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Special Feature
May 2011May 16, 2011

Image of the Month—Diagnosis

Arch Surg. 2011;146(5):628. doi:10.1001/archsurg.2011.99-b
Answer: Xanthogranulomatous Cholecystitis

Xanthogranulomatous cholecystitis (XGC) is a variant of chronic cholecystitis. It is a rare, invasive disease of the gallbladder that may radiologically appear like invasive gallbladder cancer. The disease process is benign but may invade adjacent organs such as the liver, greater omentum duodenum, colon, and common bile duct. The Calot triangle in such cases may be densely fibrosed, making dissection difficult. The pathogenesis starts with obstruction of the Rokitanski-Aschoff sinuses in chronic cholecystitis, resulting in rupture and finally leakage of infected bile into the gallbladder wall. Grossly, the specimen is shrunken and nodular with a massively thickened wall. Histologically, XGC has distinct findings showing fat-laden macrophages, foamy histocytes, and exuberant fibrous tissue.1

Patients most often present with pain and also may present with vomiting, anorexia, and weight loss. Xanthogranulomatous cholecystitis may also result in biliary strictures, causing jaundice and cholangitis. Symptoms are likely to be chronic in nature vs acute. Xanthogranulomatous cholecystitis may also be associated with internal fistulas with the hepatic duct or common bile duct as well as cholecystenteric fistulas. Cholelithiasis is often seen along with XGC. The incidence of XGC varies from 0.16% to 13.2%,2 with some apparent local variations in its incidence. Some areas such as northern India have been shown to have an incidence as high as 10%.3 Xanthogranulomatous cholecystitis affects people aged 48 to 55 years, with a slight predilection for men vs women (1:1.1).3 Wall thickening is commonly seen on ultrasound imaging. Xanthogranulomatous cholecystitis is often confused with malignancy and is hard to differentiate on computed tomography or magnetic resonance imaging. Positron emission tomography may show no uptake, suggesting a benign disease, but a false-positive result may also be seen with xanthogranulomatous inflammation. Preoperative fine-needle aspiration may show cytology consistent with XGC. Xanthogranulomatous cholecystitis, though benign, may coexist with cholecystic adenocarcinoma. Ultimately paraffin or frozen sections reveal the final diagnosis. Surgery has been demonstrated to be the most effective treatment option for XGC. Laparoscopic cholecystectomy may initially be attempted but involves a relatively higher rate of conversion to open laprotomy.2

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Article Information

Correspondence: Bishwajit Bhattacharya, MD, Department of Surgery, New York Medical College, Munger Pavilion, Ste 223, Valhalla, NY 10595 (bishwajitb@hotmail.com).

Accepted for Publication: February 16, 2010.

Author Contributions:Study concept and design: Bhattacharya and Facciuto. Acquisition of data: Bhattacharya and Katta. Analysis and interpretation of data: Katta. Drafting of the manuscript: Bhattacharya and Facciuto. Critical revision of the manuscript for important intellectual content: Bhattacharya, Katta, and Facciuto. Administrative, technical, and material support: Katta. Study supervision: Bhattacharya and Facciuto.

Financial Disclosure: None reported.

Submissions

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

References
1.
Kumar  VFausto  NAbbas  A Robbins Pathologic Basis of Disease.  Philadelphia, PA: Elsevier Saunders; 1999
2.
Wang  MZhang  TZang  L  et al.  Surgical treatment for xanthogranulomatous cholecystitis: a report of 74 cases. Surg Laparosc Endosc Percutan Tech 2009;19 (3) 231- 233
PubMedArticle
3.
Krishna  RPKumar  ASingh  RKSikora  SSaxena  RKapoor  VK Xanthogranulomatous inflammatory strictures of extrahepatic biliary tract: presentation and surgical management. J Gastrointest Surg 2008;12 (5) 836- 841
PubMedArticle
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