Diagnostic Ultrasound - Abdomen and Pelvis

Hyperplastic Cholecystosis (Adenomyomatosis)
Diagnoses: Biliary System
• Contracted GB lumen
• Presence of gallstones within GB
• Lack of mural "comet tail" artifacts or intramural cystic
space
Emphysematous Cholecystitis
• Intramural gas may mimic cholesterol deposits
• Dirty shadowing, no "comet tail" reverberation artifacts
• Clinically ill
PATHOLOGY
General Features
• Cholesterolosis: Mucosal villous hyperplasia with excessive
accumulation of triglyceride and cholesterol esters within
epithelial macrophages
○ Strawberry GB: Lipid accumulation is visible to naked eye;
yellow cholesterol deposits on background of hyperemia
mucosa ~ strawberry
• Adenomyomatosis: Excessive proliferation of surface
epithelium with invaginations into thickened muscularis
propria, forming diverticula known as RA sinuses
○ RA sinuses may be filled with bile, cholesterol crystals,
sludge, or calculi
• Gallstones in up to 90% (cholesterol)
Gross Pathologic & Surgical Features
• Focal or diffuse GB wall thickening without inflammatory
changes
• Adenomyomatosis: Diffuse or segmental GB wall
thickening with multiple cystic spaces
Microscopic Features
• Cholesterolosis
○ Fat-laden foamy macrophages within elongated villi →
small yellow subepithelial nodules → coalescent nodules
= polyps
– 2/3: Nodules < 1 mm in diameter → coarse and
granular appearance of mucosa
– 1/3: Nodules larger and polypoid
• Adenomyomatosis
○ Epithelium-lined cystic spaces in thickened muscular
layer of GB wall = intramural diverticula or RA sinuses
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Most often asymptomatic
○ When symptomatic, biliary pain (cystic duct obstructed
by prolapsing or detached polyp) or dyspepsia (poor GB
emptying)
Demographics
• Age
○ > 35 years
• Gender
○ Cholesterolosis: F > M
○ Adenomyomatosis: F > M
• Epidemiology
○ Cholesterolosis more common, 12% prevalence
○ Adenomyomatosis relatively less common, 5%
prevalence
Natural History & Prognosis
• Usually incidental finding
• No clinical significance in asymptomatic patients when
diagnosed correctly
• No conclusive evidence that presence of adenomyomatosis
increases risk for GB cancer
Treatment
• Cholecystectomy → symptomatic
DIAGNOSTIC CHECKLIST
Consider
• Consider chronic cholecystitis
Image Interpretation Pearls
• Cholesterolosis: Usually occult, multiple tiny polyps may
produce irregular GB wall
• Adenomyomatosis
○ Focal or diffuse wall thickening with intramural cystic
spaces
○ "Comet tail" reverberation artifacts
○ Hourglass appearances and fundal adenomyoma in focal
form
SELECTED REFERENCES
1. Revzin MV et al: The gallbladder: uncommon gallbladder conditions and
unusual presentations of the common gallbladder pathological processes.
Abdom Imaging. Epub ahead of print, 2014
2. Runner GJ et al: Gallbladder wall thickening. AJR Am J Roentgenol.
202(1):W1-W12, 2014
3. Pellino G et al: Stepwise approach and surgery for gallbladder
adenomyomatosis: a mini-review. Hepatobiliary Pancreat Dis Int. 12(2):136-
42, 2013
4. Meacock LM et al: Evaluation of gallbladder and biliary duct disease using
microbubble contrast-enhanced ultrasound. Br J Radiol. 83(991):615-27,
2010
5. Ash-Miles J et al: More than just stones: a pictorial review of common and
less common gallbladder pathologies. Curr Probl Diagn Radiol. 37(5):189-
202, 2008
6. Catalano OA et al: MR imaging of the gallbladder: a pictorial essay.
Radiographics. 28(1):135-55; quiz 324, 2008
7. Stunell H et al: Imaging of adenomyomatosis of the gall bladder. J Med
Imaging Radiat Oncol. 52(2):109-17, 2008
8. van Breda Vriesman AC et al: Diffuse gallbladder wall thickening: differential
diagnosis. AJR Am J Roentgenol. 188(2):495-501, 2007
9. Boscak AR et al: Best cases from the AFIP: adenomyomatosis of the
gallbladder. Radiographics. 26(3):941-6, 2006
10. Lack E et al: Pathology of the Pancreas, Gallbladder, Extrahepatic Biliary
Tract, and Ampullary Region. Oxford New York: Oxford University Press.
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acute acalculous cholecystitis. Semin Gastrointest Dis. 14(4):178-88, 2003
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