Combined segmental and focal adenomyomatosis involving the body of the gallbladder

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.

An Unusual Case of Noninvasive Adenocarcinoma Arising in a Localized Adenomyoma of the Gallbladder and Review of Literature

Adenomyoma or adenomyomatosis (ADM) of the gallbladder generally carries little or no risk of malignant transformation. Rare cases of such malignant transformation are described in the literature only in segmental type of ADM and not in localized adenomyoma. We report a case of a 58-year-old asymptomatic woman found to have an incidental 3.3 × 3.2 × 2.3 cm well-circumscribed exophytic mass on surveillance ultrasound, originating from the fundus of the gallbladder and abutting the liver capsule. The patient underwent an open cholecystectomy with resection of the mass and underlying segment of the liver. The mass was discrete and well-circumscribed with a peripheral pseudocapsule. Histologically, it showed features typical of a benign adenomyoma with variably sized distended microcysts within fibromuscular stroma. Within the lesion, however, multiple small foci amounting to approximately 5% of the total lesion showed high-grade dysplasia or adenocarcinoma in situ. Apart from cytological distinctiveness, these foci were also selectively highlighted by positive immunostaining for p53 and higher Ki-67 reactivity. Away from this lesion, the gallbladder showed cholelithiasis, mild cholecystitis, and no additional adenomyoma. There was no invasion into the gallbladder mucosa or adjacent liver. This case is highly unusual since transformation to carcinoma is not previously described in a localized or discrete adenomyoma. In the short available follow-up (4 months to date), there is no evidence of recurrence or metastasis. The long-term prognosis is expected to be favorable due to lack of invasion and complete excision, even if there is no documented literature regarding its course.

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.