What is the management approach for adenomyomatosis of the gallbladder?

Management of Gallbladder Adenomyomatosis

Cholecystectomy is the recommended treatment for symptomatic adenomyomatosis of the gallbladder, with laparoscopic approach being the standard of care regardless of presentation. 1, 2

Diagnosis and Evaluation

• Ultrasound (US) is the imaging modality of choice for diagnosing gallbladder adenomyomatosis, with high-frequency probes enabling identification of characteristic Rokitansky-Aschoff sinuses (RAS) 3
• If differentiation between tumefactive sludge and adenomyomatosis is challenging, short-interval follow-up US within 1-2 months with optimized technique is recommended 1
• Contrast-enhanced ultrasound (CEUS) can help distinguish vascular lesions from sludge and should be considered if uncertainty persists after follow-up US 1, 3
• MRI should be considered if CEUS is not available, as it can identify RAS with extremely high sensitivity 1, 3
• CT has inferior diagnostic accuracy compared to CEUS or MRI for characterizing gallbladder lesions 1

Clinical Presentation

• Most patients with adenomyomatosis remain asymptomatic, with the condition often being an incidental finding on imaging or histologic examination 4
• When symptomatic, patients typically present with:
  • Right upper quadrant abdominal pain 4, 2
  • Atypical presentations may include fever without abdominal pain 5
• Adenomyomatosis is frequently associated with gallstones (up to 84% of cases), which may influence symptomatology 2

Treatment Approach

Symptomatic Adenomyomatosis

• Cholecystectomy is indicated for all symptomatic cases of gallbladder adenomyomatosis, whether associated with gallstones or not 2
• Laparoscopic approach is the standard of care with minimal surgical risk (morbidity of 2-8%) 1
• The risk of bile duct injury during cholecystectomy is approximately 0.3-0.6% 1

Asymptomatic Adenomyomatosis

• While there is no clear consensus for asymptomatic cases, prophylactic laparoscopic cholecystectomy may be justified considering:
  • The uncertain natural history of the disease
  • Difficult differential diagnosis versus malignant lesions
  • Potential for malignant transformation in some subtypes 2, 5

Special Considerations for Pregnant Patients

• If adenomyomatosis is diagnosed during pregnancy and requires intervention:
  • Laparoscopic cholecystectomy is safe during pregnancy regardless of trimester, but ideally performed in the second trimester 6
  • For patients presenting late in the third trimester, postponing surgical intervention until delivery may be reasonable if it doesn't pose risk to maternal or fetal health 6

Follow-up Recommendations

• The Society of Radiologists in Ultrasound (SRU) consensus suggests that extended follow-up of gallbladder lesions beyond 3 years is not productive 1
• This timeframe is sufficient to identify the vast majority of polyp-associated malignancies 1

Pitfalls and Caveats

• Gallbladder adenomyomatosis can be misdiagnosed as chronic cholecystitis or gallbladder cancer on imaging 2, 3
• Although traditionally considered benign, some evidence suggests a potential association between certain subtypes of adenomyomatosis and gallbladder carcinoma 5, 2
• Careful imaging interpretation is essential, as retrospective ultrasound evaluation often reveals pathognomonic signs of gallbladder adenomyomatosis that may be missed initially 2