What is adenomyomatosis?

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Adenomyomatosis of the Gallbladder

Adenomyomatosis is a benign, degenerative condition of the gallbladder characterized by excessive epithelial proliferation and hypertrophy of the muscularis propria, forming intramural diverticula called Rokitansky-Aschoff sinuses. 1

Definition and Pathology

Adenomyomatosis is defined as a mural hyperplasia that may be diffuse, focal, or segmental with specific imaging characteristics including:

  • Thickened gallbladder wall containing small bile-filled cystic spaces (Rokitansky-Aschoff sinuses)
  • "Comet-tail" artifacts on gray-scale ultrasound
  • "Twinkling" artifacts on color Doppler imaging 1

These sinuses contain concentrated bile that may undergo crystal precipitation and calcification over time. The condition represents a non-neoplastic proliferative process rather than a true tumor.

Classification

Adenomyomatosis can be classified into three types:

  1. Fundal type: Focal thickening involving only the gallbladder fundus
  2. Segmental type: Circumferential wall thickening that creates separate compartments
  3. Diffuse type: Generalized thickening and irregularity of the mucosa and muscularis throughout the gallbladder 2

Clinical Presentation

Most patients with adenomyomatosis remain asymptomatic, with the condition often discovered incidentally during imaging for other reasons. When symptomatic, patients may experience:

  • Right upper quadrant pain (most common symptom)
  • Dyspepsia
  • Symptoms mimicking biliary colic 3, 4

The prevalence is estimated at 1-9% of the general population, typically occurring in middle age with equal distribution between sexes 2.

Diagnostic Imaging

Ultrasound (First-line imaging)

  • High-frequency probes with precise focal depth adjustment
  • Thickened gallbladder wall with small anechoic spaces (Rokitansky-Aschoff sinuses)
  • Characteristic "comet-tail" artifacts
  • "Twinkling" artifacts on color Doppler 5

Contrast-Enhanced Ultrasound (CEUS)

  • Helpful when RAS cannot be clearly identified on conventional ultrasound
  • RAS appear avascular regardless of their content 5

Magnetic Resonance Imaging (MRI)

  • Reserved for unclear cases
  • "Pearl-necklace sign" - high signal intensity foci within the thickened gallbladder wall
  • High sensitivity for detecting Rokitansky-Aschoff sinuses 1, 5

Computed Tomography (CT)

  • Not routinely indicated
  • May show "rosary sign" when performed 2

Management

Management depends on symptoms and type of adenomyomatosis:

  1. Symptomatic adenomyomatosis (any type): Cholecystectomy is recommended 2

  2. Asymptomatic adenomyomatosis:

    • Fundal type: Observation with ultrasound is generally safe
    • Segmental type: Consider cholecystectomy due to increased risk of malignancy
    • Diffuse type: Consider cholecystectomy due to difficulty visualizing any coexisting malignancy 2

Differential Diagnosis

Adenomyomatosis must be distinguished from:

  • Gallbladder polyps
  • Gallbladder carcinoma
  • Tumefactive sludge
  • Focal wall thickening from other causes 1

Relationship to Malignancy

While adenomyomatosis is generally considered benign, there is a theoretical concern about malignant potential, particularly with the segmental type. However, the actual risk of malignant transformation is very low. In cases of diagnostic uncertainty, cholecystectomy should be considered to exclude malignancy 2.

Monitoring

For asymptomatic fundal adenomyomatosis being managed conservatively:

  • Regular ultrasound follow-up is recommended
  • The optimal frequency and duration of monitoring remain undefined
  • Any change in symptoms or imaging appearance should prompt reevaluation 2

In cases of diagnostic doubt between adenomyomatosis and other gallbladder pathologies, additional imaging with CEUS or MRI should be considered before proceeding to cholecystectomy 1, 5.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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