A 40-year-old male with no PMH presented to the ED with complaints of right upper quadrant (RUQ) pain. The pain had been intermittent for the last few days, but became constant on the day of presentation. There were no alleviating or exacerbating factors. He had associated nausea, but no vomiting. He denied any fevers.
Initial VS: BP 107/75 mmHg, HR 76, T 36.9 °C (98.4 °F), RR 16, SpO2 99%
Physical exam revealed a male that appeared uncomfortable with tenderness to palpation in the RUQ. His abdomen was non-distended, and there was no rebound or guarding present.
The ED team ordered labs and performed a bedside gallbladder ultrasound. Here are a few of the ultrasound images:
What do you see? There are two abnormal findings.
Most people would see the stone in the neck of the gallbladder with shadowing present. There also is an irregular portion of the anterior gallbladder wall with calcifications and hyperechoic comet tail artifacts. This second finding is called adenomyomatosis. See the picture below where these abnormalities are pointed out.
What is Adenomyomatosis?
- It is an abnormal growth and thickening of the gallbladder wall.
- It can be focal, segmental, or diffuse.
- It can have the hyperechoic comet tail artifact as in our images or it may look like a polyp.
- It might be a pre-malignant condition.
- There have been multiple studies with contradicting results.
- In two large case series (~3000-4500 patients each) those with gallbladder cancer were found to have a higher incidence of adenomyomatosis than those without cancer
- In other case series (~4800 patients total) the incidence of adenomyomatosis was 2.4-3.3%, but no cases of gallbladder cancer were identified
- It does seem to be strongly associated with the presence of gallstones.
- One study suggested that it might be associated with later stages of gallbladder cancer. The hypothesis is that it masks the cancer, and therefore, the cancer is detected later.
- Some authors recommend early cholecystectomy when adenomyomatosis is detected, however, expert opinion does not recommend cholecystectomy unless the patient is symptomatic.
CBC, liver function tests, and lipase all came back normal. A radiology ultrasound was obtained which showed the same findings as the ED ultrasound. Surgery was consulted for unremitting pain from biliary colic, and he went to the OR the next day for a cholecystectomy.
He did well post-operatively. The pathology exam revealed chronic cholecystitis with cholelithiasis and was negative for high-grade dysplasia or malignancy.
References
- Kai K et al. Clinicopathologic features of advanced gallbladder cancer associated with adenomyomatosis. Virchows Arch. 2011 Dec;459(6):573-80.
- Kasahara Y et al. Adenomyomatosis of the gallbladder: a clinical survey of 30 surgically treated patients. Nihon Geka Hokan. 1992 Mar;61(2):190-8.
- Kim JH et al. Clinical/pathological analysis of gallbladder adenomyomatosis; type and pathogenesis. Hepatogastroenterology. 2010 May;57(99-100):420-5.
- Nabatame N et al. High risk of gallbladder carcinoma in elderly patients with segmental adenomyomatosis of the gallbladder. J Exp Clin Cancer Res. 2004 Dec;23(4):593-8.
- Nishimura A et al. Segmental adenomyomatosis of the gallbladder predisposes to cholecystolithiasis. J Hepatobiliary Pancreat Surg. 2004;11(5):342-7.
- Ootani T et al. Relationship between gallbladder carcinoma and the segmental type of adenomyomatosis of the gallbladder. Cancer. 1992 Jun;69(11):2647-52.
Nice case. Differential diagnosis of comet-tails in gallbladder is cholesterolosis (adenomyomatosis), emphysematous cholecystitis and some artifacts (lobe side from duodenum). Adenomyomatosis can also presents with GB thickening (like in this case, limited to fundus).
Best wishes
PB
Great points! Thanks for the added learning.
Best!
Andie