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Huang EY, Reeves JJ, Broderick RC, Serra JL, Goldhaber NH, An JY, Fowler KJ, Hosseini M, Sandler BJ, Jacobsen GR, Horgan S, Clary BM. Distinguishing characteristics of xanthogranulomatous cholecystitis and gallbladder adenocarcinoma: a persistent diagnostic dilemma. Surg Endosc 2024; 38:348-355. [PMID: 37783778 DOI: 10.1007/s00464-023-10461-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/06/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis which can resemble gallbladder adenocarcinoma (GAC) on preoperative imaging and present technical challenges in the performance of cholecystectomy. We examined our experience with each pathology to identify distinguishing characteristics that may guide patient counseling and surgical management. METHODS A retrospective review of all pathologically confirmed cases of XGC and GAC following cholecystectomy between 2015 and 2021 at a single institution was performed. Clinical, biochemical, radiographic, and intraoperative features were compared. RESULTS There were 37 cases of XGC and 20 cases of GAC. Patients with GAC were older (mean 70.3 years vs 58.0, p = 0.01) and exclusively female (100% vs 45.9%, p < 0.0001). There were no significant differences in accompanying symptoms between groups (nausea/vomiting, fevers, or jaundice). The mean maximum white blood cell count was elevated for XGC compared to GAC (16.4 vs 8.6 respectively, p = 0.044); however, there were no differences in the remainder of the biochemical profile, including bilirubin, liver transaminases, CEA, and CA 19-9. The presence of an intraluminal mass (61.1% vs 9.1%, p = 0.0001) and lymphadenopathy (18.8%. vs 0.0%, p = 0.045) were associated with malignancy, whereas gallbladder wall thickening as reported on imaging (87.9% vs 38.9%, p = 0.0008) and gallstones (76.5% vs. 50.0%, p = 0.053) were more often present with XGC. Cases of XGC more often had significant adhesions/inflammation (83.8% vs 55.0%, p = 0.03). CONCLUSION Clinical features that may favor benign chronic cholecystitis over gallbladder adenocarcinoma include younger age, male gender, current or prior leukocytosis, and the absence of an intraluminal mass or lymphadenopathy. Laparoscopic cholecystectomy is a safe surgical option for equivocal presentations. Intraoperative frozen section or intentional staging of more extensive procedures based upon final histopathology are valuable surgical strategies.
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Affiliation(s)
- Estella Y Huang
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA.
| | - James J Reeves
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA
| | - Joaquin L Serra
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA
| | - Nicole H Goldhaber
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA
| | - Julie Y An
- Department of Radiology, University of California, San Diego, San Diego, CA, USA
| | - Kathryn J Fowler
- Department of Radiology, University of California, San Diego, San Diego, CA, USA
| | - Mojgan Hosseini
- Department of Pathology, University of California, San Diego, San Diego, CA, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MET Building 845, La Jolla, San Diego, CA, 92093-0740, USA
| | - Bryan M Clary
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, San Diego, CA, USA
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Han S, Lee YH, Kim YR, Soh EG. Usefulness of MRI Scoring System for Differential Diagnosis between Xanthogranulomatous Cholecystitis and Wall-Thickening Type Gallbladder Cancer. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:147-160. [PMID: 38362397 PMCID: PMC10864155 DOI: 10.3348/jksr.2023.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/17/2023] [Accepted: 06/30/2023] [Indexed: 02/17/2024]
Abstract
Purpose To define an MRI scoring system for differentiating xanthogranulomatous cholecystitis (XGC) from wall-thickening type gallbladder cancer (GBC) and compare the diagnostic performance of the scoring system with the visual assessment of radiologists. Materials and Methods We retrospectively analyzed 23 and 35 patients who underwent abdominal MRI and were pathologically diagnosed with XGC and wall-thickening-type GBC after surgery, respectively. Three radiologists reviewed all MRI findings. We defined a scoring system using these MRI findings for differentiating XGC from wall-thickening type GBC and compared the area under the curve (AUC) of the scoring system with the visual assessment of radiologists. Results Nine MRI findings showed significant differences in differentiating the two diseases: diffuse gallbladder wall thickening (p < 0.001), mucosal uniformity (p = 0.002), intramural T2-high signal intensity (p < 0.001), mucosal retraction (p = 0.016), gallbladder stones (p < 0.001), T1-intermediate to high-signal intensity (p = 0.033), diffusion restriction (p = 0.005), enhancement pattern (p < 0.001), and phase of peak enhancement (p = 0.008). The MRI scoring system showed excellent diagnostic performance with an AUC of 0.972, which was significantly higher than the visual assessment of the reviewers. Conclusion The MRI scoring system showed better diagnostic performance than the visual assessment of radiologists to differentiate XGC from wall-thickening-type GBC.
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Chauhan SS, Kumar N, Rana F. Xanthogranulomatous Cholecystitis Mimicking Gall Bladder Cancer: a Diagnostic Dilemma and Review of Literature. Indian J Surg Oncol 2023; 14:796-799. [PMID: 38187839 PMCID: PMC10767170 DOI: 10.1007/s13193-023-01778-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/01/2023] [Indexed: 01/09/2024] Open
Abstract
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.
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Affiliation(s)
| | - Niranjan Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Deoghar, Jharkhand 814142 India
| | - Farah Rana
- Department of Pathology, Tata Main Hospital, Jamshedpur, India
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AlHatmi AS, Kamoona A, Al Salmi IS. Preoperative Diagnosis of Xanthogranulomatous Cholecystitis. Sultan Qaboos Univ Med J 2023; 23:415-418. [PMID: 37655087 PMCID: PMC10467545 DOI: 10.18295/squmj.5.2023.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/01/2023] [Accepted: 03/23/2023] [Indexed: 09/02/2023] Open
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Arnott W, Hutchins J, Malhotra T, Ketheesan Y, Steinberg L, Carter L, Diab J, Wong K. Xanthogranulomatous cholecystitis: diagnostic complexity and review of the literature. J Surg Case Rep 2023; 2023:rjad308. [PMID: 37337535 PMCID: PMC10276982 DOI: 10.1093/jscr/rjad308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/08/2023] [Indexed: 06/21/2023] Open
Abstract
We report the case of a 39-year-old male presenting with acute onset vomiting and diarrhoea. Initially treated empirically for gastroenteritis, imaging later confirmed a complicated episode of cholecystitis with fistular formation and intra-abdominal cyst. Following cholecystectomy, histology confirmed a case of xanthogranulomatous cholecystitis (XGC). This paper presents a detailed summary of the condition alongside a literature review of all available episodes of XGC since 2017 with the aim of highlighting diagnostic conclusions regarding the nature of the disease and its clinical manifestations.
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Affiliation(s)
- William Arnott
- Correspondence address. The Tweed Hospital, Powell St, NSW, Australia. Tel: +61297228000; E-mail:
| | - Jemima Hutchins
- Department of General Surgery, The Tweed Hospital, Tweed Heads, NSW, Australia
| | - Tanishk Malhotra
- Department of General Surgery, The Tweed Hospital, Tweed Heads, NSW, Australia
- School of Medicine, Bond University, Robina, QLD, Australia
| | - Yathurshika Ketheesan
- Department of General Surgery, The Tweed Hospital, Tweed Heads, NSW, Australia
- School of Medicine, Bond University, Robina, QLD, Australia
| | - Lilly Steinberg
- Department of General Surgery, The Tweed Hospital, Tweed Heads, NSW, Australia
- School of Medicine, Bond University, Robina, QLD, Australia
| | - Lucy Carter
- Department of General Surgery, The Tweed Hospital, Tweed Heads, NSW, Australia
- School of Medicine, Bond University, Robina, QLD, Australia
| | - Jason Diab
- Department of General Surgery, The Tweed Hospital, Tweed Heads, NSW, Australia
- John Flynn Private Hospital, Tugun, QLD, Australia
- School of Medicine, Bond University, Robina, QLD, Australia
- School of Medicine, Griffith University, Southport, QLD, Australia
| | - King Wong
- Department of General Surgery, The Tweed Hospital, Tweed Heads, NSW, Australia
- John Flynn Private Hospital, Tugun, QLD, Australia
- School of Medicine, Bond University, Robina, QLD, Australia
- School of Medicine, Griffith University, Southport, QLD, Australia
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Wang W, Korah M, Bessoff KE, Shen J, Forrester JD. Xanthogranulomatous inflammation requiring small bowel anastomosis revision: A case report. World J Gastrointest Surg 2023; 15:488-494. [PMID: 37032803 PMCID: PMC10080595 DOI: 10.4240/wjgs.v15.i3.488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/15/2023] [Accepted: 02/16/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Xanthogranulomatous inflammation (XGI) is an uncommon process involving an accumulation of inflammatory cells, commonly lipid-laden macrophages. XGI has been described to occur throughout the body but only rarely in the lower gastrointestinal tract. We describe a case of XGI contributing to chronic obstructive symptoms in the terminal ileum, in which the patient had an initial diagnostic laparoscopy, continued to have symptoms, then proceeded to have the definitive treatment. To our knowledge, this is the first report of XGI associated with a prior small bowel anastomosis.
CASE SUMMARY We report the case of a 42-year-old female who presented with intermittent epigastric pain and subjective fevers. She had undergone a laparoscopic small bowel resection for Meckel’s diverticulum five years prior. Her workup was notable for computed tomography scan demonstrating mild inflammation and surrounding stranding at the level of the prior anastomosis. She underwent a laparotomy, resection of the prior anastomosis and re-anastomosis, with final histopathological examination findings consistent with mural XGI.
CONCLUSION XGI can occur at the site of a prior bowel anastomosis and cause chronic obstructive symptoms.
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Affiliation(s)
- William Wang
- Department of Biology, Stanford University, Stanford, CA 94305, United States
- Department of Bioengineering, Stanford University, Stanford, CA 94305, United States
| | - Maria Korah
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA 94305, United States
| | - Kovi E Bessoff
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA 94305, United States
| | - Jeanne Shen
- Center for Artificial Intelligence in Medicine and Imaging, Stanford University, Palo Alto, CA 94304, United States
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA 94305, United States
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Alotaibi AM, Almasoudi E, Ahmed H, Alzwaihiri A. The incidental finding of xanthogranulomatous cholecystitis: a report of 10 cases. J Surg Case Rep 2022; 2022:rjac443. [PMID: 36158244 PMCID: PMC9491873 DOI: 10.1093/jscr/rjac443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/02/2022] [Indexed: 11/28/2022] Open
Abstract
There is insufficient clinical knowledge about xanthogranulomatous cholecystitis (XGC) due to biased reporting. This study aims to investigate the incidence of XGC and evaluate the clinical outcome regarding operative time, rate of conversion and intraoperative or postoperative complications. We included 1141 patients who underwent surgery for gallbladder disease between January 2019 and December 2021. Of 1141 patients who underwent cholecystectomy, XGC was seen in 10 (0.87%). The average age is 47 (24–81 years old) with a male to female ratio of 3:2. Biliary pancreatitis and obstructive jaundice are seen in two patients who did ERCP and stenting before surgery. One patient presented with a 4 cm necrotizing soft-tissue granuloma. The BMI was high, with class I obesity in five patients. Symptoms last from 1 to 12 weeks. One patient was only diagnosed preoperatively as XGC. Four out of 10 (40%) required more than 72 h of hospitalization. All patients underwent elective sitting surgery, with eight successfully managed by laparoscopy and one converted to open. The average operative time was 90 min (43–193 min), and a postoperative drain was inserted in four patients. The median follow-up is after 24 months (11–30 months), with no postoperative collection, bleeding, complication or readmission. XGC is a rare benign entity requiring no further action upon incidental discovery. Surgical resection is the cornerstone of management, with the laparoscopic approach considered feasible and safe. Four out of 10 patients might need more than 3 days of hospitalization. In the presence of mass, the frozen section can help guide the management.
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Affiliation(s)
- Abdulrahman Muaod Alotaibi
- Department of Surgery, Faculty of Medicine, University of Jeddah , Jeddah , Saudi Arabia
- Department of Surgery, Dr. Soliman Fakeeh Hospital , Jeddah , Saudi Arabia
| | - Eid Almasoudi
- Department of Surgery, Faculty of Medicine, University of Jeddah , Jeddah , Saudi Arabia
| | - Hassan Ahmed
- Department of Surgery, Faculty of Medicine, University of Jeddah , Jeddah , Saudi Arabia
| | - Abubakr Alzwaihiri
- Department of Surgery, Faculty of Medicine, University of Jeddah , Jeddah , Saudi Arabia
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Frountzas M, Schizas D, Liatsou E, Economopoulos KP, Nikolaou C, Apostolou KG, Toutouzas KG, Felekouras E. Presentation and surgical management of xanthogranulomatous cholecystitis. Hepatobiliary Pancreat Dis Int 2021; 20:117-127. [PMID: 33536138 DOI: 10.1016/j.hbpd.2021.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 01/12/2021] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Maximos Frountzas
- First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, 114 Vas. Sofias Ave. 11527, Athens, Greece; Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, School of Medicine, 15B Ag. Thoma Str. 11527, Athens, Greece.
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, 17 Ag. Thoma Str. 11527, Athens, Greece; Society of Junior Doctors, Surgery Workgroup, 75 Mikras Asias Str. 11527, Athens, Greece
| | - Efstathia Liatsou
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, 17 Ag. Thoma Str. 11527, Athens, Greece
| | - Konstantinos P Economopoulos
- Society of Junior Doctors, Surgery Workgroup, 75 Mikras Asias Str. 11527, Athens, Greece; Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27707, USA
| | - Christina Nikolaou
- Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, School of Medicine, 15B Ag. Thoma Str. 11527, Athens, Greece
| | - Konstantinos G Apostolou
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, 17 Ag. Thoma Str. 11527, Athens, Greece
| | - Konstantinos G Toutouzas
- First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, 114 Vas. Sofias Ave. 11527, Athens, Greece
| | - Evangelos Felekouras
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, 17 Ag. Thoma Str. 11527, Athens, Greece
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Gupta P, Marodia Y, Bansal A, Kalra N, Kumar-M P, Sharma V, Dutta U, Sandhu MS. Imaging-based algorithmic approach to gallbladder wall thickening. World J Gastroenterol 2020; 26:6163-6181. [PMID: 33177791 PMCID: PMC7596646 DOI: 10.3748/wjg.v26.i40.6163] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/12/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023] Open
Abstract
Gallbladder (GB) wall thickening is a frequent finding caused by a spectrum of conditions. It is observed in many extracholecystic as well as intrinsic GB conditions. GB wall thickening can either be diffuse or focal. Diffuse wall thickening is a secondary occurrence in both extrinsic and intrinsic pathologies of GB, whereas, focal wall thickening is mostly associated with intrinsic GB pathologies. In the absence of specific clinical features, accurate etiological diagnosis can be challenging. The survival rate in GB carcinoma (GBC) can be improved if it is diagnosed at an early stage, especially when the tumor is confined to the wall. The pattern of wall thickening in GBC is often confused with benign diseases, especially chronic cholecystitis, xanthogranulomatous cholecystitis, and adenomyomatosis. Early recognition and differentiation of these conditions can improve the prognosis. In this minireview, the authors describe the patterns of abnormalities on various imaging modalities (conventional as well as advanced) for the diagnosis of GB wall thickening. This paper also illustrates an algorithmic approach for the etiological diagnosis of GB wall thickening and suggests a formatted reporting for GB wall abnormalities.
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Affiliation(s)
- Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Yashi Marodia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Akash Bansal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Naveen Kalra
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Almas T, Murad MF, Khan MK, Ullah M, Nadeem F, Ehtesham M, Zaidi SMJ. The Spectrum of Gallbladder Histopathology at a Tertiary Hospital in a Developing Country: A Retrospective Study. Cureus 2020; 12:e9627. [PMID: 32923228 PMCID: PMC7478930 DOI: 10.7759/cureus.9627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Affections of the gallbladder remain exceedingly ubiquitous and often warrant surgical intervention. The histopathological patterns represent a spectrum, ranging from cholecystitis to gallbladder carcinoma. The present study aims to delineate the occurrence of various gallbladder histopathologies in a tertiary care hospital in Pakistan. Methods A retrospective study was conducted at Maroof International Hospital, Islamabad, Pakistan. Histopathological records of 442 gallbladder specimens obtained from cholecystectomy were analysed. The prevalence of various histopathological outcomes was assessed. The data were eventually analysed using the SPSS 23.0 software (Armonk, NY: IBM Corp.). Thereafter, the distribution of various gallbladder histopathologies was tabulated across gender. Results Of the 442 patients included, 330 were females and 112 were males, with the mean age hovering at 45.77±14.65 years. The most common histopathological findings were chronic cholecystitis and cholesterolosis, observed in 78.6% and 32.8% of the patients, respectively. While only one case of gallbladder adenocarcinoma was observed, multiple specimens divulged premalignant lesions including reactive atypia and intestinal metaplasia. Conclusions Diseases of the gallbladder often mandate prompt surgical intervention. Of these, chronic cholecystitis, which is an established risk factor for gallbladder carcinoma, is exceedingly common. The employment of histopathological techniques remains imperative in the detection of premalignant and malignant lesions that might otherwise evade macroscopic detection and thus progress to adenocarcinoma.
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Affiliation(s)
- Talal Almas
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | | | - Muhammad Kashif Khan
- Surgical Oncology, Federal Government Poly Clinic (Post Graduate Medical Institute), Islamabad, PAK.,Surgical Oncology, Maroof International Hospital, Islamabad, PAK
| | - Muneeb Ullah
- General Surgery, Maroof International Hospital, Islamabad, PAK
| | - Faisal Nadeem
- Laparoscopic Surgery, Maroof International Hospital, Islamabad, PAK
| | - Maryam Ehtesham
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
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Reghunath A, Kushvaha S, Ghasi RG, Khanna G, Surana A. Chronic gallbladder wall thickening: Is it always malignancy? SA J Radiol 2020; 24:1844. [PMID: 32537253 PMCID: PMC7276480 DOI: 10.4102/sajr.v24i1.1844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/09/2020] [Indexed: 01/20/2023] Open
Abstract
Gallbladder wall thickening, associated with features like perforation, fistula formation and invasion of adjacent organs, is often assumed to be malignant. Xanthogranulomatous cholecystitis (XGC) causes gallbladder wall thickening with similar aggressive features and closely mimics gallbladder carcinoma clinically, radiologically and surgically. Differentiating between these two is crucial for management as misdiagnosis of gallbladder cancer can lead to unnecessary radical surgery. We report a case of chronic gallbladder wall thickening, initially suspected to be malignant, but subsequently diagnosed as XGC.
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Affiliation(s)
- Anjuna Reghunath
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Suchana Kushvaha
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Rohini G Ghasi
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Geetika Khanna
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Apurva Surana
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Ito R, Kobayashi T, Ogasawara G, Kono Y, Mori K, Kawasaki S. A scoring system based on computed tomography for the correct diagnosis of xanthogranulomatous cholecystitis. Acta Radiol Open 2020; 9:2058460120918237. [PMID: 32313694 PMCID: PMC7160779 DOI: 10.1177/2058460120918237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 03/20/2020] [Indexed: 01/17/2023] Open
Abstract
Background Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic
cholecystitis. The differential diagnoses of XGC include gallbladder cancer
(GBC), adenomyomatosis, and actinomycosis of the gallbladder. Purpose To assess the usefulness of computed tomography (CT) findings in the
diagnosis of XGC and differentiation from GBC. Material and Methods We retrospectively assessed the pathological and radiological records of 13
patients with pathologically proven XGC and 33 patients with GBC. Results Significant differences were observed for the following five CT findings:
diffuse wall thickening (XGC = 85%, GBC = 15%,
P < 0.01); absence of polypoid lesions (XGC = 100%,
GBC = 48%, P < 0.01); intramural nodules or bands
(XGC = 54%, GBC = 9%, P < 0.01); pericholecystic
infiltration (XGC = 69%, GBC = 9%, P < 0.01); and
pericholecystic abscess (XGC = 23%, GBC = 0%, P = 0.018).
We defined the scoring system based on how many of the five CT findings were
observed. Our scoring system, which included these findings, revealed that
patients with three or more findings had sensitivity of 77% (95% confidence
interval [CI] = 57–87) and specificity of 94% (95% CI = 86–98). Conclusion Our scoring system can assist in the differentiation of XGC from GBC.
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Affiliation(s)
- Ryota Ito
- Department of Gastroenterological Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Takashi Kobayashi
- Department of Gastroenterological Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Gou Ogasawara
- Department of Diagnostic Radiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yoshiharu Kono
- Department of Gastroenterological Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kazuhiko Mori
- Department of Gastroenterological Surgery, Mitsui Memorial Hospital, Tokyo, Japan
| | - Seiji Kawasaki
- Department of Gastroenterological Surgery, Mitsui Memorial Hospital, Tokyo, Japan
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13
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Zhang F, Chen W, Zhang L, Hou C, Zhang M. Usefulness of Ultrasound in Differentiating Xanthogranulomatous Cholecystitis from Gallbladder Carcinoma. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2925-2931. [PMID: 31447238 DOI: 10.1016/j.ultrasmedbio.2019.07.682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/30/2019] [Accepted: 07/29/2019] [Indexed: 06/10/2023]
Abstract
Our study was aimed at finding the ultrasound (US) features of xanthogranulomatous cholecystitis (XGC) and evaluating the usefulness of US in differentiating XGC from gallbladder carcinoma (GBC). Through use of an electronic medical record system and the picture archiving and communication system, 31 cases of XGC and 52 cases of GBC with both sonograms and pathologic results were identified. Sonographic features of the abnormal gallbladder were evaluated. The smooth and intact interface between gallbladder lumen and mucosa was observed in most XGC cases (23/31, 74.2%) but in no GBC cases. XGC featured hyper-echoic foci, small hypo-echoic nodules and a layered appearance in the lesion, which were more frequently seen in the XGC group than in the GBC group. In conclusion, US may prove useful in the differential diagnosis of XGC and GBC, but more studies are required.
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Affiliation(s)
- Fan Zhang
- Department of Ultrasound, Peking University Third Hospital, Haidian District, Beijing 100191, China
| | - Wen Chen
- Department of Ultrasound, Peking University Third Hospital, Haidian District, Beijing 100191, China.
| | - Lingfu Zhang
- Department of General Surgery, Peking University Third Hospital, Haidian District, Beijing 100191, China
| | - Chunsheng Hou
- Department of General Surgery, Peking University Third Hospital, Haidian District, Beijing 100191, China
| | - Ming Zhang
- Department of Pathology, Peking University Third Hospital, Haidian District, Beijing 100191, China
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14
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Wasnik AP, Davenport MS, Kaza RK, Weadock WJ, Udager A, Keshavarzi N, Nan B, Maturen KE. Diagnostic accuracy of MDCT in differentiating gallbladder cancer from acute and xanthogranulomatous cholecystitis. Clin Imaging 2018; 50:223-228. [PMID: 29679780 DOI: 10.1016/j.clinimag.2018.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine the diagnostic accuracy of multi-detector CT (MDCT) for differentiating gallbladder cancer from acute and xanthogranulomatous cholecystitis using previously described imaging features. METHODS In this IRB approved HIPAA-compliant retrospective cohort study, contrast-enhanced MDCT of histologically confirmed acute cholecystitis (n = 17), xanthogranulomatous cholecystitis (n = 25), and gallbladder cancer (n = 18) were reviewed independently by three abdominal radiologists blinded to outcome. The primary outcome was the diagnostic accuracy of MDCT for the differentiation of gallbladder cancer from cholecystitis (acute and xanthogranulomatous) using various imaging parameters. Kappa (κ) statistics and two-way mixed-model single-measure intra-class correlation statistics (ICC) were calculated for each imaging feature and the final radiologic diagnosis. RESULTS Inter-rater agreement was moderate to substantial (κ = 0.43-0.70), sensitivity 0.67-0.78, specificity 0.22-0.33 and the positive likelihood ratio was 4.28-8.56 for the differentiation of gallbladder cancer from benign gallbladder pathology. Only three imaging findings: disrupted gallbladder mucosa (κ = 0.68), intraluminal gallstones (κ = 0.66), and gallbladder wall thickness (ICC = 0.63) had substantial inter-rater agreement. The following had slight or no agreement: intramural hypoattenuating nodules (κ = 0.17), transient hepatic attenuation differences (κ = 0.14), gallbladder wall calcification (κ = -0.01), gallbladder wall enhancement (κ = 0.18), and omental or mesenteric invasion (κ = 0.08). In the final multivariate model, the following were significant predictors useful in making or excluding diagnosis of gallbladder cancer: focal gallbladder wall thickening (p = 0.003, OR: 13.09 [95% CI: 2.40-71.48]), pericholecystic "fat stranding" (p = 0.018, OR: 0.10 [95% CI: 0.01-0.66]), and maximum short axis lymph node diameter (p = 0.043, OR: 1.18 [95% CI: 1.00-1.38]). CONCLUSION MDCT has moderate sensitivity, poor specificity, and moderate-to-substantial inter-rater repeatability for the differentiation of gallbladder cancer from acute and xanthogranulomatous cholecystitis.
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Affiliation(s)
- Ashish P Wasnik
- Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States.
| | - Mathew S Davenport
- Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States
| | - Ravi K Kaza
- Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States
| | - William J Weadock
- Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States
| | - Aaron Udager
- Department of Pathology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States
| | - Nahid Keshavarzi
- Michigan Institute of Clinical & Health Research (MICHR), University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States
| | - Bin Nan
- Department of Statistics, School of Public Health, University of Michigan, Ann Arbor, MI 48109, United States
| | - Katherine E Maturen
- Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, United States
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15
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Nacif LS, Hessheimer AJ, Rodríguez Gómez S, Montironi C, Fondevila C. Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma. World J Gastroenterol 2017; 23:8671-8678. [PMID: 29358875 PMCID: PMC5752727 DOI: 10.3748/wjg.v23.i48.8671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/13/2017] [Accepted: 11/21/2017] [Indexed: 02/07/2023] Open
Abstract
Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum, provoked biliary dilatation and jaundice, and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder, extrahepatic bile duct, and hilar lymph nodes, as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases, the best option may be radical resection following oncological principles performed by expert surgeons, in order that postoperative complications may be minimized if not avoided altogether.
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Affiliation(s)
- Lucas Souto Nacif
- Department of Surgery, Institut de Malalties Digestives I Metabòliques (IMDM), Hospital Clínic, Barcelona 08036, Spain
- CIBERehd, IDIBAPS, University of Barcelona, Barcelona 08036, Spain
| | - Amelia Judith Hessheimer
- Department of Surgery, Institut de Malalties Digestives I Metabòliques (IMDM), Hospital Clínic, Barcelona 08036, Spain
- CIBERehd, IDIBAPS, University of Barcelona, Barcelona 08036, Spain
| | | | - Carla Montironi
- Department of Pathology, Hospital Clínic, Barcelona 08036, Spain
| | - Constantino Fondevila
- Department of Surgery, Institut de Malalties Digestives I Metabòliques (IMDM), Hospital Clínic, Barcelona 08036, Spain
- CIBERehd, IDIBAPS, University of Barcelona, Barcelona 08036, Spain
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16
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Shetty A, Rehan M, Geethamani V. Xanthogranulomatous Cholecystitis with Florid Ducts of Luschka: Double Trouble Mimicking Malignancy. J Clin Diagn Res 2017; 11:ED29-ED31. [PMID: 28658786 DOI: 10.7860/jcdr/2017/27194.9906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/30/2017] [Indexed: 11/24/2022]
Abstract
Xanthogranulomatous Cholecystitis (XGC) is an uncommon inflammatory condition of gall bladder, which is often misdiagnosed as malignancy preoperatively, leading to extensive surgical resections which may not be necessary for the patient. Ducts of Luschka are a rare developmental variant of the biliary tree, which are prone to injury and bile leak during cholecystectomy. We report a case of a 52-year-old male patient who was taken up for surgery with a provisional diagnosis of chronic calculous cholecystitis. Intraoperative finding of dense adhesions, made the surgeons suspect malignancy. On histopathological examination, it was not only diagnosed as a case of XCG, but it also had florid ducts of Luschka, another rare variant needing documentation as it is a close mimicker of malignancy.
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Affiliation(s)
- Archana Shetty
- Associate Professor, Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Mudasser Rehan
- Associate Professor, Department of Surgery, Sapthagiri Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - V Geethamani
- Professor and Head, Department of Pathology, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India
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17
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Sureka B, Singh VP, Rajesh SR, Laroia S, Bansal K, Rastogi A, Bihari C, Bhadoria AS, Agrawal N, Arora A. Computed Tomography (CT) and Magnetic Resonance (MR) Findings in Xanthogranulomatous Cholecystitis: Retrospective Analysis of Pathologically Proven 30 Cases - Tertiary Care Experience. Pol J Radiol 2017; 82:327-332. [PMID: 28685006 PMCID: PMC5491692 DOI: 10.12659/pjr.901728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/18/2016] [Indexed: 01/18/2023] Open
Abstract
Background To study CT and MR findings in xanthogranulomatous cholecystitis (XGC). Material/Methods Retrospective analysis of 30 histopathologically confirmed cases of XGC. Seventeen patients underwent CECT and 13 underwent MRI. The following features were studied – wall thickness, intramural nodules, pericholecystic stranding, wall thickness, THAD, fat in gallbladder wall, cholelithiasis, infiltration, biliary dilatation, lymph nodes, complications. Results The majority of cases (22/30) showed discontinuous mucosal lining. Discontinuous mucosal lining was seen in all cases with wall thickness >10 mm, 75% of cases with wall thickness between 3–10 mm and none in normal wall thickness (p=0.03). Diffuse wall thickening was seen in 23 cases, focal thickening in 3 and polypoidal wall thickening in 2 cases. Polypoidal thickening was seen in gallbladder carcinoma. Intramural nodules were present in 87.5% of cases with discontinuous mucosal lining. Pericholecystic stranding was seen in 19, biliary dilatation in 12, liver infiltration in 13 and fat in 7 cases. Lymphadenopathy was seen in 1 case with gallbladder carcinoma. Four cases showed a signal drop in the intramural nodules on chemical shift MRI. Conclusions Discontinuous mucosal lining is evident in xanthogranulomatous cholecystitis. Diffuse wall thickening, intramural nodules, continuous or discontinuous mucosal lining and cholelithiasis may indicate XGC rather than gallbladder carcinoma. Based on correlation with pathophysiological findings, we conclude that discontinuous mucosal lining is not an unusual finding in cases of XGC. Advances in knowledge: Being aware of the radiological findings described in this article may be helpful in making preoperative radiological diagnosis of XGC. Mucosal lining may be continuous or discontinuous in XGC.
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Affiliation(s)
- Binit Sureka
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vaibhav Pratap Singh
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S Rajesh Rajesh
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shalini Laroia
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kalpana Bansal
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ajeet Singh Bhadoria
- Department of Community Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nikhil Agrawal
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Asit Arora
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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18
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FLT PET/CT Is Better Than FDG PET/CT in Differentiating Benign From Malignant Pancreatobiliary Lesions. Clin Nucl Med 2016; 41:e244-50. [PMID: 26914562 DOI: 10.1097/rlu.0000000000001163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Singh VP, Rajesh S, Bihari C, Desai SN, Pargewar SS, Arora A. Xanthogranulomatous cholecystitis: What every radiologist should know. World J Radiol 2016; 8:183-191. [PMID: 26981227 PMCID: PMC4770180 DOI: 10.4329/wjr.v8.i2.183] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/08/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis characterized by xanthogranulomatous inflammation of the gallbladder. Intramural accumulation of lipid-laden macrophages and acute and chronic inflammatory cells is the hallmark of the disease. The xanthogranulomatous inflammation of the gallbladder can be very severe and can spill over to the neighbouring structures like liver, bowel and stomach resulting in dense adhesions, perforation, abscess formation, fistulous communication with adjacent bowel. Striking gallbladder wall thickening and dense local adhesions can be easily mistaken for carcinoma of the gallbladder, both intraoperatively as well as on preoperative imaging. Besides, cases of concomitant gallbladder carcinoma complicating XGC have also been reported in literature. So, we have done a review of the imaging features of XGC in order to better understand the entity as well as to increase the diagnostic yield of the disease summarizing the characteristic imaging findings and associations of XGC. Among other findings, presence of intramural hypodense nodules is considered diagnostic of this entity. However, in some cases, an imaging diagnosis of XGC is virtually impossible. Fine needle aspiration cytology might be handy in such patients. A preoperative counselling should include possibility of differential diagnosis of gallbladder cancer in not so characteristic cases.
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