What is the treatment for gallbladder adenomyomatosis?

Treatment of Gallbladder Adenomyomatosis

Gallbladder adenomyomatosis is a benign condition that typically requires cholecystectomy only when symptomatic or when malignancy cannot be excluded. 1

Understanding Gallbladder Adenomyomatosis

Gallbladder adenomyomatosis (GA) is a benign proliferative condition of the gallbladder characterized by:

• Epithelial proliferation and thickening of the gallbladder wall
• Formation of mucosal pouches (Rokitansky-Aschoff sinuses) that extend through the thickened muscular layer
• Occurs in three patterns: diffuse, segmental, and localized (with localized being most common at 48%, followed by diffuse and segmental at 26% each) 2

Diagnostic Approach

Accurate diagnosis is essential to avoid unnecessary cholecystectomies. The Society of Radiologists in Ultrasound (SRU) consensus recommends:

1. Ultrasound (US) as the primary diagnostic tool:

   • High-frequency probes with precise focal depth adjustment can identify GA in most cases 3
   • Look for characteristic wall thickening and Rokitansky-Aschoff sinuses (RAS)

2. Contrast-enhanced ultrasound (CEUS) if RAS cannot be clearly identified on baseline US:

   • RAS appear avascular regardless of their content 3

3. MRI as a problem-solving technique for unclear cases:

   • Can definitively diagnose adenomyomatosis by demonstrating cystic-like Rokitansky-Aschoff sinuses 1
   • High sensitivity for RAS identification, though signal intensity varies based on content 3

4. CT has inferior diagnostic accuracy compared to CEUS or MRI for this purpose 1

Treatment Algorithm

1. For asymptomatic adenomyomatosis:

   • Observation is generally appropriate
   • Regular follow-up with ultrasound may be considered

2. For symptomatic adenomyomatosis:

   • Cholecystectomy is the treatment of choice 4, 2
   • Symptoms typically include dull pain in the right upper quadrant

3. For adenomyomatosis with concerning features:

   • Cholecystectomy is recommended when:
     • Malignancy cannot be excluded
     • Associated with gallstones (occurs in up to 84% of cases) 2
     • Progressive growth on follow-up imaging

Special Considerations

• While GA is predominantly a benign condition, there is a theoretical risk of malignant transformation, though this is extremely rare 2
• Prophylactic laparoscopic cholecystectomy may be justified in some cases due to:
  • Uncertain natural history of the disease
  • Difficulty in differentiating from malignant lesions in some cases 2
  • Association with gallstones, which may cause chronic inflammation

Pitfalls to Avoid

1. Misdiagnosis: GA can be misinterpreted as chronic cholecystitis or gallbladder cancer on imaging

   • Ensure proper identification of Rokitansky-Aschoff sinuses, which are pathognomonic for GA 3

2. Unnecessary surgery: Not all cases of GA require surgical intervention

   • Asymptomatic cases without concerning features can often be monitored

3. Inadequate imaging: Using inappropriate imaging techniques may lead to misdiagnosis

   • Follow the recommended imaging pathway (US → CEUS → MRI) for optimal diagnosis 1, 3

4. Overlooking associated conditions: GA is frequently associated with gallstones (84%), which may be the actual cause of symptoms 2

In summary, while gallbladder adenomyomatosis is generally benign, symptomatic cases or those with concerning features should be treated with cholecystectomy. Accurate diagnosis through appropriate imaging is crucial to avoid unnecessary surgery while ensuring proper treatment for symptomatic patients.