European Radiology

, Volume 28, Issue 9, pp 3573–3582 | Cite as

CT diagnosis of gallbladder adenomyomatosis: importance of enhancing mucosal epithelium, the “cotton ball sign”

  • Hyun Kyung Yang
  • Jeong Min LeeEmail author
  • Mi Hye Yu
  • Sang Min Lee
  • Jinyoung Park
  • Na Young Han
  • Kyoungbun Lee
  • Jin-Young Jang
  • Joon Koo Han



To determine the diagnostic value of the cotton ball sign and other CT features in patients with gallbladder (GB) wall thickenings (WTs).


Three blinded readers reviewed the preoperative CT and MR images of 101 patients with pathologically confirmed GB adenomyomatosis (GA) (n = 34) and other benign (n = 29), malignant (n = 41), and premalignant (n = 2) GBWTs. Three readers analysed the morphological features of GBWT and presence of the “cotton ball sign”, defined as fuzzy grey dots in GBWT or a dotted outer border of the inner enhancing layer on contrast-enhanced (CE) CT. In addition, the “pearl necklace sign” on MR was analysed.


In the GA group (n = 34), prevalence of the cotton ball sign and pearl necklace sign was 74% (25/34) and 44% (15/34), respectively. Presence of the cotton ball sign, smooth contour of the mucosa, double-layering enhancement, and enhancement degree weaker than the renal cortex on CT images were significant predictors of benign GBWT (p < 0.01). When differentiating GA from GB malignancy or premalignancy, accuracy of the cotton ball sign and pearl necklace sign was 81% (62/77) and 74% (57/77), respectively.


The cotton ball sign on CE-CT showed higher sensitivity and comparable specificity to those of the pearl necklace sign in differentiating GA from malignancy.

Key Points

• Prevalence of the cotton ball sign on CT was 74% in gallbladder adenomyomatosis.

• The cotton ball sign was useful in differentiating gallbladder adenomyomatosis from gallbladder cancer.

• The cotton ball sign was more sensitive than the pearl necklace sign for adenomyomatosis diagnosis.


Gallbladder diseases Adenomyoma Gallbladder neoplasms Diagnosis, differential Tomography, X-ray computed 



Contrast enhanced


Computed tomography


Gallbladder adenomyomatosis




Gallbladder wall thickening


Gradient echo sequence


Hounsfield unit


Multi-detector computed tomography


Magnetic resonance cholangiopancreatography


Magnetic resonance imaging


Portal venous phase


Rokitansky-Aschoff sinus





The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Jeong Min Lee.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic or prognostic study

• performed at one institution

Supplementary material

330_2018_5412_MOESM1_ESM.docx (28 kb)
ESM 1 (DOCX 28 kb)


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Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of RadiologySeoul National University HospitalSeoulKorea
  2. 2.The Joint Department of Medical ImagingMount Sinai Hospital-University Health Network-Women’s College Hospital, University of TorontoTorontoCanada
  3. 3.Department of RadiologySeoul National University College of MedicineSeoulKorea
  4. 4.Department of RadiologyKonkuk University School of MedicineSeoulKorea
  5. 5.Department of RadiologyHallym University Sacred Heart HospitalAnyangKorea
  6. 6.Department of RadiologyDongnam Institute of Radiological and Medical SciencesBusanKorea
  7. 7.Department of PathologyNational Cancer CenterGoyangKorea
  8. 8.Department of PathologySeoul National University HospitalSeoulKorea
  9. 9.Department of SurgerySeoul National University HospitalSeoulKorea

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