Fundal Variant of Adenomyomatosis of the Gall Bladder

Case Report
DOI: 10.17354/cr/2015/69
Fundal Variant of Adenomyomatosis of the Gall
Bladder: An Uncommon Entity
Archana Shivamurthy1, Roumina Hasan1, Sushmitha Malpe Gopal1, Shaila Talengala Bhat2, Tanvi Shetty1
Assistant Professor, Department of Pathology, Melaka Manipal Medical College, Manipal University, Manipal, Karnataka, India, 2Professor and Head,
Department of Pathology, Melaka Manipal Medical College, Manipal University, Manipal, Karnataka, India
1
Adenomyomatosis of the gallbladder is a benign and degenerative condition of the gallbladder. It is an incidental finding in gall bladder
specimens resected for chronic cholecystitis or cholelithiasis. It frequently occurs after 3rd or 4th decade of life and is often an incidental finding
in cholecystectomy specimens resected for chronic cholecystitis or cholelithiasis. Patients with adenomyomatosis are usually asymptomatic
it can be classified into three types: Segmental, fundal and diffuse types. The fundal variant is uncommon compared to the other two types.
Here, in we present a case of a fundal variant of adenomyomatosis of the gall bladder in a 65-year-old male patient.
Keywords: Adenomyomatosis, Fundus, Gall bladder
INTRODUCTION
Adenomyomatosis of the gall bladder is an uncommon
benign and hyperplastic condition of the gall bladder
characterized by the proliferation of its mucosal lining.1 The
incidence ranges from 2% to 8.7%. It is found to occur more
frequently after 3rd or 4th decade of life. However, few cases
have also been reported in pediatric population.2 A female
predominance has also been noted. Adenomyomatosis is
an incidental finding in gall bladder specimens resected
for chronic cholecystitis or cholelithiasis. Patients with
adenomyomatosis are usually asymptomatic. 1,2 Jutras
in 1960 used the term “hyperplastic cholecystoses” to
described what is now termed as adenomyomatosis.3 There
are three different variants described in adenomyomatosis.
These include segmental, fundal, and diffuse type.
soft, non-tender, and no mass was palpable. Investigations
revealed hemoglobin of 14 g/dl, the total count of
6.6 × 103/µL. Ultrasound examination of the abdomen
and pelvis showed grade one fatty infiltration of liver and
chronic cholecystitis. The patient was hence taken up for
laparoscopic cholecystectomy, and the specimen was sent
for histopathological examination.
Pathological Findings
On macroscopic examination, the cholecystectomy
specimen weighed 9 g and measured 6 cm × 3.5 cm. The
cut section showed focal bile stained, denuded mucosa. The
fundus of the gall bladder showed a multicystic mass in
the wall measuring 1 cm × 1 cm (Figure 1). A single lymph
CASE REPORT
A 65-year-old male patient came with complaints of vague
abdominal discomfort associated with lower abdominal
pain since 1-month. There was no history of fever, nausea,
vomiting, diarrhea, yellowish discoloration of the eyes
and urine. On physical examination, the abdomen was
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Figure 1: Gall bladder with focal denuded mucosa. Fundus shows a multicystic
mass
Corresponding Author:
Dr. Archana Shivamurthy, Assistant Professor, Department of Pathology, Basic Science Building, Manipal University Campus, Manipal - 576 104,
Karnataka, India. Phone: +91-9880455094. E-mail: [email protected]
IJSS Case Reports & Reviews | April 2015 | Vol 1 | Issue 11
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Shivamurthy, et al.: Adenomyomatosis of Gall Bladder
node was also identified at the neck of the gallbladder. No
stones were identified.
On microscopic examination, focally ulcerated, hyperplasytic
gall bladder mucosa was observed. Rokitansky-Aschoff
sinuses or outpouchings of the mucosa were seen penetrating
into and through the muscularis propria (Figures 2 and
3). The lining consisted of columnar epithelial cells with
no atypical features. Focal pylori metaplasia was also
found. Few glands were irregularly shaped and cystically
dilated surrounded by proliferating smooth muscle cells
(Figures 3, 4a and b). None of the glands showed features
of malignancy. The mucular layer and serosa showed few
congested vessels and lymphoplasmacytic infiltrate. Section
from the lymph node showed reactive changes. Hence, a
diagnosis of adenomyomatosis-fundal variant with chronic
cholecystitis was rendered.
DISCUSSION
Of the three variants of adenomyomatosis, segmental
form is the most common, followed by the fundal
Figure 2: Proliferation on glandular structures (H and E ×40)
variant and the diffuse type.2 The fundal variant is often
difficult to appreciate on radiology as the fundus of the
gallbladder is insufficiently visualized, because of the
intestinal gas. Even in the present case the lesion was not
detected on ultrasonography. It has also been suggested
that computerized tomography may help to distinguish
ademyomatosis of fundal type from localized chronic
cholecystitis.4,5
Both clinically and pathologically the fundal type differs
from the other two types of adenomyomatosis. This type has
a lower incidence of gall stones. No stones were detected in
our case on gross examination. The grade of inflammation is
also found to be of lower grade in these cases.2,4 Carcinoma
of the gall bladder is also found to be less commonly
associated with the fundal variant.6 No atypical features
were observed in our case.
On histopathological examination, adenomyomatosisof
the gall bladder has hyperplastic mucosa, lobules of
glandular parenchyma, cystically and irregularly dilated
glands lined by cuboidal to columnar epithelium with no
atypical features. Smooth muscle cell bundles are seen in
the surrounding stroma.1,7 On immunohistochemistry,
similar to the biliary epithelium, the epithelial cells in
adenomyomatosis show positivity for cytokeratin-7 and
cytokeratin-20 and the smooth muscle cell cells for alphasmooth muscle actin.2,4
The differential diagnosis includes adenoma and
adenocarcinoma of the gall bladder, various other
polpoidal lesions such as hyperplatic and adenomatous
polyps. Cholecystectomy is the treatment of choice for
the fundal type of adenomyomatosis if patients do not
respond to medical therapy. The latter is initiated only when
adenomyomatosis is detected on radiology.2,8
a
b
Figure 3: Proliferation of smooth muscle cells surrounding irregularly dilated
glandular structures (H and E ×40)
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Figure 4: (a and b) Irregularly dilated glandular structures lined by columnar
epithelium surrounded by proliferation of smooth muscle cell (H and E ×40)
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Shivamurthy, et al.: Adenomyomatosis of Gall Bladder
CONCLUSION
Fundal adenomyomatosis is a rare entity. It is often detected
incidentally. Due to its rare potential of developing into
benign or malignant tumor, it should be always born in
mind during evaluation of cholecystectomy specimens.
ACKNOWLEDGMENT
We wish to thank all the technical staff of the Department
of Pathology, Manipal University.
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How to cite this article: Shivamurthy A, Hasan R, Gopal SM, Bhat ST. Fundal
Variant of Adenomyomatosis of the Gall Bladder: An Uncommon Entity. IJSS
Case Reports & Reviews 2015;1(11):55-57.
Source of Support: Nil, Conflict of Interest: None declared.
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