An Important Gallbladder Pathology Mimicking Gallbladder Carcinoma: Xanthogranulomatous Cholecystitis: A Single Tertiary Center Experience

Xanthogranulomatous cholecystitis: Diagnostic dilemma and surgical solution in geriatric patients: A case report

INTRODUCTION

Xanthogranulomatous Cholecystitis (XGC) is a rare inflammatory condition characterized by the presence of xanthogranulomas within the gallbladder wall, often mimicking gallbladder carcinoma (GBC). Diagnosis is challenging and may require biopsy. Once GBC is excluded, an open cholecystectomy is recommended, although laparoscopic cholecystectomy is increasingly being performed with great caution. This case report aims to evaluate clinical and radiological features, surgical outcomes, and treatment approaches for XGC.

CASE PRESENTATION

A 70-year-old patient presented with right hypochondrial pain and a palpable gallbladder. A CT scan revealed a distended lithiasic gallbladder with a thickened irregular wall and hepatic nodules. A hepatic MRI suggested xanthogranulomatous cholecystitis. A CT-guided biopsy of the liver nodule showed no signs of malignancy. An open cholecystectomy with a trans-cystic drain was performed. Histological examination confirmed chronic xanthogranulomatous cholecystitis. The patient was discharged on postoperative day 10. A clinical and radiological follow-up at 6 months postoperatively showed no abnormalities.

CLINICAL DISCUSSION

XGC presents diagnostic challenges due to its resemblance to GBC. Imaging aids in diagnosis, but biopsy may be necessary. Open cholecystectomy is the recommended surgical treatment due to excessive local inflammation and the risk of concomitant malignancy.

CONCLUSION

Managing XGC demands a holistic approach that integrates all clinical insights and mandates close collaboration among a multidisciplinary team of surgeons, radiologists, and pathologists. Further research is needed to refine diagnostic and therapeutic strategies for this rare condition, especially in geriatric patients.

Xanthogranulomatous Cholecystitis Mimicking Gall Bladder Cancer: a Diagnostic Dilemma and Review of Literature

Xanthogranulomatous cholecystitis (XGC) is one of the rare variants of chronic cholecystitis which is characterized by inflammation of gall bladder along with infiltration by acute and chronic inflammatory cells. Intramural accumulation of lipid laden macrophages in GB wall is the hallmark of the disease. XGC results in dense adhesion of gall bladder (GB) to surrounding structures, like duodenum, colon, and stomach. The intense GB inflammation results in gall bladder perforation and development of fistulous communication between gall bladder and surrounding structures. This may also lead to formation of inflammatory mass which closely mimic gall bladder malignancy. Often differentiation from carcinoma of GB (Ca GB) on the basis of clinical presentation and even on intra-operative and radiological findings is difficult, and the issue could only be resolved on final Histopathology (HPE). We review presentation and investigation of a patient, discuss our approach in managing dilemma in treating such cases of XGC, and review the literature.

Diagnostic Point-of-Care Ultrasound (POCUS) for Abdominal Pain: A Case of Tumefactive Sludge

Biliary sludge is an extremely viscous sediment, consisting essentially of calcium bilirubinate granules and cholesterol crystals, which, due to its high viscosity, has poor and slow movement, leading to a mass-like configuration called tumefactive biliary sludge. Tumefactive sludge was first described with the advent of ultrasonography in the 1970s and is an uncommon intraluminal lesion of the gallbladder (GB). The differential diagnoses for an echogenic mass in the GB lumen include GB carcinoma, tumefactive sludge, and gangrenous cholecystitis. Ultrasonography is the election method for the screening of GB diseases, with diagnostic accuracy exceeding 90%. The point-of-care ultrasound (POCUS) has shown a major improvement in the evaluation of hepatobiliary diseases. POCUS allows the detection of GB wall thickness, pericholestatic fluid, sonographic Murphy's sign, and dilatation of the common bile duct. The authors present a case of abdominal pain caused by the presence of tumefactive sludge in the GB, in which POCUS helped establish the diagnosis and therapeutic guidance.

Grayscale ultrasonography findings for characterization of gallbladder wall thickening in non-acute setting: a systematic review and meta-analysis

BACKGROUND

The accurate characterization of gallbladder wall thickening (GWT) into benign or malignant on ultrasound (US) is a significant challenge.

METHODS

We searched the MEDLINE and EMBASE databases for studies reporting two-dimensional grayscale US in benign and malignant GWT. The pooled prevalence was calculated using a generalized linear mixed method with a random-effects model. The pooled sensitivity and specificity were calculated using a bivariate random-effects model.

RESULTS

Of the 7309 studies screened by titles, 73 studies with 18,008 patients were included. The most common findings in xanthogranulomatous cholecystitis (XGC) were lack of wall disruption and intramural hypoechoic nodules while adenomyomatosis (ADM) was frequently associated with intramural cysts and intramural echogenic foci. Echogenic foci, lack of gallbladder wall disruption, and hypoechoic nodules had a sensitivity of 89%, 77%, and 66% and specificity of 86%, 51%, and 80%, respectively for the diagnosis of benign GWT. Focal thickening and indistinct liver interface had a sensitivity of 75% and 55% and specificity of 64% and 69%, respectively for the diagnosis of malignant GWT.

CONCLUSION

intramural features (echogenic foci, hypoechoic nodules), gallbladder wall disruption, and liver interface are useful US features for the characterization of GWT.

Presentation and surgical management of xanthogranulomatous cholecystitis

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and most of the times requires surgical management. In addition, distinguishing XGC from gallbladder cancer preoperatively is still a challenge. The aim of the present systematic review was to outline the clinical presentation and surgical approach of XGC.

DATA SOURCES

The present systematic review was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases from inception until June 2020.

RESULTS

The laparoscopic cholecystectomy rate (34%) was almost equal to the open cholecystectomy rate (47%) for XGC. An important conversion rate (35%) was observed as well. The XGC cases treated by surgery were associated with low mortality (0.3%), limited intraoperative blood loss (58-270 mL), low complication rates (2%-6%), along with extended operative time (82.6-120 minutes for laparoscopic and 59.6-240 minutes for open cholecystectomy) and hospital stay (3-9 days after laparoscopic and 8.3-18 days after open cholecystectomy). Intraoperative findings during cholecystectomies for XGC included empyema or Mirizzi syndrome. In addition, complex surgical procedures, like wedge hepatic resections and bile duct excision were required during operations for XGC.

CONCLUSIONS

XGC seemed to be a rare, benign inflammatory disease that presents similar features as gallbladder cancer. The mortality and complication rates of XGC were low, despite the complex surgical procedures that might be required in some cases.

Xanthogranulomatous cholecystitis: Diagnosis and management

Xanthogranulomatous cholecystitis (XGC) is a rare form of cholecystitis, characterized by the presence of xanthogranuloma, prominent yellow structures within the gallbladder wall that is very often lithiasic. When XGC presents in its pseudo-tumoral form with occasional adjacent organ involvement, it can mimic gallbladder carcinoma (GBC). The etiopathogenesis of XGC is inflammatory destruction of Rokitansky-Aschoff sinuses containing biliary and cholesterol pigments within the gallbladder wall; this leads to a florid granulomatous histiocytic inflammatory reaction. The prevalence ranges from 1.3% to 8.8% of all cholecystectomies and varies from country to country; XGC occurs predominantly in patients over 50 years of age, and is equally distributed between males and females. Its association with GBC remains a topic of debate in the literature (between 0 and 20%). Symptoms are non-specific and generally similar to those of acute or chronic cholecystitis. XGC, when associated with altered health status, leads to the suspicion of GBC. XGC can also come to light due to an acute complication of cholecystolithiasis, in particular, gallstone migration. Imaging by sonography and CT scan is suggestive, but magnetic resonance imaging is more specific. In difficult cases, biopsy may be necessary to eliminate the diagnosis of tumor. In case of pre- or intra-operative diagnostic doubt, the opinion of a hepatobiliary specialty center can be of help. When diagnosis of GBC has been eliminated, laparoscopic cholecystectomy is recommended, although with a high risk of conversion to laparotomy and complications.

Diagnostic and surgical dilemma of cholecystitis that mimics cancer - A case report of xanthogranulomatous cholecystitis

INTRODUCTION

Xanthogranulomatous cholecystitis (XGC) is a rare and benign chronic inflammatory disease of the gallbladder that can mimic carcinoma on presentation, imaging, and gross pathology. The aim of this case report is to describe the considerations involved in navigating the diagnostic and surgical dilemma of managing XGC in a patient with findings equivocal to gallbladder cancer.

PRESENTATION OF CASE

A 64-year-old female patient presented with an incidental, suspicious gallbladder mass on imaging. Due to her asymptomatic presentation and high risk features for carcinoma on imaging, an oncologic, en-bloc resection of the mass involving the gallbladder, liver, wall of duodenum, and hepatic flexure of the colon was performed. On pathological examination, the gallbladder specimen showed marked lymphohistiocytic inflammatory infiltrate of XGC that extended into adjacent structures without dysplasia. The patient had an uncomplicated postoperative course.

DISCUSSION

Considerations around management of XGC must include the potential consequences associated with overtreating a benign entity or undertreating a potentially curable malignancy. Imaging findings that may be more suggestive of XGC include continuous mucosal lines and the presence of pericholecystic infiltration or fat stranding. Pitfalls of biopsy include potential tumour spillage and false negative results, especially when both XGC and cancer are present. Intraoperatively, macroscopic examination of the mass can also be misleading.

CONCLUSION

Surgeons must ensure that preoperative counselling includes the possibility of both XGC and gallbladder carcinoma, especially when findings are uncharacteristic. XGC must be managed with careful consideration of all findings and multidisciplinary input from a team of surgeons, radiologists, and pathologists.