In clinical practice, a cut off of 3mm is commonly used to define the upper limit of normal gall bladder wall thickness and acute cholecystitis is one thing that comes to our mind when we see increased wall thickness. Along with a compatible clinical picture, ultrasonographic features that suggest acute cholecystitis are a distended gallbladder, thickened walls, biliary sludge and lithiasis, pericholecystic fluid and the sonographic Murphy’s sign, which is defined as maximal abdominal tenderness from pressure of the ultrasound probe over the visualized gallbladder.

However, this is not the only condition that causes gall bladder wall thickening. As POCUS is not necessarily performed in a fasting patient, we must be aware that the gall bladder wall is thick in non-fasting state. In addition, any systemic disease associated with generalized hypervolemia such as congestive heart failure can lead to gall bladder wall thickening. In these patients, think of alternate etiology if the clinical picture does not fit. The presence of gall stones also does not mean much if there are no symptoms. Following image shows thickened gall bladder wall and ascites in a patient with congestive heart failure exacerbation. Note that the liver floating in ascites appears like a fish with gall bladder as its mouth. Though the wall diameter is measured in transverse plane in this example, it is generally recommended to be measured in long axis, and of the anterior wall (the one on the top).