Adenomyomatosis of the gallbladder is a hyperplastic cholecystosis of the gallbladder wall. It is a relatively common and benign cause of diffuse or focal gallbladder wall thickening, most easily seen on ultrasound and MRI.
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Epidemiology
Adenomyomatosis is relatively common, found in ~9% of all cholecystectomy specimens 6. It is typically seen in patients in their 5th decade. The incidence increases with age, presumably the result of protracted inflammation (see below). There is a female predilection (M:F=1:3).
It is most often an incidental finding and usually requires no treatment. It may be found more often in chronically inflamed gallbladders (which are at higher risk for carcinoma), but it is not a premalignant lesion in itself 6.
Clinical presentation
Adenomyomatosis per se is usually asymptomatic. It is, however, frequently associated with chronic biliary inflammation, most commonly gallstones (25-75%), but also seen in cholesterolosis (33%) and pancreatitis 2.
Pathology
Adenomyomatosis is one of the hyperplastic cholecystoses. There is hyperplasia of the wall with the formation of Rokitansky-Aschoff sinuses (intramural diverticula lined by mucosal epithelium) penetrating into the muscular wall of the gallbladder, with or without gallbladder wall thickening. Cholesterol accumulating in the Rokitansky-Aschoff sinuses becomes increasingly concentrated leading to crystal precipitation and calcification 10.
Radiographic features
Three morphological types of adenomyomatosis are described:
fundal (localized)
segmental (annular)
generalized (diffuse)
Ultrasound
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mural thickening (diffuse, focal, annular)
segmental/annular form is especially difficult to distinguish from gallbladder carcinoma
comet-tail artifact: echogenic intramural foci from which emanate V-shaped comet tail reverberation artifacts are highly specific for adenomyomatosis, representing the unique acoustic signature of cholesterol crystals within the lumina of Rokitansky-Aschoff sinuses 4
CT
abnormal gallbladder wall thickening and enhancement are common but non-specific CT features of adenomyomatosis
Rokitansky-Aschoff sinuses of sufficient size can be visualized; a CT rosary sign has been described, formed by enhancing epithelium within intramural diverticula surrounded by the relatively unenhanced hypertrophied gallbladder muscularis
calcific foci may develop in the Rokitansky-Aschoff sinuses 10
MRI
MRCP is the technique usually employed for the gallbladder and biliary tree characterization. Imaging features include:
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fluid-filled intramural diverticula/cysts 9
pearl necklace sign refers to the characteristically curvilinear arrangement of multiple rounded hyperintense intramural cavities visualized on T2-weighted MR imaging and MRCP 4
mural thickening
focal sessile mass
hourglass configuration in annular types 5
absent extra-gallbladder infiltration 8
Signal characteristics
Rokitansky-Aschoff sinuses can have a variable appearance in the one gallbladder depending on bile concentration 8:
T1: low signal to high signal with increasing bile concentration
T2: high signal to low signal with increasing bile concentration
T1C+: no enhancement
Nuclear medicine
PET-CT
Metabolic characterization with FDG PET has been suggested as a useful adjunct in problematic cases 4, but there have also been cases with increased uptake in areas of adenomyomatosis, leading to false positive results 7.
Treatment and prognosis
Cholecystectomy may be performed as a result of one or more of the following:
patient symptomatic with right upper quadrant pain (often due to gallstones)
appearances (especially when focal) may be difficult to distinguish from malignancy
Differential diagnosis
General imaging differential considerations include:
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gallbladder polyp (cholesterol polyp)
cholesterolosis: mucosal hyperplasia with the accumulation of cholesterol esters and triglycerides in the lamina propria macrophages (cf. intraluminal accumulation seen in adenomyomatosis)
Exclusion of gallbladder cancer may be most problematic in segmental and focal cases. Focal adenomyomatosis may appear as a discrete mass, known as an adenomyoma.
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