What is the treatment for gall bladder adenomyomatosis?

Treatment of Gallbladder Adenomyomatosis

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

Symptomatic Adenomyomatosis

For patients presenting with symptoms (right upper quadrant pain, fever, or other biliary symptoms), laparoscopic cholecystectomy should be performed. 1, 2, 3

• The surgical risk is minimal, with morbidity of 2-8% and bile duct injury risk of approximately 0.3-0.6% 1
• Symptoms typically include dull right upper quadrant pain, though atypical presentations such as isolated fever have been reported 3, 4
• Cholecystectomy provides definitive treatment and allows histologic confirmation of diagnosis 2, 3

Asymptomatic Adenomyomatosis

For asymptomatic patients discovered incidentally on imaging, management depends on the morphologic pattern: 2

Low-Risk Patterns (Fundal or Localized Forms)

• A wait-and-see approach with scheduled follow-up is a viable alternative for asymptomatic patients who will adhere to surveillance 2
• The Society of Radiologists in Ultrasound suggests that extended follow-up beyond 3 years is not productive, as this timeframe identifies the vast majority of polyp-associated malignancies 1

Higher-Risk Patterns (Diffuse or Segmental Forms)

• Cholecystectomy should be considered even in asymptomatic patients, particularly for segmental adenomyomatosis in older patients, given the potential premalignant association 2, 5
• When diagnosis is uncertain or imaging features are atypical, cholecystectomy is mandatory to exclude malignancy 2

Diagnostic Confirmation Before Treatment

When adenomyomatosis is suspected but diagnosis is uncertain, additional imaging should be obtained before deciding on surgery: 6

• Short-interval follow-up ultrasound within 1-2 months with optimized technique can help differentiate adenomyomatosis from tumefactive sludge or polyps 6, 1
• MRI can definitively diagnose adenomyomatosis by demonstrating cystic-like Rokitansky-Aschoff sinuses in the gallbladder wall 6
• Contrast-enhanced ultrasound (CEUS) can distinguish vascular lesions from sludge if available 6, 1

Special Populations

For pregnant patients with symptomatic adenomyomatosis: 1

• Laparoscopic cholecystectomy is safe during any trimester but ideally performed in the second trimester 1
• For patients presenting late in the third trimester, postponing surgery until after delivery is reasonable if maternal and fetal health are not at risk 1

Key Clinical Pitfalls

• Do not rely on CT for diagnosis, as its diagnostic accuracy is inferior to ultrasound, CEUS, or MRI for characterizing gallbladder lesions 6
• Preoperative diagnosis is often missed (correct in only 30% of cases), with adenomyomatosis frequently misdiagnosed as acute or chronic cholecystitis 5
• The association with malignancy remains controversial, but segmental adenomyomatosis in older patients may carry higher risk and warrants surgical intervention 2, 5