A Rare Finding During a Common Procedure: Xanthogranulomatous Cholecystitis

Abstract

Xanthogranulomatous cholecystitis is a rare variant of chronic cholecystitis characterized by severe proliferative fibrosis and accumulation of lipid-laden macrophages in regions of destructive inflammation. Xanthogranulomatous cholecystitis clinically and radiologically mimics early-stage gallbladder cancer, with wall thickening on computed tomography. The study included 14 xanthogranulomatous cholecystitis patients that were identified following retrospective analysis of the records of 1248 patients that underwent cholecystectomy between 2005 and 2011. Mean age of the 5 male and 9 female patients was 56.7 years. All 14 patients had gallbladder stones; 10 had a history of acute cholecystitis, 1 had cholangitis, and 2 presented with obstructive jaundice. A right-upper quadrant mass was palpable in 2 patients. All patients underwent cholecystectomy. Open surgery was planned and performed in 6 of the 14 patients, and laparoscopic cholecystectomy was planned in 8 patients, but was converted to open surgery in 1 case. In total, 1 patient developed wound infection, 1 patient had postoperative pneumonia, and 1 patient developed intraabdominal hematoma. None of the patients in the series died. Xanthogranulomatous cholecystitis is difficult to diagnose, both preoperatively and intraoperatively, and definitive diagnosis depends exclusively on pathological examination. Xanthogranulomatous cholecystitis should be a consideration in all difficult cholecystectomy cases.

Colecistitis xantogranulomatosa, un reto diagnóstico para el radiólogo

“…Es frecuente que la colecistitis xantogranulomatosa se diagnostique de manera inadecuada, ya que algunos hallazgos por imagen se superponen con los del carcinoma vesicular. Las tasas de carcinoma coexistente varían del 2% al 15% en los pacientes con colecistitis xantogranulomatosa 8 . La importancia de un diagnóstico adecuado es muy importante, ya que el carcinoma de vesícula tiene una tasa de supervivencia a 5 años menor del 5%.…”

Granulomatous inflammation still fooling surgeons

“…Xanthogranulomatous cholecystitis was coined in 1981 as a specific entity by Ishak et al. 2,3 It is characterised by focal to diffuse thickening of the gall bladder wall. 3,6 There is invariably accumulation of foamy macrophages, lymphocytes and plasma cells.…”

“…2 The inflammatory process is associated with marked fibrotic proliferation, which apart from distorting the architecture also leads to infiltration into surrounding structures giving a false impression of malignancy, intraoperatively as well as on radiological imagery. 2–4 The pathogenesis is still elusive, though most accepted theories believe it is due to bile entering into the interstitium of the gall bladder wall, inciting an inflammatory response. 4,5 Involvement of the adjacent tissue is the major complication, making the differentiation from carcinoma difficult.…”