Adenomyomatosis of the Gallbladder

Ifeanyi Malu,BSc.,MA., RDMS expectedMrs. Shelia Chong, MBA, RDMS

June, 2015

Normal Anatomy

GB parts• Neck• Body• Fundus-Body and neck directed toward porta hepatis-Fundus slants inferiorly to the right

--http://fitsweb.uchc.edu/student/selectives/Luzietti/Gallbladder_anatomy.htm

Normal Sonographic Anatomy

• The normal gallbladder wall appears as thin walled and anechoic

• Pear shaped saccular structure

-Ultrasoundpaedia.com

Sagittal Gallbladder

GB Sag Decub Adenomyomatosis of GB

• Diffuse gallbladder wall thickening including numerous intramural echogenic foci.

• “Comet-tail” reverberation artifact extends intraluminally from the near wall of the gallbladder.

-Ultrasoundpaedia.com

Adenomyomatosis of GBTransverse view

• Diffuse thickening of gallbladder wall

• Demonstrates circular band around the fundal region of the gallbladder wall

-Kilmas B., & Zegal (2015).

Normal Physiology

• Bile is stored in the GB until needed for digestion• The gallbladder is about 7.5–10 cm (3–4 inches) long and

about a 2.5 cm (1 inch) wide.• The gallbladder is made up of layers of tissue: -mucosa -muscular layer -perimuscular layer -serosa

-www.cancer.ca/en/cancer

Overview

• Adenomyomatosis of the Gallbladder is a common hyperplastic cholecystosis of the gallbladder wall

• Not malignant• May involve the gallbladder in a focal,

segmental, or diffuse form

-Dogra, V., & Karani, J. (2013).-Ryu et al. (n.d.).

Segmental Adenomyomatosis

• Segmental type is when the lesion is annular and separating the two compartments of the gallbladder

-Ozgonul, A., Bitiren, M., Guldur, M. E., Sogut, O., & Yilmaz, L. E. (2010).

Diffuse Adenomyomatosis

• Diffuse type is termed if it causes thickness in the gallbladder wall

-Ozgonul, A., Bitiren, M., Guldur, M. E., Sogut, O., & Yilmaz, L. E. (2010).

Fundus Adenomyomatosis

• Fundal type is defined if the lesion is localized on the “base of the gallbladder through the lumen in a hemispheric shape.”

• May appear as a discrete mass, known as an adenomyoma

-Ozgonul, A., Bitiren, M., Guldur, M. E., Sogut, O., & Yilmaz, L. E. (2010).

Transverse gallbladder fundus highly with echogenic foci within the mass

Sirigu,D. (2015).

Normal Relevant Vascular Anatomy

http://blogs.nvcc.edu/rkeith/2012/02/10/holy-gallstones-batman/

Normal Relevant Vascular Sonographic Anatomy

• Color Doppler demonstrates a twinkle artifact arising from one of the hyperechoic foci within the mass

-Sirigu, D. (n.d.).

Relevant Diagnostic Imaging Test

• Ultrasound• MRI• CT• NM• MRCP (or oral cholecystography)• Plain X-Ray

Relative Sensitivities of CT,MRI,& MRCP in the Diagnosis

-Hiroki, H., Tomoaki, I., & Hironobu ,S. et al.(2003).

Ultrasound Modality• Mural thickening (diffuse, focal, annular)

– segmental/annular form is especially difficult to distinguish from gallbladder carcinoma

• Comet-tail artifact• Considered to be the diagnostic findings on ultrasound

examination includes intramural cystic formation (anechoic diverticula) with echogenic foci and/or reverberation artifacts together with full or partial thickening of the gallbladder wall

-Ryu, Y. (n.d.).-Ghersin, Soudack, &Gaitini (2003

Sonogram in a patient with adenomyomatosis.

Adenomyomatosis GB Ultrasound Preferred

• Ultrasonography (US) is the favorite radiologic examination

• On US, diffuse or segmental gallbladder wall thickening is evident

•

-Dogra, V., & Karani, J. (2013).

Sonographic Appearance

• Sonographic appearance of GADM includes the following findings:

-focal or diffuse thickening of the gallbladder wall, -small anechoic cystic spaces within the affected portion of the wall, representing Rokitansky-Aschoff sinuses, and -intramural echogenic foci with or without associated acoustic shadows or reverberation artifacts.

Ghersin, Soudack, &Gaitini (2003).

Sag view of GADM

Hyperechoic • Longitudinal sonogram of

gallbladder shows a hyperechoic focus in the anterior wall with reverberation artifact, which is characteristic of hyperplastic cholecystosis.

-Dogra, V., & Karani, J. (2013).

Comet-tail Artifact

CT Modality

• Abnormal gallbladder wall thickening and enhancement

• Rokitansky-Aschoff sinuses of sufficient size can be visualized

• Reveal a thickened gallbladder wall with the rosary sign

Ryu, Y. (n.d.).

CT Images

CT modality• CT abdomen coronal Several

stones of various size are noted in the gallbladder. The gallbladder is not well extended and shows some mural enhancement. In the fundus and also more proximally at the infundibulum some dilated intramural diverticula are seen, so-called rosary sign.

-Ryu, Y. (n.d.).

CT

MRCP (or oral cholecystography)

• Does not rely on contrast opacification of the lumen of the gallbladder. MRCP is also able to show:

• mural thickening• focal sessile mass• pearl necklace sign • hourglass configuration in annular types

-Ryu, Y. (n.d.).

MRCP

MRCP• Numerous T2 hyperintense

intramural gallbladder foci are isointense to bile on T2 weighted sequences

-Kilmas B., & Zegal(2015)

MRCP Image

Oral cholecystogram

• Oral cholecystogram shows focal fundal thickening in a patient with focal fundal adenomyomatosis

• Better seen after partial contraction of the GB

-emedicine.medscape.com-Hagan-Ansert, S. (2012).

Pain in the right upper abdomen Ultrasound Images of Adenomyomatosis of the gallbladder with a thickened wall longitudinal

Color doppler shows twinkling artefacts caused by cholesterol crystals in the wall

.

-ultrasoundcases.info

Ultrasound Images:Color Doppler

ultrasoundcases.info

Ultrasound Images: Transverse view

ultrasoundcases.info

MRI

• Demonstrates Pearl necklace sign • Diffuse-type adenomyomatosis typically

shows early mucosal enhancement and subsequent serosal enhancement.

• Localized adenomyomatosis exhibits homogeneous enhancement

Ryu, Y. (n.d.).

MRI

MRI• Gallbladder wall thickening

with numerous T2 hyperintense intramural foci which are isointense to bile on T2 weighted sequences

Kilmas B., & Zegal(2015)

MRI IMAGE

Nuclear Medicine

• FDG-PET– metabolic characterization with PET has been

suggested as a useful adjunct in problematic cases

Ryu, Y. (n.d.).

Images Modalities

• US cannot differentiate between the segmental type of adenomyomatosis and gallbladder carcinoma

• On US, diffuse or segmental gallbladder wall thickening is evident

• Radiography is not the preferred choice• CT is useful in excluding gallbladder carcinoma.• However,ultrasonography (US) is the preferred

radiologic examination Dogra & Karani (2013)

Sonography Indications

• Acute RUQ pain• Non-visualization of GB on OCG• Excessive burping or nausea

-Chong,S. (2015)

GB Sonographic Technique

• NPO (at least 6-8 hours before the exam)• 3.5MHZ transducer used for average patient• 5.0 MHZ, 7.5MHZ or 10MHZ for very thin

patient• Must be imaged in both longitudinal and

transverse

-Chong, S. (2015).

Sonographic Scan Protocol

• Entire GB• GB, Neck• GB, Body• GB,Fundus• CBD( with color

Doppler)

-Chong, S. (2015).

Sonography Indications

• May be asymptomatic• RUQ abdominal pain• Nausea• Vomiting

-Chong,S. (2015).

Pathology Description

• Pathologically, defined as epithelial proliferation and hypertrophy of the muscularis of the gallbladder, with “outpouching of the mucosa into the thickened muscular layer.”

• Rokitansky-Aschoff sinus within the thickened muscular layer of the gallbladder

-

-Hiroki, H., Tomoaki, I., & Hironobu ,S. et al.(2003).

Epidemiology

• Common in women• Patients over 40 years has higher incidence

-Chong, S. (2015).

Etiology

• Unknown

-Kilmas B., & Zegal ,H.(2015).

Abnormal Physiology

• Gallbladder adenomyomatosis (GADM) is a “common acquired benign hyperplastic disease of the gallbladder mucosa” .

• Sonographically, it is characterized by diffuse or focal thickening of the gallbladder wall associated with small intramural cystic spaces, known as Rokitansky-Aschoff sinuses.

-Ghersin, Soudack, &Gaitini (2003)

Abnormal Clinical Findings

• May be asymptomatic• RUQ pain• Nausea• Vomiting

-Chong, S (2015).

Abnormal Sonographic Findings

• May be diffuse thickening of the wall• Present as a circular band around a section of

the wall-around the fundal area• Segmental and focal adenomyomatosis may

be difficult to differentiate from gallbladder carcinoma

-Sirigu,D.(n.d.).

Abnormal Sonographic Findings

• Does not move with position changes• Associated with comet tail artifact• Papillomas may occur singly or in groups

-Hagan-Ansert,S. (2015).

Treatment & Monitoring

Treatment• Elective surgery is often

performed in patients with right upper quadrant pain

Monitoring• Ultrasound

Differential diagnosis

• Gallbladder carcinoma• Phrygian cap• Gallbladder polyp (cholesterol polyp)• Cholelithiasis• Adenoma

-Ryu et al. (n.d.).

Prognosis

• Cholecystectomy may be performed as a result of one or more of the following:

-patient symptomatic with RUQ pain -focal appearances may be difficult to distinguish from malignancy

-http://radiopaedia.org/articles/adenomyomatosis-of-the-gallbladder

References• Adusumilli,S.,& Siegelman, E.S.(2005). MRI of the bile ducts, gallbladder,

and pancreas. In: Siegelman ES., ed. Body MRI. Philadelphia: Elsevier Inc.; 2005: 63-127

• Chong, S. (March, 2015). Gallbladder Lecture Handout. Sanford-Brown Institute, Garden City NY

• Dogra, V., & Karani, J. (2013). Adenomyomatosis Imaging. Electronically retrieved from http://emedicine.medscape.com/article/363728-overview#a1

• Ghersin,E., Soudack,M., & Gaitini,D. (2003). Twinkling Artifact in Gallbladder Adenomyomatosis. Retrieved from http://www.jultrasoundmed.org/content/22/2/229.full.pdf+html?sid=a5031d87-4b49-45f8-88a0-6ac8ea2040c2

References

• Hagen-Ansert, S.L. (2012). Textbook of Diagnostic Sonography: 2-Volume Set, 7e. Elsevier, Mosby

• Hiroki, H., Tomoaki, I., & Hironobu ,S. et al.T(2003). The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography. Radiology.2003; 227: 80-88

• Kilmas B., & Zegal ,H.(2015). Adenomyomatosis. Electronically retrieved from http://sonoworld.com/CaseDetails/Adenomyomatosis.aspx?ModuleCategoryId=631

• Ozgonul, A., Bitiren, M., Guldur, M. E., Sogut, O., & Yilmaz, L. E. (2010). Fundal Variant Adenomyomatosis of the Gallbladder: Report of Three Cases and Review of the Literature. Journal of Clinical Medicine Research, 2(3), 150–153. doi:10.4021/jocmr2010.05.338w

• Ryu, Y., et al. (n.d.). Adenomyomatosis of the Gallbladder. Available at http://radiopaedia.org/articles/adenomyomatosis-of-the-gallbladder

References• Sirigu, D. (2015). Adenomyomatosis (adenomyomatous hyperplasia) of the

gallbladder. Available at http://sonoworld.com/CaseDetails/Adenomyomatosis_(adenomyomatous_hyperplasia)_of_the_gallbladder.aspx?CaseId=485