Management of Gallbladder Adenomyomatosis
For symptomatic gallbladder adenomyomatosis, laparoscopic cholecystectomy is the definitive treatment with minimal surgical risk (2-8% morbidity, 0.3-0.6% bile duct injury risk), while asymptomatic cases require a type-specific approach: fundal type can be safely observed with ultrasound surveillance, segmental type warrants consideration for cholecystectomy due to increased malignancy risk, and diffuse type should be considered for surgery due to difficulty visualizing coexisting malignancy. 1, 2, 3
Diagnostic Approach
Initial imaging should utilize ultrasound with high-frequency probes to identify characteristic Rokitansky-Aschoff sinuses (RAS), which appear as small bile-filled cystic spaces within the thickened gallbladder wall. 1, 4 Classic sonographic findings include "comet-tail" artifacts and "twinkling" artifacts that help distinguish adenomyomatosis from other gallbladder pathology. 3, 4
When differentiation between tumefactive sludge and adenomyomatosis is challenging, perform short-interval follow-up ultrasound within 1-2 months using optimized technique with precise focal depth adjustment. 1, 2
If uncertainty persists after repeat ultrasound, escalate to contrast-enhanced ultrasound (CEUS) as the next step. 1, 2 CEUS demonstrates that RAS appear avascular regardless of their content, which helps distinguish them from vascular lesions or sludge. 1, 4
MRI should be reserved for cases where CEUS is unavailable or inconclusive, as it can identify RAS with extremely high sensitivity, though signal intensity varies based on RAS content. 1, 4 CT has inferior diagnostic accuracy compared to CEUS or MRI and is not routinely indicated. 1, 2, 4
Classification and Risk Stratification
Adenomyomatosis presents in three distinct morphologic patterns that dictate management:
- Fundal type (localized): Focal thickening isolated to the gallbladder fundus 3, 5
- Segmental type: Circumferential overgrowth creating compartments within the gallbladder wall 3, 5
- Diffuse type: Disseminated thickening and irregularity throughout the mucosa and muscularis 3, 5
Segmental adenomyomatosis carries increased malignancy risk and was present in 64% of adenomyomatosis-positive gallbladder cancers in surgical series, while no diffuse-type cases were found in advanced cancer cohorts. 6 However, adenomyomatosis-positive gallbladder cancers are more often diagnosed at advanced stages (T stage, lymph node metastasis) because the preceding adenomyomatosis may prevent early cancer detection. 6
Treatment Algorithm
Symptomatic Adenomyomatosis (Any Type)
Perform laparoscopic cholecystectomy regardless of morphologic subtype. 1 This is the standard of care with minimal surgical risk: morbidity 2-8%, bile duct injury risk 0.3-0.6%. 1, 2 Over 90% of symptomatic patients achieve complete symptom relief after cholecystectomy. 5
For pregnant patients with symptomatic adenomyomatosis, laparoscopic cholecystectomy is safe in any trimester but ideally performed in the second trimester. 1 If presenting late in the third trimester, postponing surgery until after delivery is reasonable if maternal and fetal health are not compromised. 1
Asymptomatic Adenomyomatosis
Management depends on morphologic type:
Fundal type: Safe observation with ultrasound surveillance is appropriate. 3 The majority of fundal adenomyomatosis patients are asymptomatic. 7 Extended follow-up beyond 3 years is not productive, as this timeframe identifies the vast majority of polyp-associated malignancies. 1, 2
Segmental type: Consider cholecystectomy due to increased malignancy risk, even in asymptomatic patients. 3, 6 Segmental adenomyomatosis was significantly associated with advanced T stage, lymph node metastasis, and distant metastasis in surgical series. 6
Diffuse type: Consider cholecystectomy because disseminated wall thickening makes visualization of any coexisting malignancy difficult. 3
Common Pitfalls
Preoperative diagnostic accuracy is poor: Only 20% of adenomyomatosis cases are correctly diagnosed preoperatively, with most misdiagnosed as chronic cholecystitis (50%) or suspected gallbladder carcinoma (10%). 7 This underscores the importance of proper imaging technique and interpretation.
In cases of diagnostic doubt, always offer cholecystectomy to avoid overlooked malignancy. 3 The low surgical risk justifies intervention when uncertainty exists about excluding cancer.
Gallstones coexist in approximately 67% of adenomyomatosis cases, with cholesterol stones predominating (60%). 7 The presence of stones does not change the management algorithm but may contribute to symptoms.