To determine how often color doppler Ultrasound twinkling artifact is seen in various gallbladder pathologies and to determine if it can be used to distinguish between them.

A total of 486 consecutive patients were prospectively studied with abdominal ultrasound. Grey-scale and color doppler images of all gallbladder walls and stones were obtained with the addition of spectral doppler in select cases. Each case was categorized as to whether the gallbladder wall was thin or thick, focally or diffusely thick, whether stones were present and whether comet-tail and twinkling artifact was seen. Relevant clinical data and the final ultrasound interpretation were noted. Pathologic follow-up is in progress.

No normal appearing thin wall twinkled (n•332). The comet-tail artifact was seen in 49 patients, 42 (85.7%) of which twinkled. Only 4.5% (2 of 44) of polyps twinkled. Thirty seven (27.8%) of 133 patients with gallstones twinkled. When the wall was thick and no comet-tails were seen, 3 (2.7%) of 112 twinkled. Three of 3 cancers did not twinkle. In 3 cases of wall thickening, twinkling was seen in the absence of comet-tails. In 5 cases, twinkling led to the discovery of subtle comet-tails which had previously been difficult to confirm; this discovery significantly altered the final ultrasound interpretation.

Twinkling is highly associated with comet-tail artifact (p<0.001) in the gallbladder wall (the latter having a known association with adenomyomatosis) and is infrequent in both normal and thick-walled gallbladders of various other etiologies. Twinkling can aid in the diagnosis of adenomyomatosis as it is often readily apparent even when comet-tails are absent or poorly seen and may help distinguish adenomyomatosis from other gallbladder pathologies.