What is the initial management for symptomatic mild adenomyomatosis?

Management of Symptomatic Mild Adenomyomatosis

For symptomatic mild gallbladder adenomyomatosis, cholecystectomy is the recommended treatment to completely eliminate symptoms. 1

Understanding Adenomyomatosis

Gallbladder adenomyomatosis (GA) is a benign, acquired condition characterized by:

• Excessive epithelial proliferation with hypertrophy of the muscularis propria
• Formation of intramural diverticula known as Rokitansky-Aschoff sinuses (RAS)
• Three recognized types: fundal, segmental, and diffuse

The condition occurs most commonly in middle-aged adults with equal gender distribution 2. While the exact pathogenesis remains unclear, chronic inflammation of the gallbladder appears to be a necessary precursor 1.

Diagnostic Features

Diagnosis is typically made through imaging studies:

• Ultrasound (US): First-line imaging modality showing:

  • Thickened gallbladder wall containing cysts
  • "Comet-tail" artifacts
  • "Twinkling" artifacts 2

• MRI with cholangiography sequences: Reference examination showing characteristic "pearl necklace" sign 1

• CT scan: May show "rosary sign" formed by enhanced proliferative mucosal epithelium with intramural diverticula 3

Management Algorithm for Symptomatic Adenomyomatosis

1. Symptomatic mild adenomyomatosis

   • Recommended treatment: Cholecystectomy
   • Expected outcome: Complete resolution of symptoms 1

2. Type-specific considerations:

   • Fundal type: Cholecystectomy for symptomatic cases
   • Segmental type: Cholecystectomy recommended (even if asymptomatic) due to increased risk of malignancy
   • Diffuse type: Cholecystectomy recommended due to difficulty visualizing any coexisting malignancy 2

Important Clinical Considerations

• Symptoms may include abdominal pain or hepatic colic, even without associated gallstones (which are present in 50-90% of cases)
• Adenomyomatosis can present as an attack of acalculous cholecystitis 1
• The condition is extremely rare in children and adolescents, with only a few reported cases 4, 5

Monitoring Recommendations

For asymptomatic fundal adenomyomatosis that is not surgically treated:

• Regular ultrasound monitoring is recommended
• However, optimal frequency and duration of monitoring remain undefined 2

Surgical Approach

Laparoscopic cholecystectomy is the standard surgical approach for symptomatic adenomyomatosis, with excellent outcomes reported even in rare pediatric cases 4, 5.

Key Caveat

If there is any diagnostic uncertainty regarding the possibility of gallbladder cancer, cholecystectomy is justified even in asymptomatic cases 1.