Imaging of adenomyomatosis of the gall bladder

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.

Differentiation of gallbladder adenomyomatosis from early-stage gallbladder cancer before surgery

Backgrounds/Aims

This study aimed to compare the perioperative and clinical outcomes in patients undergoing laparoscopic cholecystectomy for gallbladder adenomyomatosis (GBA) or early-stage gallbladder cancer (GBC).

Methods

The perioperative and clinical outcomes of 194 patients diagnosed with GBA and 30 patients diagnosed with GBC who underwent laparoscopic cholecystectomy in our institution from January 2011 to December 2017 were retrospectively compared.

Results

There were no significant differences between the GBA and GBC groups in sex (male:female ratio 1.0:0.8 vs. 1.0:0.7, p=0.734), BMI (23.9±3.4 vs. 24.0±3.8 kg/m², p=0.916), or preoperative liver function tests. Patients in the GBC group were significantly older (50.5±14.1 vs. 65.9±10.6 years, p<0.001) and had a higher ASA grade (40.3 vs. 63.4% grade II or III, p=0.043) than patients in the GBA group. Although there was no significant difference in preoperative diagnostic methods (p=0.442), the GBC group showed a significantly higher rate of misdiagnosis on preoperative imaging compared with postoperative histopathologic findings (30.9% vs. 53.3%, p=0.011). There were significantly more patients with gallstones in the GBA group than in the GBC group (68.6% vs. 40.0%, p=0.004).

Conclusions

In older patients hospitalized for biliary colic without gallstones but with a thickened gallbladder wall with inflammation on preoperative diagnostic exam, the possibility of early-stage GBC should be considered.

Contrast-enhanced ultrasonography in differential diagnosis of focal gallbladder adenomyomatosis and gallbladder cancer

BACKGROUND

Focal gallbladder adenomyomatosis (ADM) is a common disease that mimics gallbladder cancer (GBC) on ultrasonography.

OBJECTIVE

Here we aim to assess the value of contrast-enhanced ultrasound (CEUS) in differentiating ADM from GBC.

METHODS

Forty-one histopathologically proven focal ADMs and 34 GBCs (≤T2 stage) were enrolled in the study. Lesion location, blood flow signals, contrast pattern and appearance on contrast-enhanced ultrasound (CEUS) were compared respectively.

RESULTS

Lesions were detected in fundus, body, neck at the rates of 61.0% (25/41), 26.8% (11/41) and 12.2% (5/41), respectively, in ADM patients, in comparison to 29.4% (10/34), 32.4% (11/34) and 38.2% (13/34), respectively, in GBC patients (p = 0.009). Blood flow signals were detected in 19.5% (8/41) of cases in ADMs, compared to 58.8% (20/34) in GBCs (p = 0.001). On CEUS, iso-enhancement, hypo-enhancement, intramural anechoic space and intactness of GB wall were detected in 41.5% (17/41), 39.0% (16/41), 56.1% (23/41) and 80.5% (33/41) cases of ADMs, in contrast to 17.6% (6/34), 20.6% (7/34), 20.6% (7/34) and 17.6% (6/34) of GBCs (p = 0.001, p = 0.001, p = 0.002, p < 0.001, respectively). The prior Youden's index were 0.81 based on intactness of GB wall on CEUS.

CONCLUSION

Combined with CEUS helps improve the differential diagnosis accuracy of focal gallbladder ADMs.

Pathogenesis of gallbladder adenomyomatosis and its relationship with early-stage gallbladder carcinoma: an overview

The exact pathogenesis of gallbladder adenomyomatosis is still lacking and some controversies over its diagnosis and treatment exist. Originally recognized as a precancerous lesion, adenomyomatosis is currently recognized by recent studies as a benign alteration of the gallbladder that is often associated with cholecystitis and cholecystolithiasis. Gallbladder carcinoma is an extremely malignant disease with a 5-year survival rate of less than 5%. Therefore, it is important to diagnose, differentiate, and confirm the relationship between adenomyomatosis and early-stage gallbladder carcinoma. However, the early clinical symptoms of adenomyomatosis are extremely similar to those of gallbladder stones and cholecystitis, increasing the difficulty to identify and treat this disease. This article summarizes the research progress on gallbladder adenomyomatosis, aiming to improve the understanding of the pathogenesis of adenomyomatosis and further provide insight for its clinical diagnosis and treatment.

CT diagnosis of gallbladder adenomyomatosis: importance of enhancing mucosal epithelium, the "cotton ball sign". Eur Radiol. 2018;28:3573-3582. [PMID: 29633001 DOI: 10.1007/s00330-018-5412-4]

OBJECTIVES

To determine the diagnostic value of the cotton ball sign and other CT features in patients with gallbladder (GB) wall thickenings (WTs).

METHODS

Three blinded readers reviewed the preoperative CT and MR images of 101 patients with pathologically confirmed GB adenomyomatosis (GA) (n = 34) and other benign (n = 29), malignant (n = 41), and premalignant (n = 2) GBWTs. Three readers analysed the morphological features of GBWT and presence of the "cotton ball sign", defined as fuzzy grey dots in GBWT or a dotted outer border of the inner enhancing layer on contrast-enhanced (CE) CT. In addition, the "pearl necklace sign" on MR was analysed.

RESULTS

In the GA group (n = 34), prevalence of the cotton ball sign and pearl necklace sign was 74% (25/34) and 44% (15/34), respectively. Presence of the cotton ball sign, smooth contour of the mucosa, double-layering enhancement, and enhancement degree weaker than the renal cortex on CT images were significant predictors of benign GBWT (p < 0.01). When differentiating GA from GB malignancy or premalignancy, accuracy of the cotton ball sign and pearl necklace sign was 81% (62/77) and 74% (57/77), respectively.

CONCLUSION

The cotton ball sign on CE-CT showed higher sensitivity and comparable specificity to those of the pearl necklace sign in differentiating GA from malignancy.

KEY POINTS

• Prevalence of the cotton ball sign on CT was 74% in gallbladder adenomyomatosis. • The cotton ball sign was useful in differentiating gallbladder adenomyomatosis from gallbladder cancer. • The cotton ball sign was more sensitive than the pearl necklace sign for adenomyomatosis diagnosis.

Negative signals for adenomyomatosis of the gallbladder upon diffusion-weighted whole body imaging with background body signal suppression/T2-weighted image fusion analysis

Differentiation between adenomyomatosis (ADM) and cancer of the gallbladder is necessary during diagnosis. Diffusion-weighted whole body imaging with background body signal suppression (DWIBS) images are able to indicate cancer and inflammation. The fusion of a DWIBS with a T2 weighted image (DWIBS/T2) facilitates both functional and anatomical investigations. In the present study, patient records and images from patients with surgically confirmed ADM from April 2012 to October 2014 were analyzed retrospectively. The enrolled patients, including 6 men (64.2±13.1 years) and 4 women (57.3±12.4 years) were subjected to DWIBS/T2 during routine clinical practice. The diagnosis of ADM was based on magnetic resonance cholangiopancreatography, transabdominal ultrasonography, and endoscopic ultrasonography; ADM was diagnosed definitively when cystic lesions were observed, indicating the Rokitansky-Aschoff sinus. A single patient was indicated to be positive by DWIBS/T2 imaging. The Rokitansky-Aschoff sinus revealed a relatively high signal intensity; however, it was not as strong as that of the spleen. The signal intensity was also high on an apparent diffusion coefficient map, suggesting T2 shine-through. The thickened wall displayed low signal intensity. The aforementioned results indicate that ADM may be negative upon DWIBS/T2 imaging; one false positive case was determined to be ADM, accompanied by chronic cholecystitis. The majority of patients with ADM displayed negative findings upon DWIBS/T2 imaging, and chronic cholecystitis may cause false positives.

A literature review of radiological findings to guide the diagnosis of gallbladder adenomyomatosis

BACKGROUND

Gallbladder adenomyomatosis (GA) is a benign gallbladder entity discovered as an asymptomatic gallbladder mass. Since gallbladder cancer is in the differential diagnosis for gallbladder masses, the ability to differentiate benign disease avoids a more extensive oncologic resection. This study sought to review imaging modalities used to diagnose GA.

METHODS

PubMed and SciVerse Scopus were systematically searched using the terms: "gallbladder adenomyomatosis" and "gallbladder imaging" for articles published between January 2000 and January 2015.

RESULTS

A total of 14 articles were reviewed in this analysis. Contemporary series report the use of ultrasound (US), computed tomography (CT) or magnetic resonance imaging (MRI) in GA imaging. Ultrasound detection of Rokitansky-Aschoff sinuses, visualized as small cystic spaces with associated "comet-tail" or "twinkling" artifact, is pathognomonic for GA. A "Pearl-Necklace" sign of small connected sinuses on MRI or "Rosary" sign on CT are additional characteristics that may assist in establishing a diagnosis.

CONCLUSION

Ultrasound is the most commonly used tool to investigate GA. If not diagnostic, CT or MRI are effective in attempting to differentiate a benign or malignant cholecystic mass. Characteristic signs should lead the surgeon to perform a laparoscopic cholecystectomy in symptomatic patients or manage non-operatively in asymptomatic patients.

Differentiating between adenomyomatosis and gallbladder cancer: revisiting a comparative study of high-resolution ultrasound, multidetector CT, and MR imaging

Objective

To compare the diagnostic performance of high-resolution ultrasound (HRUS) with contrast-enhanced CT and contrast-enhanced magnetic resonance imaging (MRI) with MR cholangiopancreatography (MRCP) to differentiate between adenomyomatosis (ADM) and gallbladder cancer (GBCA).

Materials and Methods

Forty patients with surgically proven ADM (n = 13) or GBCA at stage T2 or lower (n = 27) who previously underwent preoperative HRUS, contrast-enhanced CT, and contrast-enhanced MRI with MRCP were retrospectively included in this study. According to the well-known diagnostic criteria, two reviewers independently analyzed the images from each modality separately with a five-point confidence scale. The interobserver agreement was calculated using weighted κ statistics. A receiver operating characteristic curve analysis was performed and the sensitivity, specificity, and accuracy were calculated for each modality when scores of 1 or 2 indicated ADM.

Results

The interobserver agreement between the two reviewers was good to excellent. The mean Az values for HRUS, multidetector CT (MDCT), and MRI were 0.959, 0.898, and 0.935, respectively, without any statistically significant differences between any of the modalities (p > 0.05). The mean sensitivity of MRI with MRCP (80.8%) was significantly higher than that of MDCT (50.0%) (p = 0.0215). However, the mean sensitivity of MRI with MRCP (80.8%) was not significantly different from that of HRUS (73.1%) (p > 0.05). The mean specificities and accuracies among the three modalities were not significantly different (p > 0.05).

Conclusion

High-resolution ultrasound and MRI with MRCP have comparable sensitivity and accuracy and MDCT has the lowest sensitivity and accuracy for the differentiation of ADM and GBCA.

Actual status of clinical diagnosis in patients with primary gallbladder cancer associated with adenomyomatosis

AIM

The purpose of this study was to reveal differences in clinical diagnosis of gallbladder cancer among patients with or without adenomyomatosis (ADM) by analyzing demonstrated tumor patterns on imaging and diagnostic opportunities.

METHODS

Ninety-seven patients with gallbladder cancer were enrolled. Demonstrated imaging patterns were classified into mass lesion (ML), wall thickening (WT), and papillary lesion (PL). Clinical status during periodic follow up and other diagnostic opportunities were determined from medical records.

RESULTS

All adenomyomatosis-associated cases were diagnosed at the T2 or higher stage. The distribution of demonstrated imaging patterns was significantly different between the adenomyomatosis-associated and non-adenomyomatosis-associated groups (p = 0.0002). No adenomyomatosis-associated gallbladder cancer had the PL pattern, which was readily identifiable and characteristic of early-stage cancer. The WT pattern presented difficulties for diagnosis, and the ML pattern was relatively specific, although most of these cases were at advanced stages. Approximately 40% of ADM patients were found to be in advanced stages of gallbladder cancer, in spite of undergoing periodic follow up.

CONCLUSIONS

This study revealed the difficulty of early diagnosis of primary gallbladder cancer in the setting of concurrent ADM. Current results suggest the possible utility of preventive cholecystectomy for management of asymptomatic ADM patients.

A comparative study of clinicopathological features between chronic cholecystitis patients with and without Helicobacter pylori infection in gallbladder mucosa. PLoS One. 2013;8:e70265. [PMID: 23936177 PMCID: PMC3728185 DOI: 10.1371/journal.pone.0070265]

Background

Helicobacter pylori has been isolated from 10%–20% of human chronic cholecystitis specimens but the characteristics of “Helicobacter pylori positive cholecystitis” remains unclear. This study aims to compare the clinicopathological features between chronic cholecystitis patients with and without Helicobacter pylori infection in gallbladder mucosa.

Methods

Three hundred and twenty-six chronic cholecystitis patients were divided into two groups according to whether Helicobacter pylori could be detected by culture, staining or PCR for Helicobacter 16s rRNA gene in gallbladder mucosa. Positive samples were sequenced for Helicobacter pylori-specific identification. Clinical parameters as well as pathological characteristics including some premalignant lesions and the expression levels of iNOS and ROS in gallbladder were compared between the two groups.

Results

Helicobacter pylori infection in gallbladder mucosa was detected in 20.55% of cholecystitis patients. These patients had a higher prevalence of acid regurgitation symptoms (p = 0.001), more histories of chronic gastritis (p = 0.005), gastric ulcer (p = 0.042), duodenal ulcer (p = 0.026) and higher presence of Helicobacter pylori in the stomach as compared to patients without Helicobacter pylori infection in the gallbladder mucosa. Helicobacter pylori 16s rRNA in gallbladder and gastric-duodenal mucosa from the same individual patient had identical sequences. Also, higher incidences of adenomyomatosis (p = 0.012), metaplasia (p = 0.022) and higher enhanced expressions of iNOS and ROS were detected in Helicobacter pylori infected gallbladder mucosa (p<0.05).

Conclusions

Helicobacter pylori infection in gallbladder mucosa is strongly associated with Helicobacter pylori existed in stomach. Helicobacter pylori is also correlated with gallbladder premalignant lesions including metaplasia and adenomyomatosis. The potential mechanism might be related with higher ROS/RNS production but needs further investigation.

Differentiation of adenomyomatosis of the gallbladder from early-stage, wall-thickening-type gallbladder cancer using high-resolution ultrasound

OBJECTIVES

To evaluate the diagnostic performance of transabdominal high-resolution ultrasound (HRUS) for differentiation of adenomyomatosis from early-stage, wall-thickening-type gallbladder (GB) cancer.

METHODS

HRUS was defined as the addition of high megahertz imaging to conventional low megahertz imaging with use of state-of-the-art imaging technology. HRUS findings were retrospectively compared in 45 patients with adenomyomatosis and 28 patients with stage T1/T2 wall-thickening-type GB cancer. For evaluating HRUS performance in the differential diagnosis of adenomyomatosis from GB cancer, receiver operating characteristic curve analysis was used with a five-point confidence scale independently scored by three blinded radiologists who also analysed morphological abnormalities.

RESULTS

The area under the receiver operating characteristic curve (A (z)) values of HRUS in the diagnosis of adenomyomatosis were 0.948, 0.915 and 0.917 for reviewers 1, 2 and 3. Symmetrical wall thickening, intramural cystic spaces, intramural echogenic foci and twinkling artefacts were significantly associated with adenomyomatosis (P < 0.05), whereas irregular thickening of the outer wall, focal innermost hyperechoic layer (IHL) discontinuity, IHL irregularity, IHL thickening greater than 1 mm, loss of multilayer pattern in the GB wall, and intralesional vascularity were significantly associated with cancer (P < 0.05). The sensitivity, specificity and accuracy of intramural cystic spaces/echogenic foci for the diagnosis of adenomyomatosis were 80.0 %, 85.7 % and 82.2 %.

CONCLUSIONS

This study showed that HRUS can be helpful for distinguishing adenomyomatosis from early-stage, wall-thickening-type GB cancer.

Color Doppler twinkling artifacts from gallbladder adenomyomatosis with 1.8 MHz and 4.0 MHz color Doppler frequencies

The purpose of this study was to investigate the diagnostic value of color Doppler twinkling artifacts (CDTAs) in the evaluation of gallbladder adenomyomatosis with differently colored Doppler frequencies. An ultrasound was performed by an experienced radiologist in 17 patients with typical gallbladder adenomyomatosis. Two abdominal radiologists retrospectively evaluated the anatomic locations, the intensity of 69 CDTAs on 1.8 MHz and 4.0 MHz Doppler frequencies, and the intensity of the corresponding comet-tail artifacts. Statistical analysis was performed using the Friedman and Kruskal-Wallis test. The intensity of the CDTAs was significantly greater than that of the comet-tail artifacts, regardless of the color Doppler frequency and anatomic location (p < 0.001). The intensity of the CDTAs on 1.8 MHz was significantly higher than that on 4.0 MHz color Doppler frequency (p < 0.05). In conclusion, CDTAs may be useful in recognizing gallbladder adenomyomatosis, and 1.8 MHz color Doppler frequency is more highly recommended than 4.0 MHz for the visualization of CDTAs.

Adenomyomatosis of the gallbladder--case report

Adenomyomatosis of the gallbladder is a benign, mostly asymptomatic condition of an unknown aetiology. Hyperplastic changes in the gallbladder wall cause an overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula or sinus tracts termed Rokitansky-Aschoff sinuses. Adenomyomatosis is divided on general, segmental and localised. Ultrasound examination, computerized tomography and magnetic resonance are used in diagnostic procedure. The importance of the disease lies in the fact that it can cause recurrent right upper quadrant pain so it must be concerned in resolving pain cause. This paper was aimed at explaining the aetiology of the disease, its clinical manifestation, making diagnosis and therapy in order to make its diagnosis and treatment possible.

Adenomyomatosis of the gallbladder: the "good omen" comet

BACKGROUND

As emergency physicians perform bedside ultrasound with greater frequency, greater numbers of incidental and potentially unfamiliar sonographic findings will be encountered.

OBJECTIVES

Illustrate, discuss, and briefly review literature regarding one such finding and diagnosis in right upper quadrant sonography.

CASE REPORT

A middle-aged woman was evaluated in the Emergency Department for abdominal pain. Limited bedside sonography of the gallbladder revealed mural thickening and comet-tailing. A diagnosis of adenomyomatosis was made.

CONCLUSION

Gallbladder adenomyomatosis can produce ultrasound findings similar to those of more serious and emergent gallbladder diseases. Cognizance of the sonographic details and typical clinical characteristics will allow the emergency physician to appropriately assess and disposition patients with this condition.