Utility of multiple endoscopic techniques in differential diagnosis of gallbladder adenomyomatosis from gallbladder malignancy with bile duct invasion: A case report

BACKGROUND Gallbladder adenomyomatosis(GAM) is a benign lesion, characterized by thickening of the gallbladder wall and a focal mass, which overlap with the features of gallbladder malignancy. Consequently, differential diagnosis of GAM from gallbladder cancer is difficult and approximately 20% of suspected malignant biliary strictures are postoperatively confirmed as benign lesions.Herein, we report a case in which a preoperative diagnosis of GAM was made by a combination of endoscopic and imaging techniques.CASE SUMMARY A 40-year-old man was referred to our hospital chiefly for a fever and right upper abdominal pain with dark urine. Enhanced computed tomography showed thickening of the gallbladder wall and a mass in the gallbladder neck with involvement of the hepatic bile ducts, which was suspected to be malignant.Gallbladder malignancy with bile duct invasion was ruled out by subsequent endoscopic examinations, including endoscopic retrograde cholangiopancreatography, intraductal ultrasound, and Spy Glass. Endoscopic examinations showed a homogeneous hyperechoic lesion with smooth margins of benign bile duct stricture suggestive of inflammatory stenosis of the bile duct.The patient underwent laparoscopic cholecystectomy. GAM was postoperatively diagnosed and confirmed based on the histopathology results, which are consistent with the preoperative diagnosis. Notably, no malignant event occurred in the patient during a 12-mo follow-up period.CONCLUSION A combination of endoscopic techniques may help in the differential diagnosis of GAM from gallbladder cancer.

Biliary strictures:diagnostic considerations and approach

Biliary strictures present a diagnostic challenge,especially when no etiology can be ascertained after laboratory evaluation,abdominal imaging and endoscopic retrograde cholangiopancreatography(ERCP)sampling.These strictures were traditionally classified as indeterminate strictures,although with advances in endoscopic techniques and better understanding of hepato-biliary pathology,more are being correctly diagnosed.The implications of missing a malignancy in patients with biliary strictures—and hence delaying surgery—are grave but a significant number of patients(up to 20%)undergoing surgery for suspected biliary malignancy can have benign pathology.The diagnostic approach to these patients involves detailed history and physical examination and depends on the presence or absence of jaundice,level of obstruction,and presence or absence of a mass lesion.While abdominal imaging helps to find the level of obstruction and provides a‘road map’for further endoscopic investigations,tissue diagnosis is usually needed to make decisions on management.Initially ERCP was the only modality to investigate these strictures but now,with the development of endoscopic ultrasound with fine needle aspiration and the availability of newer techniques such as intraductal ultrasound,single-operator cholangioscopy and confocal laser endomicroscopy,the diagnostic approach to biliary strictures has changed significantly.In this review,we will focus on the decision-making process for patients with biliary strictures and discuss the key decision points that should dictate further diagnostic investigations at each step.