Endoscopic sonography in the diagnosis of xanthogranulomatous cholecystitis

The Role of Endoscopic Ultrasound in the Diagnosis of Gallbladder Lesions

Gallbladder (GB) diseases represent various lesions including gallstones, cholesterol polyps, adenomyomatosis, and GB carcinoma. This review aims to summarize the role of endoscopic ultrasound (EUS) in the diagnosis of GB lesions. EUS provides high-resolution images that can improve the diagnosis of GB polypoid lesions, GB wall thickness, and GB carcinoma staging. Contrast-enhancing agents may be useful for the differential diagnosis of GB lesions, but the evidence of their effectiveness is still limited. Thus, further studies are required in this area to establish its usefulness. EUS combined with fine-needle aspiration has played an increasing role in providing a histological diagnosis of GB tumors in addition to GB wall thickness.

Xanthogranulomatous cholecystitis: a European and global perspective

INTRODUCTION

Xanthogranulomatous cholecystitis (XGC) is often mistaken for, and may predispose to, gallbladder carcinoma (GB Ca). This study reviews the worldwide variation of the incidence, investigations, management and outcome of patients with XGC.

METHODS

Data from 29 studies, cumulatively containing 1599 patients, were reviewed and results summarized by geographical region (Europe, India, Far East and Americas) with 95% confidence intervals (CIs) to present variability within regions. The main study outcomes were incidence, association with GB Ca and treatment of patients with XGC.

RESULTS

Overall, the incidence of XGC was 1.3-1.9%, with the exception of India where it was 8.8%. The incidence of GB Ca associated with XGC was lowest in European studies (3.3%) varying from 5.1-5.9% in the remaining regions. Confusion with or undiagnosed GB Ca led to 10.2% of patients receiving over or under treatment.

CONCLUSIONS

XGC is a global disease and is associated with GB Ca. Characteristic pathological, radiological and clinical features are shared with GB Ca and contribute to considerable treatment inaccuracy. Tissue sampling by pre-operative endoscopic ultrasound or intra-operative frozen section is required to accurately diagnose gallbladder pathology and should be performed before any extensive resection is performed.

Outcomes of Xanthogranulomatous cholecystitis in laparoscopic era: A retrospective Cohort study

INTRODUCTION:

Xanthogranulomatous cholecystitis (XGC) is a rare variant of cholecystitis and reported incidence of XGC varies from different geographic region from 0.7% -9%. Most of the clinicians are not aware of the pathology and less evidence is available regarding the optimal treatment of this less common form of cholecystitis in the present era of laparoscopic surgery.

MATERIALS AND METHODS:

A retrospective cohort study was conducted in a tertiary care university hospital from 1989 to 2009. Histopathologically confirmed XGC study patients (N=27) were compared with non-Xanthogranulomatous cholecystitis (NXGC) control group (N=27). The outcomes variables were operative time, complication rate and laparoscopic to open cholecystectomy conversion rate. The study group (XGC) was further divided in to three sub groups; group I open cholecystectomy (OC), laparoscopic cholecystectomy (LC) and laparoscopic converted to open cholecystectomy (LCO) for comparative analysis to identify the significant variables.

RESULTS:

During the study period 6878 underwent cholecystectomy including open cholecystectomy in 2309 and laparoscopic cholecystectomy in 4569 patients. Histopathology confirmed xanthogranulomatous cholecystitis in 30 patients (0.43% of all cholecystectomies) and 27 patients qualified for the inclusion criterion. Gallbladder carcinoma was reported in 100 patients (1.45%) during the study period and no association was found with XGC. The mean age of patients with XGC was 49.8 year (range: 29-79), with male to female ratio of 1:3. The most common clinical features were abdominal pain and tenderness in right hypochondrium. Biliary colic and acute cholecystitis were the most common preoperative diagnosis. Ultrasonogram was performed in all patients and CT scan abdomen in 5 patients. In study population (XGC), 10 were patients in group I, 8 in group II and 9 in group III. Conversion rate from laparoscopy to open was 53 % (n=9), surgical site infection rate of 14.8% (n=4) and common bile duct injury occurred one patient in open cholecystectomy group (3.7%). Statistically significant differences between group I and group II were raised total leukocyte count: 10.6±3.05 vs. 7.05±1.8 (P-Value 0.02) and duration of surgery in minutes: 248.75±165 vs. 109±39.7 (P-Value 0.04). The differences between group III and group II were duration of surgery in minutes: 208.75±58 vs. 109±39.7 (P-Value 0.03) and duration of symptoms in days: 3±1.8 vs. 9.8±8.8 (P-Value 0.04). The mean hospital stay in group I was 9.7 days, group II 5.6 days and in group III 10.5 days. Two patients underwent extended cholecystectomy based on clinical suspicion of carcinoma. No mortality was observed in this study population. Duration of surgery was higher in XGC group as compared to controls (NXGC) (203±129 vs.128±4, p-value=0.008) and no statistically significant difference in incidence proportion of operative complication rate were observed among the group (25.9% vs. 14.8%, p-value=0.25. Laparoscopic surgery was introduced in 1994 and 17 patients underwent laparoscopic cholecystectomy and higher conversion rate from laparoscopic to open cholecystectomy was observed in 17 study group (XGC) as compared to 27 Control group (NXGC) 53%vs.3.3% with P-value of < 0.023.

CONCLUSION:

XGC is a rare entity of cholecystitis and preoperative diagnosis is a challenging task. Difficult dissection was encountered in open as well in laparoscopic cholecystectomy with increased operation time. Laparoscopic cholecystectomy was carried out with high conversion rate to improve the safety of procedure. Per operative clinical suspicion of malignancy was high but no association of XGC was found with gallbladder carcinoma, therefore frozen section is recommended before embarking on radical surgery.

Extended surgical resection for xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma: A case report and review of literature

Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory disease of the gallbladder, rarely involving adjacent organs and mimicking an advanced gallbladder carcinoma. The diagnosis is usually possible only after pathological examination. A 46 year-old woman was referred to our center for suspected gallbladder cancer involving the liver hilum, right liver lobe, right colonic flexure, and duodenum. Brushing cytology obtained by endoscopic retrograde cholangiography (ERC) showed high-grade dysplasia. The patient underwent an en-bloc resection of the mass, consisting of right lobectomy, right hemicolectomy, and a partial duodenal resection. Pathological examination unexpectedly revealed an XGC.

Only six cases of extended surgical resections for XGC with direct involvement of adjacent organs have been reported so far. In these cases, given the possible coexistence of XGC with carcinoma, malignancy cannot be excluded, even after cytology and intraoperative frozen section investigation. In conclusion, due to the poor prognosis of gallbladder carcinoma on one side and possible complications deriving from highly aggressive inflammatory invasion of surrounding organs on the other side, it seems these cases should be treated as malignant tumors until proven otherwise. Clinicians should include XGC among the possible differential diagnoses of masses in liver hilum.

[The application of digestive endoscopic ultrasonography in the gallbladder pathology]

A WELL DEFINED PATHOLOGY: Bilary lithiasis and vesicular parietal abnormalities constitute the totality of the gallbladder pathology. The surgical experience and widely current use of digestive imaging, notably ultrasonography, have contributed to enlightening our knowledge of this pathology. POTENTIAL DIAGNOSTIC PROBLEMS: There is no particular problem in the diagnosis of gallbladder lithiasis and its treatment is currently codified. However the discovery of thickened gallbladder wall or polyps increases the fear of gallbladder cancer. A FUNDAMENTAL ROLE FOR ENDOSCOPIC ULTRASONOGRAPHY: Within the framework of screening for cancer, endoscopic ultrasonography, the performance of which in gallbladder pathology has rarely been studied, appears promising. Other than its role in the control of the extension of gallbladder cancers, it provides reliable characterisation of most of the polyps. Hence its place today is unavoidable in the therapeutic decision trees of such affections.

Xanthogranulomatous cholecystitis: 15 years' experience

The demographic and clinical aspects of xanthogranulomatous cholecystitis (XGC) over a period of 15 years are reviewed. The review entailed examining 12,426 clinical files of patients who had undergone cholecystectomy, including 182 patients with a histopathologic diagnosis of XGC. Altogether, 1.46% of the cholecystectomies performed were done on patients with a diagnosis of XGC. XGC presented in patients over the age of 32, with a male/female ratio of 2:1. Thickening of the gallbladder wall, seen on ultrasonography and computed tomography scans, was demonstrated in 100% of the cases. A total of 17% of the cases presented in acute form. Obstructive jaundice was observed in 23% of the patients, 11 of which cases were associated with choledocholithiasis (30% of these patients had jaundice) and the rest with extrinsic obstruction of the bile tract (Mirizzi syndrome). XGC was associated with lithiasis in 85% of the cases. A malignant lesion was suspected during operation in 30% of the cases, requiring histopathologic examination during surgery. Carcinomatous lesions were found in 3% of the cases. Surgical difficulty was reported in 65% of the cases, resulting in the performance of partial cholecystectomy in 35%. XGC is an infrequent form of chronic inflammation of the gallbladder, the clinical presentation of which is similar to that of cholecystitis; given the thickening of the gallbladder wall, it makes cholecystectomy difficult. As XGC may resemble adenocarcinoma, differentiation is essential by means of intraoperative histologic examination to ensure optimal surgical treatment.

Xanthogranulomatous Cholecystitis A Surgical Challenge

Xanthogranulomatous cholecystitis is a severe inflammatory process, which gives rise to dense adhesions that complicate cholecystectomy. Four cases of significant injuries to the main biliary passages and surrounding structures are discussed. We suggest greater caution in the dissection of the gall bladder; a lower threshold for early conversion, examining frozen sections in suspicious cases and accurate preoperative diagnosis whenever possible.

Endoscopic sonography in the diagnosis of gallbladder wall lesions in patients with gallstones

PURPOSE

The purpose of this study was to evaluate the diagnostic accuracy of endoscopic sonography (EUS) in the detection of gallbladder wall lesions in patients with and without gallstones.

METHODS

We retrospectively reviewed the medical records, sonograms, and sonographic reports of 62 patients who underwent cholecystectomy for gallbladder wall lesions evaluated by EUS. We assessed the accuracy of EUS in diagnosing gallbladder wall lesions in the presence or absence of gallstones and on the basis of the size and number of stones and the size of the gallbladder wall lesions. We also evaluated the effect of acoustic shadowing. The EUS results were compared with the histopathologic results.

RESULTS

EUS correctly diagnosed the gallbladder wall lesions in 17 (71%) of 24 patients with gallstones and in 34 (89%) of 38 patients without gallstones. The diagnostic accuracy of EUS was 86% in patients with gallbladder wall lesions smaller than 20 mm and 79% in patients with gallbladder wall lesions 20 mm or larger. The diagnostic accuracy was 75% in patients with gallstones smaller than 5 mm and 67% in patients with stones 5 mm or larger. The accuracy was 67% in patients with 1-5 stones and 83% in patients with 6 or more stones. None of these differences was statistically significant. Acoustic shadowing did not affect the diagnostic accuracy of EUS.

CONCLUSIONS

The diagnostic accuracy of EUS for gallbladder wall lesions is not affected by the presence of gallstones. However, better diagnostic criteria must be established based on larger studies, and technical refinements of the equipment are needed to increase the accuracy of EUS in the diagnosis of gallbladder wall lesions.