Xanthogranulomatous cholecystitis: What every radiologist should know

Abstract

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.

Prognostic significance of promoter DNA hypermethylation of the cysteine dioxygenase 1 (CDO1) gene in primary gallbladder cancer and gallbladder 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 [ 24 ]. In addition, although XGC is not believed to be a premalignant lesion, the frequency of coexisting XGC and GB cancer is nearly 10% [ 25 ].…”

Xanthogranulomatous cholecystitis: A 14‐year experience

“…Both ultrasonography and CT often show cholelithiasis and moderate‐to‐marked focal or diffuse thickening of the gallbladder wall. A characteristic radiological finding is the presence of nodules or bands in the thickened wall, hypoechoic in ultrasonography and hypodense in the CT . However, it is very uncommon to obtain a preoperative diagnosis of XGC, and therefore, we believe that it is very important that both radiologists and surgeons maintain a high index of suspicion and be attentive to the presence of these findings in order to achieve a preoperative diagnosis, which could influence the decision to use a laparotomic or laparoscopic approach.…”

Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma

“…The difficulty in reaching a definitive diagnosis preoperatively in cases of aggressive XGC lies in the considerable overlap they may present with GBC. Both share peak incidences in the sixth and seventh decades of life, arise more commonly in women[ 8 ], have been associated with cholelithiasis and chronic inflammation, and present vague clinical signs and symptoms suggestive of biliary colic or acute or chronic cholecystitis[ 9 ]. Jaundice and cholestasis may be seen in both, though jaundice in the setting of GBC portends worse prognosis.…”

“…Radiological findings in XGC may include the presence of gallstones and gallbladder wall thickening (diffuse 80%-90%, focal 10%-20%), intramural hypoattenuated nodules, and continuous mucosal line enhancement. Though typically considered characteristic of XGC, intramural nodules may also be seen in well-differentiated GBC with abundant mucin production[ 8 ]. Features more commonly associated with malignant pathology, including mass lesion, hepatic invasion, and enlarged lymph nodes, may also be seen in XGC[ 5 , 9 ].…”