1) Adenomyomatosis of the gallbladder is a benign condition involving thickening of the gallbladder wall with small cysts forming within the thickened muscle layer. 2) Ultrasound is usually the preferred imaging method to diagnose adenomyomatosis and will show diffuse or focal gallbladder wall thickening along with small anechoic cysts and comet-tail artifacts. 3) Adenomyomatosis can be asymptomatic but may sometimes cause right upper quadrant pain, nausea or vomiting. Surgical removal of the gallbladder is often performed if a patient is symptomatic or if the imaging findings are difficult to distinguish from gallbladder cancer.

1. Adenomyomatosis of the
Gallbladder
Ifeanyi Malu,BSc.,MA., RDMS expected
Mrs. Shelia Chong, MBA, RDMS
June, 2015

2. 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/Gallbladd
er_anatomy.htm

3. Normal Sonographic Anatomy
• The normal
gallbladder wall
appears as thin
walled and
anechoic
• Pear shaped
saccular structure
-Ultrasoundpaedia.com

4. 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

5. Adenomyomatosis of GB
Transverse view
• Diffuse
thickening of
gallbladder wall
• Demonstrates
circular band
around the
fundal region of
the gallbladder
wall
-Kilmas B., & Zegal (2015).

6. 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

7. 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.).

8. 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).

9. 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).

10. 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).

11. Transverse gallbladder fundus highly
with echogenic foci within the mass
Sirigu,D. (2015).

12. Normal Relevant Vascular Anatomy
http://blogs.nvcc.edu/rkeith/2012/02/10/holy-gallstones-batman/

13. 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.).

14. Relevant Diagnostic Imaging Test
• Ultrasound
• MRI
• CT
• NM
• MRCP (or oral cholecystography)
• Plain X-Ray

15. Relative Sensitivities of CT,MRI,&
MRCP in the Diagnosis
-Hiroki, H., Tomoaki, I., & Hironobu ,S. et al.(2003).

16. 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

17. 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).

18. 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).

19. 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

20. 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.).

21. 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

22. 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.).

23. MRCP
MRCP
• Numerous T2 hyperintense
intramural gallbladder foci
are isointense to bile on T2
weighted sequences
-Kilmas B., & Zegal(2015)
MRCP Image

24. 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).

25. 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

26. Ultrasound Images:Color Doppler
ultrasoundcases.info

27. Ultrasound Images: Transverse view
ultrasoundcases.info

28. 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.).

29. 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

30. Nuclear Medicine
• FDG-PET
– metabolic characterization with PET has been
suggested as a useful adjunct in problematic
cases
Ryu, Y. (n.d.).

31. 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)

32. Sonography Indications
• Acute RUQ pain
• Non-visualization of GB on OCG
• Excessive burping or nausea
-Chong,S. (2015)

33. 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).

34. Sonographic Scan Protocol
• Entire GB
• GB, Neck
• GB, Body
• GB,Fundus
• CBD( with color
Doppler)
-Chong, S. (2015).

35. Sonography Indications
• May be asymptomatic
• RUQ abdominal pain
• Nausea
• Vomiting
-Chong,S. (2015).

36. 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).

37. Epidemiology
• Common in women
• Patients over 40 years has higher incidence
-Chong, S. (2015).

38. Etiology
• Unknown
-Kilmas B., & Zegal ,H.(2015).

39. 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)

40. Abnormal Clinical Findings
• May be asymptomatic
• RUQ pain
• Nausea
• Vomiting
-Chong, S (2015).

41. 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.).

42. 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).

43. Treatment & Monitoring
Treatment
• Elective surgery is often
performed in patients with
right upper quadrant pain
Monitoring
• Ultrasound

44. Differential diagnosis
• Gallbladder carcinoma
• Phrygian cap
• Gallbladder polyp (cholesterol polyp)
• Cholelithiasis
• Adenoma
-Ryu et al. (n.d.).

45. 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

46. 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=a50
31d87-4b49-45f8-88a0-6ac8ea2040c2

47. 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?ModuleCateg
oryId=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

48. 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