Which condition is most consistent with the findings in the image below?

The ultrasound image shows echogenic foci with dirty shadowing and reverberation artifacts within the gallbladder wall and lumen. These features are characteristic of emphysematous cholecystitis, a severe, life-threatening variant of acute cholecystitis caused by gas-forming organisms (e.g., Clostridium or E. coli) infecting the gallbladder wall.

Sonographic features of emphysematous cholecystitis:

Echogenic gas within the gallbladder wall or lumen

Reverberation or "dirty" shadowing artifacts

May show intramural gas bubbles or "ring-down" artifact

Often seen in diabetic or immunocompromised patients

No gallstones may be present ("acalculous cholecystitis")

Clinical context:

More common in elderly men and diabetics

Presents with right upper quadrant pain, fever, and leukocytosis

Surgical emergency due to risk of perforation and sepsis

Differentiation from other options:

A. Adenomyomatosis: Involves gallbladder wall thickening with “comet tail” artifacts due to Rokitansky-Aschoff sinuses, not intramural gas.

B. Porcelain gallbladder: Shows curvilinear calcification of the gallbladder wall — dense echogenic rim with posterior shadowing.

C. Gangrenous cholecystitis: May show wall irregularity, intraluminal membranes, and absence of Doppler flow but lacks intramural gas.