From the Guidelines
The management of adenomyomatosis of the gallbladder is primarily conservative for asymptomatic patients, with surgical intervention reserved for symptomatic cases. Asymptomatic adenomyomatosis discovered incidentally requires only regular monitoring with ultrasound every 6-12 months to assess for changes or complications. For patients experiencing symptoms such as right upper quadrant pain, nausea, or dyspepsia, cholecystectomy (surgical removal of the gallbladder) is the definitive treatment. Laparoscopic cholecystectomy is preferred over open surgery due to faster recovery times and fewer complications, as recommended by the 2020 World Society of Emergency Surgery guidelines for the diagnosis and treatment of acute calculus cholecystitis 1. Medical management with ursodeoxycholic acid (10-15 mg/kg/day) may provide temporary symptom relief but does not treat the underlying condition. Pain management with NSAIDs like ibuprofen (400-600 mg every 6 hours) or acetaminophen (500-1000 mg every 6 hours) can be used for symptomatic relief while awaiting surgery. Dietary modifications including low-fat diet and avoiding trigger foods may help reduce symptoms. The rationale for conservative management in asymptomatic cases is that adenomyomatosis is a benign, non-neoplastic condition with very low malignant potential, while surgical intervention for symptomatic cases addresses the mechanical and inflammatory issues causing pain and discomfort. It is essential to consider the patient's treatment goals and attitudes, as well as the potential risks and benefits of each treatment option, when making a decision about management, as outlined in the guidelines for the treatment of gallstones by the American College of Physicians 1.
From the Research
Management Approach for Adenomyomatosis of the Gallbladder
The management approach for adenomyomatosis of the gallbladder involves several key considerations, including:
- Diagnosis: Imaging techniques such as high-resolution ultrasound, MRI, and CT scans can confirm the diagnosis of gallbladder adenomyomatosis without the need for invasive procedures like vesicular biopsy 2.
- Symptomatic vs. Asymptomatic: Symptomatic adenomyomatosis is an indication for cholecystectomy, which results in complete disappearance of symptoms 3.
- Type of Adenomyomatosis: There are three types of adenomyomatosis: fundal, segmental, and diffuse. Cholecystectomy may be considered for segmental type due to its increased risk of malignancy and for diffuse type due to its difficult visualization of any coexisting malignancy 4.
- Diagnostic Doubt: If there is any diagnostic doubt about the possibility of gallbladder cancer, a cholecystectomy is justified 2, 3.
Treatment Options
Treatment options for adenomyomatosis of the gallbladder include:
- Cholecystectomy: Laparoscopic cholecystectomy is the gold standard for symptomatic adenomyomatosis or radiological suspicion of gallbladder cancer 2.
- Wait-and-see Policy: In selected asymptomatic patients, a wait-and-see policy is a viable alternative, with scheduled follow-ups 5.
- Observation: Asymptomatic fundal adenomyomatosis can be safely observed with ultrasound, although the frequency and duration of monitoring are unknown 4.
Key Considerations
Key considerations in the management of adenomyomatosis of the gallbladder include:
- The potential risk of malignancy associated with adenomyomatosis, particularly in segmental and diffuse types 4, 5.
- The importance of accurate diagnosis to avoid overlooked malignancy 2, 4.
- The need for individualized management approaches based on patient symptoms, adenomyomatosis type, and diagnostic certainty 2, 4, 5, 3.