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XANTHOGRANULOMATOUS CHOLECYSTITIS

Manoj Mulchandani, L F Nagori
Dept. of Surgery, Bombay Hospital, Mumbai 400 020.
Xanthogranulomatous cholecystitis is an uncommon form of chronic cholecystitis which presents with complications and preoperatively mimics as malignancy. Here we are presenting one such case.

INTRODUCTION

Xanthogranulomatous cholecystitis is an uncommon focal or diffuse destructive inflammatory disease of the gallbladder that is assumed to be a variant of conventional chronic cholecystitis. Although it is a pathological entity, it still has clinical implication.

CASE REPORT

A 51 year old male presented with acute abdominal pain of sudden onset. Pain was in right upper abdomen and was associated with vomiting and fever. There was no history of jaundice. Patient was on anti-convulsants for 10 years for post head injury convulsions. He had history of surgery for duodenal ulcer perforation done 30 years back.

On examination, patient was febrile with pulse rate of 110/min. Per abdomen examination revealed tenderness and guarding in right hypochondrium and umbilical region with no lump palpable and patient was in ileus. On investigating the patient, WBC count was 35,100 and other blood investigations were within normal limits. USG showed thick walled gall bladder with multiple gall stones and pericholecystic fluid was present, CBD and pancreas were normal. Patient was diagnosed as having acute cholecystitis and responded to conservative management. Patient was regularly followed up and was admitted for cholecystectomy. Ultrasound showed thick walled gall bladder with mass lesion in gall bladder wall with multiple stones common bile duct was normal.

Patient underwent open cholecystectomy. Intra-operative findings showed marked dense adhesions between gall bladder, liver and colon. Plane between gall bladder and liver was difficult. Gall bladder was inflamed and distended with no mass lesion and common bile duct was normal. Bile culture was normal. On gross examination gall bladder was 9 cm in length and 4 cm in breath, thick walled with multiple calculi and inflammation. Microscopic examination revealed ulcerated necrotic mucosa with dense chronic inflammation in the wall and several large nodular aggregate and sheets of xanthoma cells and multinucleated histiocytes in the wall. Patient was diagnosed as having xanthogranulomatous cholecystitis and was discharged on 8th post-operative day.

DISCUSSION

Xanthogranulomatous cholecystitis is more of a pathological entity. Its pathogenesis consists of an interplay between obstruction to bile flow with infection and subsequent inflammation associated with leakage of bile to tissues where histiocytes accumulate and phagocytose the bile pigment, haemosiderin and cholesterol, resulting in formation of xanthoma cells. Normally it presents at 45-60 years of age group with equal incidence in both the sexes with more malignant potential in females. Xanthogranulomatous cholecystitis has unusual presentation. It presents mainly with complications such as empyema pericholecystic abscess, perforation and cholecysto-duodenal fistula. The symptoms are generally of short duration. It presents very rarely as biliary colic. It is very rarely diagnosed radiological but on ultrasound can be suspected with thickened gall bladder wall, infiltration of liver, mass in gall bladder and absence of biliary tract dilatation. Xanthogranulomatous cholecystitis is always a histological diagnosis where grossly nodules are seen in wall of gall bladder and microscopically there is infiltration of gall bladder muscle layer with foamy cells (lipid laden histiocytes), multinucleated giant cells and inflammatory cells.

Fig. 1
Fig.1 : Photograph showing xanthogranulomatous cholecystitis with xanthoma cells in muscularis mucosa.

CONCLUSION

Correct diagnosis of xanthogranulomatous cholecystitis or its clinical suspicion is important due to its unusual clinical presentation, high frequency of pre-operative and intra-operative complications and occasional simulation to malignancy due to appearance of mass lesion and infiltration of liver on ultrasonography.

REFERENCES

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  3. Nakashiro H, Haraoka S, Fujiwara K. Xanthogranulomatous cholecystitis - Cell composition and a possible pathogenic role of cell mediated immunity. Pathology Research Practical 1995; 191 (11) : 1078-80.
  4. Howard TJ, Bennion RS, Thompson JE. Xanthogranulomatous cholecystitis, a chronic inflammatory pseudo-tumor of the gall bladder. American Surgery 1991; 57 (12) : 821-4.
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