUMB CEUS liver guidelines: rare focal liver lesions—non-infectious, non-neoplastic. Med Ultrason. 2023;25(4):435–444. doi:10.11152/mu-4192
3. Cocco G, Delli Pizzi A, Basilico R, Fabiani S, Taraschi AL, Pascucci L, et al. Imaging of gallbladder metastasis. Insights Imaging. 2021;12(1):100. doi:10.1186/s13244-021-01049-8
4. Waller GC, Sarpel U. Gallbladder cancer. Surg Clin North Am. 2024;104(6):1263–1280. doi:10.1016/j.suc.2024.03.006

Authors

Joana Frias, Rosa Coelho, Guilherme Macedo

ULS São João, Gastroenterology Department