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Gallbladder Pathology Online

Adenomyomatous Hyperplasia of the Gallbladder

Dr Sampurna Roy  MD    

 

Adenomyomatous hyperplasia is now recognized as a common condition of the gallbladder wall, occurring in up to 8.7% of cholecystectomy specimens.

This is the most confusing lesion within the gall bladder, which may simulate malignancy.

It is known by a variety of names including cholecystis glandularis proliferans, adenomyomatosis,   adenomyoma, diverticular disease, intramural diverticulosis and cholecystitis cystica.

Adenomyomatous hyperplasia is more common in females and its incidence increases with age.

The majority of patients present with complaints of chronic right upper quadrant pain.

It may produce symptoms even in the absence of cholelithiasis and it usually occurs within the fundus.

Cholelithiasis is present in 50% of cases.

The diagnosis may be made on cholecystography or ultrasound. 

There are out-pouchings of the mucosa into the muscle coat, which is thickened up to 5 times normal.

Some of these are dilated, the mucosa has papillary folds, smooth muscle hypertrophy may be seen in the neck of the gall bladder.

This may occur secondary to muscle thickening or may be congenital.

They are usually 1.5 cm in diameter.

There are three variants of adenomyomatous hyperplasia:

- Localized (or fundal) :  The localized variant is the most common and is also known as an adenomyoma.

At gross examination, it is characterized by a  well-formed mass in the gallbladder fundus. The mass may have a semilunar or crescent shape.

Cut sections of the mass have a honeycombed appearance that is created by multiple, small cystic spaces.

The cystic spaces represent prominent epithelial invaginations (Rokitansky-Aschoff sinuses or intramural diverticula).

- Segmental :  The segmental variant is characterized by focal circumferential thickening in the gallbladder wall. The segmental variant is typically located in the body of the gallbladder, giving it an hourglass configuration at gross inspection.

- Diffuse :  Diffuse adenomyomatous hyperplasia is characterized by diffuse gallbladder wall thickening with intramural diverticula that appear as cystic spaces within the wall.

Microscopic features: 

  

Adenomyomatous hyperplasia is histologically characterized by epithelial and smooth muscle proliferation.

Normal gallbladder epithelium lines the epithelial structures that may extend down into the subserosa and reach the serosa.

Hyperplastic smooth muscle cells accompany the epithelial invaginations that contain inspissated bile, mucus, or stones.

Inflammatory and fibrotic changes may be present as well as  metaplastic changes (intestinal metaplasia, pyloric gland metaplasia).

Dysplastic changes and in situ and invasive carcinomas may arise from the epithelium of adenomyomatous hyperplasia.

The development of carcinoma is related to the presence of stones, chronic inflammation, and metaplastic changes rather than adenomyomatous hyperplasia.

Thus, adenomyomatous hyperplasia is  not considered a premalignant lesion.

Cases of segmental adenomyomatous hyperplasia of the gallbladder with perineural invasion have been reported.

Perineural and intraneural invasion was noted in the subserosal layer.

The mechanism by which the epithelial structures "invaded" the perineural spaces and the nerves is unclear but it has been suggested by the authors that the migration of the benign glandlike structures into the nerves is related to the production of chemotactic factors or signaling substances and the activation of cell receptors.

Other authors have suggested that perineural invasion is due to extension and growth of epithelial ductal structures along tissue  planes of least resistance, such as the perineural space, and growth of hyperplastic  nerve trunks in close proximity to or within epithelial structures.

The pattern of perineural invasion in cases of adenomyomatous hyperplasia should not be confused with adenocarcinoma.

Attention to the general architecture of the lesion and the bland cytologic features of the glands and ductal structures should prevent this misinterpretation.

Visit: Mucosal Hyperplasia of the Gallbladder

 

Further reading:

Adenomyomatous hyperplasia of the gallbladder eith perineural invasion: revisited

Combined segmental and focal adenomyomatosis involving the body of gallbladder

Polypoid lesions of the gallbladder: report of 100 cases

Adenomyomatous hyperplasia of the human gallbladder.

Adenomyomatous hyperplasia of the gallbladder with perineural invasion

Papillary mucinous adenoma arising in adenomyomatous hyperplasia of the gall bladder

 

 

 

Dr  Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)

          

 

 

 

 

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