Xanthogranulomatous cholecystitis: a European and global perspective

Abstract

Introduction: Xanthogranulomatous cholecystitis (XGC) is often mistaken for, and may predispose to, gallbladder carcinoma (GB Ca). This study reviews the worldwide variation of the incidence, investigations, management and outcome of patients with XGC.

Methods: Data from 29 studies, cumulatively containing 1599 patients, were reviewed and results summarized by geographical region (Europe, India, Far East and Americas) with 95% confidence intervals (CIs) to present variability within regions. The main study outcomes were incidence, association with GB Ca and treatment of patients with XGC.

Results: Overall, the incidence of XGC was 1.3-1.9%, with the exception of India where it was 8.8%. The incidence of GB Ca associated with XGC was lowest in European studies (3.3%) varying from 5.1-5.9% in the remaining regions. Confusion with or undiagnosed GB Ca led to 10.2% of patients receiving over or under treatment.

Conclusions: XGC is a global disease and is associated with GB Ca. Characteristic pathological, radiological and clinical features are shared with GB Ca and contribute to considerable treatment inaccuracy. Tissue sampling by pre-operative endoscopic ultrasound or intra-operative frozen section is required to accurately diagnose gallbladder pathology and should be performed before any extensive resection is performed.

Figure 1

Imaging from patients with xanthogranulomatous cholecystitis (XGC). (a) An ultrasound scan demonstrating diffuse wall thickening (cursor) and intramural echogenic nodules (arrow). (b) Computed tomography (CT) post contrast image demonstrating continuous enhancement of the mucosal wall (small arrows)

Figure 2

Computed tomography (CT) scans from patients with biopsy-proven gall bladder cancer. (a) Circumferential enhancement of the mucosa with focal wall thickening (small arrows). (b) Circumferential enhancement of the mucosa with focal thickening (small arrow) and breach of the mucosa (arrowheads) with invasion into segment 4b of the liver (contrast with the figure showing XGC)

Figure 3

Magnetic resonance imaging demonstrating features of xanthogranulomatous cholecystitis (XGC). (a) A T2 weighted magnetic resonance image (MRI) demonstrating fluid within the wall of the gall bladder (large arrow). (b) A T1 weighted MRI demonstrating continuous enhancement of the mucosal line (small arrows)

Figure 4

A summary of the search strategy in this review

Figure 5

(a) Incidence of xanthogranulomatous cholecystitis (XGC) in resected gallbladders. (b) Proportion of XGC patients that are male. (c) Mean ages of XGC patients. (d) Proportion of XGC patients with gall stones. (e) Proportion of XGC patients with coexisting cancer. The circle represents the mean value for each study, the horizontal bars represent 95% confidence intervals for each study and the diamond represents the pooled data for all studies in each geographical region

Figure 6

A suggested treatment pathway for patients with ultrasounds features suggesting XGC or GB Ca.CT: computed tomography scan; GB Ca: gall bladder carcinoma; GB: gall bladder; USS: ultrasounds scan; XGC: xanthogranulomatous cholecystitis