Management of Gallbladder Adenomyomatosis
For symptomatic adenomyomatosis, laparoscopic cholecystectomy is the definitive treatment and should be performed regardless of presentation type, with minimal surgical risk (2-8% morbidity). 1, 2
Diagnostic Confirmation
Before proceeding with management decisions, ensure accurate diagnosis:
Ultrasound with high-frequency probes is the primary imaging modality, looking specifically for Rokitansky-Aschoff sinuses (RAS), "comet-tail" artifacts, and "twinkling" artifacts on color Doppler. 1, 3
If differentiation from tumefactive sludge or malignancy remains uncertain after initial ultrasound, obtain short-interval follow-up ultrasound within 1-2 months with optimized technique (proper patient preparation, high-frequency probes, appropriate focal depth). 1, 2
If uncertainty persists after repeat ultrasound, contrast-enhanced ultrasound (CEUS) should be the next step, as it can distinguish vascular lesions from sludge and identify avascular RAS regardless of content. 1, 4, 3
MRI should be considered if CEUS is unavailable, as it identifies RAS with extremely high sensitivity and shows characteristic "pearl necklace" sign. 1, 4, 5
CT has inferior diagnostic accuracy compared to CEUS or MRI and should not be routinely used for characterization. 1, 2
Treatment Algorithm by Clinical Presentation
Symptomatic Adenomyomatosis (Any Type)
Proceed directly to laparoscopic cholecystectomy for patients with abdominal pain, hepatic colic, or cholecystitis symptoms, even without gallstones. 1, 6, 5
- The bile duct injury risk is only 0.3-0.6%. 1, 2
- Cholecystectomy results in complete symptom resolution. 5
Asymptomatic Adenomyomatosis
Management depends on the anatomic subtype:
Segmental type: Consider cholecystectomy due to increased malignancy risk and difficulty excluding coexisting cancer. 6
Diffuse type: Consider cholecystectomy because diffuse wall involvement makes visualization of any coexisting malignancy difficult. 6
Fundal type: Observation with ultrasound surveillance is safe, though optimal surveillance intervals remain undefined. 6
Critical Exception: Suspected Malignancy
If any features suggest invasive or malignant tumor (focal wall thickening ≥4 mm adjacent to mass, sessile morphology, concurrent liver masses), immediately refer to an oncologic specialist rather than following routine surveillance. 4
When diagnostic doubt exists between adenomyomatosis and malignancy, always perform cholecystectomy to avoid overlooking cancer. 6, 5
Special Population: Pregnancy
Laparoscopic cholecystectomy is safe during any trimester, but ideally perform in the second trimester. 1
For late third-trimester presentations, postponing surgery until after delivery is reasonable if maternal and fetal health are not at risk. 1
Follow-Up Recommendations
Extended surveillance beyond 3 years is not productive, as this timeframe identifies the vast majority of polyp-associated malignancies. 1, 2
For asymptomatic fundal adenomyomatosis under observation, specific surveillance intervals are not established, but should not exceed 3 years total duration. 1, 6
Common Pitfalls to Avoid
Do not rely on CT for characterization—it has inferior accuracy compared to ultrasound, CEUS, or MRI. 1, 2
Do not dismiss symptoms in the absence of gallstones—50-90% of symptomatic adenomyomatosis cases have no associated stones. 5
Do not perform prolonged surveillance—if diagnosis remains uncertain after appropriate imaging (ultrasound → CEUS or MRI), proceed to cholecystectomy rather than extended observation. 6, 5
Do not confuse adenomyomatosis with gallbladder carcinoma—look for RAS, comet-tail artifacts, and absence of focal wall thickening ≥4 mm to distinguish benign from malignant disease. 4, 3