adenomiomatosis

Colecistosis Hiperplásicas, Pólipos VesicularesDr. Cristóbal Padilla LópezR1 Imagenología Diagnóstica y TerapéuticaHospital Regional de Alta Especialidad del Bajío

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martes, 13 de noviembre de 12

Adenomiomatosis

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Adenomiomatosis

Adenomioma Diverticulosis intramural

Colecistitis quística Enfermedad diverticular

Colecistitis glandular proliferativa

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Adenomiomatosis

Colecistosis hiperplásica de la pared vesicular.

Es relativamente común.

Condición benigna.

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Epidemiología

1-9 % de las piezas de colecistectomía.

Típicamente visto en paciente de la 5ª década de la vida.

La incidencia incrementa con la edad.

H:M, 1:3

Hallazgos incidental, sin potencial maligno y no requiere tratamiento.

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 (1): 80-8.

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Patología

Se presenta una hiperplasia de la pared

Formación de divertículos intramurales de la mucosa (Senos de Rokitansky-Aschoff)

Penetran en la pared muscular de la vesícula.

Puede o no haber engrosamiento de la pared.

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occurring in up to 8.7% of cholecystectomy speci-mens (60). Throughout the literature, a variety ofnames have been applied to this lesion, includingadenomyomatosis, adenomyoma, diverticulardisease, intramural diverticulosis, cholecystitiscystica, and cholecystitis glandularis proliferans.Adenomyomatous hyperplasia is more commonin women than men (7). The majority of patientspresent with complaints of chronic right upperquadrant pain, and 90% have coexistent gall-stones.

There are three variants of adenomyomatoushyperplasia: localized (or fundal), segmental, anddiffuse. The localized variant is the most commonand is also known as an adenomyoma. At grossexamination, it is characterized by a well-formedmass in the gallbladder fundus. The mass mayhave a semilunar or crescent shape (8). Cut sec-tions of the mass have a honeycombed appear-ance that is created by multiple, small cysticspaces (7). The cystic spaces represent prominent

Figure 32. Adenomyomatous hyperplasia. Photomi-crograph (original magnification, !4; H-E stain) showspapillary hyperplasia of the surface mucosa (!) anddeeply penetrating dilated glands (solid arrows) sur-rounded by hyperplastic smooth muscle cells (openarrow).

Figure 33. Adenomyomatous hyperplasia in a 65-year-old woman with chronic right upper quadrantpain. Abdominal radiograph shows multiple, punctate,calcific opacities in the right upper quadrant.

Figure 34. Diffuse adenomyomatous hyperplasia in a48-year-old woman with postprandial pain. (a) Longi-tudinal US image of the gallbladder shows diffuse gall-bladder wall thickening with areas of polypoid nodular-ity. (b) Photograph of the opened resected gallbladdershows hemorrhagic gallbladder mucosa with multiple,small, cystic spaces in the wall (arrows). Some of thecystic spaces contained pigmented calculi.

408 March-April 2002 RG f Volume 22 ! Number 2Patología

Existe acumulación intraluminal de colesterol.

Los cristales se precipitan y se atrapan en los senos.

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Hallazgos Radiográficos

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Se decriben tres tipos morfológicos de adenomiomatosis:

Generalizada (difusa): Vesícula en collar de perlas.

Segmental (anular): Compartimentos más frecuente en el cuello, 1/3 distal.

Fúndica (localizada), o adenomixoma: Masa sésil lisa en el fondo de la vesícula.

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occurring in up to 8.7% of cholecystectomy speci-mens (60). Throughout the literature, a variety ofnames have been applied to this lesion, includingadenomyomatosis, adenomyoma, diverticulardisease, intramural diverticulosis, cholecystitiscystica, and cholecystitis glandularis proliferans.Adenomyomatous hyperplasia is more commonin women than men (7). The majority of patientspresent with complaints of chronic right upperquadrant pain, and 90% have coexistent gall-stones.

There are three variants of adenomyomatoushyperplasia: localized (or fundal), segmental, anddiffuse. The localized variant is the most commonand is also known as an adenomyoma. At grossexamination, it is characterized by a well-formedmass in the gallbladder fundus. The mass mayhave a semilunar or crescent shape (8). Cut sec-tions of the mass have a honeycombed appear-ance that is created by multiple, small cysticspaces (7). The cystic spaces represent prominent

Figure 32. Adenomyomatous hyperplasia. Photomi-crograph (original magnification, !4; H-E stain) showspapillary hyperplasia of the surface mucosa (!) anddeeply penetrating dilated glands (solid arrows) sur-rounded by hyperplastic smooth muscle cells (openarrow).

Figure 33. Adenomyomatous hyperplasia in a 65-year-old woman with chronic right upper quadrantpain. Abdominal radiograph shows multiple, punctate,calcific opacities in the right upper quadrant.

Figure 34. Diffuse adenomyomatous hyperplasia in a48-year-old woman with postprandial pain. (a) Longi-tudinal US image of the gallbladder shows diffuse gall-bladder wall thickening with areas of polypoid nodular-ity. (b) Photograph of the opened resected gallbladdershows hemorrhagic gallbladder mucosa with multiple,small, cystic spaces in the wall (arrows). Some of thecystic spaces contained pigmented calculi.

408 March-April 2002 RG f Volume 22 ! Number 2

Engrosamiento mural

Difuso

Focal

Anular

Una masa focal orienta mas sobre un carcinoma vesicular.

Ultrasonido

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Ultrasonido

Artefacto en cola de cometa.

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Adenomiomatosis Focal

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Adenomiomatosis del fundus13


Adenomiomatosis segmentaria14


Relojde

Arena

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No necesita contraste para visualizar el lumen vesicular.

Puede detectar:

Engrosamiento mural.

masa focales sésiles.

signos del collar de perlas.

Reloj de arena en tipos anulares.

ColangiopancreatoRM

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Tomografía

Engrosamiento anormal de la vesícula y realce son comunes pero no específicos.

Pueden visualizarse los senos de Rokitansky-Aschoff si es que son de suficiente tamaño.

Signo del rosario.

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Tratamiento

Colecistectomía:

Paciente sintomático con dolor en cuadrante superior derecho.

Sospecha de lesión maligna, cuando son focales es dificil distinguir.

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DDx

Carcinoma de vesícula

Gorro frigio

Polipo de colesterol

Colelitiasis

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carcinoma

Gorro frigio

Polipo25


Diagnósticos diferenciales

La exclusión del cancer de vesícula puede ser problemático en casos focales o segmentales.

Adenomiomatosis focal puede aparecer como una masa discreta --> Adenomioma.

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Colesterolosis

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ColesterolosisAnomalía histológica adquirida de la pared vesicular.

Depósitos anormales de triglicéridos, precursores de colesterol y ésteres de colesterol.

Macrófagos de la lámina propia, epitelio y estroma.

La distribución puede ser difusa. (80%)

Acúmulos polipoideos. (10%)

Mixta. (10%)

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Colesterolosis

Generalmente no produce síntomas.

El diagnóstico ecográfico se sospecha ante la presencia de pólipos.

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Poliposis vesicular

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Introducción

Se define como cualquier lesión elevada de la mucosa.

Incluye entidades tanto benignas como malignas.

95% benignas

5% malignas

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Benignos 95%

Pólipos de colesterol: > 50% de todos los pólipos

Adenoma: 30% aprox, pb premaligno.

Pólipos inflamatorios

Adenomiomatosis

Otros raros.

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Malignos: 5%

Adenocarcinoma: aprox 90% de los malignos

Otras entidades raras incluyen:

Metástasis

Carcinoma de células escamosas

Angiosarcoma

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Son relativamente frecuentes.

5% de la población

Más del 90% son benignos, la mayoría son de colesterol.

Edad promedio: 40-50 años

H:M, 1:2.9

Epidemiología

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Presentación clínica

Son hallazgos incidentales en pacientes con malestar abdominal.

Generalmente son asintomáticos.

Pacientes con Sx de Peut-Jeghers tienen una alta prevalencia.

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Patología

El hallazgo histológico puede ser variable.

Pólipos de colesterol son masas amarillas lobuladas con un pedículo.

Se componen de macrógafos cubiertos de epitelio normal.

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Heterotopic mucosa in the bile duct may mani-fest as an intraluminal polyp (45) or a focal stric-ture (Fig 25) that causes biliary obstruction (48).The polyp usually has medium echotexture onUS images and can be demonstrated as an immo-bile intraluminal mass on cholangiograms.

Cholesterol Polyps

Clinical and Pathologic Features.—Choles-terol polyps of the gallbladder represent approxi-mately one-half of all polypoid lesions in the gall-bladder and have no malignant potential (49,50).The majority of patients are women between 40and 50 years of age. The female-to-male ratio is2.9:1 (49). Cholesterol polyps are typically foundin patients who are being evaluated for epigastricdistress and right upper quadrant pain. Only asmall number of cases are associated with choleli-thiasis and cholesterolosis (8).

At histologic examination, cholesterol polypsare composed of lipid-laden macrophages that arepositive for oil red O stain. Normal gallbladderepithelium covers the polyp (Fig 26a), and its in-foldings may form glandlike structures (6).

At gross inspection, cholesterol polyps appearas small, yellow, lobulated, polypoid or tumorlikeprojections attached to the gallbladder mucosa bya pedicle (Fig 26b) (7). Any portion of the gall-

bladder may be affected. Cholesterol polyps aresingle or multiple and are usually less than 10 mmin diameter (6), although polyps up to 20 mm indiameter have been reported (9).

Radiologic Features.—On US images, smallcholesterol polyps appear as brightly echogenicmasses or nodules attached to the gallbladder wall(Fig 27a). They are typically round or slightlylobulated and do not produce posterior acousticshadowing. It is often difficult to distinguish anonshadowing adherent stone from a cholesterolpolyp, as they have similar US characteristics.Large cholesterol polyps are generally less echo-genic than smaller polyps (Fig 27b) and may con-tain a characteristic aggregation of echogenic foci.The finding of echogenic aggregates with transab-dominal or endoscopic US may be useful in dif-ferentiating large cholesterol polyps from adeno-mas or adenocarcinomas (9).

On unenhanced CT scans, cholesterol polypsare difficult to see, most likely because the attenu-ation values of the polyps and bile are similar.However, they are readily detected on contrast-enhanced CT scans because of the vascularitywithin the polyp (10). Often, cholesterol polypsmay appear to be floating within the lumen of thegallbladder on CT scans because the thin stalk isnot seen. In these cases, the polyps are indistin-guishable from floating stones or tumefactivesludge.

Figure 26. Cholesterol polyp. (a) Photomicrograph (original magnification, !100; H-E stain) shows normal gall-bladder epithelium overlying sheets of lipid-laden macrophages, forming the head of the polyp. (b) Photograph of anopened resected gallbladder shows multiple, yellow, lobulated polyps attached to the gallbladder mucosa.


Heterotopic mucosa in the bile duct may mani-fest as an intraluminal polyp (45) or a focal stric-ture (Fig 25) that causes biliary obstruction (48).The polyp usually has medium echotexture onUS images and can be demonstrated as an immo-bile intraluminal mass on cholangiograms.

Cholesterol Polyps

Clinical and Pathologic Features.—Choles-terol polyps of the gallbladder represent approxi-mately one-half of all polypoid lesions in the gall-bladder and have no malignant potential (49,50).The majority of patients are women between 40and 50 years of age. The female-to-male ratio is2.9:1 (49). Cholesterol polyps are typically foundin patients who are being evaluated for epigastricdistress and right upper quadrant pain. Only asmall number of cases are associated with choleli-thiasis and cholesterolosis (8).

At histologic examination, cholesterol polypsare composed of lipid-laden macrophages that arepositive for oil red O stain. Normal gallbladderepithelium covers the polyp (Fig 26a), and its in-foldings may form glandlike structures (6).

At gross inspection, cholesterol polyps appearas small, yellow, lobulated, polypoid or tumorlikeprojections attached to the gallbladder mucosa bya pedicle (Fig 26b) (7). Any portion of the gall-

bladder may be affected. Cholesterol polyps aresingle or multiple and are usually less than 10 mmin diameter (6), although polyps up to 20 mm indiameter have been reported (9).

Radiologic Features.—On US images, smallcholesterol polyps appear as brightly echogenicmasses or nodules attached to the gallbladder wall(Fig 27a). They are typically round or slightlylobulated and do not produce posterior acousticshadowing. It is often difficult to distinguish anonshadowing adherent stone from a cholesterolpolyp, as they have similar US characteristics.Large cholesterol polyps are generally less echo-genic than smaller polyps (Fig 27b) and may con-tain a characteristic aggregation of echogenic foci.The finding of echogenic aggregates with transab-dominal or endoscopic US may be useful in dif-ferentiating large cholesterol polyps from adeno-mas or adenocarcinomas (9).

On unenhanced CT scans, cholesterol polypsare difficult to see, most likely because the attenu-ation values of the polyps and bile are similar.However, they are readily detected on contrast-enhanced CT scans because of the vascularitywithin the polyp (10). Often, cholesterol polypsmay appear to be floating within the lumen of thegallbladder on CT scans because the thin stalk isnot seen. In these cases, the polyps are indistin-guishable from floating stones or tumefactivesludge.

Figure 26. Cholesterol polyp. (a) Photomicrograph (original magnification, !100; H-E stain) shows normal gall-bladder epithelium overlying sheets of lipid-laden macrophages, forming the head of the polyp. (b) Photograph of anopened resected gallbladder shows multiple, yellow, lobulated polyps attached to the gallbladder mucosa.


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Características Radiológicas

Predecir la histología basados en puramente en imágenes no es posible.

Los adenomas se consideran premalignos, Qx.

El indicador mas útil de malignidad son pólipos de más de 10mm de diámetro: 37-87%.

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Benigno Maligno

Tamaño menor de 5mm5-10 mm Mayor de 10mm

Morfología Pedunculado Sésil

Número Múltiple Solitario

Crecimiento Estable Crece

TC/RM Realce similar al resto de la pared Mayor realce

US Focos pequeños ecogénicoArt. Cola de cometa

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Ultrasonido

Es el estudio inicial de elección.

Ayuda a diferenciar pólipos de colesteros de aquellos que puden llegar a requerir tratamiento.

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Xanthogranulomatous Cholecystitis

Clinical and Pathologic Features.—Xan-thogranulomatous cholecystitis is an unusualform of chronic cholecystitis that may simulate

malignancy radiologically and pathologically (51).It is predominantly seen in women between theages of 60 and 70 years (52). Patients presentwith signs and symptoms of cholecystitis: rightupper quadrant pain, vomiting, leukocytosis, anda positive Murphy sign. Slightly less than one-halfof patients have a tender, palpable, right upperquadrant mass at physical examination (53).Complications are present in 32% of cases (54)and include perforation, abscess formation, fistu-lous tracts to the duodenum or skin, and exten-sion of the inflammatory process to the liver, co-lon, or surrounding soft tissues.

Although the mechanism leading to the forma-tion of xanthogranulomatous cholecystitis has notbeen firmly established, extravasation of bile intothe gallbladder wall is believed to have a role inthe development of the inflammatory process. Ithas been postulated that bile enters the gallblad-der wall through mucosal ulceration or rupture ofRokitansky-Aschoff sinuses when there is gall-bladder or cystic duct obstruction that results inincreased intraluminal pressure.

The histologic components of xanthogranulo-matous cholecystitis include foamy histiocytes,lymphocytes, plasma cells, polymorphonuclearleukocytes, fibroblasts, and foreign body giantcells. The foamy histiocytes predominate andmay contain bile or ceroid pigment (Fig 28) (7).

Figure 27. Sonographic appearance of cholesterol polyps. (a) Longitudinal US image of the gall-bladder in a 35-year-old woman with epigastric distress shows multiple small hyperechoic polyps(arrow) in the gallbladder. (b) Longitudinal US image of the gallbladder in a 40-year-old man withright upper quadrant pain shows two 5-mm hypoechoic cholesterol polyps (arrows) in the gallblad-der fundus.

Figure 28. Xanthogranulomatous cholecystitis.Photomicrograph (original magnification, !2; H-Estain) shows a thickened, fibrotic gallbladder wallwith a centrally located xanthogranulomatous chole-cystitis lesion (arrows) containing chronic inflamma-tory cells, bile pigment, and foamy pigment-ladenmacrophages.

RG f Volume 22 ! Number 2 Levy et al 405

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Tomografía

Pequeñas lesiones no se detectan.

Pólipos grandes aparecen como imágenes de densidad de tejido blando en la luz de la vesícula.

Realce similar al resto de la vesícula.

Realce más intenso en imágenes sospechosas de malignidad.

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Tratamiento y Pronóstico

Las recomendaciones de tratamiento en menores de 10mm varían.

Pólipos menores de 5mm no requieren seguiminento.

Otros sugieren seguimiento anual.

5-10mm seguimiento para asegurar que no crezcan, 3-6 meses.

>10mm requieren colecistectomía.

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DDx.

Litos.

Usualmente móviles, pero pueden estar adheridos.

Sombra acústica.

Lodo biliar.

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Referencias

LevyAD, Murakata LA, Abbott RM, Rohrmann CA. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. RadioGraphics2002; 22: 387–413.

Gallbladder polyps, cholesterolosis, adenomyomatosis, and acute acalculous cholecystitis. Semin Gastrointest Dis. 2003 Oct;14(4):178-88.

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Boscak AR, Al-hawary M, Ramsburgh SR. Best cases from the AFIP: Adenomyomatosis of the gallbladder. Radiographics. 26 (3): 941-6.

Rumack. Diagnóstico por ecografía, Tomo I. Cap. 6, Pags: 204:207.

Cotran RS, Kumar V, Robbins SL: Robbins Pathologic Basis of Disease. 5th ed. Philadelphia, W.B. Saunders, 1994.

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 (1): 80-8

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adenomiomatosis

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