Description of the first case of adenomyomatosis of the gallbladder in an infant. Case Rep Pediatr. 2014;2014:248369. [PMID: 25024860 PMCID: PMC4082867 DOI: 10.1155/2014/248369]

Adenomyomatosis of the Gallbladder as a Cause of Abdominal Pain in Pediatrics: A Case Report of an Adolescent and a Literature Review

Objectives

Adenomyomatosis (ADM) of the gallbladder is a benign condition, which is characterized by mucosal hyperplasia of the gallbladder and formation of intramucosal invagination through the thickened mucosal layer. The pathogenesis is unclear. This condition is rare in children. The aim of this publication is to present the case of a teenager with ADM of the gallbladder and review the pediatric literature on this topic.

Methods

A 17-year-old female presented with severe postprandial right upper quadrant abdominal pains. The abdominal ultrasound revealed ADM of the gallbladder.

Results

A curative laparoscopic cholecystectomy was performed. Since 1998, eleven of the 13 pediatrics cases reported with ADM of the gallbladder were symptomatic and a cholecystectomy was curative in all of them.

Conclusion

ADM of the gallbladder should be considered in the differential diagnosis of recurrent right abdominal upper quadrant pains in pediatrics. Abdominal ultrasound is the best diagnostic procedure. In symptomatic patients, a cholecystectomy is curative.

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.

Morphological and immunophenotypical analysis of the spindle cell component in adenomyomatous hyperplasia of the gallbladder

Background

Adenomyomatous hyperplasia (AMH) of the gallbladder, reported in 1-8.7% of cholecystectomies, consists of cystically dilated sinuses/glands with a surrounding spindle cell proliferation which is thought to be composed of smooth muscle cells. Myofibroblasts are contractile cells that secrete a variety of biochemical modulators causing a “field-effect”. Myofibroblasts can be immunohistochemically distinguished from smooth muscle cells by their desmin negativity.

Methods

Eighteen cases of AMH and five cases each of chronic follicular cholecystitis, chronic cholecystitis, gallbladder carcinoma and 10 colonic diverticular disease were stained with actin and desmin. The percentage of myofibroblasts was estimated by the difference between actin and desmin staining in the same field. Statistical anlysis was performed using SPSS 22.0.

Results

The percentage of actin staining was significantly higher in AMH and gallbladder carcinoma compared to chronic follicular and chronic cholecystitis (p = 0.04). The percentage of desmin staining did not show any significant difference between the four groups. The estimated myofibroblastic population was significantly higher in AMH when compared to chronic follicular and chronic cholecystitis (p = 0.005).

Conclusion

The spindle cell proliferation around cystically dilated glands in AMH is composed predominantly of myofibroblasts and of smooth muscle cells as previously described. This finding suggest a derangement in epithelial-stromal interactions as the underlying pathophysiology in AMH.

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.

A narrative review of gallbladder adenomyomatosis: what we need to know

Gallbladder adenomyomatosis (GA) is increasingly encountered in clinical practice due to increasing use of imagings especially ultrasound (US). Clinicians need to know what is the implication of this condition and its proper management. GA is a degenerative and proliferative disease characterized by excessive epithelial proliferation associated with hypertrophy of muscularis propria. This leads to outpouchings of mucosa into or beyond the muscle layer forming intramural diverticula recognized as Rokitansky-Aschoff sinuses (RAS). Three types of GA are recognised: fundal, segmental and diffuse type. In fundal GA, there is focal thickening involving the GB fundus. In segmental GA, there is circumferential overgrowth of the GB wall that leads to formation of compartments. In diffuse GA, there is disseminated thickening and irregularity of the mucosa and muscularis. The pathogenesis of GA is unknown. It commonly occurs in middle age with equal sex distribution. Diagnosis of GA is by imagings showing thickened gallbladder wall containing cysts. Characteristic features are “comet-tail” artefacts and “twinkling” artefacts on US, “pearl-necklace sign” on magnetic resonance imaging (MRI) and “rosary sign” on computed tomography (CT). Cholecystectomy should be offered for symptomatic GA of any type. For asymptomatic GA, cholecystectomy may be considered for segmental type for its increased risk of malignancy and for diffuse type for its difficult visualization of any coexisting malignancy. Asymptomatic fundal GA can be safely observed with US. How frequent and how long should a fundal GA be monitored with US remains unknown. In case of diagnostic doubt, cholecystectomy should always be offered to avoid overlooked malignancy.

Combined Fundal and Segmental Adenomyomatosis of the Gallbladder in a Child: A Rare Case Report

Adenomyomatosis of the gallbladder (AMG) is characterized by mucosal hyperplasia leading to invagination through the thickened muscle layer, which is relatively common in adults, but is rare in childhood. We report a 12-year-old boy with adenomyomatosis of the gallbladder combined segmental and fundal type. This combined type is rare in adults and is first reported here in childhood. Although initial imaging with computed tomography (CT) suggested the presence of a circular solid mass-like lesion because of its rare morphology, repeated ultrasonography (US) was useful for leading to a correct diagnosis.

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.

Diffuse Adenomyomatosis of the Gallbladder in a Child

Adenomyomatosis of the gallbladder (ADMG) is characterized by proliferation of the mucosal epithelium and hypertrophy of the muscularis. ADMG is predominantly diagnosed by using ultrasonography. Although ADMG is benign in nature, lithiasis, and chronic inflammation secondary to it may lead to dysplastic changes and cancer. Mucosal invagination through the hypertrophied muscularis results in large intramural diverticula or sinus tracts which are visible at radiology, known as Rokitansky-Aschoff sinuses. Histologically, ADMG manifests with hyperplasia of the muscular layer and proliferation of mucosal glandular tissues. We describe a case of ADMG in an 8-year-old girl presenting with recurrent abdominal pain. Diagnosis was made using ultrasound, and the condition was successfully treated with open cholecystectomy. Ultrasound scanning in children presenting with recurrent abdominal pain may lead to more accurate diagnosis of ADMG during childhood.

Adenomyomatosis of the gallbladder in childhood: A systematic review of the literature and an additional case report

AIM: To investigate the diagnostic and therapeutic assessment in children with adenomyomatosis of the gallbladder (AMG).

METHODS: AMG is a degenerative disease characterized by a proliferation of the mucosal epithelium which deeply invaginates and extends into the thickened muscular layer of the gallbladder, causing intramural diverticula. Although AMG is found in up to 5% of cholecystectomy specimens in adult populations, this condition in childhood is extremely uncommon. Authors provide a detailed systematic review of the pediatric literature according to PRISMA guidelines, focusing on diagnostic and therapeutic assessment. An additional case of AMG is also presented.

RESULTS: Five studies were finally enclosed, encompassing 5 children with AMG. Analysis was extended to our additional 11-year-old patient, who presented diffuse AMG and pancreatic acinar metaplasia of the gallbladder mucosa and was successfully managed with laparoscopic cholecystectomy. Mean age at presentation was 7.2 years. Unspecific abdominal pain was the commonest symptom. Abdominal ultrasound was performed on all patients, with a diagnostic accuracy of 100%. Five patients underwent cholecystectomy, and at follow-up were asymptomatic. In the remaining patient, completely asymptomatic at diagnosis, a conservative approach with monthly monitoring via ultrasonography was undertaken.

CONCLUSION: Considering the remote but possible degeneration leading to cancer and the feasibility of laparoscopic cholecystectomy even in small children, evidence suggests that elective laparoscopic cholecystectomy represent the treatment of choice. Pre-operative evaluation of the extrahepatic biliary tree anatomy with cholangio-MRI is strongly recommended.