Symptomatic Gallbladder Adenomyomatosis: A rare clinical presentation.

INTRODUCTION AND IMPORTANCE: Gallbladder Adenomyomatosis (GA) is a benign rare condition that is mostly asymptomatic but can present as abdominal pain. GA usually occurs in the middle-aged population with an equal sex distribution. CASE PRESENTATION: A case of a 49-years-old female who sought medical care several times due to abrupt abdominal pain. She underwent echography, Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) before performing laparoscopic cholecystectomy for symptomatic GA. The pathology report confirmed acalculous cholecystitis in the presence of GA. CLINICAL DISCUSSION: In fact, echography can reveal the "comet- tail" sign, the CT can show the "rosary sign"; and MRI shows the "pearl necklace" sign. These signs, in the absence of gallstones, can justify the abdominal pain hence the diagnosis of symptomatic GA. CONCLUSION: GA is being increasingly reported; however, symptomatic cases remain the exception. We believe that awareness to this entity should be raised so that healthcare professionals can establish the diagnosis efficiently.

Age and incidence of occult pancreaticobiliary reflux in patients with benign gallbladder diseases.

BACKGROUND: Occult pancreaticobiliary reflux (OPBR) has a significant correlation with diseases of the gallbladder and biliary system. This study examined the incidence of OPBR by age in patients with benign gallbladder diseases. METHODS: We assessed 475 patients with benign gallbladder diseases who underwent surgery at Shanghai East Hospital from December 2020 to December 2021. Bile samples collected during surgery were tested for amylase. Patients with bile amylase >110 U/L (n = 64) were classified as the OPBR group; the rest (n = 411) as controls. RESULTS: Of the participants, 375 had gallbladder stone (GS), 170 had gallbladder polyp (GP), and 49 had gallbladder adenomyomatosis (GA). The OPBR group was generally older, with OPBR incidence increasing with age, peaking post-45. Rates by age were: 4.9% (<35), 5.2% (35-44), 20.7% (45-54), 22.5% (55-64) and 17.6% (≥65), mainly in GS patients. ROC analysis for predicting OPBR by age yielded an area under the curve of 0.656, optimal cut-off at 45 years. Logistic regression indicated age > 45, GP, male gender, and BMI ≥ 24 kg*m-2 as independent OPBR predictors in GS patients. Based on these variables, a predictive nomogram was constructed, and its effectiveness was validated using the ROC curve, calibration curve and decision curve analysis (DCA). Further stratification revealed that among GS patients ≤ 45, concurrent GA was an OPBR risk; for > 45, it was GP and male gender. CONCLUSIONS: The incidence of OPBR in GS patients is notably influenced by age, with those over 45, especially males without GP, being at heightened risk.

Imaging update on gallbladder adenomyomatosis and its mimics.

Radiologists across many imaging modalities commonly encounter gallbladder adenomyomatosis. The classic imaging appearances of gallbladder adenomyomatosis are well described and confirm benignity. However, in clinical practice, adenomyomatosis can be challenging to differentiate from other gallbladder pathologies that require cholecystectomy. In this article, we describe the common and uncommon appearances of gallbladder adenomyomatosis on multimodality imaging, helping differentiate adenomyomatosis from non-benign gallbladder abnormalities. Accurately differentiating adenomyomatosis from its mimics provides the surgical team with important clinical and surgical management information, improving patient outcomes.

Simultaneous laparoscopic treatment of median arcuate ligament syndrome and segmental adenomyomatosis of the gallbladder: A case report.

INTRODUCTION: Median Arcuate Ligament Syndrome (MALS) is a condition in which the median arcuate ligament tightly compresses the celiac artery. A patient presented with MALS and segmental adenomyomatosis of the gallbladder, both treated simultaneously using a laparoscopic approach. PRESENTATION OF CASE: A 48-year-old male with adenomyomatosis of the gallbladder presented with postprandial epigastric pain. Abdominal three-dimensional computed tomography scan showed compression of the celiac artery, and the patient was diagnosed with MALS. Laparoscopic dissection of the median arcuate ligament and cholecystectomy were performed to treat both conditions. By optimizing port positions, both conditions could be treated simultaneously. The patient was discharged on postoperative day 6 and has no recurrent symptoms 20 months postoperatively. DISCUSSION: To the best of our knowledge, there are no previously reported cases of simultaneous laparoscopic division of the median arcuate ligament and cholecystectomy. CONCLUSION: By optimizing the port positions, laparoscopic division of the median arcuate ligament and cholecystectomy were performed simultaneously, minimally invasively, safely and effectively.

Spectrum of imaging findings in hyperplastic cholecystosis and potential mimics.

Adenomyomatosis and cholesterolosis of the gallbladder, collectively termed hyperplastic cholecystosis, are commonly encountered incidental findings on imaging studies performed for a variety of indications including biliary colic or nonspecific abdominal pain. These pathologies are rarely the source of symptoms, generally considered benign and do not require further work-up. However, their imaging characteristics can overlap with more sinister conditions that should not be missed. In this review, the imaging findings of adenomyomatosis and cholesterolosis will be reviewed followed by other gallbladder pathologies that might mimic these conditions radiologically. Important differentiating factors will be discussed that can aid the radiologist in making a more confident imaging diagnosis.

Controversy and consideration of gallbladder adenomyomatosis / 中华肝胆外科杂志

The detection rate of gallbladder adenomyomatosis has gradually increased, but the accuracy of preoperative diagnosis is low. Most doctors tend to expand the operation indications because they are worried about the carcinogenesis. But there are still great controversies on the key issues such as whether it is cancerous, operation indications and how to follow up for non-surgical patients. This article will review these key issues.

Postmortem Diagnosis of Gallbladder Cancer Presenting as Pulmonary Lymphangitic Carcinomatosis With Concurrent Gallbladder Adenomyomatosis.

In pulmonary lymphangitic carcinomatosis, it can be difficult to identify the primary site of the cancer on computed tomography (CT) imaging. Here, we report a rare case of pulmonary lymphangitic carcinomatosis, which was difficult to diagnose as gallbladder cancer. An 81-year-old woman, previously followed up for gallbladder adenomyomatosis, presented with persistent cough. CT revealed multiple small nodular opacities, irregular interlobular septal thickening, and bilateral pleural effusions. Based on the CT findings and the presence of malignant cells in the pleural fluid, a presumptive diagnosis of pulmonary lymphangitic carcinomatosis was made, but the primary site was not identified. The patient died of respiratory failure in two months. Autopsy confirmed gallbladder cancer with pulmonary lymphangitic carcinomatosis and multiorgan metastasis. Clinicians should be aware that in patients with gallbladder adenomyomatosis, gallbladder cancer can present with rapidly progressive respiratory symptoms even in the absence of an evident mass or increased gallbladder wall thickening.

A Case of Early-Stage Gallbladder Cancer, Positive for ALDH1A1, Which Arose from Adenomyomatosis of the Gallbladder.

Adenomyomatosis (ADM) of the gallbladder is a condition characterized by the proliferation of Rokitansky-Aschoff sinus (RAS), in which the epithelium of the gallbladder extends into the muscular layer, causing a thickening of the gallbladder wall. Although ADM is generally considered not to be a precancerous lesion of gallbladder cancer, there are some reports of cases of gallbladder cancer from ADM. Therefore, the relationship between ADM and gallbladder cancer remains controversial. We herein report a case of early-stage gallbladder cancer, BilIN3 (high grade), arising from ADM that was positive for ALDH1A1, an important marker of stem cells and cancer stem cells.

Gallbladder Imaging Interpretation Pearls and Pitfalls: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging.

The gallbladder is a source of common disease processes with a wide variety of presentations. Common pathologies include acute or chronic cholecystitis, adenomyomatosis, cancer, polyps, and postoperative complications. Accurate imaging assessment of the gallbladder can be very challenging and fraught with potential pitfalls. Ultrasound is the imaging modality of choice for the initial evaluation of patients who present with right upper quadrant pain. CT is often used as part of a broader evaluation of patient's abdominal pain if nongallbladder pathologies are also suspected. MRI/MRCP is typically reserved for problem-solving and evaluating patients who present with cholestatic presentation. We discuss common pitfalls, diagnostic challenges, and problem-solving approaches to the imaging evaluation of common gallbladder patho logies.

Technique of straightening the guidewire using a balloon catheter for successful endoscopic transpapillary gallbladder stenting.

Video 1The technique of straightening the guidewire, looped in the neck of the gallbladder because of segmental adenomyomatosis, using a balloon catheter during endoscopic transpapillary gallbladder stent placement.

Intravascular adenomyomatosis: a morphologic variant of intravenous leiomyomatosis associated with endometriosis and potential for misdiagnosis.

Intravenous leiomyomatosis (IVL) is a quasi-malignant smooth muscle tumor involving lymphatic and venous spaces of the myometrium. Rare cases of IVL with admixed endometrial glands and stroma have been described, termed intravascular adenomyomatosis. We report four additional cases of intravascular adenomyomatosis and expand the clinicopathologic features of these rare tumors. Patients were 39-45 years old and presented with symptoms of dysmenorrhea, postmenopausal bleeding, or pelvic mass. All cases were associated with endometriosis. Three cases comprised intravascular bland smooth muscle tumors with plexiform features, and in some foci, the intravascular tumor contained endometrial type glands and stroma. In one case, there was extensive (>10) foci of intravascular adenomyomatosis without evidence of associated smooth muscle neoplasm but did have an endometrial polyp with adenomyomatous features. None of the cases had nuclear atypia, increased mitotic activity, or tumor cell necrosis. The endometrial stromal components were positive for CD10 and negative or weakly positive for desmin by immunohistochemistry. Two cases underwent molecular testing for JAZF1 and PHF1 rearrangements with negative results. Three patients had no evidence of disease at the time of the last follow-up, and one had persistent but stable disease 7 years after incomplete surgical removal and megestrol acetate treatment. Intravascular adenomyomatosis is a variant morphology rarely seen in IVL that lacks characteristic morphologic and molecular features of endometrial stromal sarcoma. Similar to IVL, prognosis is likely linked to completeness of surgical resection. In this study, we found that intravascular adenomyomatosis is frequently associated with endometriosis, a novel finding to add to the literature on this rare IVL variant.

Diffuse Gallbladder Adenomyomatosis in a Child.

Adenomyomatosis of the gallbladder is a benign condition, usually occurring in middle age, in which the epithelium of the gallbladder proliferates and the gallbladder wall thickens with the presence of Rokitansky-Aschoff sinuses (RAS). The diffuse form is an unusual subtype of adenomyomatosis. Herein, we describe a 17-year-old female who presented with dull and intermittent pain in the right hypochondriac region for more than a month. Ultrasound followed by magnetic resonance imaging showed marked diffuse gallbladder wall thickening. A gross cholecystectomy specimen showed a diffusely enlarged gallbladder. The final diagnosis of gallbladder adenomyomatosis (GA) was confirmed by the histopathologic appearance of muscular and epithelial hyperplasia, contributing to mural thickening with epithelial invaginations forming the pathognomonic intramural diverticula known as the RAS. This case highlights that the diffuse form of GA is uncommon and is often accompanied by chronic inflammation, sometimes requiring differential diagnosis from gallbladder malignancies, especially when there is no image showing a "comet tail" of cholesterol crystals in the wall.

Gallbladder adenomyomatosis: Diagnosis and management.

INTRODUCTION: Gallbladder adenomyomatosis is a benign acquired gallbladder disease. It can mimic cancer on radiological findings, leading to a diagnostic dilemma. The management and prognosis of these two gallbladder anomalies are entirely different. Therefore, it is essential to recognize the pathognomonic features of gallbladder adenomyomatosis is in order to accurately diagnose this pathology. This paper presents two encountered cases of gallbladder adenomyomatosis is, their diagnostic modalities as well as the algorithmic approach of their management. These two-case reports have been reported in line with the SCARE Criteria 2020 [1]. PRESENTATION OF CASE: Patient-1 was symptomatic. He was explored by an abdominal ultrasound picturing gallbladder wall thickening while the biopsy showed pleomorphic proliferation of inflammatory cells. An examination of the liver with MRI was indicated, showing diffuse parietal thickening with multiple cystic pockets. He underwent laparoscopic cholecystectomy with simple operative follow-up. Patient 2 was asymptomatic, a staging CT scan of acute pancreatitis revealed focal mural thinking of the gallbladder wall. A liver MRI showed an intramural cystic formation in the vesicular fundus. Given the inconclusive imaging results, laparoscopic cholecystectomy was performed. Histological examination confirmed the diagnosis of GA. DISCUSSION: Adenomyomatosis is usually asymptomatic. Imaging can confirm the diagnosis of gallbladder adenomyomatosis without the need for invasive procedures such as vesicular biopsy. Histologic examination can also confirm the diagnosis when cholecystectomy is done. High resolution ultra-sound is the most efficient radiological examination. Laparoscopic cholecystectomy is the gold standard for symptomatic GA or radiological suspicion of a gallbladder cancer. CONCLUSION: The practitioner should always consider gallbladder carcinoma before confirming the GA, as they share the same features but with a far worse prognosis. The likelihood of malignancy depends on radiological characteristics. In the case of inconclusive findings, cholecystectomy is justified.

Adenomyomatosis of the Common Bile Duct and Ampulla of Vater.

Adenomyomatosis is a rare benign lesion that has been observed in different sites throughout the gastrointestinal tract, most frequently in the gallbladder. Few cases have been described in the stomach, small bowel, bile ducts, and ampullary region. Adenomyomas of the vaterian system (ampulla and common bile duct) have important clinical consequences, since the majority of these lesions present with biliary tract obstruction and mimic malignant behavior. As a consequence, considering the diagnostic difficulty of these lesions, patients are often treated with extensive surgery (pancreaticoduodenectomy). We report 2 cases of adenomyomatosis: one of the ampulla of Vater and the other of the common bile duct, as well as a review of reported cases in the literature. Both of our patients presented with epigastralgia and had laboratory or endoscopic evidence of biliary obstruction. Both patients underwent endoscopic ultrasound, one of them with fine-needle aspiration; however, it was not possible to exclude the possibility of cancer. The diagnosis of adenomyoma was only confirmed by the surgical specimen after pancreaticoduodenectomy.

A adenomiomatose é uma lesão benigna rara que tem sido observada em diferentes locais do trato gastrointestinal, mais frequentemente na vesícula biliar. Poucos casos foram descritos no estômago, intestino delgado, vias biliares e ampola de Vater. Os adenomiomas do sistema de Vater (ampola e via biliar principal) têm importantes consequências clínicas, uma vez que a maioria dessas lesões se apresenta com obstrução biliar, sugerindo comportamento maligno. Como consequência, na maioria dos casos, e considerando a dificuldade diagnóstica destas lesões, os doentes são frequentemente submetidos a cirurgia extensa (pancreaticoduodenectomia). Reportamos dois casos de adenomiomatose da ampola de Vater e via biliar principal, bem como uma revisão dos casos descritos na literatura. Os doentes apresentaram-se com queixas de epigastralgia e evidência laboratorial ou endoscópia de obstrução biliar. Em ambos os casos foi realizada ultrassonografia endoscópica e em um deles punção aspirativa poragulha fina, não tendo sido possível excluir a possibilidade de malignidade. O diagnóstico de adenomioma foi apenas confirmado na peça cirúrgica após pancreaticoduodenectomia.

Diffuse Gallbladder Adenomyomatosis with an Inflammatory Complication in an Adult.

Gallbladder adenomyomatosis (GA) is a benign alteration of the gallbladder wall. There are three types involved: segmental, fundal, and diffuse pattern; the last type is very rare. Ultrasound is the imaging method of choice for diagnosing that shows Rokitansky-Aschoff sinuses with cholesterol deposition creating comet-tail artifacts. Asymptomatic GA does not require surgery in case there are no malignant lesions defined by imaging diagnosis. We present the rare case of a 51-year-old man who was admitted to hospital due to abdominal pain concomitant with inflammatory syndrome. Imaging and histological findings were appropriate to diagnose diffuse GA and complication of cholecystitis.

A case of incidental infantile gallbladder adenomyomatosis: an unusual US finding of uncertain clinical significance.

Adenomyomatosis of the gallbladder is defined as hypertrophy of the gallbladder mucosal epithelium that invaginates into a thickened muscularis propria, leading to the formation of intramural diverticula. It is typically considered a benign condition most commonly affecting adults and, rarely, children. In this case report, we present a case of gallbladder adenomyomatosis in a 3-month-old infant. The diagnosis was made incidentally on ultrasound examination of the abdomen, in an otherwise asymptomatic child with no laboratory test abnormalities and no underlying disease. The purpose of this case report is to make infantile adenomyomatosis and its implications known to clinicians, as the literature on this topic is limited. To the best of our knowledge, this is the youngest reported case of adenomyomatosis in the pediatric population.

B-mode ultrasonographic diagnosis in gallbladder wall thickening.

Diseases associated with gallbladder wall thickening include benign entities such as adenomyomatosis of the gallbladder, acute and chronic cholecystitis, and hyperplasia associated with pancreaticobiliary maljunction, and also cancer. Unique conditions such as sclerosing cholecystitis and cholecystitis associated with immune checkpoint inhibitor treatment can also manifest as wall thickening, as in some systemic inflammatory conditions. Gallbladder cancer, the most serious disease that can show wall thickening, can be difficult to diagnose early and to distinguish from benign causes of wall thickening, contributing to a poor prognosis. Differentiating between xanthogranulomatous cholecystitis and gallbladder cancer with wall thickening can be particularly problematic. Cancers that thicken the wall while coexisting with benign lesions that cause wall thickening represent another potential pitfall. In contrast, some benign gallbladder lesions that can cause wall thickening, such as adenomyomatosis and acute cholecystitis, typically show characteristic ultrasonographic features that, together with clinical findings, permit easier diagnosis. In this review of the literature, we describe B-mode abdominal ultrasonographic diagnosis of gallbladder lesions showing wall thickening.

Infantile Adenomyomatosis of the Gallbladder in a 3-Month-Old.

Adenomyomatosis of the gallbladder is an acquired condition of the gallbladder with epithelial, mucosal, and muscular hypertrophy. The result is usually gallbladder wall thickening with associated diverticula known as Rokitansky-Aschoff's sinuses. These mucosal invaginations of the gallbladder wall may extend beyond the muscular layer. The condition is typically asymptomatic and is predominantly diagnosed in adults between 50 and 60 years of age, usually with concomitant cholelithiasis, motility disorders, or chronic inflammation. Few cases within the literature have been described in the pediatric population and even fewer within this subset have been diagnosed in infants. We describe a case of a 3-month-old male with failure to thrive, persistent nonbilious, nonbloody emesis, and elevated transaminases with ultrasound evidence of gallbladder adenomyomatosis. The patient was managed with outpatient laboratory monitoring and follow-up imaging.