0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Diagnosis FREE

Arch Surg. 2008;143(11):1130. doi:10.1001/archsurg.143.11.1130.
Text Size: A A A
Published online

ANSWER: DIFFUSE ADENOMYOMATOSIS OF THE GALLBLADDER

The “necklace appearance” of the mass was more clearly demonstrated on magnetic resonance imaging, representing bile in the Rokitansky-Aschoff sinuses. The gallbladder lumen was narrowed because of the hypertrophic mucosa and muscular wall. The bile was hyperintense on T1- and T2-weighted images. Diffuse adenomyomatosis of the gallbladder was indicated, but occult gallbladder cancer could not be excluded. A 9 × 6 × 4-cm pink gallbladder mass was resected. Narrowed lumen (7 × 1 × 0.7 cm) was apparent (Figure 2). Adenomyomatosis was diagnosed microscopically. There was no evidence of gallbladder cancer.

Place holder to copy figure label and caption
Figure 2.

Photograph of the gross pathologic specimen obtained by cholecystectomy reveals hypertrophy of the muscular wall (*) and narrowing of the lumen (L).

Graphic Jump Location

Adenomyomatosis of the gallbladder is a relatively common disease that is found in 2% to 5% of specimens obtained at cholecystectomy.1 Pathologically, it is defined by epithelial proliferation and hypertrophy of the muscularis of the gallbladder, with outpouching of the mucosa into the thickened muscular layer (Rokitansky-Aschoff sinuses).1,2 The pathogenesis of this condition remains unknown. Nevertheless, gallbladder adenomyomatosis seems unlikely to be a congenital lesion because its incidence increases with age, with the majority of individuals with the disease in their 50s and 60s.3

Adenomyomatosis of the gallbladder has been defined as segmental, diffuse, and fundal in terms of morphology type. The segmental type in particular appears to be a predisposing factor for cholelithiasis.2 Clinical features of this condition are similar to those of gallstones and/or cholecystitis. This disorder is increasingly being recognized in asymptomatic cases and incidentally during imaging investigation.4 Ultrasonography is the most widely used method for evaluating suspected gallbladder diseases; however, recent studies suggest that magnetic resonance imaging may be the more accurate diagnostic tool for gallbladder adenomyomatosis.1,4

What is the relationship between gallbladder carcinoma and adenomyomatosis of the gallbladder? Adenomyomatosis is currently considered to carry no risk of malignant change. However, there has been reported to be a strong association between gallbladder cancer and segmental-type adenomyomatosis of the gallbladder.5 Furthermore, a well-differentiated gallbladder carcinoma with mucin production can have cystic components that may mimic adenomyomatosis.6 In this patient, in addition to the clinically persistent symptoms, the imaging findings led us to perform cholecystectomy because of the possibility of occult cancer and the risk of malignancy.

Return to Quiz Case.

Correspondence: Ray-Hwang Yuan, MD, PhD, Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan (yuan@ha.mc.ntu.edu.tw).

Accepted for Publication: January 26, 2007.

Author Contributions:Study concept and design: Liu and Yuan. Acquisition of data: Liu, Yang, and Lee. Analysis and interpretation of data: Liu and Yuan. Drafting of the manuscript: Liu and Yuan. Critical revision of the manuscript for important intellectual content: Yang, Lee, and Yuan. Administrative, technical, and material support: Yang and Lee. Study supervision: Yuan.

Financial Disclosure: None reported.

Haradome  HIchikawa  TSou  H  et al.  The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography. Radiology 2003;227 (1) 80- 88
PubMed Link to Article
Nishimura  AShirai  YHatakeyama  K Segmental adenomyomatosis of the gallbladder predisposes to cholecystolithiasis. J Hepatobiliary Pancreat Surg 2004;11 (5) 342- 347
PubMed Link to Article
Zani  APacilli  MConforti  ACasati  ABosco  SCozzi  DA Adenomyomatosis of the gallbladder in childhood: report of a case and review of the literature. Pediatr Dev Pathol 2005;8 (5) 577- 580
PubMed Link to Article
Yoshimitsu  KHonda  HAibe  H  et al.  Radiologic diagnosis of adenomyomatosis of the gallbladder: comparative study among MRI, helical CT, and transabdominal US. J Comput Assist Tomogr 2001;25 (6) 843- 850
PubMed Link to Article
Ootani  TShirai  YTsukada  KMuto  T Relationship between gallbladder carcinoma and the segmental type of adenomyomatosis of the gallbladder. Cancer 1992;69 (11) 2647- 2652
PubMed Link to Article
Yoshimitsu  KIrie  HAibe  H  et al.  Well-differentiated adenocarcinoma of the gallbladder with intratumoral cystic components due to abundant mucin production: a mimicker of adenomyomatosis. Eur Radiol 2005;15 (2) 229- 233
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 2.

Photograph of the gross pathologic specimen obtained by cholecystectomy reveals hypertrophy of the muscular wall (*) and narrowing of the lumen (L).

Graphic Jump Location

Tables

References

Haradome  HIchikawa  TSou  H  et al.  The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography. Radiology 2003;227 (1) 80- 88
PubMed Link to Article
Nishimura  AShirai  YHatakeyama  K Segmental adenomyomatosis of the gallbladder predisposes to cholecystolithiasis. J Hepatobiliary Pancreat Surg 2004;11 (5) 342- 347
PubMed Link to Article
Zani  APacilli  MConforti  ACasati  ABosco  SCozzi  DA Adenomyomatosis of the gallbladder in childhood: report of a case and review of the literature. Pediatr Dev Pathol 2005;8 (5) 577- 580
PubMed Link to Article
Yoshimitsu  KHonda  HAibe  H  et al.  Radiologic diagnosis of adenomyomatosis of the gallbladder: comparative study among MRI, helical CT, and transabdominal US. J Comput Assist Tomogr 2001;25 (6) 843- 850
PubMed Link to Article
Ootani  TShirai  YTsukada  KMuto  T Relationship between gallbladder carcinoma and the segmental type of adenomyomatosis of the gallbladder. Cancer 1992;69 (11) 2647- 2652
PubMed Link to Article
Yoshimitsu  KIrie  HAibe  H  et al.  Well-differentiated adenocarcinoma of the gallbladder with intratumoral cystic components due to abundant mucin production: a mimicker of adenomyomatosis. Eur Radiol 2005;15 (2) 229- 233
PubMed Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles