Adenomyomatosis Imaging 

  • Author: Vikram S Dogra, MD; Chief Editor: John Karani, MBBS, FRCR   more...
 
Updated: May 25, 2011
 

Overview

Differentiating between adenomyomatosis and cholesterolosis is difficult at times. Hyperplastic cholecystosis is the term used to describe cholesterolosis and adenomyomatosis. The imaging characteristics of adenomyomatosis are demonstrated in the images below.[1, 2, 3]

Sonogram in a patient with adenomyomatosis. Sonogram in a patient with adenomyomatosis. Oral cholecystogram shows focal fundal thickening Oral cholecystogram shows focal fundal thickening in a patient with focal fundal adenomyomatosis.

Adenomyomatosis is a benign condition characterized by hyperplastic changes of unknown etiology involving the gallbladder wall and causing overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula or sinus tracts termed Rokitansky-Aschoff sinuses. Adenomyomatosis is a common tumorlike lesion of the gallbladder with no malignant potential and may involve the gallbladder in a focal, segmental, or diffuse form.

The etiology of cholesterolosis is also unknown. Cholesterolosis is a local phenomenon unrelated to atherosclerosis. Triglycerides and cholesterol esters are deposited in the lamina propria of the gallbladder wall. Grossly, the lipid deposits are visible, lending the gallbladder wall a strawberry-like appearance—hence, the term strawberry gallbladder. The deposits vary in size and can be as large as 1 cm.

Preferred examination

Ultrasonography (US) is the preferred radiologic examination. Oral cholecystogram can be used to diagnose adenomyomatosis; however, use of ultrasonography (US) and magnetic resonance imaging (MRI) is preferred. MRI, computed tomography (CT) scanning, and positron emission tomography (PET) can be used as problem-solving modalities, especially to differentiate hyperplastic cholecystosis from gallbladder carcinoma.[4, 5, 6, 2, 7, 8, 9, 10, 11, 12, 13]

Limitations of techniques

Occasionally, US cannot differentiate between the segmental type of adenomyomatosis and gallbladder carcinoma.

Next

Radiography

If Rokitansky-Aschoff sinuses are patent, oral cholecystogram demonstrates the characteristic appearance of sinuses filled with contrast. (See the image below.)

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

In patients with cholesterolosis, an oral cholecystogram demonstrates the larger polypoid cholesterol deposits as fixed lucencies in the opacified lumen. The deposits are distinguished from gallbladder stones by a failure to move with compression and positional change. Ultrasonography shows the lesions as nonshadowing, nonmobile intraluminal echoes.

Degree of confidence

Radiography is not the preferred choice.

Previous
Next

Computed Tomography

CT scans of adenomyomatosis reveal a thickened gallbladder wall with the rosary sign. The rosary sign is formed by the enhanced proliferative mucosal epithelium, with the intramural diverticula surrounded by the unenhanced hypertrophied muscle coat of the gallbladder.[2, 8]

Degree of confidence

Findings on CT scan usually are confirmed further by other imaging modalities. CT is useful in excluding gallbladder carcinoma.

Ching et al studied the accuracy of CT in differentiating adenomyomatosis from gallbladder cancer in a retrospective study of 36 patients with pathologically proven adenomyomatosis or gallbladder cancer who had undergone preoperative abdominal CT. The authors determined from study findings that CT is limited in the detection and differentiation of adenomyomatosis and gallbladder cancer, but the diagnosis of adenomyomatosis can be made with reasonable accuracy when thickening of the gallbladder wall is seen to contain small cystic-appearing spaces.[2]

Previous
Next

Magnetic Resonance Imaging

MRI can be used in cases that are difficult to diagnose, being well able to differentiate adenomyomatosis from cholesterolosis .[7, 11, 13] Gallbladder wall thickening with multiple intramural cystic components from Rokitansky-Aschoff sinuses can be visualized readily using MRI and is considered diagnostic of adenomyomatosis.

T2-weighted MRI breath-hold sequences are superior to other sequences in visualizing Rokitansky-Aschoff sinuses.

Diffuse-type adenomyomatosis typically shows early mucosal enhancement and subsequent serosal enhancement. Localized adenomyomatosis exhibits homogeneous enhancement, showing smooth continuity with the surrounding gallbladder epithelium.

Previous
Next

Ultrasonography

Intramural cystic formation (anechoic diverticula) with echogenic foci and/or reverberation artifacts together with full or partial thickening of the gallbladder wall are considered to be the diagnostic findings on US examination. Reverberation artifact from cholesterol crystals is V-shaped and shorter in length than artifact from air. Sometimes, the calcium present within the sinuses may give rise to twinkle artifact.

On US, diffuse or segmental gallbladder wall thickening is evident. Intramural diverticula may be seen. Diverticula containing bile are anechoic, and those containing sludge or stone are hyperechoic, with or without shadowing or reverberation artifacts.

If intramural diverticula are not identified, differentiating adenomyomatosis from other causes of gallbladder wall thickening, such as inflammation or carcinoma, is difficult. (See the images below.)

Sonogram in a patient with adenomyomatosis. Sonogram in a patient with adenomyomatosis. Transverse sonogram of the gallbladder shows multiTransverse sonogram of the gallbladder shows multiple hyperechoic foci within the gallbladder wall with reverberation artifact. These findings are seen in patients with hyperplastic cholecystosis. Transverse sonogram in a patient with adenomyomatoTransverse sonogram in a patient with adenomyomatosis. Gallbladder wall is thickened, and many hyperechoic foci are seen in the gallbladder wall. Longitudinal sonogram of gallbladder shows a hyperLongitudinal sonogram of gallbladder shows a hyperechoic focus in the anterior wall with reverberation artifact, which is characteristic of hyperplastic cholecystosis.

Degree of confidence

Segmental and focal adenomyomatosis may be difficult to differentiate from gallbladder carcinoma if characteristic features are not present.

Previous
Next

Nuclear Imaging

Small polypoid lesions of strawberry gallbladder can be differentiated successfully from gallbladder carcinoma using PET scanning with 18-fluorodeoxyglucose (FDG). PET reveals a focus of FDG uptake at the site of gallbladder carcinoma. No focal uptake is noted in cholesterol polyps.[14]

Previous
 
Contributor Information and Disclosures
Author

Vikram S Dogra, MD  Professor of Diagnostic Radiology, Urology, and Biomedical Engineering, University of Rochester School of Medicine; Director, Division of Ultrasound, Associate Chair of Education and Research, Department of Imaging Sciences, University of Rochester Medical Center

Vikram S Dogra, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of Program Directors in Radiology, Radiological Society of North America, Society of Radiologists in Ultrasound, and Society of Uroradiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric P Weinberg, MD  Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital

Eric P Weinberg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD  Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Arnold C Friedman, MD  FACR, Professor, Department of Radiology, Arizona Health Science Center at the University of Arizona.

Arnold C Friedman, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America

Disclosure: Nothing to disclose.

Robert M Krasny, MD  Resolution Imaging Medical Corporation

Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America

Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR  Clinical Director of Radiology and Consultant Radiologist, Department of Radiology, King's College Hospital, UK

John Karani, MBBS, FRCR is a member of the following medical societies: British Institute of Radiology, British Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, European Society of Gastrointestinal and Abdominal Radiology, European Society of Radiology, Radiological Society of North America, and Royal College of Radiologists

Disclosure: Nothing to disclose.

References
  1. Boscak AR, Al-Hawary M, Ramsburgh SR. Best cases from AFIP:Adenomyomatosis of the gallbladder. Radiographics. 2006;3:941-946.

  2. Ching BH, Yeh BM, Westphalen AC, Joe BN, Qayyum A, Coakley FV. CT differentiation of adenomyomatosis and gallbladder cancer. AJR Am J Roentgenol. Jul 2007;189(1):62-6. [Medline].

  3. Owen CC, Bilhartz LE. Gallbladder polyps, cholesterolosis, adenomyomatosis, and acute acalculous cholecystitis. Semin Gastrointest Dis. Oct 2003;14(4):178-88. [Medline].

  4. Ash-Miles J, Roach H, Virjee J, Callaway M. More than just stones: a pictorial review of common and less common gallbladder pathologies. Curr Probl Diagn Radiol. Sep-Oct 2008;37(5):189-202. [Medline].

  5. Stunell H, Buckley O, Geoghegan T, O'Brien J, Ward E, Torreggiani W. Imaging of adenomyomatosis of the gall bladder. J Med Imaging Radiat Oncol. Apr 2008;52(2):109-17. [Medline].

  6. Poonam Y, Ashu S, Rohini G. Clinics in diagnostic imaging (121). Gallbladder adenomyomatosis. Singapore Med J. Mar 2008;49(3):262-4; quiz 265. [Medline].

  7. Catalano OA, Sahani DV, Kalva SP, Cushing MS, Hahn PF, Brown JJ, et al. MR imaging of the gallbladder: a pictorial essay. Radiographics. Jan-Feb 2008;28(1):135-55; quiz 324. [Medline].

  8. Chao C, Hsiao HC, Wu CS, Wang KC. Computed tomographic finding in adenomyomatosis of the gallbladder. J Formos Med Assoc. Apr 1992;91(4):467-9. [Medline].

  9. Franquet T, Bescos JM, Barberena J, Montes M. Acoustic artifacts and reverberation shadows in gallbladder sonograms: their cause and clinical implications. Gastrointest Radiol. Summer 1990;15(3):223-8. [Medline].

  10. Hwang JI, Chou YH, Tsay SH, et al. Radiologic and pathologic correlation of adenomyomatosis of the gallbladder. Abdom Imaging. Jan-Feb 1998;23(1):73-7. [Medline].

  11. Kim MJ, Oh YT, Park YN, et al. Gallbladder adenomyomatosis: findings on MRI. Abdom Imaging. Jul-Aug 1999;24(4):410-3. [Medline].

  12. Levy AD, Murakata LA, Rohrmann CA Jr. Gallbladder carcinoma: radiologic-pathologic correlation. Radiographics. Mar-Apr 2001;21(2):295-314; questionnaire, 549-55. [Medline].

  13. Yoshimitsu K, Honda H, Jimi M, et al. MR diagnosis of adenomyomatosis of the gallbladder and differentiation from gallbladder carcinoma: importance of showing Rokitansky-Aschoff sinuses. AJR Am J Roentgenol. Jun 1999;172(6):1535-40. [Medline].

  14. Koh T, Taniguchi H, Kunishima S, Yamagishi H. Possibility of Differential Diagnosis of Small Polypoid Lesions in the Gallbladder Using FDG-PET. Clin Positron Imaging. Sep 2000;3(5):213-218. [Medline].

Previous
Next
 
Sonogram in a patient with adenomyomatosis.
Transverse sonogram of the gallbladder shows multiple hyperechoic foci within the gallbladder wall with reverberation artifact. These findings are seen in patients with hyperplastic cholecystosis.
Oral cholecystogram shows focal fundal thickening in a patient with focal fundal adenomyomatosis.
Transverse sonogram in a patient with adenomyomatosis. Gallbladder wall is thickened, and many hyperechoic foci are seen in the gallbladder wall.
Longitudinal sonogram of gallbladder shows a hyperechoic focus in the anterior wall with reverberation artifact, which is characteristic of hyperplastic cholecystosis.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.