Xanthogranulomatous cholecystitis: What every radiologist should know

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.

Differentiating carcinoma from benign causes of nonspecific gall bladder wall thickening: A prospective observational study on the role of multiparametric MRI and proposition of an MpMRI-based criteria

BACKGROUND

In nonspecific gall bladder (GB) wall thickening on ultrasonography (USG) or computed tomography (CT), the patient undergoes a more major surgery for a benign cause or a redo surgery for malignancy if diagnosed inaccurately.

PURPOSE

To evaluate whether malignant and benign causes of nonspecific GB wall thickening can be accurately differentiated on multiparametric magnetic resonance imaging (MpMRI) and to propose MpMRI-based diagnostic criteria.

METHODS

Thirty-six of 94 nonspecific GB wall thickening patients underwent MpMRI in a 1.5 T scanner. The MRI characterization was compared with histopathology. Statistical analysis calculated various MRI parameters' sensitivity, specificity, and accuracy in distinguishing benign and malignant lesions. The receiver operating curve analysis provided the apparent diffusion coefficient (ADC) cut-off value.

RESULTS

MpMRI had 100% sensitivity and 92.31% specificity in detecting malignant wall thickening. The sensitivity and specificity of various parameters like intact mucosa on T2-weighted imaging (T2WI), smooth-enhancing mucosa, identification of wall layers on T2WI, and diffusion-weighted imaging (DWI) were 100% and 84.62%, 100% and 92.31%, 100% and 96.15%, and 100% and 53.85%, respectively, in differentiating benign from malignant thickening. Malignancy showed lower ADC values; the cut-off was 1.107 × 10-3 mm2/s. Intramural nodule/cyst on T2WI, chemical shift imaging, and dynamic contrast-enhanced MRI (DCE-MRI) showed 100% positive predictive value for benign wall thickening.

CONCLUSION

MpMRI accurately differentiates benign from malignant GB wall thickening and is recommended when USG or CT are inconclusive. This will help decide the type of surgery, simple cholecystectomy for benign or radical surgery for a malignant cause. Accurate prediction by MpMRI will reduce patient morbidity and improve survival.

A comprehensive exploration of gallbladder health: from common to rare imaging findings

This comprehensive review explores a wide range of imaging findings associated with the gallbladder (GB), from anatomic variants to rare diseases. Through an in-depth review of diagnostic modalities including ultrasound, magnetic resonance cholangiopancreatography, CT, and MRI, we aim to highlight the crucial role of imaging techniques in diagnosing GB disorders, as congenital anomalies, inflammatory diseases, neoplasms, and surgical complications. Employing a detailed analysis and comparison of imaging findings across various modalities, this review seeks to improve diagnostic accuracy for GB-related pathologies, facilitating optimal patient management.

Application of contrast-enhanced ultrasonography for gallbladder squamous cell carcinoma: a case report

Preoperative diagnosis of Gallbladder squamous cell carcinoma (GBSCC) is difficult, and the contrast-enhanced ultrasound (CEUS) pattern has never been reported before. We present a case of GBSCC where CEUS revealed special findings that facilitated early diagnosis. CEUS demonstrated irregular peripheral ring-like enhancement during the arterial phase, with hypoenhancement in the late phases, and an irregular non-enhancing area persistently present in the center of the lesion.

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.

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.

Cholecystoappendiceal fistula associated with xanthogranulomatous cholecystitis

Xanthogranulomatous cholecystitis is a rare chronic inflammatory disease of the gallbladder associated with complications such as perforation, dense adhesions and fistulation. We present a case of a female patient in her 20s who presented with three episodes of recurrent cholecystitis over 3 months. Her medical history included an endoscopic retrograde cholangiopancreatography for obstructive jaundice due to choledocholithiasis. As there was no possibility of performing an urgent cholecystectomy during her initial admission, she was listed for an elective operation. Laparoscopic inspection revealed a pericholecystic mass involving the omentum, transverse colon, duodenum and liver and findings suspicious of a cholecystoappendiceal fistula. Laparoscopic cholecystectomy and appendicectomy were performed. Early index admission laparoscopic cholecystectomy should be performed in patients with acute cholecystitis to prevent higher grades of operative difficulty and associated complications. This case presentation-cholecystoappendiceal fistula associated with xanthogranulomatous cholecystitis-emphasises the necessity of complying with national guidelines in managing acute calculous cholecystitis.

Deep-learning models for differentiation of xanthogranulomatous cholecystitis and gallbladder cancer on ultrasound

BACKGROUND

The radiological differentiation of xanthogranulomatous cholecystitis (XGC) and gallbladder cancer (GBC) is challenging yet critical. We aimed at utilizing the deep learning (DL)-based approach for differentiating XGC and GBC on ultrasound (US).

METHODS

This single-center study comprised consecutive patients with XGC and GBC from a prospectively acquired database who underwent pre-operative US evaluation of the gallbladder lesions. The performance of state-of-the-art (SOTA) DL models (GBCNet-convolutional neural network [CNN] and RadFormer, transformer) for XGC vs. GBC classification in US images was tested and compared with popular DL models and a radiologist.

RESULTS

Twenty-five patients with XGC (mean age, 57 ± 12.3, 17 females) and 55 patients with GBC (mean age, 54.6 ± 11.9, 38 females) were included. The performance of GBCNet and RadFormer was comparable (sensitivity 89.1% vs. 87.3%, p = 0.738; specificity 72% vs. 84%, p = 0.563; and AUC 0.744 vs. 0.751, p = 0.514). The AUCs of DenseNet-121, vision transformer (ViT) and data-efficient image transformer (DeiT) were significantly smaller than of GBCNet (p = 0.015, 0.046, 0.013, respectively) and RadFormer (p = 0.012, 0.027, 0.007, respectively). The radiologist labeled US images of 24 (30%) patients non-diagnostic. In the remaining patients, the sensitivity, specificity and AUC for GBC detection were 92.7%, 35.7% and 0.642, respectively. The specificity of the radiologist was significantly lower than of GBCNet and RadFormer (p = 0.001).

CONCLUSION

SOTA DL models have a better performance than radiologists in differentiating XGC and GBC on the US.

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

INTRODUCTION

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

CASE PRESENTATION

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

CLINICAL DISCUSSION

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

CONCLUSION

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

Imaging update on gallbladder adenomyomatosis and its mimics

Radiologists across many imaging modalities commonly encounter gallbladder adenomyomatosis. The classic imaging appearances of gallbladder adenomyomatosis are well described and confirm benignity. However, in clinical practice, adenomyomatosis can be challenging to differentiate from other gallbladder pathologies that require cholecystectomy. In this article, we describe the common and uncommon appearances of gallbladder adenomyomatosis on multimodality imaging, helping differentiate adenomyomatosis from non-benign gallbladder abnormalities. Accurately differentiating adenomyomatosis from its mimics provides the surgical team with important clinical and surgical management information, improving patient outcomes.

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

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

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.

Successful Treatment of Xanthogranulomatous Cholecystitis Following Total Knee Replacement

Xanthogranulomatous cholecystitis (XGC) is a rare form of chronic gallbladder inflammation that most commonly presents as acute cholecystitis and is often mistaken for carcinoma of the gallbladder. This case details the hospital course and follow-up of a 77-year-old male who developed suspected acute acalculous cholecystitis (AAC) resulting in severe sepsis after elective left total knee arthroplasty (TKA). Histopathological findings after elective cholecystectomy later revealed XGC as the underlying etiology.

Preoperative Diagnosis of Xanthogranulomatous Cholecystitis

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Gallbladder Cancer or Diffuse Xanthogranulomatous Cholecystitis: A Case of Management Dilemma During Elective Cholecystectomy With Unexpected Severe Mass-Like Pericholecystic Fibrosis and Inflammation

A 52-year-old man was scheduled to undergo an elective laparoscopic cholecystectomy for an increasingly symptomatic cholelithiasis. The pre-operative diagnosis was established clinically and confirmed with ultrasonography (US), showing gallstones and thickened gallbladder wall. Intraoperatively, extensive dense adhesions of the omentum to the entire subdiaphragmatic surface of the liver and the diaphragm were encountered. The adhesions of the omentum and colon were completely obscuring the Morrison's space with cartilage-like consistency at the supposed anatomical projection of the gallbladder fundus. Due to these unexpected pathological findings and uncertain disease biology, a decision was made to abort and re-schedule the surgery after obtained tissue biopsy results, magnetic resonance cholangiopancreatography (MRCP), and tumor markers carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and alpha fetoprotein (AFP) were available. CA 19-9 was found elevated 10-fold, while AFP and CEA levels were within normal limits. A follow-up cholecystectomy was performed, and final pathology revealed diffuse xanthogranulomatous cholecystitis (XC) and extensive inflammatory changes, adhesions, and fibrosis and no malignancy. The patient tolerated the procedure well and was discharged home on day two after surgery. His follow-up examination was unremarkable. Distinguishing between XC and gallbladder carcinoma is important to appropriately guide management and treatment.

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.

Spectrum of imaging findings in hyperplastic cholecystosis and potential mimics

Adenomyomatosis and cholesterolosis of the gallbladder, collectively termed hyperplastic cholecystosis, are commonly encountered incidental findings on imaging studies performed for a variety of indications including biliary colic or nonspecific abdominal pain. These pathologies are rarely the source of symptoms, generally considered benign and do not require further work-up. However, their imaging characteristics can overlap with more sinister conditions that should not be missed. In this review, the imaging findings of adenomyomatosis and cholesterolosis will be reviewed followed by other gallbladder pathologies that might mimic these conditions radiologically. Important differentiating factors will be discussed that can aid the radiologist in making a more confident imaging diagnosis.

Spontaneous cholecystocutaneous fistula secondary to xanthogranulomatous cholecystitis: a case report

BACKGROUND

Xanthogranulomatous cholecystitis, a rare variant of cholecystitis, may infrequently be complicated by spontaneous cholecystocutaneous fistula.

CASE PRESENTATION

We report the case of a 75-year-old Saudi Arabian man who presented with "a painful area of redness" (cellulitis) over his right upper abdomen. Abdominal computed tomography revealed multiple collections, which were drained surgically. A discharging sinus was identified, and a fistulogram revealed cholecystocutaneous fistula during his follow-up visit. The patient underwent laparoscopic management and recovered uneventfully. Final histopathological evaluation confirmed acute-on-chronic xanthogranulomatous cholecystitis .

CONCLUSIONS

Although rare, surgeons should consider cholecystocutaneous fistula in the differential diagnosis of anterior abdominal wall abscesses, particularly in patients with concurrent or background symptoms of gallbladder disease. We report the first case of laparoscopic management for cholecystocutaneous fistula in Saudi Arabia.

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.

Xanthogranulomatous cholangitis mimicking cholangiocarcinoma: Case report and review of literature

Introduction

Xanthogranulomatous cholangitis is an extremely rare diagnosis and is believed to be an extension of xanthogranulomatous cholecystitis, a benign inflammatory process characterized by lipid-laden foamy macrophages (called “xanthoma cells”) occurring in a background of chronic inflammation consisting of lymphocytes, plasma cells, and eosinophils. Here, we report a case of xanthogranulomatous cholangitis mimicking cholangiocarcinoma.

Case presentation

A 72 year old male with history of recurrent cholangitis had preoperative workup highly suggestive of intrahepatic cholangiocarcinoma. He underwent right hepatectomy and portal lymphadenectomy, with pathology showing xanthogranulomatous cholangitis, with no evidence of malignancy. Interestingly, the patient did not have xanthogranulomatous cholecystitis.

Discussion

We reviewed the current literature on xanthogranulomatous cholangitis, and identified only 14 previously reported cases. In our case series, there were six female and eight male patients. Among the 14 patients, 11 presented to the hospital with jaundice. Twelve patients had preoperative workup concerning for malignancy. The diagnosis of xanthogranulomatous cholangitis was confirmed through pathology in 13 patients, and through endoscopic ultrasound biopsy in one patient. In our review, seven patients had associated xanthogranulomatous cholecystitis, three patients had an isolated case of xanthogranulomatous cholangitis, and four patients had unknown status. Our patient is the fourth case of isolated xanthogranulomatous cholangitis without xanthogranulomatous cholecystitis.

Conclusion

Xanthogranulomatous cholangitis is a very rare phenomenon that can lead to benign strictures of the bile ducts, especially in the setting of recurrent cholangitis. It can mimic malignancies, such as cholangiocarcinoma, and should be considered in the differential diagnosis.

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Xanthogranulomatous cholangitis is an extremely rare inflammatory process.

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It involves lipid-laden macrophages of the bile duct.

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Patients with xanthogranulomatous cholangitis frequently present with jaundice.

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It can mimic malignancies, including bile duct, liver, gallbladder, and pancreatic cancers.

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It should be included in the differential diagnosis of biliary abnormalities

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.

Xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma - Analysis of 8 cases

Background/Aim

Xanthogranulomatous cholecystitis (XGC) is a rare destructive inflammatory disease of the gallbladder. It is frequently misdiagnosed as gallbladder carcinoma (GBC) as it mimics latter with regard to clinical manifestations, imaging and intraoperative findings, often leading to extended surgical resection in these patients. The aim of this study was to evaluate the diagnostic dilemma of XGC cases clinico-radiologically diagnosed with GBC.

Materials and Methods

From January 2017 to June 2019, a total of eight cases histopathologically diagnosed as XGC, were misdiagnosed with GBC based on preoperative and intra-operative findings. The clinical characteristics, imaging, intra-operative findings, and surgical data of these patients were collected and analyzed.

Results

A total of 2154 cholecystectomy specimens were received in the histopathology section during the study period. Sixty-nine cases (3.2%) were histologically diagnosed as XGC, of which 8 cases (11.6%) were preoperatively diagnosed with GBC. These cases were predominantly seen in males in the age range of 24-62 years. The most common clinical presentation was chronic cholecystitis. Gallstones were present in all the 8 cases. Six cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging. Intraoperatively, adhesions to adjacent organs were observed in seven cases. All these eight cases misdiagnosed with GBC underwent aggressive surgical treatment following which histopathology ultimately revealed XGC.

Conclusion

Neither clinical manifestations nor laboratory tests/radiological methods can provide an effective means of differentiating between XGC and GBC. Preoperative diagnosis is difficult, and histopathology remains the gold standard to differentiate the two entities.

Xanthogranulomatous Pancreatitis Accompanied by Xanthogranulomatous Cholecystitis: A Case Report and Literature Review

Xanthogranulomatous pancreatitis (XGP) is extremely rare, with only 31 cases reported in the English literature to date. We reviewed previously reported 17 articles about XGP and report an additional case of XGP. This is the first case of XGP with xanthogranulomatous cholecystitis accompanied by intraductal papillary mucinous carcinoma (IPMC) in an 80-year-old woman. She was referred to our hospital with jaundice and general malaise and was found to have a cystic mass at the pancreatic head and a solid mass at the pancreatic tail, with dilation of both the main pancreatic duct and biliary tract noted on computed tomography. Diagnosis of IPMC at the pancreatic head with neuroendocrine tumor at the pancreatic tail was made, and the patient underwent subtotal stomach-preserving pancreatoduodenectomy with enucleation of the mass at the tail. Pathological examination revealed IPMC with xanthogranulomatous changes around the IPMC and at the pancreatic tail and gallbladder. Xanthogranulomatous pancreatitis could be induced by inflammatory reaction due to obstruction of the pancreatic duct and biliary tract by mucin produced in the IPMC. It is sometimes difficult to preoperatively differentiate XGP from malignant pancreatic tumors, such as pancreatic carcinoma or neuroendocrine tumor, using imaging studies.

Acute Severe Transaminitis as a Unique Presentation of Chronic Cholecystitis

The hepatocellular function can be evaluated using aspartate aminotransferase (AST) and alanine aminotransferase (ALT) which are biochemical markers of the liver. Whenever there is an ischemic, toxic, or inflammatory injury to the liver, necrosis of the hepatocytes occurs and these biochemical markers are released into the circulation, showing an acute elevation in serum levels.

In this case report, we discuss the unique clinical presentation of a female patient who came to the Emergency Room (ER) with acute onset chest pain with laboratory findings of elevated serum aminotransferases and cholestatic markers and was ultimately diagnosed with chronic cholecystitis.

The usual clinical presentation associated with extremely elevated levels of liver enzymes can be one of three cases: acute viral hepatitis, toxin-induced liver injury, or acute ischemic insult to the liver. However, our patient was diagnosed with chronic cholecystitis despite her unique initial presentation of acute, severe transaminitis.

While one may find elevated liver enzyme levels in acute cholecystitis, owing to the sudden nature of the inflammatory process, chronic cholecystitis is not known to cause high levels of serum amino transaminases or fulminant liver failure.

Our case report indicates a diverse phenotype of chronic cholecystitis with an unusual presentation of acute, severe transaminitis. It helps expand the differential diagnoses of acute elevation of liver function tests (LFTs). Further studies are needed to explore the pathology behind chronic cholecystitis in order to understand its impact on liver damage.

A contemporary analysis of xanthogranulomatous cholecystitis in a Western cohort

BACKGROUND

Xanthogranulomatous cholecystitis is a particularly destructive variant of cholecystitis marked by unique inflammatory changes evident in pathologic specimens. Multiple case series have evaluated this process. However, these often focus on differentiating it from malignancy and have largely been conducted in Asia, where the disease may differ from that seen in the Western hemisphere. This study evaluated surgical outcomes after cholecystectomy for xanthogranulomatous cholecystitis at a high-volume tertiary care institution in the United States. The goal was to determine whether the process can be identified preoperatively and whether modifications should be made to the operative approach in this setting.

METHODS

Patients with histopathological confirmation of xanthogranulomatous cholecystitis who underwent cholecystectomy between 2002 and 2019 were identified from an updated institutional database. Data regarding demographics, imaging findings, surgical procedures, and perioperative complications were reviewed retrospectively. A cohort of patients undergoing cholecystectomy for more typical diagnoses was also identified for comparison.

RESULTS

Twenty-seven patients with a histopathologic diagnosis of xanthogranulomatous cholecystitis were identified. The median age was 64, and 17/27 (63.0%) were male. The majority of cases were done electively on patients admitted that day (17/27). Seventeen patients were evaluated with diagnostic ultrasonography, 21 with computed tomography scan, and 8 with magnetic resonance imaging; 21/27 patients had multiple modality studies. The most common singular finding was gallbladder wall thickening, but the radiographic findings were otherwise inconsistent. Twenty-five patients had planned laparoscopic cholecystectomies, but only 10 were completed. Only 8 of the 15 converted procedures were completed as simple cholecystectomies. Five patients required subtotal cholecystectomy. Median estimated blood loss was 250 cm³, and the median time of procedure was nearly 3 hours. Eight patients had complications, including 6 severe complications such as intraoperative bile duct injury.

CONCLUSION

Xanthogranulomatous cholecystitis unfortunately has a nonspecific presentation, which can make it difficult to recognize preoperatively. It is to be suspected in cases featuring a distended, severely inflamed gallbladder that does not match the benign appearance of the patient. When the diagnosis is suspected, an open approach is justified and patients should be counseled as to the increased likelihood of atypical approaches and elevated risk of complication. Referral to a hepatobiliary specialist is to be considered.

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.

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.

Routine examination of gallbladder specimens after cholecystectomy: a single-centre analysis of the incidence, clinical and histopathological aspects of incidental gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma is often found incidentally on histopathologic examination after cholecystectomy-this is referred as incidental gallbladder carcinoma (IGC). Routine vs selective histopathological assessment of gallbladders is under debate and this study evaluates the role of regular specimens' examination, based on a single-centre analysis of incidence, clinical and histopathological aspects of IGC.

METHODS

Patients who underwent cholecystectomy, between July 2010 and January 2020, were considered. Exclusion criteria were age under 18 and preoperative diagnosis of GB carcinoma. Demographic, clinical and histopathological data were retrospectively collected, continuous variables with a normal distribution were evaluated with Student's t-test and ANOVA.

RESULTS

Some 5779 patients were included. The female/male ratio was 2.5:1. Chronic cholecystitis (CC) was the most common finding on specimens (99.3%), IGC was found in six cases (0.1%). In the latter group, there were 5 women and patients were older than those with benign disease-73.7 [Formula: see text] 5.38 years vs 55.8 [Formula: see text] 0.79 years (p < 0.05). In all the cases, the GB was abnormal on intraoperative inspection and beside cancer, histopathology showed associated CC and/or dysplasia. Upon diagnosis, disease was at advanced stage-one stage II, one stage IIIA, one stage IIIB, three stage IVA. Two patients are alive, three died of disease progression-median survival was 7 months (range 2-14).

CONCLUSIONS

In this series, ICG was rare, occurred most commonly in old adult women and was diagnosed at an advanced stage. In all the cases, the GB was abnormal intraoperatively, therefore macroscopic GB anomalies demand histopathological assessment of the specimen.

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

INTRODUCTION

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

PRESENTATION OF CASE

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

DISCUSSION

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

CONCLUSION

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

Gallbladder cancer revisited: the evolving role of a radiologist

Gallbladder cancer is the most common malignancy of the biliary tract. It is also the most aggressive biliary tumor with the shortest median survival duration. Complete surgical resection, the only potentially curative treatment, can be accomplished only in those patients who are diagnosed at an early stage of the disease. Majority (90%) of the patients present at an advanced stage and the management involves a multidisciplinary approach. The role of imaging in gallbladder cancer cannot be overemphasized. Imaging is crucial not only in detecting, staging, and planning management but also in guiding radiological interventions. This article discusses the role of a radiologist in the diagnosis and management of gallbladder cancer.

Xanthogranulomatous Cholecystitis: A Diagnostic Challenge for Radiologists, Surgeons, and Pathologists

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder characterized by severe proliferative fibrosis and the accumulation of lipid-laden macrophages in areas of destructive inflammation. Misdiagnosis is highly usual, and its macroscopic appearance may often be confused with gallbladder carcinoma. Here we discuss the case of a 56-year-old male who presented in the emergency room with fever, chills, and nausea. The routine laboratory investigations were normal except for elevated white blood cell counts. Abdominal ultrasound showed borderline gallbladder wall thickening. However, after CT scan findings, the suspect diagnosis of acute cholecystitis with possible perforation was made and the cholecystectomy was performed. The definitive diagnosis was delayed until the final pathology result came as a surprise, and later confirmed the histologic diagnosis of XGC. We consider this an important case because of the histopathologic finding of fibrotic thickened gallbladder wall with abundant histiocytes and pericholecystic fat stranding along with perforation and extensive inflammatory changes in the right upper quadrant of the abdomen which is highly suggestive and indicative of XGC in comparison to gallbladder carcinoma (GC). All things considered, clinically and grossly XGC presents in a similar fashion as GC; histopathology confirmed the diagnosis of XGC.

Xanthogranulomatous Cholecystitis: Is Surgery Difficult? Is Laparoscopic Surgery Recommended?

Introduction: Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder (GB). XGC surgery is a difficult process due to its clinical, radiological, and intraoperative findings. In this study, our aim is to show the difficulties of XGC surgery and to find out if laparoscopic surgery is a sufficient procedure. Materials and Methods: Histological findings of 3339 cholecystectomy patients, who were operated between January 2015 and January 2020, were retrospectively reviewed. Age, gender, radiological results, clinical features, intraoperative findings, and surgical management of the patients with XGC were recorded. Results: XGC was observed in 70 patients (2.09%). The average age was 53.75. M:F ratio was 1.2. In radiological examinations, gallstones were found in 94.2% of the patients and GB wall thickness (≥3 mm) was increased in 58.5% of the patients. Around 45.7% of the patients came to the clinic with chronic cholecystitis and 32.9% with acute cholecystitis. In the intraoperative period, adhesions were observed in 80% and increase in GB wall thickness was observed in 77.1% of the patients. The operation started laparoscopically in 66 patients. In 14 patients (21.2%), it was converted to open surgery usually due to insufficient dissection of Calot's triangle. Gallbladder carcinoma (GBC) was suspected in 6 patients, but none of them had malignancy in frozen sections or histology. Conclusions: XGC surgery is difficult due to its radiological, clinical, and intraoperative features and mimicking GBC. It can be converted to open cholecystectomy due to difficulties in laparoscopic dissection. However, since conversion cholecystectomy rates are reasonable, laparoscopic surgery is recommended in patients with suspected XGC.

Chronic gallbladder wall thickening: Is it always malignancy?

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.

Benign gallbladder diseases: Imaging techniques and tips for differentiating with malignant gallbladder diseases

Benign gallbladder diseases usually present with intraluminal lesions and localized or diffuse wall thickening. Intraluminal lesions of the gallbladder include gallstones, cholesterol polyps, adenomas, or sludge and polypoid type of gallbladder cancer must subsequently be excluded. Polyp size, stalk width, and enhancement intensity on contrast-enhanced ultrasound and degree of diffusion restriction may help differentiate cholesterol polyps and adenomas from gallbladder cancer. Localized gallbladder wall thickening is largely due to segmental or focal gallbladder adenomyomatosis, although infiltrative cancer may present similarly. Identification of Rokitansky-Aschoff sinuses is pivotal in diagnosing adenomyomatosis. The layered pattern, degree of enhancement, and integrity of the wall are imaging clues that help discriminate innocuous thickening from gallbladder cancer. High-resolution ultrasound is especially useful for analyzing the layering of gallbladder wall. A diffusely thickened wall is frequently seen in inflammatory processes of the gallbladder. Nevertheless, it is important to check for coexistent cancer in instances of acute cholecystitis. Ultrasound used alone is limited in evaluating complicated cholecystitis and often requires complementary computed tomography. In chronic cholecystitis, preservation of a two-layered wall and weak wall enhancement are diagnostic clues for excluding malignancy. Magnetic resonance imaging in conjunction with diffusion-weighted imaging helps to differentiate xathogranulomatous cholecystitis from gallbladder cancer by identifying the presence of fat and degree of diffusion restriction. Such distinctions require a familiarity with typical imaging features of various gallbladder diseases and an understanding of the roles that assorted imaging modalities play in gallbladder evaluations.

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.

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.

[Differential diagnosis of gallbladder abnormalities : Ultrasound, computed tomography, and magnetic resonance imaging]

CLINICAL ISSUE

Due to the high prevalence of clinically suspected cholecystitis or cholecystolithiasis the gallbladder is one of the organs examined the most by imaging.

STANDARD RADIOLOGICAL METHODS

In most clinical settings ultrasound is the primary imaging method because of its wide availability, speed and superior spatial resolution. In cases of ambiguous findings or potential complications computed tomography (CT) and magnetic resonance imaging (MRI) are used.

METHODICAL INNOVATIONS

When specific problems arise these imaging modalities may be enhanced by special techniques, e. g. contrast-enhanced ultrasound or dual-energy CT, and specific MRI sequences.

PERFORMANCE

Special variants of cholecystitis, such as xanthogranulomatous cholecystitis and adenomyomatosis, may pose a particularly difficult diagnostic problem as they may resemble other diseases. Sequelae of cholecystolithiasis, such as the Mirizzi syndrome and acute bowel obstruction, may complicate the imaging algorithm as the location and the symptoms shift. Cases of neoplastic diseases of gallbladder cancer and other malignancies require a broad spectrum of imaging modalities.

ACHIEVEMENTS

Although the gallbladder can easily be examined with ultrasound, some cases require a more thorough ultrasound examination. In some cases only a combination of multiple imaging modalities yield the diagnosis. Further developments regarding technical issues and the diagnostic algorithm can be expected.

PRACTICAL RECOMMENDATIONS

Ultrasound is the best first imaging modality. In cases of ambiguous findings or clinical complications CT or MRI are recommended.

Gallbladder polypoid lesions are inaccurately reported and undermanaged: a retrospective study of the management of gallbladder polypoid lesions detected at ultrasound in symptomatic patients during a 36-month period

AIM

To investigate whether gallbladder polypoid lesions (GPL) are accurately reported and managed by radiologists, sonographers, general practitioners (GPs) and surgeons.

MATERIALS AND METHODS

Consecutive abdominal ultrasound examinations indicating GPL in symptomatic patients performed during 2011-2013 were captured and analysed. The study comprised 244 patients who satisfied the inclusion criteria.

RESULTS

Of the ultrasound reports retrieved, 238/244 reports (98%) erroneously described the polypoid lesions as polyps. One hundred and thirty-two of the 244 (54%) reports recommended follow-up, 5/244 (2%) recommended no follow-up, 35/244 (14%) deemed the findings insignificant, and 72/244 (30%) did not comment. Regarding GP referral, 57/184 (31%) patients were correctly referred to general surgeons, 20/184 (11%) to gastroenterologists, and 107/184 (58%) were not referred to secondary care. Forty-three of the 244 patients (18%) underwent cholecystectomy. Regarding subsequent biliary presentations, 63/244 patients (26%) presented at a later date with biliary symptoms; 13/63 (21%) of these eventually had cholecystectomies with 2/13 (15%) experiencing potentially life-threatening pancreatitis episodes. Regarding the surgical approach, differences were observed in the way individual surgeons managed polypoid lesions, with some veering towards cholecystectomy, others towards follow-up ultrasound, and some towards discharge.

CONCLUSION

GPL tend to be misreported by radiologists and sonographers, unappreciated by GPs, and variably managed by surgeons. These factors delay definitive therapy and seem to contribute to future biliary presentations. A fresh educational approach is required to raise awareness among radiologists, sonographers, and GPs regarding the clinical relevance and possible representations of GPL, and a uniform strategy is needed for managing GPL.

In-Phase and Opposed-Phase Imaging: Applications of Chemical Shift and Magnetic Susceptibility in the Chest and Abdomen

An earlier incorrect version appeared online. This article was corrected on December 17, 2018.