What is the recommended management for a patient with gallbladder adenomyomatosis, particularly those with a thickened gallbladder wall or recurrent biliary colic?

Management of Gallbladder Adenomyomatosis

For symptomatic gallbladder adenomyomatosis or segmental/diffuse patterns, laparoscopic cholecystectomy is the definitive treatment, while asymptomatic fundal adenomyomatosis can be safely observed with ultrasound surveillance. 1, 2, 3

Diagnostic Confirmation

Before determining management, confirm the diagnosis using characteristic imaging features:

• Ultrasound findings: Look for "comet-tail" artifacts and "twinkling" artifacts, which are pathognomonic for Rokitansky-Aschoff sinuses within the thickened gallbladder wall 3
• MRI findings: The "pearl-necklace sign" showing cystic-like Rokitansky-Aschoff sinuses definitively diagnoses adenomyomatosis and excludes malignancy 4, 3
• CT findings: The "rosary sign" pattern may be visible 3

MRI is particularly valuable when ultrasound is equivocal, as it can definitively distinguish adenomyomatosis from gallbladder carcinoma—adenomyomatosis shows characteristic intramural cysts while malignancy shows vascular enhancement 4

Classification-Based Management Algorithm

Management depends on both symptom status and anatomical pattern:

Symptomatic Patients (Recurrent Biliary Colic, Fever, or Abdominal Pain)

Perform laparoscopic cholecystectomy regardless of adenomyomatosis subtype 1, 2, 3, 5

• This applies to all three anatomical patterns: fundal, segmental, and diffuse 2, 3
• Symptoms may include typical biliary colic or atypical presentations like isolated fever without abdominal pain 5
• The presence of concurrent gallstones (found in 84% of cases) further supports surgical intervention 6

Asymptomatic Patients: Pattern-Specific Approach

Segmental adenomyomatosis: Offer cholecystectomy due to increased malignancy risk associated with this subtype 2, 3

Diffuse adenomyomatosis: Consider cholecystectomy because the diffuse wall thickening makes it difficult to visualize any coexisting malignancy 2, 3

Fundal adenomyomatosis: Ultrasound surveillance is a safe alternative to immediate surgery 2, 3

• This is the lowest-risk pattern for malignant transformation 2
• Patients must adhere to scheduled follow-up imaging 2
• The optimal frequency and duration of surveillance remains undefined in current literature 3

Critical Pitfalls and Caveats

When diagnosis is uncertain, always proceed with cholecystectomy 1, 3

• Gallbladder adenomyomatosis and gallbladder carcinoma share overlapping imaging features, particularly wall thickening 1, 6
• The consequences of missing malignancy far outweigh the minimal risks of laparoscopic cholecystectomy 1
• Retrospective studies show that adenomyomatosis is frequently misinterpreted as chronic inflammation or suspected neoplasia on initial ultrasound 6

Consider short-interval follow-up imaging (1-2 months) with optimized ultrasound technique if differentiation from tumefactive sludge or polyp is challenging 4

• Contrast-enhanced ultrasound (CEUS) can distinguish vascular lesions from adenomyomatosis 4
• If CEUS is unavailable, MRI is the next best option 4

The association between adenomyomatosis and malignancy remains controversial but cannot be dismissed 2, 3, 5

• Recent reports suggest adenomyomatosis may predispose to gallbladder malignancy, particularly the segmental subtype 2, 3
• While historically considered purely benign, the disease is no longer classified with absolute certainty as having zero malignant potential 2, 5

Surgical Considerations

Laparoscopic cholecystectomy carries minimal risk in appropriate candidates 4

• Morbidity ranges from 2-8%, with bile duct injury occurring in 3-6 per 1000 patients 4
• Mortality is 2-7 per 1000 patients, primarily related to underlying comorbidities rather than the procedure itself 4
• Patient selection requires assessment of surgical risk factors, particularly in patients with cirrhosis or significant comorbidities 4

Prophylactic laparoscopic cholecystectomy may be justified even in some asymptomatic cases 6

• Consider the uncertain natural history of the disease 6
• Factor in the difficulty of reliably distinguishing adenomyomatosis from malignant lesions on imaging 6
• Weigh the low surgical risk against the potential for disease progression 6