Adenomyomatosis of the gallbladder

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Adenomyomatosis of the gallbladder is a hyperplastic cholecystosis of the gallbladder wall. It is a relatively common and benign cause of diffuse or focal gallbladder wall thickening, most easily seen on ultrasound and MRI.

Epidemiology

Adenomyomatosis is relatively common, found in ~9% of all cholecystectomy specimens ⁵⁶. It is typically seen in patients in their 5^th decade. The incidence increases with age, presumably the result of protracted inflammation (see below). There is a female predilection (M:F=1:3).

It is most often an incidental finding and usually requires no treatment. It may be found more often in chronically inflamed gallbladders (which are at higher risk for carcinoma), but it is not a premalignant lesion in itself ^56..

Clinical presentation

Adenomyomatosis per se is usually asymptomatic. It is, however, frequently associated with chronic biliary inflammation, most commonly gallstones (25-75%), but also seen in cholesterolosis (33%) and pancreatitis ².

Pathology

Adenomyomatosis is one of the hyperplastic cholecystoses. There is hyperplasia of the wall with the formation of Rokitansky-Aschoff sinuses (intramural diverticula lined by mucosal epithelium) penetrating into the muscular wall of the gallbladder, with or without gallbladder wall thickening. Cholesterol accumulation in adenomyomatosis is intraluminal, as cholesterol crystals precipitate in the bile trapped in Rokitansky-Aschoff sinuses.

Radiographic features

Three morphological types of adenomyomatosis are described:

fundal (localised)
segmental (annular)
generalised (diffuse)

Ultrasound

mural thickening (diffuse, focal, annular)
- segmental/annular form is especially difficult to distinguish from gallbladder carcinoma
comet-tail artifact: echogenic intramural foci from which emanate V-shaped comet tail reverberation artifacts are highly specific for adenomyomatosis, representing the unique acoustic signature of cholesterol crystals within the lumina of Rokitansky-Aschoff sinuses ⁴

CT

abnormal gallbladder wall thickening and enhancement are common but non-specific CT features of adenomyomatosis
Rokitansky-Aschoff sinuses of sufficient size can be visualised; a CT rosary sign has been described, formed by enhancing epithelium within intramural diverticula surrounded by the relatively unenhanced hypertrophied gallbladder muscularis

MRI

MRCP is the technique usually employed for the gallbladder and biliary tree characterisation. Imaging features include:

mural thickening
focal sessile mass
fluid-filled intramural diverticula
- pearl necklace sign refers to the characteristically curvilinear arrangement of multiple rounded hyperintense intramural cavities visualised on T2-weighted MR imaging and MRCP ⁴
hourglass configuration in annular types⁵

Nuclear medicine

PET-CT

Metabolic characterisation with FDG PET has been suggested as a useful adjunct in problematic cases ⁴, but there have also been cases with increased uptake in areas of adenomyomatosis, leading to false positive results ⁶⁷

Treatment and prognosis

Cholecystectomy may be performed as a result of one or more of the following:

patient symptomatic with right upper quadrant pain (often due to gallstones)
appearances (especially when focal) may be difficult to distinguish from malignancy

Differential diagnosis

General imaging differential considerations include:

gallbladder carcinoma
Phrygian cap
gallbladder polyp (cholesterol polyp)
- cholesterolosis: mucosal hyperplasia with the accumulation of cholesterol esters and triglycerides in the lamina propria macrophages (cf. intraluminal accumulation seen in adenomyomatosis)
cholelithiasis
papillomatosis ⁸

Exclusion of gallbladder cancer may be most problematic in segmental and focal cases. Focal adenomyomatosis may appear as a discrete mass, known as an adenomyoma.

-<p><strong>Adenomyomatosis of the gallbladder</strong> is a <a href="/articles/gallbladder-cholecystosis-1">hyperplastic cholecystosis</a> of the <a href="/articles/gallbladder">gallbladder</a> wall. It is a relatively common and benign cause of <a href="/articles/diffuse-gallbladder-wall-thickening-differential">diffuse</a> or <a href="/articles/focal-gallbladder-wall-thickening-differential">focal gallbladder wall thickening</a>, most easily seen on ultrasound and MRI. </p><h4>Epidemiology</h4><p>Adenomyomatosis is relatively common, found in ~9% of all cholecystectomy specimens <sup>5</sup>. It is typically seen in patients in their 5<sup>th</sup> decade. The incidence increases with age, presumably the result of protracted inflammation (see below). There is a female predilection (M:F=1:3).</p><p>It is most often an incidental finding and usually requires no treatment. It may be found more often in chronically inflamed gallbladders (which are at higher risk for carcinoma), but it is not a <a title="premalignant" href="/articles/premalignant">premalignant</a> lesion in itself <sup>5</sup>.</p><h4>Clinical presentation</h4><p>Adenomyomatosis per se is usually asymptomatic. It is, however, frequently associated with chronic biliary inflammation, most commonly <a href="/articles/gallstones-1">gallstones</a> (25-75%), but also seen in <a href="/articles/gallbladder-wall-cholesterolosis">cholesterolosis</a> (33%) and <a href="/articles/pancreatitis">pancreatitis</a> <sup>2</sup>.</p><h4>Pathology</h4><p>Adenomyomatosis is one of the hyperplastic cholecystoses. There is hyperplasia of the wall with the formation of <a href="/articles/rokitansky-aschoff-sinuses">Rokitansky-Aschoff sinuses</a> (intramural diverticula lined by mucosal epithelium) penetrating into the muscular wall of the gallbladder, with or without gallbladder wall thickening. Cholesterol accumulation in adenomyomatosis is intraluminal, as cholesterol crystals precipitate in the bile trapped in Rokitansky-Aschoff sinuses.</p><h4>Radiographic features</h4><p>Three morphological types of adenomyomatosis are described:</p><ul>
+<p><strong>Adenomyomatosis of the gallbladder</strong> is a <a href="/articles/gallbladder-cholecystosis-1">hyperplastic cholecystosis</a> of the <a href="/articles/gallbladder">gallbladder</a> wall. It is a relatively common and benign cause of <a href="/articles/diffuse-gallbladder-wall-thickening-differential">diffuse</a> or <a href="/articles/focal-gallbladder-wall-thickening-differential">focal gallbladder wall thickening</a>, most easily seen on ultrasound and MRI. </p><h4>Epidemiology</h4><p>Adenomyomatosis is relatively common, found in ~9% of all cholecystectomy specimens <sup>6</sup>. It is typically seen in patients in their 5<sup>th</sup> decade. The incidence increases with age, presumably the result of protracted inflammation (see below). There is a female predilection (M:F=1:3).</p><p>It is most often an incidental finding and usually requires no treatment. It may be found more often in chronically inflamed gallbladders (which are at higher risk for carcinoma), but it is not a <a href="/articles/premalignant">premalignant</a> lesion in itself <sup>6.</sup></p><h4>Clinical presentation</h4><p>Adenomyomatosis per se is usually asymptomatic. It is, however, frequently associated with chronic biliary inflammation, most commonly <a href="/articles/gallstones-1">gallstones</a> (25-75%), but also seen in <a href="/articles/gallbladder-wall-cholesterolosis">cholesterolosis</a> (33%) and <a href="/articles/pancreatitis">pancreatitis</a> <sup>2</sup>.</p><h4>Pathology</h4><p>Adenomyomatosis is one of the hyperplastic cholecystoses. There is hyperplasia of the wall with the formation of <a href="/articles/rokitansky-aschoff-sinuses">Rokitansky-Aschoff sinuses</a> (intramural diverticula lined by mucosal epithelium) penetrating into the muscular wall of the gallbladder, with or without gallbladder wall thickening. Cholesterol accumulation in adenomyomatosis is intraluminal, as cholesterol crystals precipitate in the bile trapped in Rokitansky-Aschoff sinuses.</p><h4>Radiographic features</h4><p>Three morphological types of adenomyomatosis are described:</p><ul>
-<a href="/articles/comet-tail-artifact-3">comet-tail artifact</a>: echogenic intramural foci from which emanate V-shaped comet tail reverberation artifacts are highly specific for adenomyomatosis, representing the unique acoustic signature of cholesterol crystals within the lumina of Rokitansky-Aschoff sinuses <sup>4</sup>
+<a href="/articles/comet-tail-artifact-4">comet-tail artifact</a>: echogenic intramural foci from which emanate V-shaped comet tail reverberation artifacts are highly specific for adenomyomatosis, representing the unique acoustic signature of cholesterol crystals within the lumina of Rokitansky-Aschoff sinuses <sup>4</sup>
~~-<li>hourglass configuration in annular types</li>~~
-</ul><h5>Nuclear medicine</h5><h6>PET-CT</h6><p>Metabolic characterisation with FDG PET has been suggested as a useful adjunct in problematic cases <sup>4</sup>, but there have also been cases with increased uptake in areas of adenomyomatosis, leading to false positive results <sup>6</sup></p><h4>Treatment and prognosis</h4><p>Cholecystectomy may be performed as a result of one or more of the following:</p><ul>
+<li>hourglass configuration in annular types <sup>5</sup>
+</li>
+</ul><h5>Nuclear medicine</h5><h6>PET-CT</h6><p>Metabolic characterisation with FDG PET has been suggested as a useful adjunct in problematic cases <sup>4</sup>, but there have also been cases with increased uptake in areas of adenomyomatosis, leading to false positive results <sup>7</sup></p><h4>Treatment and prognosis</h4><p>Cholecystectomy may be performed as a result of one or more of the following:</p><ul>
-</ul><p>Exclusion of <a href="/articles/gallbladder-malignancy">gallbladder cancer</a> may be most problematic in segmental and focal cases. Focal adenomyomatosis may appear as a discrete mass, known as an adenomyoma.</p>
+</ul><p>Exclusion of <a href="/articles/gallbladder-cancer-2">gallbladder cancer</a> may be most problematic in segmental and focal cases. Focal adenomyomatosis may appear as a discrete mass, known as an adenomyoma.</p>

References changed:

5. Wong H & Lee K. The Hourglass Gallbladder. Abdom Radiol (NY). 2018;43(5):1268-9. <a href="https://doi.org/10.1007/s00261-017-1273-6">doi:10.1007/s00261-017-1273-6</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28765977">Pubmed</a>
6. Mellnick V, Menias C, Sandrasegaran K et al. Polypoid Lesions of the Gallbladder: Disease Spectrum with Pathologic Correlation. Radiographics. 2015;35(2):387-99. <a href="https://doi.org/10.1148/rg.352140095">doi:10.1148/rg.352140095</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/25763724">Pubmed</a>
7. Maldjian PD, Ghesani N, Ahmed S et-al. Adenomyomatosis of the gallbladder: another cause for a "hot" gallbladder on 18F-FDG PET. AJR Am J Roentgenol. 2007;189 (1): W36-8. <a href="http://dx.doi.org/10.2214/AJR.05.1284">doi:10.2214/AJR.05.1284</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/17579133">Pubmed citation</a><span class="auto"></span>
8. Bonatti M, Vezzali N, Lombardo F et al. Gallbladder Adenomyomatosis: Imaging Findings, Tricks and Pitfalls. Insights Imaging. 2017;8(2):243-53. <a href="https://doi.org/10.1007/s13244-017-0544-7">doi:10.1007/s13244-017-0544-7</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28127678">Pubmed</a>
8. Boscak AR, Al-Hawary M, Ramsburgh SR. Best cases from the AFIP: Adenomyomatosis of the gallbladder. (2006) Radiographics : a review publication of the Radiological Society of North America, Inc. 26 (3): 941-6. <a href="https://doi.org/10.1148/rg.263055180">doi:10.1148/rg.263055180</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16702464">Pubmed</a> <span class="ref_v4"></span>
5. Mellnick VM, Menias CO, Sandrasegaran K et-al. Polypoid lesions of the gallbladder: disease spectrum with pathologic correlation. Radiographics. 2015;35 (2): 387-99. <a href="http://dx.doi.org/10.1148/rg.352140095">doi:10.1148/rg.352140095</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/25763724">Pubmed citation</a><span class="auto"></span>
6. Maldjian PD, Ghesani N, Ahmed S et-al. Adenomyomatosis of the gallbladder: another cause for a "hot" gallbladder on 18F-FDG PET. AJR Am J Roentgenol. 2007;189 (1): W36-8. <a href="http://dx.doi.org/10.2214/AJR.05.1284">doi:10.2214/AJR.05.1284</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/17579133">Pubmed citation</a><span class="auto"></span>
7. Bonatti M, Vezzali N, Lombardo F, et al. Gallbladder adenomyomatosis: imaging findings, tricks and pitfalls. (2017) Insights into imaging. 8 (2): 243-253. <a href="https://doi.org/10.1007/s13244-017-0544-7">doi:10.1007/s13244-017-0544-7</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28127678">Pubmed</a> <span class="ref_v4"></span>

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