Xanthogranulomatous cholecystitis

Clinical History

A 50-year-old male with intermittent right upper quadrant abdominal pain.

Imaging Findings

A 50-year-old male was admitted to our hospital with complaints of right upper quadrant pain. Whereas he had no fever, a cholecystitis was suspected. The white blood cell count was 7,400/mm³ with a normal differential count. The patient underwent an ultrasound examination. During the ultrasound examination, a Murphy sign was present. The wall of the gallbladder contained hypoechoic nodules representing foci of xanthogranulomatous inflammation (Fig. 1a) as well as multiple hyperechoic calculi with acoustic shadowing (Fig. 1b). Ultrasound examination also showed thick hypoechoic band and a gallbladder filled with biliary sludge (Fig. 1c).The patient underwent open cholecystectomy. Histologic examination confirmed the diagnosis of xanthogranulomatous cholecystitis (Fig.2).

Discussion

Xanthogranulomatous cholecystitis (XGC) is an uncommon form of chronic cholecystitis, representing between 0.7% and 13.2% of gallbladder disease [1] and mainly affecting women between 60 and 70 years old. The term xanthogranulomatous cholecystitis was initially proposed by Goodman and Ishak [4] in 1981 in a review of 40 cases from the Armed Forces Institute of Pathology. Previous reports by Christensen and Ishak [4] and Amazon and Rywlin [4] had noted a pseudotumoral form of chronic cholecystitis that was characterised by the presence of xanthomalike foam cells and scarring and that contained ceroid (waxlike) nodules in an inflamed gallbladder wall. Its importance lies in the fact that clinically and radiologically it can be confused with the prognostically far more serious condition of carcinoma of the gallbladder. XGC lacks true malignant features, such as pleomorphism, cellular atypia, and increased or bizarre mitotic figures. In the AFIP series of 40 cases of XGC, eight cases were associated with adenocarcinoma (five of the gallbladder and three of the bile ducts) [4]. Benbow found that three of 35 cases of gallbladder carcinoma involved XGC in addition to the tumor [4]. In the 168 cases of XGC seen at the AFIP since 1981, 19 have been associated with tumors, which includes seven with adenocarcinoma of the gallbladder, two with adenocancinoma of the cystic duct, one with leiomyosarcoma of the gallbladder, two with metastases of the gallbladder, one with carcinoma of the common bile duct, two with villose adenomas, two with adenocarcinoma of the ampulla of Vater, and two with adenocarcinoma of the pancreas [4]. Although the mechanism leading to this condition remains unclear, extravasation of bile into the gallbladder wall, with involvement of Rokitansky-Aschoff sinuses, or extravasation through a small ulceration in the mucosa, appears to be a precipitating factor. The presence of calculi or biliary tree obstruction may play an important role. Vomiting, right upper quadrant pain, positive Murphy sign on sonography, and leukocytosis are similar to the findings described in other types of cholecystitis [2]. Sonography is currently the technique of choice in the investigation of patients with gallbladder disease. Gallstones and a thickened and echogenic gallbladder wall are frequent radiologic findings, but they are nonspecific. The presence of sludge is also common. Hypoechoic nodules and bands in the gallbladder wall are the most characteristic findings in XGC [2,3]. Xanthogranulomatous nodules behave as well-defined hypoechoic areas. This finding suggests that the hypoechoic bands might be caused by a more generalized involvement of the mucosa, which is sometimes evident in the surgical specimen. The explanation of this sonographic appearance might lie in the lipid content of the lesion or in its cellular density. Because XGC is associated with a high frequency of complications (gallbladder perforation, hepatic abscess, biliary ductal stricture and obstruction, ascending cholangitis, and biliary fistula) and coexistent malignancy, early diagnosis is important [3]. For treatment, cholecystectomy is recommended. Occasionally, however, the inflammatory reaction and fibrosis within the gallbladder are so severe that conventional cholecystectomy is unsafe. In these instances, a subtotal cholecystectomy is required [2].

Differential Diagnosis List

Final Diagnosis

Xanthogranulomatous cholecystitis

URL:	https://www.eurorad.org/case/8024
DOI:	10.1594/EURORAD/CASE.8024
ISSN:	1563-4086