What is the recommended treatment for gallbladder adenomyomatosis?

Management of Gallbladder Adenomyomatosis

For symptomatic gallbladder adenomyomatosis, cholecystectomy is the recommended treatment as it results in complete resolution of symptoms and eliminates any potential risk of malignant transformation. 1

Understanding Gallbladder Adenomyomatosis

Gallbladder adenomyomatosis (GBA) is a benign hyperplastic condition affecting the gallbladder wall, characterized by:

• Thickening of the gallbladder wall with invagination of the epithelium into the muscular layer, forming Rokitansky-Aschoff sinuses (RAS) 2
• Three distinct patterns: diffuse, segmental, and localized/fundal forms 3, 4
• Prevalence of 1-9% in cholecystectomy specimens, with increasing incidence after age 50 1
• Frequent association with gallstones (50-90% of cases) 1

Diagnostic Approach

Accurate diagnosis is essential to differentiate adenomyomatosis from malignancy:

• Ultrasound (US) is the first-line imaging modality, showing:

  • Gallbladder wall thickening
  • Small bile-filled cystic spaces (RAS)
  • Characteristic "comet tail" artifacts 2

• For unclear cases on conventional US:

  • Contrast-enhanced ultrasound (CEUS) can help identify RAS, which appear avascular regardless of content 2
  • MRI with cholangiography sequences is the reference examination, showing characteristic "pearl necklace" images 1
  • Short-interval follow-up US within 1-2 months with optimized technique may be helpful for lesions >10mm 5

Treatment Algorithm Based on Clinical Presentation

For Symptomatic Patients:

• Cholecystectomy is strongly recommended regardless of the pattern of adenomyomatosis 1
• Symptoms may include:
  • Abdominal pain or hepatic colic (even without gallstones)
  • Acalculous cholecystitis 1

For Asymptomatic Patients:

Treatment should be guided by the pattern of adenomyomatosis and associated risk factors:

• Localized/fundal type:

  • Higher risk of malignancy
  • Cholecystectomy recommended, especially if >10mm 3, 4

• Segmental type:

  • Intermediate risk
  • Consider cholecystectomy, particularly with other risk factors 3

• Diffuse type:

  • Lower risk of malignancy
  • Observation with regular follow-up may be appropriate 3

• Additional factors favoring cholecystectomy:

  • Any diagnostic uncertainty regarding potential malignancy
  • Presence of large gallstones (>3cm) 5
  • Calcified gallbladder 5

Special Considerations

• Recent studies suggest a potential association between adenomyomatosis and gallbladder cancer, with adenomyomatosis-positive gallbladder cancers often diagnosed at more advanced stages 6
• Laparoscopic cholecystectomy is the preferred surgical approach, with minimal morbidity (2-8%) in elective cases 5
• The risk of bile duct injury during laparoscopic cholecystectomy (3-6 per 1000 patients) should be considered 5
• For patients with prohibitive surgical risk, careful monitoring may be appropriate 3

Follow-up for Non-surgical Management

For patients managed non-surgically:

• Regular ultrasound surveillance
• Immediate evaluation for any new or worsening symptoms
• Consider cholecystectomy if changes in size or appearance occur during follow-up 3