Gallbladder

1. Adenomyomatosis of the Gallbladder Ifeanyi Malu,BSc.,MA ., RDMS expected Mrs. Shelia Chong, MBA, RDMS June, 2015

2. Normal Anatomy GB parts Neck Body Fundus -Body and neck directed toward porta hepatis -Fundus slants inferiorly to the right --http ://fitsweb.uchc.edu/student/selectives/Luzietti/Gallbladder_anatomy.htm

3. Normal Sonographic Anatomy The normal gallbladder wall appears as thin walled and anechoic P ear shaped saccular structure - Ultrasoundpaedia.com

4. Sagittal Gallbladder GB Sag Decub Adenomyomatosis of GB Diffuse gallbladder wall thickening including numerous intramural echogenic foci. “ Comet-tail” reverberation artifact extends intraluminally from the near wall of the gallbladder . -Ultrasoundpaedia.com

5. Adenomyomatosis of GB Transverse view Diffuse thickening of gallbladder wall Demonstrates circular band around the fundal region of the gallbladder wall -Kilmas B., & Zegal (2015).

6. Normal Physiology Bile is stored in the GB until needed for digestion The gallbladder is about 7.5–10 cm (3–4 inches) long and about a 2.5 cm (1 inch) wide . The gallbladder is made up of layers of tissue: -mucosa - muscular layer - perimuscular layer -serosa -www.cancer.ca/ en /cancer

7. Overview Adenomyomatosis of the Gallbladder is a common hyperplastic cholecystosis of the gallbladder wall Not malignant M ay involve the gallbladder in a focal, segmental, or diffuse form -Dogra , V., & Karani , J. (2013 ). - Ryu et al. ( n.d. ).

8. Segmental Adenomyomatosis S egmental type is when the lesion is annular and separating the two compartments of the gallbladder - Ozgonul , A., Bitiren , M., Guldur , M. E., Sogut , O., & Yilmaz, L. E. (2010).

9. Diffuse Adenomyomatosis D iffuse type is termed if it causes thickness in the gallbladder wall - Ozgonul , A., Bitiren , M., Guldur , M. E., Sogut , O., & Yilmaz, L. E. (2010).

10. Fundus A denomyomatosis F undal type is defined if the lesion is localized on the “base of the gallbladder through the lumen in a hemispheric shape.” M ay appear as a discrete mass, known as an  adenomyoma - Ozgonul , A., Bitiren , M., Guldur , M. E., Sogut , O., & Yilmaz, L. E. (2010).

11. Transverse gallbladder fundus highly with echogenic foci within the mass Sirigu,D . (2015).

12. Normal Relevant Vascular Anatomy http ://blogs.nvcc.edu/rkeith/2012/02/10/holy-gallstones-batman/

13. Normal Relevant Vascular Sonographic Anatomy Color Doppler demonstrates a twinkle artifact arising from one of the hyperechoic foci within the mass - Sirigu , D. ( n.d. ).

14. Relevant Diagnostic Imaging Test Ultrasound MRI CT NM MRCP (or oral cholecystography) Plain X-Ray

15. Relative Sensitivities of CT,MRI,& MRCP in the Diagnosis -Hiroki , H., Tomoaki , I., & Hironobu ,S. et al .( 2003).

16. Ultrasound Modality M ural thickening (diffuse, focal, annular) segmental/annular form is especially difficult to distinguish from gallbladder carcinoma C omet-tail artifact Considered to be the diagnostic findings on ultrasound examination includes intramural cystic formation (anechoic diverticula) with echogenic foci and/or reverberation artifacts together with full or partial thickening of the gallbladder wall - Ryu , Y. ( n.d . ). - Ghersin , Soudack , & Gaitini (2003

17. Sonogram in a patient with adenomyomatosis . Adenomyomatosis GB Ultrasound Preferred U ltrasonography (US) is the favorite radiologic examination On US, diffuse or segmental gallbladder wall thickening is evident - Dogra , V., & Karani , J. ( 2013 ).

18. Sonographic Appearance S onographic appearance of GADM includes the following findings: - focal or diffuse thickening of the gallbladder wall, -small anechoic cystic spaces within the affected portion of the wall, representing Rokitansky-Aschoff sinuses , and - intramural echogenic foci with or without associated acoustic shadows or reverberation artifacts. Ghersin , Soudack , & Gaitini (2003).

19. Sag view of GADM Hyperechoic Longitudinal sonogram of gallbladder shows a hyperechoic focus in the anterior wall with reverberation artifact, which is characteristic of hyperplastic cholecystosis . -Dogra, V., & Karani , J. (2013). Comet-tail Artifact

20. CT Modality A bnormal gallbladder wall thickening and enhancement Rokitansky-Aschoff sinuses of sufficient size can be visualized Reveal a thickened gallbladder wall with the rosary sign Ryu, Y. ( n.d. ).

21. CT Images CT modality CT abdomen coronal Several stones of various size are noted in the gallbladder. The gallbladder is not well extended and shows some mural enhancement. In the fundus and also more proximally at the infundibulum some dilated intramural diverticula are seen, so-called rosary sign . -Ryu , Y. ( n.d. ). CT

22. MRCP (or oral cholecystography) Does not rely on contrast opacification of the lumen of the gallbladder.  MRCP is also able to show: mural thickening focal sessile mass pearl necklace sign hourglass configuration in annular types -Ryu , Y. ( n.d. ).

23. MRCP MRCP Numerous T2 hyperintense intramural gallbladder foci are isointense to bile on T2 weighted sequences -Kilmas B., & Zegal (2015) MRCP Image

24. Oral cholecystogram Oral cholecystogram shows focal fundal thickening in a patient with focal fundal adenomyomatosis Better seen after partial contraction of the GB -emedicine.medscape.com -Hagan- Ansert , S. (2012).

25. Pain in the right upper abdomen Ultrasound Images of Adenomyomatosis of the gallbladder with a thickened wall longitudinal Color doppler shows twinkling artefacts caused by cholesterol crystals in the wall . -ultrasoundcases.info

26. Ultrasound I mages:Color Doppler ultrasoundcases.info

27. Ultrasound Images: Transverse view ultrasoundcases.info

28. MRI Demonstrates Pearl necklace sign Diffuse-type adenomyomatosis typically shows early mucosal enhancement and subsequent serosal enhancement . Localized adenomyomatosis exhibits homogeneous enhancement Ryu, Y . ( n.d. ).

29. MRI MRI Gallbladder wall thickening with numerous T2 hyperintense intramural foci which are isointense to bile on T2 weighted sequences Kilmas B., & Zegal (2015) MRI IMAGE

30. Nuclear Medicine FDG-PET metabolic characterization with PET has been suggested as a useful adjunct in problematic cases  Ryu, Y. ( n.d. ).

31. Images Modalities US cannot differentiate between the segmental type of adenomyomatosis and gallbladder carcinoma On US, diffuse or segmental gallbladder wall thickening is evident Radiography is not the preferred choice CT is useful in excluding gallbladder carcinoma . However,ultrasonography (US) is the preferred radiologic examination Dogra & Karani (2013)

32. Sonography Indications Acute RUQ pain Non-visualization of GB on OCG Excessive burping or nausea -Chong,S. (2015)

33. GB Sonographic Technique NPO (at least 6-8 hours before the exam) 3.5MHZ transducer used for average patient 5.0 MHZ, 7.5MHZ or 10MHZ for very thin patient Must be imaged in both longitudinal and transverse -Chong, S. (2015).

34. Sonographic Scan Protocol Entire GB GB, Neck GB, Body GB,Fundus CBD( with color Doppler) - Chong, S. (2015).

35. Sonography Indications May be asymptomatic RUQ abdominal pain Nausea Vomiting - Chong,S . (2015).

36. Pathology Description Pathologically , defined as epithelial proliferation and hypertrophy of the muscularis of the gallbladder, with “outpouching of the mucosa into the thickened muscular layer.” Rokitansky-Aschoff sinus within the thickened muscular layer of the gallbladder - -Hiroki , H., Tomoaki , I., & Hironobu ,S. et al .( 2003).

37. Epidemiology Common in women Patients over 40 years has higher incidence -Chong, S. (2015).

38. Etiology Unknown -Kilmas B., & Zegal ,H.(2015).

39. Abnormal Physiology Gallbladder adenomyomatosis (GADM) is a “common acquired benign hyperplastic disease of the gallbladder mucosa” . Sonographically , it is characterized by diffuse or focal thickening of the gallbladder wall associated with small intramural cystic spaces, known as Rokitansky-Aschoff sinuses. - Ghersin , Soudack , & Gaitini (2003)

40. Abnormal Clinical Findings May be asymptomatic RUQ pain Nausea Vomiting -Chong, S (2015).

41. Abnormal Sonographic Findings May be diffuse thickening of the wall Present as a circular band around a section of the wall-around the fundal area Segmental and focal adenomyomatosis may be difficult to differentiate from gallbladder carcinoma - Sirigu,D .( n.d. ).

42. Abnormal Sonographic Findings Does not move with position changes Associated with comet tail artifact Papillomas may occur singly or in groups -Hagan- Ansert,S . (2015).

43. Treatment & Monitoring Treatment Elective surgery is often performed in patients with right upper quadrant pain Monitoring Ultrasound

44. Differential diagnosis G allbladder carcinoma Phrygian cap Gallbladder polyp (cholesterol polyp) Cholelithiasis Adenoma - Ryu et al. ( n.d. ).

45. Prognosis Cholecystectomy may be performed as a result of one or more of the following: -patient symptomatic with RUQ pain -focal appearances may be difficult to distinguish from malignancy -http ://radiopaedia.org/articles/adenomyomatosis-of-the-gallbladder

46. References Adusumilli,S .,& Siegelman , E.S.(2005). MRI of the bile ducts, gallbladder, and pancreas. In: Siegelman ES., ed. Body MRI. Philadelphia: Elsevier Inc.; 2005: 63-127 Chong, S. (March, 2015). Gallbladder Lecture Handout. Sanford-Brown Institute, Garden City NY Dogra, V., & Karani , J. (2013). Adenomyomatosis Imaging. Electronically retrieved from http:// emedicine.medscape.com/article/363728-overview#a1 Ghersin,E ., Soudack,M ., & Gaitini,D . ( 2003). Twinkling Artifact in Gallbladder Adenomyomatosis. Retrieved from http :// www.jultrasoundmed.org/content/22/2/229.full.pdf+html?sid=a5031d87-4b49-45f8-88a0-6ac8ea2040c2

47. References Hagen- Ansert , S.L. (2012). Textbook of Diagnostic Sonography: 2-Volume Set, 7e. Elsevier, Mosby Hiroki, H., Tomoaki , I., & Hironobu ,S. et al.T (2003). The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography . Radiology. 2003; 227: 80-88 Kilmas B., & Zegal ,H.(2015). Adenomyomatosis. Electronically retrieved from http:// sonoworld.com/CaseDetails/Adenomyomatosis.aspx?ModuleCategoryId=631 Ozgonul , A., Bitiren , M., Guldur , M. E., Sogut , O., & Yilmaz, L. E. (2010). Fundal Variant Adenomyomatosis of the Gallbladder: Report of Three Cases and Review of the Literature. Journal of Clinical Medicine Research , 2 (3), 150–153. doi:10.4021/jocmr2010.05.338w Ryu , Y., et al. ( n.d. ). Adenomyomatosis of the Gallbladder. Available at http://radiopaedia.org/articles/adenomyomatosis-of-the-gallbladder

48. References Sirigu , D. (2015). Adenomyomatosis ( adenomyomatous hyperplasia) of the gallbladder. Available at http ://sonoworld.com/CaseDetails/Adenomyomatosis_(adenomyomatous_hyperplasia)_of_the_gallbladder.aspx?CaseId=485