Gallbladder Fundal Adenomyomatosis and Cholelithiasis Is Again Noted
Insights Imaging. 2017 Apr; viii(two): 243–253.
Gallbladder adenomyomatosis: imaging findings, tricks and pitfalls
Matteo Bonatti
aneDepartment of Radiology, Bolzano Cardinal Hospital, 5 Boehler Street, 39100 Bolzano, Italy
Norberto Vezzali
iDepartment of Radiology, Bolzano Primal Hospital, 5 Boehler Street, 39100 Bolzano, Italian republic
Fabio Lombardo
aneDepartment of Radiology, Bolzano Central Hospital, 5 Boehler Street, 39100 Bolzano, Italy
Federica Ferro
1Department of Radiology, Bolzano Central Infirmary, v Boehler Street, 39100 Bolzano, Italy
Giulia Zamboni
2Section of Radiology, University of Verona, 10 LA Scuro Place, 37134 Verona, Italian republic
Martina Tauber
3Department of Pathology, Bolzano Central Infirmary, five Boehler Street, 39100 Bolzano, Italy
Giampietro Bonatti
oneDepartment of Radiology, Bolzano Central Hospital, 5 Boehler Street, 39100 Bolzano, Italian republic
Received 2016 November 10; Revised 2017 January 13; Accepted 2017 Jan 17.
Abstruse
Abstruse
Gallbladder adenomyomatosis (GA) is a beneficial amending of the gallbladder wall that can exist plant in upwards to 9% of patients. GA is characterized past a gallbladder wall thickening containing pocket-size bile-filled cystic spaces (i.east., the Rokitansky–Aschoff sinuses, RAS). The bile contained in RAS may undergo a progressive concentration process leading to crystal precipitation and calcification development. A correct characterization of GA is primal in order to avert unnecessary cholecystectomies. Ultrasound (The states) is the imaging modality of option for diagnosing GA; the apply of loftier-frequency probes and a precise focal depth adjustment enable right identification and characterization of GA in the majority of cases. Dissimilarity-enhanced ultrasound (CEUS) can be performed if RAS cannot be conspicuously identified at baseline U.s.: RAS appear avascular at CEUS, independently from their content. Magnetic resonance imaging (MRI) should be reserved for cases that are unclear on Us and CEUS. At MRI, RAS can be identified with extremely high sensitivity, only their bespeak intensity varies widely according to their content. Positron emission tomography (PET) may be helpful for excluding malignancy in selected cases. Computed tomography (CT) and cholangiography are not routinely indicated in the suspicion of GA.
Pedagogy points
ane. Gallbladder adenomyomatosis is a common benign lesion (one–9% of the patients).
two. Identification of Rokitansky–Aschoff sinuses is crucial for diagnosing gallbladder adenomyomatosis.
3. Sonography is the imaging modality of choice for diagnosing gallbladder adenomyomatosis.
four. Intravenous dissimilarity material administration increases ultrasound accuracy in diagnosing gallbladder adenomyomatosis.
5. Magnetic resonance is a problem-solving technique for unclear cases.
Keywords: Gallbladder, Rokitansky–Aschoff sinuses of the gallbladder, Gallbladder diseases, Ultrasonography, Magnetic resonance imaging
Main text
Gallbladder adenomyomatosis
Gallbladder adenomyomatosis (GA) is a beneficial alteration of the gallbladder wall characterized by excessive epithelial proliferation associated with hyperplasia of the muscularis propria, resulting in gallbladder wall thickening. The excessive epithelial proliferation leads to epithelial infolding within the underlying muscular layer with subsequent germination of epithelium-lined diverticular pouches, the so-chosen Rokitansky–Aschoff sinuses (RAS; Fig.1) [one–iv]. The content of RAS consists of bile that may undergo progressive aridity over time, leading to cholesterine crystal precipitation [five]. Moreover, cholesterine crystals may induce a chronic inflammatory reaction leading to intramural dystrophic calcification development. The serosa is never involved by GA.
Gallbladder adenomyomatosis: pathology findings. Macroscopically (a) GA is characterized past gallbladder wall thickening (lines) containing small cystic spaces (arrows) representing Rokitansky–Aschoff sinuses. Microscopically, at low (2×) magnification (b and c), wall thickening is due to hyperplasia of the muscular layer (lines); a variable degree of epithelial proliferation (arrowheads) is as well appreciable and epithelium-lined cystic spaces, representing RAS (arrows), tin can be observed within the muscular layer. Biliary stones (star) may be present within RAS. At high (40×) magnification (d), the proliferative mucosal glandular component that leads to epithelial infolding (arrowheads) and RAS germination is better recognizable
Adenomyomatosis may involve the gallbladder co-ordinate to four main patterns: localized, segmental, annular and diffuse (Fig.ii) [6, 7].
Gallbladder adenomyomatosis: patterns of gallbladder wall involvement. Drawings showing localized gallbladder adenomyomatosis (a), annular gallbladder adenomyomatosis (b), segmental gallbladder adenomyomatosis (c) and diffuse gallbladder adenomyomatosis (d)
Localized GA is the virtually common design and is characterized by a focal thickening, unremarkably involving the fundal region (the so-called "fundal GA"). The uninvolved gallbladder wall appears physiologically thin and the overall gallbladder shape is usually maintained.
Segmental GA is characterized by the interest of a larger portion of the gallbladder wall, typically the fundus and the distal 3rd of the trunk. The involved portion appears contracted, whereas the uninvolved one maintains its normal shape.
Annular GA is characterized past a ring-class thickening of the gallbladder wall, usually involving the eye portion. The gallbladder appears contracted only in the involved portion, changing its global morphology and condign "hourglass-shaped". In some cases, epithelial proliferation may exist particularly conspicuous and subdivide the gallbladder lumen into ii divide compartments. As a consequence, biliary sludge and stones may accumulate into the isolated fundal compartment [8]. According to some authors, annular GA should be considered a subtype of segmental GA [9].
Lengthened GA is characterized by the involvement of the whole organ that consequently appears contracted, even later on fasting.
The pathogenesis of GA is not fully understood: an association with gallbladder stones and chronic inflammatory changes has been highlighted in many studies [one, five, 10–13], simply a correlation with acquired wall motility as a consequence of increased endoluminal pressure has besides been postulated [14, 15]. GA is a beneficial lesion as the hyperplastic epithelium of GA has no higher neoplastic potential than that of a normal gallbladder, even though gallbladder carcinoma may also ascend in association with GA [16]. Some studies take shown an increase in gallbladder cancer prevalence among patients with segmental type adenomyomatosis compared to patients without GA or with other patterns of GA, in particular, in the elderly. Even so, these results may have been influenced by the higher prevalence of cholecystolithiasis in patients affected by segmental type GA, which represents a well-known risk cistron for gallbladder carcinoma [x–13, 16]. GA may increase in size over time and this change past itself must non be considered an index of malignancy [17]. Patients affected by GA are usually asymptomatic. When present, symptoms may include right upper quadrant hurting, possibly besides equally a issue of the presence of gallbladder stones.
GA is often observed in cholecystectomy specimens, with a reported prevalence of 1–9% in pathology series [1, 4, nine, 13]. GA represents most 40% of benign gallbladder lesions [i, 4].
Given its relatively loftier prevalence and the continuous increase in imaging studies performance, GA can be ofttimes encountered during everyday practice. The radiologist plays a central part in the diagnosis of GA and its main aim is to distinguish GA from neoplastic gallbladder wall thickenings (Fig.three) in gild to avoid unnecessary cholecystectomies. It is also important to accurately describe the gallbladder wall involvement pattern, as it can modify patient management.
Gallbladder cancer: gallbladder adenocarcinoma may involve the gallbladder wall with various patterns. This example of gallbladder adenocarcinoma with annular interest (white lines) tin be differentiated from an adenomyomatosis because of the absence of cystic spaces (RAS) within the wall thickening on ultrasound (a) and considering of the presence of hypodense tissue between the gallbladder wall and the adjacent liver (arrows) on contrast-enhanced CT (b)
At that place are no universally accepted guidelines for GA management. Given the lack of malignancy potential, GA is usually considered a "don't bear on" lesion and cholecystectomy should be routinely reserved for symptomatic patients only or in case of inconclusive imaging findings. In whatever example, the surgical option might exist considered in patients with segmental type GA, given its higher association with gallbladder cancer, and in patients with diffuse GA, given the possible difficulties in identifying neoplastic foci within the wall thickening [18].
In this commodity, we review multimodality imaging findings of GA, providing tips that may increment diagnostic conviction and highlighting possible pitfalls.
Imaging of gallbladder adenomyomatosis
Besides GA, differential diagnosis of gallbladder wall thickenings includes the post-prandial state, acute and chronic cholecystitis, cholesterine polyps, neoplasms and many other less common atmospheric condition. Independently from the radiological modality, an imaging clue for diagnosing GA is the detection, within a thickened gallbladder wall, of Rokitansky–Aschoff sinuses. Information technology must exist kept in mind that RAS may show extremely different imaging features according to their variable content that may range from articulate bile to calcifications. Moreover, it must exist considered that tiny cystic spaces, resembling RAS, have been identified also in rare cases of mucine-producing gallbladder carcinomas [19]; anyhow, overall lesion shape in these neoplasms was much more irregular than in cases of GA.
Oral cholecystography
Oral cholecystography (OC) was the first imaging modality used for diagnosing GA, only present represents an obsolete technique. The noesis of typical GA findings at OC, however, enables ameliorate understanding of the imaging patterns we are now dealing with. In item, besides gallbladder wall thickening and possible strictures formation, the nearly relevant finding at OC was the visualization of rounded contrast media collections next to the gallbladder lumen, representing RAS (Fig.4) [xx]. This finding represents the imaging demonstration of the communication betwixt RAS and the gallbladder lumen.
Gallbladder adenomyomatosis: typical oral cholecystography findings. In this instance of fundal type GA, RAS (arrows) are filled by contrast material every bit a effect of their communication with the gallbladder lumen. Courtesy of Marco Ferigato, radiographer at Bolzano Central Infirmary
Ultrasound
Trans-intestinal ultrasound (United states of america) represents the imaging modality of choice for the detection and label of GA, with accuracy values that range from 91.five to 94.viii% in differentiating GA from early-phase gallbladder cancer [21].
Imaging findings
Focal or diffuse gallbladder wall thickening (Fig.5) can be easily detected at US and represents the consequence of both epithelial hypertrophy and muscular hyperplasia. Wall thickening represents a hallmark of GA, being always present, just it is poorly specific, as it tin be plant in nearly gallbladder pathologies. Anyhow, in GA, the outer gallbladder layer must appear sharp and a clear cleavage airplane with the liver must always be present. No pericholecystic fluid should exist observed.
Gallbladder adenomyomatosis: typical US findings in annular type (a), fundal type (b and d), segmental type (c) and diffuse type (e). Gallbladder wall thickening (line) is always seen in gallbladder adenomyomatosis, merely information technology is non-specific. On b-mode images, Rokitansky–Aschoff sinuses (arrows) typically appear anechoic (a), simply they can as well announced hyperechoic if cholesterine crystals or calcifications are present (b and c). Comet-tail reverberation artefacts (Figures b and e, arrowheads) or audio-visual shadowing (c, arrowheads) are usually observed profoundly in RAS. On color Doppler images (d), twinkling artefacts (arrowheads) may be observed profoundly in RAS
Small anechoic cystic spaces (one – x mm) representing clear bile-filled RAS should be recognized inside the thickened gallbladder, being pathognomonic for GA (Fig.5a). Whenever cholesterine crystals fill RAS, they appear as intramural echogenic spots in association with reverberation artefacts (Fig.5b and eastward). Reverberation artefacts are the consequence of the coexistence of different acoustic impedance media, i.e., articulate bile and cholesterine crystals, inside RAS and appear as hyperechoic "comet-tail" artefacts that project deeply into RAS. Sometimes RAS themselves may be not straight recognizable at the origin of reverberation artefacts. Calcification-filled RAS appear as intramural echogenic spots associated with posterior acoustic shadowing (Fig.5c). Also, the presence of cholesterine crystal- or calcification-filled RAS is virtually diagnostic for GA.
Twinkling artefacts on colour Doppler ultrasound (Fig.5d) are due to the interaction of the ultrasound beam with a rough audio-visual interface composed past randomly disposed strongly reflecting media (i.e., cholesterine crystals or calcifications) [22]. Twinkling artefacts appear as rapidly alternating red and blue colour Doppler signals, "comet-tail" shaped, deeply in RAS, and are better appreciable using depression-frequency probes [23]. Their presence is strongly associated with GA.
Tips & tricks
Patient's fasting is central in society to correctly evaluate the gallbladder and, in detail, whenever dealing with gallbladder wall thickenings. A minimum of 8 h of fasting is recommended before upper abdomen sonography.
A precise focal depth aligning is crucial in club to correctly investigate every portion of the gallbladder wall for the presence of GA. In item, information technology is often necessary to set the focal indicate to a very superficial position in guild to evaluate patients with fundal blazon GA.
The employ of high-frequency probes (Fig.half dozen) increases U.s. accurateness in the diagnosis of GA. Indeed, GA often involves gallbladder fundus, which is usually unsatisfactorily evaluated by means of the classical 4–5-MHz convex probes; every suspicious finding in this expanse must be further investigated by means of higher frequency (vii–9 MHz) linear probes for better characterization.
US of gallbladder adenomyomatosis: use of different frequencies probes. In this patient with diffuse GA, the gallbladder wall is poorly evaluable by means of a conventional five-MHz convex probe (a). Using a high-resolution 7-MHz linear probe (b) hyperechoic Rokitansky–Aschoff sinuses (arrows) can exist highlighted within a diffusely thickened gallbladder wall; moreover, the serosa maintains sharp margins (arrowheads)
The introduction of harmonic imaging has increased US accurateness in depiction of gallbladder wall morphology and in detection of Rokitansky–Aschoff sinuses. Harmonic imaging should always be used in the suspicion of GA.
GA is sometimes poorly visible with the classical sub-costal approach, particularly in obese patients. The interposition of hepatic parenchyma between the probe and the gallbladder wall (i.e., the so-called hepatic window) may overcome this limitation, increasing image quality.
Pitfalls & limitations
United states of america is an operator-dependent imaging modality and the ability in depicting GA varies according to the operator's feel. Moreover, sonographic examination may exist express in instance of obese patients and bowel gas interposition.
A possible imaging pitfall is the differentiation betwixt cholesterine polyps and GA. Polyps appear as solid nodules with exophytic growth inside the gallbladder lumen, whereas GA appears as focal or diffuse mural thickening. Anyway, polyps and adenomyomatosis may coexist in some patients (Fig.7).
US of gallbladder adenomyomatosis: differential diagnosis with cholesterine polyps. Cholesterine polyps (arrow) must not be dislocated with gallbladder adenomyomatosis (line); nonetheless, the two alterations may coexist in the same patient
Large round hyperechoic intramural collections without acoustic shadowing or reverberation artefacts, representing cholesterine-filled RAS (Fig.8), may sometimes be observed. This finding may cause diagnostic doubts.
Us of gallbladder adenomyomatosis: pitfalls. Cholesterine crystals may accrue inside large Rokitansky–Aschoff sinuses, determining a hyperechoic attribute (arrows) without acoustic shadowing
Endoscopic ultrasound
Endoscopic ultrasound (EUS) is an invasive imaging modality that is capable of accurately evaluating the gallbladder wall as the loftier-frequency probe can exist positioned in its close proximity without the interposition of other anatomical structures. This results in a higher accuracy in the evaluation of gallbladder wall thickenings in comparison to US. EUS findings are the aforementioned every bit trans-abdominal ones (i.e., gallbladder wall thickening with intramural cystic spaces and/or echogenic foci, comet-tail artefacts and twinkling artefacts) and tin be highlighted with higher sensitivity, in particular, in obese patients [24]. The main limitations to EUS reside in its invasiveness, low tolerability and costs; therefore, EUS is not routinely considered for the diagnosis of GA. Moreover, it has been demonstrated that EUS can draw some microcystic spaces that may exist present in gallbladder cancer [8].
Contrast-enhanced ultrasound
Intravenous administration of micro-bubble contrast fabric represents a useful complement to conventional U.s. and is increasingly used for diverse indications in abdominal imaging (e.g., for the differential diagnosis of focal liver lesions and for the characterization of renal cysts). In contempo years, contrast enhanced ultrasound (CEUS) has been proposed, with encouraging results, besides for the differential diagnosis of gallbladder wall thickenings [25, 26] and Tang et al. have demonstrated that dissimilarity material administration significantly increases US sensitivity in the detection of RAS and in the delineation of gallbladder wall continuity in patients with GA [27]. CEUS implicates the use of dedicated low mechanical index presets and intravenous administration of a bolus of 2.4 ml of contrast cloth, containing viii μl/ml sulphur hexafluoride microbubbles, followed by a 10-ml saline flush; the target lesion is and then scanned for the following 3–v min in guild to assess its vascularization.
Imaging findings
The thickened gallbladder wall shows the same caste of enhancement as the side by side normal wall in the majority of the cases, whereas a relative hyper-enhancement may be observed in about 15% of the cases. Wall enhancement typically shows a trilaminar pattern during the arterial stage equally a consequence of increased mucosal and serosal vascularization. The external layer must show no discontinuities.
Avascular spaces, representing RAS, must be observed within the thickened gallbladder wall (Fig.9). RAS appear avascular in every phase of the dynamic report, independently from their content. The identification of avascular spaces within a gallbladder wall thickening is virtually pathognomonic for GA.
Gallbladder adenomyomatosis: typical contrast-enhanced ultrasound (CEUS) findings. On CEUS, the thickened gallbladder wall shows discrete contrast enhancement, whereas Rokitansky–Aschoff sinuses (arrows) announced as avascular structures during every phase of the exam
Tips & tricks
Intramural avascular spaces are all-time appreciated 70–100 s afterwards endovenous contrast material assistants when the gallbladder wall shows a homogeneous high-degree enhancement.
Pitfalls & limitations
The depression mechanical index preset used for the performance of CEUS may reduce the accuracy in the label of gallbladder wall thickenings located in deep positions, abroad from the abdominal surface and from the probe. This may significantly limit CEUS accuracy in lesions involving the gallbladder cervix and in obese patients.
Magnetic resonance
Thanks to the contempo technical developments, to its multiplanarity and to its high tissue dissimilarity resolution, magnetic resonance imaging (MRI) is becoming an increasingly requested imaging technique for the study of gallbladder pathologies [9]. On the other mitt, MRI remains a time- and resource-consuming imaging modality and, therefore, the indications for its use must exist accurately evaluated. MRI is the imaging modality that offers the highest accuracy in diagnosing GA and, in particular, in differentiating GA from gallbladder carcinoma (accuracy 93.0%) [28].
Imaging findings
Gallbladder wall thickening can be clearly depicted both on T1- and on T2-weighted images, and is not a specific finding. Anyway, MRI warrants high specificity in the diagnosis of GA by accurately ruling out extra-parietal infiltration, which is indicative of gallbladder carcinoma.
RAS typically appear markedly hyperintense on T2-weighted images (Fig.x) [29], hypointense on T1-weighted images and testify no contrast enhancement. Anyway, progressive bile concentration and calcification development may alter the MRI appearance of RAS that may become increasingly hyperintense on T1-weighted images (Fig.11) and relatively hypointense on T2-weighted ones.
Gallbladder adenomyomatosis: typical MRI findings. On MRI, GA can exist identified equally a mural thickening (line) containing minor T2-hyperintense spaces representing RAS (arrows). RAS can be amend identified on fat-saturated T2-weighted images (b) than on non-fatty-saturated ones (a)
MRI of gallbladder adenomyomatosis: T1-hyperintense Rokitansky–Aschoff sinuses. Rokitansky–Aschoff sinuses (pointer) may appear hyperintense on T1-weighted images if containing concentrated bile or calcifications
Tips & tricks
The use of fat-saturated T2-weighted sequences increases RAS conspicuity.
MR cholangiopancreatography (MRCP) images tin can exist useful for identifying RAS that sometimes may be overlooked on axial images. On MRCP images, many RAS can be usually observed ane side by side to each other forth the involved gallbladder wall leading to the and then-called pearl necklace sign (Fig.12) [thirty].
MRI of gallbladder adenomyomatosis: the pearl necklace sign. On heavily T2-weighted images, like in this maximum intensity project reconstruction of a volumetric MRCP, a lot of RAS can be identified ane next to the other effectually the gallbladder, leading to the and so-called pearl necklace sign
RAS may be extremely small and, therefore, barely recognizable on thick slab T2-weighted images. The conquering of volumetric respiratory-triggered T2-weighted images increases the sensitivity of MRI in recognizing minor RAS and offers the possibility of multiplanar reconstructions.
Contrast material assistants is not routinely indicated in the suspicion of GA. Indeed, heavily T2-weighted fast spin-echo sequences are the almost reliable for the identification of RAS.
Diffusion-weighted imaging can be helpful in the differential diagnosis between benign and cancerous gallbladder wall thickenings. Ogawa et al. [31] demonstrated that malignant thickenings prove significantly lower credible diffusion coefficient (ADC) values than benign ones. Despite this, some overlap exists between benign and malignant lesions.
Pitfalls & limitations
T1-hyperintense RAS can be frequently observed. This must not enhance any doubtfulness in the diagnosis of GA, existence the consequence of concentrated biliary content, cholesterine crystals or calcifications.
RAS with unlike content, and consequently with different indicate intensities, oft coexist in the aforementioned patient.
Computed tomography
The finding of a gallbladder wall thickening at computed tomography (CT) may correspond a diagnostic dilemma; in fact, unless clear signs of malignancy are present, CT has an unsatisfactory accuracy in their differential diagnosis. The accuracy of CT in differentiating GA from gallbladder carcinoma is between 40 and 75% [32] and a confident diagnosis of GA is possible only if big (at least 3–iv mm) RAS are present.
Imaging findings
Gallbladder wall thickening without extra-parietal growth tin be confidently observed at CT, with sensitivity comparable to the other modalities.
Well-delimitated hypodense intramural spaces, representing RAS, tin be confidently recognized just if they reach 3–4 mm in diameter and if they take a clear bile content (Fig.13). If RAS are clearly identified, CT diagnosis of GA can be made.
Gallbladder adenomyomatosis: typical CT findings. At CT, gallbladder adenomyomatosis is characterized past mural thickening (line) containing cystic spaces representing Rokitansky–Aschoff sinuses (arrows). Large RAS can be easily identified on 3-mm-thick reconstructions (a), whereas for identifying smaller RAS thin slices evaluation is crucial (b)
Focal intramural calcifications (Fig.fourteen) are virtually pathognomonic for GA. Unfortunately, GA shows intramural calcifications only in a minority of the cases.
CT of gallbladder adenomyomatosis: intramural calcifications. CT accurately depicts intramural calcifications (arrows) that may develop within Rokitansky–Aschoff sinuses and which are pathognomonic for gallbladder adenomyomatosis
Tips & tricks
CT images evaluation using sparse slice thickness (1–ii mm) increases accuracy in identifying RAS and in excluding extramural infiltration, although it shows more than background racket compared to thicker reconstructions.
Endovenous contrast cloth administration is key in order to increase CT accurateness in RAS recognition and to exclude the presence of extra-parietal growth.
Pitfalls & limitations
Due to their tiny dimensions and to the low tissue contrast resolution of the technique, RAS cannot be clearly identified at CT in the majority of the cases.
Positron emission tomography
Despite its low spatial resolution, positron emission tomography (PET) offers the possibility of obtaining metabolic information from body tissues. Subsequently i.v. administration of fluorine-18-fluorodeoxiglucose (18 F-FDG), loftier glucose-consuming tissues (i.eastward., neoplastic and inflammatory ones) tin can be identified. PET is not usually performed in the suspicion of GA, simply patients afflicted by GA may sometimes undergo PET for other reasons.
Imaging findings
GA typically shows no 18 F-FDG uptake or lower uptake compared to the liver (Fig.15). This finding is not specific for GA, but may aid in excluding malignancy [33].
Gallbladder adenomyomatosis: typical PET-CT findings. Gallbladder adenomyomatosis (circle) usually shows an F-18FDG uptake equal or lower than the adjacent liver
Pitfalls & limitations
An acute inflammatory reaction sometimes surrounds RAS, generating an increased 18 F-FDG uptake that leads to false positive diagnosis of neoplasm [34].
PET has depression spatial resolution and its accuracy in excluding early gallbladder neoplasms may be unsatisfactory in lesions measuring less then i cm.
Conclusions
United states of america represents the imaging modality of choice for diagnosing GA, whereas CEUS should exist considered the second-line imaging modality. MRI is the problem-solving technique for unclear cases at U.s.a. and CEUS. PET may be considered for excluding malignancy in cases undiagnosed at The states, CEUS and MRI. CT, endoscopic ultrasound and oral cholecystography are not routinely considered for diagnosing GA.
Abbreviations
| GA | Gallbladder adenomyomatosis |
| RAS | Rokitansky–Aschoff sinuses |
| OC | Oral cholecystography |
| US | Trans-abdominal ultrasound |
| EUS | Endoscopic ultrasound |
| CEUS | Contrast-enhanced ultrasound |
| MRI | Magnetic resonance imaging |
| ADC | Credible improvidence coefficient |
| CT | Computed tomography |
| PET | Positron emission tomography |
Footnotes
Based on the EPOS "Gallbladder adenomyomatosis: are we sure to know it?" DOI 10.1594/ecr2014/C-0198
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359147/
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