Management of Adenomyomatosis of the Gallbladder

Treatment Algorithm

The American College of Physicians recommends laparoscopic cholecystectomy as the preferred approach for symptomatic patients with adenomyomatosis, given the patient's age and expected lower surgical risk 1
The presence of symptoms attributable to biliary disease, such as steady, severe right upper quadrant pain lasting >15 minutes, unaffected by position or antacids, warrants surgical intervention, as recommended by the American College of Physicians 1, 2
Expectant management is recommended for asymptomatic adenomyomatosis, as the benign natural history and extremely low malignant potential of the condition do not justify prophylactic surgery, according to the American College of Physicians 1, 2
The American Gastroenterological Association suggests that belching, bloating, fatty food intolerance, and chronic diffuse pain are not attributable to gallbladder disease and should not prompt cholecystectomy 2

At 40-50 years old, patients have a lower surgical risk compared to elderly patients, making laparoscopic cholecystectomy safer if indicated, as reported by the World Journal of Emergency Surgery 3
The American College of Physicians recommends that sufficient life expectancy and symptomatic relief from cholecystectomy provide meaningful quality of life benefit 1
The American College of Physicians suggests that there is no increased risk factors for gallbladder cancer that would warrant prophylactic surgery in patients with adenomyomatosis, unlike patients with calcified gallbladders or stones >3 cm 1, 2

Adenomyomatosis is defined as mural hyperplasia (benign overgrowth of the gallbladder wall) that may be diffuse, focal, or segmental, characterized by Rokitansky-Aschoff sinuses and comet-tail artifact on gray-scale ultrasound or twinkling artifact on color Doppler imaging due to intramural cholesterol crystals, according to the Society of Radiologists in Ultrasound 4, 5, 6
The Society of Radiologists in Ultrasound 2022 guidelines explicitly categorize adenomyomatosis as a benign entity that must be distinguished from true gallbladder polyps and malignancies 4, 5, 6

Adenomyomatosis shows characteristic imaging artifacts (comet-tail, twinkling) that gallbladder cancer does not, with avascular Rokitansky-Aschoff sinuses at contrast-enhanced ultrasound (CEUS), unlike the marked early enhancement seen in neoplastic lesions 6, 7