IS Case 189: Gallstones

Samuel Madoff, MD

Imaging Sciences URMC 2008
Publication Date: 2009-05-22


Patient is a 57-year-old female with fever.




The wall-echo-shadow (WES) sign is identified during right upper quadrant ultrasound examinations for suspected gallbladder disease. The finding signifies a gallbladder either distended with or collapsed around stone(s).

Specifically, the WES sign is composed of two parallel, curvilinear, echogenic lines defined by an intervening hypoechoic space. The near field echogenic line represents the gallbladder wall, while the deeper line is the surface of the gallstone(s). The hypoechoic layer sandwiched between the wall and the gallstones is attributed to bile. Acoustic shadowing deep to the far field echogenic line results from heterogeneous attenuation of the ultrasound beam by the gallstones.

The differential diagnosis includes a porcelain gallbladder and visualization of a bowel loop, commonly the duodenum, within the gallbladder fossa.

Notably, caution should be exercised to avoid passing off a WES sign as nothing more than a loop of bowel.


  1. Rybicki FJ. The WES Sign. Radiology. 2000 Mar;214(3):881-2. [PMID: 10715062]
  2. Dogra V, Rubens DJ (eds). Ultrasound Secrets. Philadelphia, PA: Hanley and Belfus; 2004

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