Xanthogranulomatous cholecystitis: diagnostic performance of CT to differentiate from gallbladder cancer

Diagnostic and therapeutic challenges in xanthogranulomatous cholecystitis: A rare case report

INTRODUCTION AND IMPORTANCE

Xanthogranulomatous cholecystitis (XGC) is a rare, aggressive gallbladder condition marked by chronic inflammation, fibrosis, and lipid-laden macrophages. It often mimics gallbladder carcinoma clinically and radiologically, complicating diagnosis and treatment. Early differentiation from malignancy is essential for proper management. This case emphasizes the diagnostic challenges of XGC and the need for a multidisciplinary approach.

CASE PRESENTATION

A 61-year-old man presented with four months of intermittent right upper quadrant abdominal pain radiating to the back, without fever, jaundice, or weight loss. Examination revealed right hypochondrial tenderness, and labs showed elevated inflammatory markers. Imaging indicated gallstones, gallbladder wall thickening, and ill-defined liver boundaries, raising malignancy concerns. A biopsy confirmed xanthogranulomatous cholecystitis (XGC), ruling out carcinoma. He underwent successful laparoscopic cholecystectomy, with histopathology confirming XGC. Recovery was uneventful, and he remained symptom-free at six-month follow-up.

CLINICAL DISCUSSION

XGC is a diagnostic challenge due to its nonspecific symptoms and imaging findings that overlap with malignancy. Preoperative biopsy, as performed in this case, can be invaluable in guiding management. Laparoscopic cholecystectomy, though technically demanding due to dense adhesions and local invasion, is feasible in selected cases. Histopathology remains the gold standard for definitive diagnosis, revealing chronic inflammation and lipid-laden macrophages without malignancy.

CONCLUSION

This case underscores the importance of considering XGC in the differential diagnosis of gallbladder masses, particularly when imaging suggests local invasion. Preoperative biopsy and histopathology play pivotal roles in distinguishing XGC from malignancy. Successful laparoscopic management, despite its challenges, highlights the potential for minimally invasive surgery in carefully selected cases.

Gallbladder and biliary pathology: lessons learned from multidisciplinary conference

The radiologic diagnosis of biliary disease can be challenging due to atypical or delayed presentation, rare or less common entities, and imaging overlap of benign and malignant processes. Establishing a specific diagnosis, when possible, is important to avoid progression of infections to sepsis and multiorgan failure, and for appropriate staging and management in cases of malignancy. Gallstones are the most common biliary disease, and along with stone-related complications, including cholecystitis and choledocholithiasis, constitute the majority of acute biliary pathology. Late and atypical manifestations of acute cholecystitis demonstrate imaging overlap with primary gallbladder cholangiocarcinoma, especially with cases of exuberant inflammatory reaction such as xanthogranulomatous cholecystitis. Additional challenging scenarios related to gallbladder disease, that may be benign or malignant, include adjacent fistulas and lymphadenopathy. Dropped gallstones, especially in atypical locations, may be misdiagnosed as neoplastic. Recurrent cholecystitis after cholecystectomy, whether related to subtotal cholecystectomy or to stumpitis, is another entity that can be confusing to the radiologist with a documented history of cholecystectomy. Inflammatory and autoimmune conditions, such as pseudotumors and IgG4 disease, are a less common but not infrequent cause of diagnostic dilemma. Furthermore, biliary strictures and hepatobiliary cystic lesions can be benign or malignant and could constitute a diagnostic and management challenge. The goal of this manuscript is to present the lessons learned from multidisciplinary conferences on the above entities and suggest tips and pearls to maximize the value of radiologists' contribution to patient management.

Xanthogranulomatous Cholecystitis in a 15-Year-Old Girl: A Case Report and Literature Review

Xanthogranulomatous cholecystitis (XGC) is a rare and severe variant of cholecystitis that poses significant diagnostic and surgical challenges. While predominantly seen in adults, its occurrence in pediatric patients is exceedingly rare, with very few cases documented in the literature. We present the case of a 15-year-old girl initially diagnosed with acute calculous cholecystitis who underwent a laparoscopic cholecystectomy. Intraoperatively, extensive pseudo-tumorous inflammation was identified, with fusion of the gallbladder into the omentum, duodenum, and colon, necessitating a subtotal cholecystectomy. Her postoperative recovery was complex, requiring endoscopic retrograde cholangiopancreatography (ERCP), and she was ultimately discharged after a prolonged hospital stay. Histopathological examination confirmed the diagnosis of XGC. This case highlights the complexities of managing this rare entity in pediatric patients.

Radiological Findings for Distinguishing Between Xanthogranulomatous Cholecystitis and Gallbladder Cancer

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a rare, chronic gallbladder inflammation often mistaken for gallbladder cancer (GBC) on imaging. Accurate differentiation is vital for appropriate treatment. This study aims to enhance computed tomography (CT) scan diagnostic accuracy for distinguishing XGC from GBC.

METHODS

This retrospective study included patients diagnosed with XGC and GBC between 2014 and 2023. CT images of 70 patients (16 GBC, 54 XGC) were reviewed. Radiologists assessed CT parameters: gallbladder wall thickening, intramural hypoattenuating nodules, enhancement characteristics, mucosal line continuity, pericholecystic fat stranding, presence of stones, bile duct dilatation, hepatic invasion, invasion to adjacent structures, and lymph node size.

RESULTS

Among 70 patients, there were 38 males (54%) and 32 females (46%), with a median age of 62 years. GBC patients were significantly older (median age 72 years) compared to XGC patients (60 years) (P=0.001). Diffuse gallbladder wall thickening was more frequent in XGC (70%) than GBC (12.5%) (P<0.001). Continuous mucosal lines and intramural hypoattenuating nodules were more common in XGC (P<0.001 and P=0.010, respectively). Intrahepatic bile duct dilatation and invasion to adjacent structures were significantly linked with GBC (P<0.001 and P=0.043). Lymph nodes with a short axis>8 mm indicated GBC (P<0.001), with a cutoff providing 71.4% sensitivity and 84% specificity (AUC: 0.843, P<0.001). CT showed 75% sensitivity (95% CI: 48-93%), 74% specificity (95% CI: 60%-85%), and 74% accuracy (95% CI: 62%-84%).

CONCLUSION

CT imaging can effectively differentiate XGC from GBC, and larger studies can further improve diagnostic accuracy.

An institutional approach to thick wall gall bladder and our experience of 5450 gallstone disease

INTRODUCTION

Gallstone disease (GSD) has a high prevalence in India. GSD presentation varies from being asymptomatic to severe complications. Laparoscopic cholecystectomy (LC) is the procedure of choice. Histopathological varies from chronic cholecystitis to carcinoma gall bladder (CaGB). Thick wall gall bladder (TWGB) is grey zone. Various parameters of GSD especially TWGB were evaluated to develop an approach to reduce perioperative complications and histopathological surprises.

PATIENTS AND METHODS

This study was conducted at the Department of Surgical Gastroenterology, Dr. RMLIMS, Lucknow. Data of all patients undergoing cholecystectomy between January 2015 and March 2023 were analysed retrospectively. Demographic profile, clinical presentation, blood investigations, radiological findings, operative findings and histopathology report were examined. Clinical and radiological features of difficult cholecystectomies, incidence and type of bile duct injury (BDI), presentation and outcomes of TWGB, incidence of incidental CaGB and its outcome, were evaluated and analysed.

RESULTS

A total of 5450 patients underwent cholecystectomy during the study period. GSD is common in females and 4 th decade. The laparoscopic to open conversion rate was 1.2%, the most common cause was unclear anatomy. The incidence of BDI in our series was 0.11% ( n = 6). The most common histopathological outcome was chronic cholecystitis followed by xanthogranulomatous cholecystitis. Incidence of incidental carcinoma gall in our series was 0.3% ( n = 16) with an overall survival of 68.75% at a mean follow-up of 19.4 months. TWGB workup includes contrast-enhanced computed tomography, intraoperative most have difficult cholecystectomy and had a higher rate of conversion, injury and incidental CaGB.

CONCLUSION

Thorough pre-operative evaluation and using the suggested algorithm may decrease perioperative complications and histopathological surprises after LC.

Xanthogranulomatous Cholecystitis: A Retrospective Review of Clinical Diagnosis and Treatment from a Single Center

The objective of this study was to evaluate and compare the histopathological, clinical, and treatment characteristics of xanthogranulomatous cholecystitis (XGC) in patients undergoing cholecystectomy at a single center. Aim: We aim to enhance the understanding of its presentation and improve its differential diagnosis from other gallbladder pathologies. Methods: We retrospectively reviewed 6783 cholecystectomy cases performed between January 2015 and January 2023 at the General Surgery Clinic of Haydarpaşa Numune Training and Research Hospital, and a diagnosis of xanthogranulomatous cholecystitis was histopathologically established in 131 patients. In this retrospective study, we examined the clinicopathological characteristics, preoperative imaging methods and findings, histopathological images, surgical procedure methods, and postoperative complications of 131 patients. Results: The study included 131 patients, with ages ranging from 18 to 88 years, of which 74 (56.5%) were female and 57 (43.5%) were male. Ultrasound imaging was performed on 128 patients. Ultrasound imaging revealed wall thickening in 72.7% of cases, hypoechoic nodules in 13.3%, biliary tract pathologies in 10.9%, and adenomyomatosis in 3.1%. A total of 59 cases had MRI. On MRI, wall thickening was observed in 50.8% of cases, biliary tract pathologies in 33.9%, adenomyomatosis in 10.2%, hypoechoic nodules in 3.4%, and hypoechoic nodules + wall thickening (HN + WT) in 1.7%. Histopathological diagnosis was diffuse in 79.4% of cases and focal in 20.6%. In addition to cholecystectomy, non-surgical interventions were not required in 77.1% of the cases, while 11.5% underwent ERCP, 9.2% underwent percutaneous procedures, 1.5% underwent both ERCP and percutaneous procedures, and 0.8% underwent other non-surgical interventions. Of the surgeries, 93.1% were elective and 6.9% were emergency. Postoperative complications were not observed in 84% of the patients; 5.3% experienced surgical complications, 5.3% had surgical site infection, and 5.3% had other complications (pneumonia and urinary infection). The length of hospital stay ranged from 0 to 26 days, with a mean of 5.27 ± 4.59 days and a median of 4 days. Conclusions: Xanthogranulomatous cholecystitis is a rare disease of the gallbladder with no characteristic radiological or clinical findings and can often be confused with gallbladder cancer. Further studies involving larger populations are needed to improve the preoperative diagnosis.

Machine learning-based diagnostic model for preoperative differentiation between xanthogranulomatous cholecystitis and gallbladder carcinoma: a multicenter retrospective cohort study

Background

Xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma (GBC) share similar imaging and serological profiles, posing significant challenges in accurate preoperative diagnosis. This study aimed to identify reliable indicators and develop a predictive model to differentiate between XGC and GBC.

Methods

This retrospective study involved 436 patients from Zhejiang Provincial People's Hospital and The Affiliated Lihuili Hospital of Ningbo University. Comprehensive preoperative imaging, including ultrasound, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and blood tests, were analyzed. Machine learning (Random Forest method) was employed for variable selection, and a multivariate logistic regression analysis was used to construct a nomogram for predicting GBC. Statistical analyses were performed using SPSS and RStudio software.

Results

The study identified gender, Murphy's sign, absolute neutrophil count, glutamyl transpeptidase level, carcinoembryonic antigen level, and comprehensive imaging diagnosis as potential risk factors for GBC. A nomogram incorporating these factors demonstrated high predictive accuracy for GBC, outperforming individual or combined traditional diagnostic methods. External validation of the nomogram showed consistent results.

Conclusion

The study successfully developed a predictive nomogram for distinguishing GBC from XGC with high accuracy. This model, integrating multiple clinical and imaging indicators, offers a valuable tool for clinicians in making informed diagnostic decisions. The findings advocate for the use of comprehensive preoperative evaluations combined with advanced analytical tools to improve diagnostic accuracy in complex medical conditions.

Distinguishing characteristics of xanthogranulomatous cholecystitis and gallbladder adenocarcinoma: a persistent diagnostic dilemma

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.

Usefulness of MRI Scoring System for Differential Diagnosis between Xanthogranulomatous Cholecystitis and Wall-Thickening Type Gallbladder Cancer

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.

Xanthogranulomatous cholecystitis in a patient with ulcerative colitis and primary sclerosing cholangitis: A case report

Chronic gallbladder disease due to xanthogranulomatous cholecystitis is uncommon, and its symptoms are generally vague. While there is no firm evidence to link xanthogranulomatous cholecystitis to primary sclerosing cholangitis or ulcerative colitis. The patient is a 41-year-old male with a history of ulcerative colitis, primary sclerosing cholangitis, and biliary stenting who complained of symptoms of anorexia, jaundice, and pruritus. In the initial ultrasound exam, there was evidence of intrahepatic and extra-hepatic bile duct dilation along with a significant and mass-like circumferential thickening of the gallbladder wall. Magnetic resonance cholangiopancreatography was performed for further evaluation, which indicated increased gallbladder wall thickness, containing multiple T2 hyper-signal nodules while the mucosal layer was intact. There was also a filling defect in the common bile duct's distal portion. These findings matched a xanthogranulomatous cholecystitis diagnosis and a possibly malignant lesion in the distal of the common bile duct. The patient ultimately had a cholecystectomy, and pathology findings confirmed the diagnosis of xanthogranulomatous cholecystitis. Biopsy specimens obtained from the distal of the common bile duct lesion were microscopically identified as intramucosal adenocarcinoma. In patients with a history of primary sclerosing cholangitis who present with nonspecific symptoms suggesting chronic gallbladder disease and radiologic evidence of circumferential gallbladder wall thickening containing intramural nodules and intact mucosa, xanthogranulomatous cholecystitis should be kept in mind.

Preoperative Diagnosis of Xanthogranulomatous Cholecystitis

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Xanthogranulomatous cholecystitis: diagnostic complexity and review of the literature

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.

Xanthogranulomatous Cholecystitis Mimicking Carcinoma Gallbladder

Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and can mimic gallbladder carcinoma. Distinguishing XGC from gallbladder cancer preoperatively is challenging. We present a case of a 62-year-old male who presented with features of carcinoma gallbladder in the CECT abdomen and MRCP. Intraoperatively, there was a mass in the gallbladder and extension into the adjacent structures with involvement of the hepatic artery, 1^st part of the duodenum, portal vein, and hepatic flexure of the colon, and thus a palliative cholecystectomy was done. The histopathological report came out as XCG. The case aims to outline the clinical presentation of XGC and differentiate it from carcinoma gallbladder.

Contrast-Enhanced CT and Ultrasonography Features of Intracholecystic Papillary Neoplasm with or without associated Invasive Carcinoma

OBJECTIVE

To assess the contrast-enhanced CT and ultrasonography (US) findings of intracholecystic papillary neoplasm (ICPN) and determine the imaging features predicting ICPN associated with invasive carcinoma (ICPN-IC).

MATERIALS AND METHODS

In this retrospective study, we enrolled 119 consecutive patients, including 60 male and 59 female, with a mean age ± standard deviation of 63.3 ± 12.1 years, who had pathologically confirmed ICPN (low-grade dysplasia [DP] = 34, high-grade DP = 35, IC = 50) and underwent preoperative CT or US. Two radiologists independently assessed the CT and US findings, focusing on wall and polypoid lesion characteristics. The likelihood of ICPN-IC was graded on a 5-point scale. Univariable and multivariable logistic regression analyses were performed to identify significant predictors of ICPN-IC separately for wall and polypoid lesion findings. The performances of CT and US in distinguishing ICPN-IC from ICPN with DP (ICPN-DP) was evaluated using the area under the receiver operating characteristic curve (AUC).

RESULTS

For wall characteristics, the maximum wall thickness (adjusted odds ratio [aOR] = 1.4; 95% confidence interval [CI]: 1.1-1.9) and mucosal discontinuity (aOR = 5.6; 95% CI: 1.3-23.4) on CT were independently associated with ICPN-IC. Among 119 ICPNs, 110 (92.4%) showed polypoid lesions. Regarding polypoid lesion findings, multiplicity (aOR = 4.0; 95% CI: 1.6-10.4), lesion base wall thickening (aOR = 6.0; 95% CI: 2.3-15.8) on CT, and polyp size (aOR = 1.1; 95% CI: 1.0-1.2) on US were independently associated with ICPN-IC. CT showed a higher diagnostic performance than US in predicting ICPN-IC (AUC = 0.793 vs. 0.676; p = 0.002).

CONCLUSION

ICPN showed polypoid lesions and/or wall thickening on CT or US. A thick wall, multiplicity, presence of wall thickening in the polypoid lesion base, and large polyp size are imaging findings independently associated with invasive cancer and may be useful for differentiating ICPN-IC from ICPN-DP.

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.

Noninvasive preoperative differential diagnosis of gallbladder carcinoma and xanthogranulomatous cholecystitis: A retrospective cohort study of 240 patients

Background

Xanthogranulomatous cholecystitis (XGC) is an extremely rare entity. Due to XGC’s clinical and radiological resemblance to gallbladder carcinoma (GBC), intraoperative frozen section during cholecystectomy is often performed to exclude the diagnosis of GBC. Our study is aiming to find a noninvasive indicator of XGC. To our knowledge, this is the largest XGC cohort ever studied.

Methods

This study retrospectively collected clinical characteristics, serological tests, and imaging features of 150 GBC patients and 90 XGC patients. The diagnosis of these 150 GBC patients and 90 XGC patients was based on intraoperative frozen section histopathology. T‐test was utilized to compare differences between XGC and GBC. Receiver operating characteristic (ROC) curve was conducted and the area under the curve (AUC) was managed to evaluate the validity.

Results

The carcinoembryonic antigen (CEA) level in blood tests was significantly elevated in GBC patients than in XGC patients (p = 0.007). The presence of submucosal hypo‐attenuated nodules (80% in XGC, 16% in GBC, p < 0.001), low density border (60% in XGC, 21% in GBC, p = 0.001), and nodular thickening in the bottom of the gallbladder with calcification (70% in XGC, 37% in GBC, p = 0.004) is significantly associated with XGC patients, whereas massive hilar infiltration (0% in XGC, 21% in GBC, p < 0.001), multiple lymph nodes in the hilar area (10% in XGC, 72% in GBC, p = 0.001), and gallbladder mucosal line continuity (50% in XGC, 95% in GBC, p = 0.002) are highly associated with GBC patients. The ROC curve was performed and the gallbladder mucosal line continuity (AUC = 0.708) and the AUC of low density border around the occupation (AUC = 0.654) showed a good prediction of XGC.

Conclusions

Gallbladder mucosal line continuity and low density border around the occupation presented good indication value for the diagnosis of XGC. Our study proposed a noninvasive differential diagnosis method for XGC and GBC.

Complications of cholecystitis: a comprehensive contemporary imaging review

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

Key Imaging Findings for the Prospective Diagnosis of Rare Diseases of the Gallbladder and Cystic Duct

There are various diseases of the gallbladder and cystic duct, and imaging diagnosis is challenging for the rare among them. However, some rare diseases show characteristic imaging findings or patient history; therefore, familiarity with the imaging presentation of rare diseases may improve diagnostic accuracy and patient management. The purpose of this article is to describe the imaging findings of rare diseases of the gallbladder and cystic duct and identify their pathological correlations with these diseases.

Imaging Spectrum of Granulomatous Diseases of the Abdomen and Pelvis

A granuloma is a compact organization of mature macrophages that forms because of persistent antigenic stimulation. At the microscopic level, granulomas can undergo various morphologic changes, ranging from necrosis to fibrosis, which along with other specialized immune cells define the appearance of the granulomatous process. Accordingly, the imaging features of granulomatous diseases vary and can overlap with those of other diseases, such as malignancy, and lead to surgical excisions and biopsy. However, given the heterogeneity of granulomas as a disease group, it is often hard to make a diagnosis on the basis of the histopathologic features of granulomatous diseases alone owing to overlapping microscopic features. Instead, a multidisciplinary approach is often helpful. Radiologists need to be familiar with the salient clinical manifestations and imaging findings of granulomatous diseases to generate an appropriate differential diagnosis. ^©RSNA, 2021.

Diagnostic performance of preoperative CT in differentiating between benign and malignant origin of suspicious gallbladder lesions

PURPOSE

To determine diagnostic performance of preoperative CT in differentiating between benign and malignant suspicious gallbladder lesions and to develop a preoperative risk score.

METHOD

All patients referred between January 2007 and September 2018 for suspicion of gallbladder cancer (GBC) or incidentally found GBC were retrospectively analyzed. Patients were excluded when preoperative CT or histopathologic examination was lacking. Two radiologists, blinded to histopathology results, independently reviewed CT images to differentiate benign disease from GBC. Multivariable analysis and internal validation were used to develop a risk score for GBC. Model discrimination, calibration, and diagnostic performance were assessed.

RESULTS

In total, 118 patients with 39 malignant (33 %) and 79 benign (67 %) lesions were included. Sensitivity of CT for diagnosing GBC was 90 % (95 % confidence interval [CI]: 76-97). Specificity rates were 61 % (95 % CI: 49-72) and 59 % (95 % CI: 48-70). Three predictors of GBC (irregular lesion aspect, absence of fat stranding, and locoregional lymphadenopathy) were included in the risk score ranging from -1 to 4. Adequate performance was found (AUC: 0.79, calibration slope: 0.89). In patients allocated >0 points, the model showed higher performance in excluding GBC than the radiologists (sensitivity 92 % [95 % CI: 79-98]). Moreover, when allocated >3 points, the risk score was superior in diagnosing GBC (specificity 99 % [95 % CI: 93-100]).

CONCLUSIONS

Sensitivity rates of CT for differentiation between benign and malignant gallbladder lesions are high, however specificity rates are relatively low. The proposed risk score may facilitate differentiation between benign and malignant suspicious gallbladder lesions.

Xanthogranulomatous cholecystitis mimicking gallbladder cancer on 18F-fluorodeoxyglucose positron emission tomography/computed tomography scan

The abnormal thickening of the gallbladder (GB) wall can be caused by a malignant condition like gallbladder carcinoma or by benign lesions such as chronic cholecystitis or xanthogranulomatous cholecystitis (XGC). Mural thickening is a common finding between them as fluorodeoxyglucose (FDG) can be taken up by inflammatory cells also. Here, we present a patient with irregular thickening of the GB wall which was suspected to of GB carcinoma since FDG positron emission tomography/computed tomography scan showed increased tracer uptake in the lesion. However, after surgery the histopathological report was suggestive of XGC.

Imaging-based algorithmic approach to gallbladder wall thickening

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.

Xanthogranulomatous cholecystitis: a rare gallbladder pathology from a single-center perspective

Purpose

The aim of this study was to review patients with xanthogranulomatous cholecystitis (XGC).

Methods

A total of 79 patients diagnosed with XGC were included in the study. The criteria for XGC in the pathology specimens were the presence of histiocytes, cholesterol deposits, lipids, and focal or widespread wall enlargement.

Results

Patients were diagnosed with XGC, of which 52 (65.8%) were male and 27 (34.2%) were female, creating a male-to-female ratio of 2:1. The mean age was 65.8 ± 14.3 years (range, 36–97 years). The most common presenting symptom was abdominal pain (63.3%), and the least common presenting symptom was jaundice (8.9%). Of the total, 25 patients were found to have pathological conditions with the potential to obstruct the bile duct or to slow bile flow. A frozen section examination was performed on 20 patients due to suspicion of a tumor by intraoperative macroscopic examination. However, no malignancy was detected in the cases who underwent a frozen section examination. An increase in wall thickness of the gallbladder was observed in 81.6% (n = 31) of the patients on computed tomography scans and in 81.8% (n = 18) of the patients on magnetic resonance imaging scans in which possible tumor lesions were reported, but no tumor was detected.

Conclusion

It is difficult to diagnose XGC either preoperatively or intraoperatively, and further imaging methods are needed in the preoperative period other than ultrasonography. However, a definitive diagnosis depends exclusively on pathologic examination.

Xanthogranulomatous cholecystitis: experience in 100 cases

Background

Xanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe foam cells and fibrosis, and can be an inducement of difficulty in cholecystectomy. The purpose of this study was to review the clinical findings and imageology features of XGC and to optimize the treatment option.

Methods

This retrospective study collected clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications of 100 patients with XGC after evaluating 50005 cholecystectomy specimens between 2009 and 2018 in a single institute. heir clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications were collected and analyzed.

Results

Patients showed various clinical symptoms, ultrasonography was performed in all patients, CT and MRI were further arranged selectively before the operation, but none of the patients were prediagnosed. Fifty-two patients received open cholecystectomy. Laparoscopic cholecystectomy (LC) was planned in 48 patients within whom 8 cases were converted to open cholecystectomy. No partial cholecystectomy was performed. The intraoperative findings included cholecystolithiasis, choledocholithiasis, thickened gallbladder wall, lesions infiltrating into adjacent tissues, disordered Calot’s triangle anatomy, enlarged regional lymph nodes, internal gallbladder fistula, and hepatic abscesses. Frozen-section analysis was performed in 48 patients under the suspicion of gallbladder carcinoma (GBCa), but only 2 cases were finally confirmed.

Conclusions

The preoperative diagnosis of XGC was challenging. Open cholecystectomy was the most preferred treatment, and conversion to open was often necessary after LC.

Xanthogranulomatous cholecystitis: a review of 31 patients

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory gallbladder disease which is difficult to diagnose and treat; XGC may be confused with gallbladder cancer. The present study aimed to evaluate the clinical and radiological features and surgical outcomes, with the aim to determine the appropriate treatment approaches for XGC.

METHODS

This retrospective study analyzed the clinical characteristics, intraoperative findings, and postoperative outcomes of 31 patients (2.0%) who were diagnosed with XGC based on histopathological findings among 1513 patients who underwent cholecystectomy at our hospital between January 2010 and July 2019.

RESULTS

Preoperative ultrasonography and computed tomography findings indicated acute cholecystitis, chronic cholecystitis, and suspicious XGC in 26 (83.9%) patients with thickening of the gallbladder wall and suspicious gallbladder cancer in 5 (16.1%) patients. Abdominal pain and jaundice were observed in 18 (58.1%) patients and 5 (16.1%) patients, respectively. Biliary drainage before surgery was performed in 21 (67.7%) patients. Laparoscopic cholecystectomy, which was performed in 23 (74.2%) patients, was converted to open cholecystectomy in 12 (52.2%) of these 23 patients. Among the patients with other diseases treated during the study period, laparoscopic cholecystectomy was performed in 1377 patients and converted to open surgery in 71 (5.2%) patients. Five patients with suspicious gallbladder cancer underwent open surgery. In these patients, intraoperative frozen section analysis was useful in distinguishing between XGC and gallbladder cancer and was important in avoiding unnecessarily extended surgery.

CONCLUSION

Laparoscopic cholecystectomy for XGC is possible, but often difficult due to severe inflammation. The frequency of conversion to open surgery is higher in patients with XGC than those with other forms of cholecystitis. XGC may resemble gallbladder cancer based on the diagnostic imaging findings, and intraoperative frozen section analysis is essential to avoid unnecessarily extended surgery.

Evaluation of gallbladder wall thickening: a multimodality imaging approach

INTRODUCTION

Gallbladder (GB) wall thickening is a relatively common finding on imaging. While there are clear recommendations for the management of gallstones, GB wall thickening presents a significant challenge. Despite advances in radiological as well as endoscopic techniques, the ability to characterize GB wall thickening is still limited.

AREAS COVERED

This review summarizes the currently available literature on various imaging investigations to characterize GB wall thickening. This review also summarizes the differences between benign and malignant GB wall thickening based on available imaging modalities. Transabdominal ultrasonography is the first-line investigation for evaluation of GB wall thickening. However, further characterization requires additional imaging tests. Magnetic resonance imaging (MRI) with the use of gadolinium and diffusion-weighted sequence is the preferred modality for GB wall characterization.

EXPERT OPINION

The accurate characterization of GB wall thickening is a challenging task. The available imaging criteria allow differentiation of benign and malignant GB wall thickening with moderate accuracy. The advanced imaging techniques, including contrast enhanced ultrasound, contrast-enhanced endoscopic ultrasound, and shear wave elastography, continue to evolve. There is a need for a well-designed reporting system for GB wall thickening to ensure uniformity of reporting of imaging tests, especially in regions with a high prevalence of GB cancer.

A scoring system based on computed tomography for the correct diagnosis of xanthogranulomatous cholecystitis

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.

Incidentally detected focal fundal gallbladder wall thickening: Differentiation contrast enhanced ultrasound features with high-resolution linear transducers

AIM

To investigate the value of contrast enhanced ultrasound with high resolution linear transducers (HF-CEUS) for differential diagnosis of focal fundal gallbladder (GB) wall thickening.

METHODS

A total of 32 patients with incidentally detected focal fundal GB wall thickening were included. After conventional B mode ultrasound (BMUS) examinations, HF-CEUS were performed with a 7.5-12 MHz 9L4 linear transducer (S2000 HELX OXANA unit, Siemens). Two radiologists independently reviewed the HF-CEUS enhancement patterns to determine the differential features between malignancy and benignity with a five-point confidence scale. The diagnostic accuracy of BMUS and HF-CEUS for GB wall thickening was compared. The final gold standard was surgery with histological examination.

RESULTS

Final diagnoses included GB adenocarcinoma (n = 16), adenomyomatosis (n = 12), Xanthogranulomatous (n = 2) and cholecystitis (n = 2). HF-CEUS features associated with GB adenocarcinoma including arterial phase inhomogeneous hyperenhancement, venous phase hypoenhancement and disruption of GB wall layer structure (P < 0.05). Two small (5 mm) liver metastasis were confirmed by HF-CEUS during the late phase liver sweep as hypoenhanced lesions. Nonenhanced Rokitansky-Aschoff sinuses were clearly observed in 83.3% focal adenomyomatosis. Overall sensitivity, specificity and accuracy for differentiation between malignant and benign focal fundal GB wall thickening of HF-CEUS and BMUS were 84.3% vs 53.1%, 90.6% vs 59.3% and 87.5% vs 56.2% (P < 0.005).

CONCLUSIONS

CEUS performed with high frequency linear transducers could be a useful alternative in the differential diagnosis of focal fundal GB wall thickening on conventional ultrasound.

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.

Diagnostic accuracy of MDCT in differentiating gallbladder cancer from acute and xanthogranulomatous cholecystitis

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.

Xanthogranulomatous Cholecystitis with Florid Ducts of Luschka: Double Trouble Mimicking Malignancy

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.

Computed Tomography (CT) and Magnetic Resonance (MR) Findings in Xanthogranulomatous Cholecystitis: Retrospective Analysis of Pathologically Proven 30 Cases - Tertiary Care Experience

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.

[Value of ultrasonography in diagnosis of xanthogranulomatous cholecystitis]

OBJECTIVE

To assess the value of ultrasonography in differential diagnosis of xanthogranulomatous cholecystitis (XGC) and wall-thickening type of gallbladder cancer (GBC).

METHODS

The clinical features and sonographic finding of 31 patients with XGC and 36 patients with wall-thickening type of GBC were retrospectively reviewed. The diagnosis of all cases was confirmed by pathological examination, and the ultrasonographic manifestations of the thickening of the gallbladder wall, intramural hypoechoic nodules, gallbladder mucosa line, gallbladder stones, biliary dilatation and gallbladder-liver boundary were compared between two groups.

RESULTS

There were significant differences in the intramural hypoechoic nodules, the continuous gallbladder wall mucosal line and dilatation of bile duct between XGC and GBC groups (all P<0.05), while no statistically significant differences in the other sonographic features(all P>0.05). In the six positive sonographic features of the XGC patients, the intramural hypoechoic nodules and the continuous mucosa line of the gallbladder wall had highest accuracy in the diagnosis of XGC(64.2% and 65.7%).

CONCLUSIONS

Intramural hypoechoic nodule and the continuous mucosal line are characteristic sonographic features of XGC, which can be used for the diagnosis of XGC.

Spectrum of Xanthogranulomatous Processes in the Abdomen and Pelvis: A Pictorial Review of Infectious, Inflammatory, and Proliferative Responses

OBJECTIVE

Xanthogranulomatous (XG) processes are rare inflammatory conditions with the characteristic pathologic feature of lipid-laden macrophages or histiocyte cells. Imaging findings are nonspecific and can simulate aggressive neoplastic processes. XG processes can be caused by infection, inflammation, histolytic process, or an inherited lysosomal disorder. XG infectious processes are mainly seen in cholecystitis and pyelonephritis, but several other organs can also be involved. Histiocytic processes can be divided into Langerhans and non-Langerhans cell histiocytosis. The non-Langerhans cell histiocytosis entities include Erdheim-Chester disease, Rosai-Dorfman disease, juvenile xanthogranuloma, and hemophagocytic lymphohistiocytosis. The inherited lysosomal disorders resulting in XG processes include Nieman-Pick, Gaucher, and other lysosomal storage disorders.

CONCLUSION

Radiologists need to be able to recognize features of xanthogranulomatous processes to help facilitate patient management.

Xanthogranulomatous cholecystitis: diagnostic performance of US, CT, and MRI for differentiation from gallbladder carcinoma

OBJECTIVES

The purpose of this study is to evaluate the diagnostic performance of HRUS, CT, and MRI for differentiating xanthogranulomatous cholecystitis (XGC) from gallbladder (GB) cancer.

MATERIALS AND METHODS

Patients with surgically proven XGC (n = 40) and GB cancer (n = 44), who had undergone at least one HRUS (n = 43), CT (n = 82), or MRI (n = 34) examination between 2000 and 2012, were included. Two radiologists retrospectively graded the likelihood of XGC or GB cancer using a 5-point confidence scale; they also assessed the imaging features. Statistical analyses were performed using ROC, ANOVA, and Fisher's exact test.

RESULTS

Diagnostic performance of MRI was better than HRUS for differentiating XGC from GB cancer (AUCs = 0.867 and 0.911 vs. AUCs = 0.818 and 0.86). However, HRUS showed a better performance than CT (AUCs = 0.818 and 0.86 vs. AUCs = 0.806 and 0.84) with moderate to excellent agreement (κ = 0.48-0.83). Statistically common findings for XGC included non-focal thickening, smooth GB wall, presence of intramural nodules, type I enhancement of wall, transient hepatic attenuation difference, and continuity of mucosa (p < 0.05). Co-existence of gallstones (OR = 16.5), non-focal thickening (OR = 14.7), and collapsed lumen (OR = 13.0) on HRUS, and type I enhancement on CT (OR = 3.52) were independently associated with XGC (p < 0.05).

CONCLUSION

Although MRI showed a better performance than both HRUS and CT, HRUS showed a better performance than CT. The co-existence of gallstones, non-focal thickening, and collapsed lumen on HRUS was independently associated with XGC.

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.

Gallbladder Tuberculosis Mimicking Gallbladder Carcinoma: A Case Report and Literature Review

Gallbladder tuberculosis (GT) is extremely rare, and it is difficult to differentiate from other gallbladder diseases, such as gallbladder carcinoma and Xanthogranulomatous Cholecystitis. A correct preoperative diagnosis of GT is difficult. The final diagnosis is usually made postoperatively according to surgical biopsy. Here, we report a case of a patient who underwent surgery with the preoperative diagnosis of gallbladder carcinoma. We reviewed the literature and present the process of differential diagnosis between two or more conditions that share similar signs or symptoms.

Xanthogranulomatous cholecystitis: What every radiologist should know

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.

Diffusion-weighted magnetic resonance imaging to differentiate malignant from benign gallbladder disorders

PURPOSE

To retrospectively evaluate the utility of apparent diffusion coefficient (ADC) and lesion to spinal cord ratio (LSR) in diffusion-weighted magnetic resonance (MR) imaging (DWI) as compared with morphological assessment alone, for differentiating malignant from benign gallbladder disorders.

METHODS

This study was approved by the ethics committee, and written informed consent was waived. Ninety-one patients (13 malignancy and 78 benignancy) were reviewed. ADC was calculated using two DW images with different motion-probing gradient strengths (b=0, 1000s/mm(2)). LSR was measured by dividing the signal intensity of a thickened gallbladder wall by the maximum signal intensity of the lumbar enlargement of the spinal cord. In addition, the morphology of the gallbladders was assessed with conventional MR imaging.

RESULTS

In receiver operating characteristic curve analysis, the areas under the curves for ADC and LSR were 0.861 and 0.906, respectively. Three morphological findings were considered: a massive formation, a disrupted mucosal line, and the absence of a two-layered pattern. When a combination of two or more of these morphological findings was positive for malignancy, the sensitivity, specificity, and accuracy were 76.9%, 84.0%, and 83.0%, respectively. When a combination of three or more of the above morphological findings together with ADC of less than 1.2 × 10(-3)mm(2)/s or LSR of more than 0.48 were positive for malignancy, these values were 73.0%, 96.2%, and 92.9%, respectively. There were significant differences in specificity and accuracy.

CONCLUSION

Use of ADC and LSR in DWI can improve diagnostic performance for differentiating malignant from benign gallbladder disorders.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: An analysis of 42 cases

AIM: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis (XGC) clinically.

METHODS: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our hospital, among which 42 were misdiagnosed as gallbladder carcinoma (GBC) based on preoperative radiographs and/or intra-operative findings. The clinical characteristics, preoperative imaging, intra-operative findings, frozen section (FS) analysis and surgical procedure data of these patients were collected and analyzed.

RESULTS: The most common clinical syndrome in these 42 patients was chronic cholecystitis, followed by acute cholecystitis. Seven (17%) cases presented with mild jaundice without choledocholithiasis. Thirty-five (83%) cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging, and 29 (69%) cases presented with abnormal enhancement in hepatic parenchyma neighboring the gallbladder, which indicated hepatic infiltration. Intra-operatively, adhesions to adjacent organs were observed in 40 (95.2%) cases, including the duodenum, colon and stomach. Thirty cases underwent FS analysis and the remainder did not. The accuracy rate of FS was 93%, and that of surgeon’s macroscopic diagnosis was 50%. Six cases were misidentified as GBC by surgeon’s macroscopic examination and underwent aggressive surgical treatment. No statistical difference was encountered in the incidence of postoperative complications between total cholecystectomy and subtotal cholecystectomy groups (21% vs 20%, P > 0.05).

CONCLUSION: Neither clinical manifestations and laboratory tests nor radiological methods provide a practical and effective standard in the differential diagnosis between XGC and GBC.

Gallbladder carcinoma: causes of misdiagnosis at CT

Gallbladder carcinomas can present with varied imaging features on computed tomography. The three major imaging features include (1) focal or diffuse wall thickening with or without irregularity of the gallbladder; (2) polypoidal intraluminal mass; and (3) large mass obscuring and replacing the gallbladder, often extending to the liver. Patterns of wall thickening or polypoid growth are often confused with various benign gallbladder diseases due to overlap of imaging findings. Moreover, gallbladder carcinomas that coexist with benign gallbladder diseases make accurate preoperative diagnosis more difficult. Recently, high-resolution ultrasound (HRUS) has been regarded as a problem-solving tool for gallbladder diseases. In this article, we will illustrate various imaging presentations of gallbladder cancer, along with imaging pitfalls and recently updated HRUS findings.

Xanthogranulomatous cholecystitis in the laparoscopic era is still a challenging disease

BACKGROUND

Xanthogranulomatous cholecystitis is an unusual inflammatory process of the gallbladder which is difficult to diagnose and manage and may be confused with gallbladder cancer. Many surgeons and pathologists are not familiar with this condition. We aim to highlight this condition and to review the role of laparoscopy in its management.

PATIENTS AND METHODS

We reviewed the records of 4406 patients who underwent cholecystectomy in 8 years at two teaching hospitals in North Jordan. Forty-two cases of Xanthogranulomatous cholecystitis were identified. The details of these patients were analyzed. The findings were compared with results of a previous study in all cholecystectomy patients conducted in the same centers.

RESULTS

The incidence of Xanthogranulomatous cholecystitis was 0.95 %. Twenty-five patients (59.5 %) presented as acute emergencies. Nine patients (21.4 %) had jaundice. Ultrasound showed marked gallbladder wall thickening in 36 patients (85.7 %). Compared with all cholecystectomy patients, xanthogranulomatous cholecystitis patients showed higher conversion rate from laparoscopic to open cholecystectomy (31.4 vs. 3.2 %, p < 0.001) and higher morbidity (33.3 vs. 6.4 % p < 0.001).

CONCLUSIONS

Xanthogranulomatous cholecystitis is rare. Acute presentation, associated jaundice, and gallbladder wall thickening should raise the suspicion of the condition. Laparoscopic cholecystectomy is associated with high conversion rate.

A Longitudinal Computed Tomography Imaging in the Diagnosis of Gallbladder Cancer

Background/Aim. To assess whether the diagnostic power of longitudinal multiplanar reformat (MPR) images is superior to that of conventional horizontal images for gallbladder cancer (GBC). Methods. Between 2006 and 2010, a total of 54 consecutive patients with preoperatively diagnosed gallbladder neoplasms located in gallbladder bed were analyzed. These patients underwent cholecystectomy with resection of the adjacent liver parenchyma. The patients were divided into the GBC group (n = 30) and the benign group (n = 24). MPR images obtained by preoperative multidetector row CT (MDCT) were assessed. Results. Mucosal line was more significantly disrupted in GBC group than that in benign group (93% [28/30 patients] versus 13% [3/24], p < 0.001). Maximum (9.3 [4.2-24.8] versus 7.0 mm [2.4-22.6], p = 0.29) and minimum (1.2 [1.0-2.4] versus 1.3 mm [1.0-2.6], p = 0.23) wall thicknesses on a single MPR plane did not differ significantly; however, the wall thickness ratio (max/min) differed significantly (6.8 [1.92-14.0] versus 5.83 [2.3-8.69], p = 0.04). Partial liver enhancement adjacent to tumor on longitudinal images was more common in GBC (40.0% [12/30 patients] versus 12.5% [3/24], p = 0.03). Mucosal line disruption was the most reliable independent predictor of diagnosis (odds ratio, 8.5; 95% CI, 5.99-28.1, p < 0.001). Conclusion. Longitudinal MPR images are more useful than horizontal images for the diagnosis of GBC.