What is the best approach to diagnose and treat a patient with symptoms suggestive of fungal gallstones versus adenomyosis?

Fungal Gallstones vs Adenomyomatosis: Diagnostic and Management Approach

Critical First Point: Fungal Gallstones Do Not Exist as a Clinical Entity

"Fungal gallstones" is not a recognized medical condition—gallstones are composed of cholesterol, pigment, or mixed components, never fungal material. The question likely reflects confusion between two entirely separate conditions: standard gallstone disease and gallbladder adenomyomatosis, neither of which involves fungal infection. 1, 2

Understanding the Actual Clinical Entities

Gallstone Disease (Cholelithiasis)

Gallstones form from bile component precipitation—37-86% are cholesterol-rich, 2-27% are pigment stones, and 4-16% are mixed stones. 2

• Diagnosis requires ultrasound as first-line imaging with 96% accuracy for gallstone detection. 3, 4
• Most patients (>80%) remain asymptomatic throughout their lifetime. 3, 2
• Symptomatic presentation includes severe, steady right upper quadrant/epigastric pain lasting >15 minutes, unaffected by position changes or antacids. 3, 4

Gallbladder Adenomyomatosis

Adenomyomatosis is a benign acquired anomaly characterized by mucosal epithelium hypertrophy invaginating into a thickened muscularis, forming Rokitansky-Aschoff sinuses. 5

• Prevalence in cholecystectomy specimens is 1-9%, with balanced sex ratio and increased incidence after age 50. 5
• Associated with gallstones in 50-90% of cases, but can occur independently. 5
• Three forms exist: segmental, fundal (most common), and diffuse. 5

Diagnostic Algorithm

Step 1: Initial Imaging

Obtain abdominal ultrasound immediately for any patient with right upper quadrant pain or suspected biliary disease. 3, 4

• For adenomyomatosis, ultrasound identifies intraparietal pseudo-cystic images and pathognomonic "comet tail" artifacts. 5, 6
• Ultrasound also detects gallstones with 96% accuracy and evaluates for complications. 3

Step 2: Advanced Imaging When Diagnosis Unclear

MRI with MRCP sequences is the reference examination for adenomyomatosis, showing characteristic "pearl necklace" images. 5, 6

• MRI has 85-100% sensitivity for detecting choledocholithiasis if bile duct stones are suspected. 3, 4
• High-resolution ultrasound is the most efficient radiological examination for adenomyomatosis. 6

Step 3: Rule Out Malignancy

If any diagnostic doubt exists about gallbladder cancer versus adenomyomatosis, cholecystectomy is justified. 5, 6

• Adenomyomatosis can mimic cancer on radiological findings, creating a diagnostic dilemma. 6
• The practitioner must always consider gallbladder carcinoma before confirming adenomyomatosis, as they share features but have vastly different prognoses. 6

Treatment Algorithm

For Symptomatic Gallstones

Laparoscopic cholecystectomy is the definitive treatment and should be performed early (within 7-10 days, ideally within 24 hours of hospital admission for acute cholecystitis). 3, 7, 8

• Early surgery reduces hospital stay by 4 days and decreases serious adverse events compared to delayed surgery. 7
• Mortality is extremely low (0.054% in women under 49 years). 4, 7
• Single-shot antibiotic prophylaxis is recommended; no postoperative antibiotics needed for uncomplicated cases. 3, 7

For Adenomyomatosis

Symptomatic adenomyomatosis is an absolute indication for cholecystectomy, which results in complete symptom disappearance in >90% of patients. 5, 9

• Asymptomatic adenomyomatosis is NOT an indication for surgery, but the radiological diagnosis must be beyond any doubt. 5
• If inconclusive imaging findings raise suspicion for gallbladder cancer, laparoscopic cholecystectomy is justified. 5, 6
• Follow-up studies show over 90% of patients are completely relieved of symptoms after cholecystectomy. 9

Critical Pitfalls to Avoid

Do not pursue "fungal gallstone" workup—this is not a real entity and will delay appropriate diagnosis and treatment. 1, 2

Do not attribute non-specific symptoms like indigestion, flatulence, heartburn, or bloating to gallstones, as these are unlikely to resolve with cholecystectomy. 4

Do not delay imaging when gallbladder pathology is suspected, as complications (acute cholecystitis, cholangitis, biliary pancreatitis) can be life-threatening. 4

Do not perform expectant management once symptoms develop in gallstone disease—symptomatic disease has a 6.63-fold increased risk of complications. 7

Do not rely solely on absence of sonographic Murphy sign to rule out acute cholecystitis if the patient received pain medication prior to imaging. 4

Regarding Invasive Fungal Disease

If the question actually concerns invasive fungal infections (which do NOT cause gallstones but can affect the liver/spleen/GI tract in immunocompromised patients):

Fungal infections in the liver and spleen are best visualized by CT and particularly by MRI scanning in granulocytopenic patients. 1

• Definite diagnosis requires histological and/or cultural evidence from tissue biopsies or positive cultures from sterile body fluids. 1
• If clinically feasible, biopsy specimens should be taken from suspected areas. 1
• This scenario applies only to severely immunocompromised patients (hematologic malignancies, prolonged granulocytopenia), not typical gallbladder disease patients. 1