Clinics and Research in Hepatology and Gastroenterology (2014) 38, 659—660
Available online at
ScienceDirect www.sciencedirect.com
IMAGE OF THE MONTH
MR cholangiography features of adenomyomatosis A. Arbache , S. El Mouhadi , L. Arrivé ∗ Sorbonne universités, UPMC université Paris 06, faculté de médecine Pierre-et-Marie-Curie, Department of Radiology, Saint-Antoine Hospital, Assistance publique—Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France Available online 26 September 2014
A 50-year-old woman was referred to our institution with recurrent right upper quadrant pain. Physical examination was unremarkable. Liver tests and tumor markers were normal. Abdominal ultrasound examination showed small gallbladder stones and a focal thickening of gallbladder wall. CT scan confirmed ultrasound findings, with focal gallbladder wall thickening at gallbladder fundus, containing several peripheral hypodense areas (Fig. 1a). Liver and perivesicular fat were normal. MR cholangiography showed multiple parietal diverticular dilations characteristic for the diagnosis of adenomyomatosis of the gallbladder. It is the so-called ‘‘pearl necklace sign’’, key point for diagnosis of adenomyomatosis (Fig. 1b). A laparoscopic cholecystectomy was performed. Histopathologic analysis did not show evidence of malignant tumor of gallbladder, but confirmed the diagnosis of adenomyomatosis with muscular and epithelial hyperplasia contributing to mural thickening, with epithelial invaginations forming the pathognomonic intramural diverticula. The patient recovered quickly. Adenomyomatosis of the gallbladder is a relatively common disease that is found in 2%—5% of specimens obtained
∗
Corresponding author. E-mail address: [email protected] (L. Arrivé).
http://dx.doi.org/10.1016/j.clinre.2014.08.008 2210-7401/© 2014 Elsevier Masson SAS. All rights reserved.
at surgery [1]. It is an acquired hyperplastic lesion of the gallbladder characterized by the proliferation and the invagination of the mucosa layer of the gallbladder wall, which form a diverticular penetrating thickened muscular layer: the so-called Rokitansky-Aschoff sinuses. Three morphological types are described: diffuse, segmental and focal forms. Adenomyomatosis is usually asymptomatic and is most often an incidental finding. It is however frequently associated with chronic cholecystitis, gallstones (25—75%) but also seen in cholesterolosis (33%) and pancreatitis. Adenomyomatosis has no intrinsic malignant potential and usually requires no specific treatment. It can occasionally produce abdominal pain, and in some cases cholecystectomy may be indicated for relief of symptoms. The sonographic finding of cholesterol crystals, shown as ‘‘comet-tail’’ reverberation artifacts within a thickened gallbladder wall, suggests this diagnosis. MR imaging allows to differentiate adenomyomatosis from gallbladder carcinoma by demonstrating the fluid-filled intramural mucosal diverticula (Rokitansky-Aschoff sinuses), as intramural lesions that are hyperintense on T2-weighted images, hypointense on T1-weighted images, and nonenhancing. It
660
Figure 1 a: coronal CT scan demonstrated a thickening of gallbladder wall with several parietal hypodense areas (arrow); b: MR cholangiography: diverticular dilations and invaginations of the mucosae in the gallbladder wall: the ‘‘pearl necklace sign’’ (arrows).
characteristically shows curvilinear arrangement of multiple rounded hyperintense intraluminal cavities visualized at T2weighted MR imaging and MR cholangiography: The ‘‘pearl necklace sign’’ [2].
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Williams I, Slavin G, Cox Ag, et al. Diverticular disease (adenomyomatosis of the gallbladder): a radiological-pathological survey. Br J Radiol 1986;59:29—34. [2] Haradome H, Ichikawa T, Sou H, et al. The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography. Radiology 2003;227:80—8.
A. Arbache et al.
Available online at
ScienceDirect www.sciencedirect.com
IMAGE OF THE MONTH
MR cholangiography features of adenomyomatosis A. Arbache , S. El Mouhadi , L. Arrivé ∗ Sorbonne universités, UPMC université Paris 06, faculté de médecine Pierre-et-Marie-Curie, Department of Radiology, Saint-Antoine Hospital, Assistance publique—Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France Available online 26 September 2014
A 50-year-old woman was referred to our institution with recurrent right upper quadrant pain. Physical examination was unremarkable. Liver tests and tumor markers were normal. Abdominal ultrasound examination showed small gallbladder stones and a focal thickening of gallbladder wall. CT scan confirmed ultrasound findings, with focal gallbladder wall thickening at gallbladder fundus, containing several peripheral hypodense areas (Fig. 1a). Liver and perivesicular fat were normal. MR cholangiography showed multiple parietal diverticular dilations characteristic for the diagnosis of adenomyomatosis of the gallbladder. It is the so-called ‘‘pearl necklace sign’’, key point for diagnosis of adenomyomatosis (Fig. 1b). A laparoscopic cholecystectomy was performed. Histopathologic analysis did not show evidence of malignant tumor of gallbladder, but confirmed the diagnosis of adenomyomatosis with muscular and epithelial hyperplasia contributing to mural thickening, with epithelial invaginations forming the pathognomonic intramural diverticula. The patient recovered quickly. Adenomyomatosis of the gallbladder is a relatively common disease that is found in 2%—5% of specimens obtained
∗
Corresponding author. E-mail address: [email protected] (L. Arrivé).
http://dx.doi.org/10.1016/j.clinre.2014.08.008 2210-7401/© 2014 Elsevier Masson SAS. All rights reserved.
at surgery [1]. It is an acquired hyperplastic lesion of the gallbladder characterized by the proliferation and the invagination of the mucosa layer of the gallbladder wall, which form a diverticular penetrating thickened muscular layer: the so-called Rokitansky-Aschoff sinuses. Three morphological types are described: diffuse, segmental and focal forms. Adenomyomatosis is usually asymptomatic and is most often an incidental finding. It is however frequently associated with chronic cholecystitis, gallstones (25—75%) but also seen in cholesterolosis (33%) and pancreatitis. Adenomyomatosis has no intrinsic malignant potential and usually requires no specific treatment. It can occasionally produce abdominal pain, and in some cases cholecystectomy may be indicated for relief of symptoms. The sonographic finding of cholesterol crystals, shown as ‘‘comet-tail’’ reverberation artifacts within a thickened gallbladder wall, suggests this diagnosis. MR imaging allows to differentiate adenomyomatosis from gallbladder carcinoma by demonstrating the fluid-filled intramural mucosal diverticula (Rokitansky-Aschoff sinuses), as intramural lesions that are hyperintense on T2-weighted images, hypointense on T1-weighted images, and nonenhancing. It
660
Figure 1 a: coronal CT scan demonstrated a thickening of gallbladder wall with several parietal hypodense areas (arrow); b: MR cholangiography: diverticular dilations and invaginations of the mucosae in the gallbladder wall: the ‘‘pearl necklace sign’’ (arrows).
characteristically shows curvilinear arrangement of multiple rounded hyperintense intraluminal cavities visualized at T2weighted MR imaging and MR cholangiography: The ‘‘pearl necklace sign’’ [2].
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Williams I, Slavin G, Cox Ag, et al. Diverticular disease (adenomyomatosis of the gallbladder): a radiological-pathological survey. Br J Radiol 1986;59:29—34. [2] Haradome H, Ichikawa T, Sou H, et al. The pearl necklace sign: an imaging sign of adenomyomatosis of the gallbladder at MR cholangiopancreatography. Radiology 2003;227:80—8.
A. Arbache et al.
