Treatment of Gallbladder Adenomyomatosis
For symptomatic gallbladder adenomyomatosis, cholecystectomy (preferably laparoscopic) is the definitive treatment and should be performed promptly. 1, 2, 3, 4
Symptomatic Adenomyomatosis
Cholecystectomy is mandatory for all symptomatic cases, regardless of the morphological subtype (diffuse, segmental, or fundal). 1, 2, 3
Laparoscopic cholecystectomy should be performed early, ideally within 7-10 days of symptom onset if acute inflammation is present, following the same principles as acute cholecystitis management. 5, 6
Symptoms typically include right upper quadrant pain, though rare presentations with fever alone have been documented. 4, 7
The presence of coexisting gallstones (occurring in approximately 84% of cases) does not change the indication for surgery when symptoms are present. 2
Asymptomatic Adenomyomatosis: Risk-Stratified Approach
The management of asymptomatic adenomyomatosis depends critically on the morphological subtype, as different patterns carry varying malignancy risks. 1, 3
High-Risk Patterns Requiring Surgery
Segmental adenomyomatosis warrants cholecystectomy even when asymptomatic due to increased malignancy risk. 3
Diffuse adenomyomatosis should undergo cholecystectomy because coexisting malignancy is difficult to visualize on imaging. 3
Low-Risk Pattern Allowing Observation
Fundal (localized) adenomyomatosis in asymptomatic patients can be safely observed with ultrasound surveillance. 1, 3
This wait-and-see approach is appropriate only for patients who will adhere to scheduled follow-ups. 1
The optimal frequency and duration of ultrasound monitoring remains undefined in the literature. 3
When Diagnosis is Uncertain
Cholecystectomy should always be performed when there is diagnostic doubt to avoid overlooking gallbladder malignancy. 1, 3
Adenomyomatosis can be difficult to distinguish from chronic inflammation or neoplasia on imaging, despite characteristic features like "comet-tail" artifacts on ultrasound, "pearl-necklace sign" on MRI, and "rosary sign" on CT. 2, 3
Retrospective analysis often reveals pathognomonic signs that were initially misinterpreted. 2
Rationale for Surgical Management
The recommendation for cholecystectomy in many cases stems from several considerations:
While historically considered benign, recent reports highlight a potential association between adenomyomatosis and gallbladder malignancy, particularly with segmental subtypes. 1, 2, 3, 4
The uncertain natural history of the disease and difficulty in differential diagnosis from malignant lesions justify prophylactic laparoscopic cholecystectomy in many scenarios. 2
Laparoscopic cholecystectomy is minimally invasive with >97% success rate and allows patients to return to work approximately 9 days sooner than delayed approaches. 6
Critical Pitfalls to Avoid
Do not delay surgery in symptomatic patients or when diagnostic uncertainty exists regarding potential malignancy. 1, 3
Do not apply a wait-and-see approach to segmental or diffuse patterns, even if asymptomatic, due to malignancy risk and diagnostic limitations. 3
Do not assume all asymptomatic adenomyomatosis requires immediate surgery—fundal type can be safely observed with appropriate surveillance. 1, 3