Differential diagnosis and treatment options for xanthogranulomatous cholecystitis

The incidental finding of xanthogranulomatous cholecystitis: a report of 10 cases

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.

Machine Learning-Based Radiological Features and Diagnostic Predictive Model of Xanthogranulomatous Cholecystitis

Background

Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that is sometimes indistinguishable from gallbladder cancer (GBC), thereby affecting the decision of the choice of treatment. Thus, this study aimed to analyse the radiological characteristics of XGC and GBC to establish a diagnostic prediction model for differential diagnosis and clinical decision-making.

Methods

We investigated radiological characteristics confirmed by the RandomForest and Logistic regression to establish computed tomography (CT), magnetic resonance imaging (MRI), CT/MRI models and diagnostic prediction model, and performed receiver operating characteristic curve (ROC) analysis to prove the effectiveness of the diagnostic prediction model.

Results

Based on the optimal features confirmed by the RandomForest method, the mean area under the curve (AUC) of the ROC of the CT and MRI models was 0.817 (mean accuracy = 0.837) and 0.839 (mean accuracy = 0.842), respectively, whereas the CT/MRI model had a considerable predictive performance with the mean AUC of 0.897 (mean accuracy = 0.906). The diagnostic prediction model established for the convenience of clinical application was similar to the CT/MRI model with the mean AUC and accuracy of 0.888 and 0.898, respectively, indicating a preferable diagnostic efficiency in distinguishing XGC from GBC.

Conclusions

The diagnostic prediction model showed good diagnostic accuracy for the preoperative discrimination of XGC and GBC, which might aid in clinical decision-making.

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.

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

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is an uncommon, focal, or diffuse destructive inflammatory disease of the gallbladder mimicking or being together with the gallbladder carcinoma. This study aimed to evaluate the diagnosis, treatment, and outcomes of patients with XGC as a single tertiary center experience in the light of literature.

MATERIALS AND METHODS

Data about 34 patients with XGC identified after evaluating 2212 cholecystectomy specimens between January 2013 and December 2018 in a single tertiary center were documented to determine demographics (sex, age), clinical symptoms and findings, biochemical and imaging clues and operative findings, duration of hospitalization, postoperative complications, and histopathologic results.

RESULTS

Thirty-four patients with XGC were evaluated (17 male and 17 female patients with a mean age of 53; range, 25 to 78). Preoperative diagnosis was chronic calculous cholecystitis in 5 patients, cholelithiasis in 12 cases, acute calculous cholecystitis in 16 and emphysematous cholecystitis in 1 patient. Ultrasound was performed in all patients, computerized tomography in 11, contrast-enhanced magnetic resonance imaging in 9, and magnetic resonance cholangiopancreatography in 7 patients. None of the patients were diagnosed preoperatively. All patients received laparoscopic cholecystectomy, among whom 9 were converted to open. Partial cholecystectomy was performed in 1 patient. One patient with gallbladder adenocarcinoma was treated with radical cholecystectomy. XGC has nonspecific clinical and radiologic findings; thus, preoperative diagnosis is generally absent. Open cholecystectomy is the recommended treatment modality. Conversion to open is frequently necessary after laparoscopy. Complete cholecystectomy is the ultimate goal; however, partial cholecystectomy may be preferred to protect the structures of the hepatic hilum. Preoperative imaging studies (ultrasound or computerized tomography) of 34 patients showed a gallbladder stone in 18 patients, microlithiazis in 12 patients, sludge in 10 patients, and gallbladder sclerosis in 5 patients.

CONCLUSIONS

Diagnosis of XGC and differentiation from gallbladder carcinoma may be difficult through preoperative or peroperative studies, even imaging is useful; the definitive diagnosis depends exclusively on pathologic examination. The surgeon should be prepared for every possibility.

How Can We Manage Gallbladder Lesions by Transabdominal Ultrasound?

The most important role of ultrasound (US) in the management of gallbladder (GB) lesions is to detect lesions earlier and differentiate them from GB carcinoma (GBC). To avoid overlooking lesions, postural changes and high-frequency transducers with magnified images should be employed. GB lesions are divided into polypoid lesions (GPLs) and wall thickening (GWT). For GPLs, classification into pedunculated and sessile types should be done first. This classification is useful not only for the differential diagnosis but also for the depth diagnosis, as pedunculated carcinomas are confined to the mucosa. Both rapid GB wall blood flow (GWBF) and the irregularity of color signal patterns on Doppler imaging, and heterogeneous enhancement in the venous phase on contrast-enhanced ultrasound (CEUS) suggest GBC. Since GWT occurs in various conditions, subdividing into diffuse and focal forms is important. Unlike diffuse GWT, focal GWT is specific for GB and has a higher incidence of GBC. The discontinuity and irregularity of the innermost hyperechoic layer and irregular or disrupted GB wall layer structure suggest GBC. Rapid GWBF is also useful for the diagnosis of wall-thickened type GBC and pancreaticobiliary maljunction. Detailed B-mode evaluation using high-frequency transducers, combined with Doppler imaging and CEUS, enables a more accurate diagnosis.

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.

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome: A case report

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Acute cholecystitis with empyema and Mirizzi Syndrome mimics both XGC and malignancy.

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Subtotal fenestrating cholecystectomy is both safe and effective in these cases.

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PTC can be considered over ERCP for first-line pre-operative biliary drainage.

Introduction

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma.

Presentation of case

A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis.

Discussion

Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient.

Conclusion

Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation.

Usefulness of Ultrasound in Differentiating Xanthogranulomatous Cholecystitis from Gallbladder Carcinoma

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.

Xanthogranulomatous Cholecystitis: Analysis of 108 Patients

The aim of this study was to evaluate the clinical and radiological features of xanthogranulomatous cholecystitis (XGC) and the results of surgical treatment. This retrospective study concerns clinical, radiological, and surgical data as well as histopathological findings and postoperative results of 108 patients with XGC who were identified after evaluating 7916 cholecystectomy specimens between 2004 and 2014 in a single institute. One hundred eight patients with XGC were evaluated (56 males and 52 females, mean age 62.3 years). Clinical findings at referral included acute and chronic cholecystitis, Mirizzi's syndrome, choledocholithiasis, cholangitis, and acute pancreatitis. Ultrasound was performed in all patients, CT in 25, contrast-enhanced MRI in 29, and magnetic resonance cholangiopancreatography (MRCP) in 25 patients. None of the patients were diagnosed preoperatively, but mild-moderate degrees of wall thickening were present in most. Fifty-four patients received open cholecystectomy, while 54 received laparoscopic intervention, among whom 23 were converted to open. Partial cholecystectomy was performed in 11 patients. Two patients with gallbladder adenocarcinoma were treated with radical cholecystectomy. XGC has nonspecific clinical and radiological findings; thus, preoperative diagnosis is generally absent. Open cholecystectomy is the recommended treatment modality. Conversion to open is frequently necessary after laparoscopy. Complete cholecystectomy is the ultimate goal; however, partial cholecystectomy may be preferred to protect the structures of the hepatic hilum.