Adenomyomatosis of the gallbladder
Updates to Article Attributes
Adenomyomatosis of the gallbladder is a hyperplastic cholesterolosischolestosis of the gallbladder wall. It is a relatively common and benign conditioncause of focal gallbladder wall thickening. It is most easily seen on ultrasound and MRI.
Epidemiology
Adenomyomatosis is relatively common, found in ~5% of all cholecystectomy specimens1-3 and is. It is typically seen in patients in their 5th decade. The incidence increases with age which may be the result of protracted inflammation (see below). There is a female predilection (M:F = 1:3).
It is most often an incidental finding, has no intrinsic malignant potential, and usually requires no treatment.
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 formation of intramural mucosal diverticula (Rokitansky-Aschoff sinuses) 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 (intramural diverticula lined by mucosal epithelium).
Radiographic features
Three morphological types of adenomyomatosis are described:
-
generalised (diffusefundal (localised) - segmental (annular)
-
fundal (localisedgeneralised (diffuse)- also termed adenomyoma
Ultrasound
- mural thickening (diffuse, focal, annular)
- focal mass is most concerning as it may be 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 nonspecific CT features of adenomyomatosis
- Rokitansky-Aschoff sinuses of sufficient size can be visualized; a CT rosary sign has been described, formed by enhancing epithelium within intramural diverticula surrounded by the relatively unenhanced hypertrophied gallbladder muscularis
Oral cholecystogram and MRCP
Historically oral cholecystograms were performed, however, due to low sensitivity and a high rate of contrast allergies it has now largely been replaced by MRCP which does not rely on contrast opacification of the lumen of the gallbladder. MRCP is also able to detect:
- mural thickening
- focal sessile mass
- pearl necklace sign (fluid filled intramural diverticula)
- hourglass configuration in annular types
MRI
-
pearl necklace sign
alludesrefers to the characteristically curvilinear arrangement of multiple rounded hyperintense intraluminal cavities visualized at T2-weighted MR imaging andMR cholangiopancreatography of adenomyomatosisMRCP 4
Treatment and prognosis
In general cholecystectomy isCholecystectomy 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)
- cholelithiasis
Exclusion of gallbladder cancer may be most problematic in segmental and focal cases.Focal Focal adenomyomatosis may appear as a discrete mass, known as an adenomyoma.
Metabolic characterisation with PET may be a useful adjunct in problematic cases 4.
-<p><strong>Adenomyomatosis of the gallbladder</strong> is a hyperplastic cholesterolosis of the <a href="/articles/gallbladder">gallbladder</a> wall. It is a relatively common and benign condition. It is most easily seen on ultrasound and MRI. </p><h4>Epidemiology</h4><p>Adenomyomatosis is relatively common, found in ~5% of all cholecystectomy specimens<sup>1-3</sup> and is typically seen in patients in their 5<sup>th</sup> decade. The incidence increases with age which may be 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, has no intrinsic malignant potential, and usually requires no treatment.</p><h4>Clinical presentation</h4><p>Adenomyomatosis per se is usually asymptomatic. It is however frequently associated with chronic biliary inflammation, most commonly <a title="gallstones" href="/articles/gallstones">gallstones</a> (25-75%) but also seen in cholesterolosis (33%) and <a title="pancreatitis" href="/articles/pancreatitis">pancreatitis</a> <sup>2</sup>.</p><h4>Pathology</h4><p>Adenomyomatosis is one of the <a href="/articles/hyperplastic-cholecystoses">hyperplastic cholecystoses</a>. There is hyperplasia of the wall with formation of intramural mucosal diverticula (<a href="/articles/rokitansky-aschoff-sinuses">Rokitansky-Aschoff sinuses</a>) 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 <a href="/articles/rokitansky-aschoff-sinuses">Rokitansky-Aschoff sinuses</a> (intramural diverticula lined by mucosal epithelium).</p><h4>Radiographic features</h4><p>Three morphological types of adenomyomatosis are described:</p><ol>-<li>generalised (diffuse)</li>- +<p><strong>Adenomyomatosis of the gallbladder</strong> is a hyperplastic cholestosis of the <a href="/articles/gallbladder">gallbladder</a> wall. It is a relatively common and benign cause of <a href="/articles/focal-gallbladder-wall-thickening-differential">focal gallbladder wall thickening</a>. It is most easily seen on ultrasound and MRI. </p><h4>Epidemiology</h4><p>Adenomyomatosis is relatively common, found in ~5% of all cholecystectomy specimens <sup>1-3</sup>. It is typically seen in patients in their 5<sup>th</sup> decade. The incidence increases with age which may be 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, has no intrinsic malignant potential, and usually requires no treatment.</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">gallstones</a> (25-75%) but also seen in cholesterolosis (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 formation of intramural mucosal diverticula (<a href="/articles/rokitansky-aschoff-sinuses">Rokitansky-Aschoff sinuses</a>) 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 <a href="/articles/rokitansky-aschoff-sinuses">Rokitansky-Aschoff sinuses</a> (intramural diverticula lined by mucosal epithelium).</p><h4>Radiographic features</h4><p>Three morphological types of adenomyomatosis are described:</p><ul>
- +<li>fundal (localised)</li>
-<li>fundal (localised) - also termed adenomyoma</li>-</ol><h5>Ultrasound</h5><ul>- +<li>generalised (diffuse)</li>
- +</ul><h5>Ultrasound</h5><ul>
-<a href="/articles/pearl-necklace-sign">pearl necklace sign</a> alludes to the characteristically curvilinear arrangement of multiple rounded hyperintense intraluminal cavities visualized at T2-weighted MR imaging and MR cholangiopancreatography of adenomyomatosis <sup>4</sup>-</li></ul><h4>Treatment and prognosis</h4><p>In general cholecystectomy is performed as a result of one or more of the following:</p><ul>- +<a href="/articles/pearl-necklace-sign">pearl necklace sign</a> refers to the characteristically curvilinear arrangement of multiple rounded hyperintense intraluminal cavities visualized at T2-weighted MR imaging and MRCP <sup>4</sup>
- +</li></ul><h4>Treatment and prognosis</h4><p>Cholecystectomy may be performed as a result of one or more of the following:</p><ul>
-<li><a href="/articles/cholesterol-poly-of-the-gallbladder">cholesterol polyp</a></li>- +<li>
- +<a title="Gallbladder polyp" href="/articles/gallbladder-polyp">gallbladder polyp</a> (cholesterol polyp)</li>
-</ul><p>Exclusion of <a href="/articles/benign-vs-malignant-features-of-gallbladder-polyps-1">gallbladder cancer</a> may be most problematic in segmental and focal cases. <a href="/articles/adenomyomatosis-of-the-gallbladder">Focal adenomyomatosis</a> may appear as a discrete mass, known as an adenomyoma.</p><p>Metabolic characterisation with PET may be a useful adjunct in problematic cases <sup>4</sup>.</p>- +</ul><p>Exclusion of <a href="/articles/benign-vs-malignant-features-of-gallbladder-polyps-1">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><p>Metabolic characterisation with PET may be a useful adjunct in problematic cases <sup>4</sup>.</p>
Tags changed:
- focal gallbladder wall thickening
- ultrasound
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