Hospital: Complejo Asistencial Universitario de Salamanca.
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Aut@r o Autores: M. Maciá Fernández, A. Pantiru, C. González Donadeo, A. Verdú Seguí, D. Vargas Jiménez, J. Santos Sánchez.,
Presentación:
An 85-year-old woman was attended in the emergency department for acute right upper quadrant pain and abdominal guarding. Personal history was significant for recurrent biliary colic episodes. Laboratory performed showed leukocytosis (18,500 cel/mm3) and an increased C-reactive protein (12,30 mg/dl). Initial ultrasound examination revealed a diffuse hyperechoic gallbladder wall thickening with the presence of an intraluminal gallstone, confirming the clinical suspicion of acute cholecystitis. A contrast enhanced CT scan of the abdomen and pelvis (Fig. 1A) was further performed prior to surgery, showing diffuse gallbladder wall thickening with a preserved continuous mucosal line. Intramural hypoattenuated nodules and an intraluminal gallstone were also seen. The patient went on to have a laparoscopic surgery that was finally converted to a laparotomy because of multiple adhesions of omentum and duodenum to the gallbladder wall. The adhesions were removed and a cholecystoduodenal fistula was noticed. The fistulous path was closed and a Kehr’s T-tube was placed in the common bile duct. Histopathological analysis revealed xanthogranulomatous cholecystitis. Five days after procedure, however, the patient began with abdominal pain and distension, as well as vomiting and failure to have bowel movement. Plain abdominal radiograph (Fig. 1B) demonstrated dilated loops of small bowel and “stack of coins” sign. Non-contrast CT (Fig.1 C, D) confirmed the diagnosis of gallstone ileus. Enterotomy and stone extraction resolved the intestinal obstruction. The patient left the hospital after a favorable evolution.
Discusión:
Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis, with an incidence rate of 1.3 to 8.8%.1 The diagnostic challenge consists in differentiating xanthogranulomatous cholecystitis from gallbladder carcinoma (GBC). The coexistence of diffuse gallbladder wall thickening, hypo-attenuated intramural nodules, continuous mucosal line, and gallbladder stone suggests XGC, whereas disrupted mucosal line, focal gallbladder wallthickening, intrahepatic biliary dilation and lymph node enlargement are more common in patients with GBC.1 The prevalence of post-operative inflammatory adhesions and fistulae to adjacent organs are higher than would be expected after a routine cholecystectomy. A coexisting fistula between the gallbladder and adjacent organ was present in 1.1 to -12.1%. Cholecystoduodenal fistula and gallstone ileus coexisting is rare. Parra JA et al described only one case between 26 cases of histologically confirmed XGC.
Conclusión:
Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis, with an incidence rate of 1.3 to 8.8%.1 The diagnostic challenge consists in differentiating xanthogranulomatous cholecystitis from gallbladder carcinoma (GBC). The coexistence of diffuse gallbladder wall thickening, hypo-attenuated intramural nodules, continuous mucosal line, and gallbladder stone suggests XGC, whereas disrupted mucosal line, focal gallbladder wallthickening, intrahepatic biliary dilation and lymph node enlargement are more common in patients with GBC.1 The prevalence of post-operative inflammatory adhesions and fistulae to adjacent organs are higher than would be expected after a routine cholecystectomy. A coexisting fistula between the gallbladder and adjacent organ was present in 1.1 to -12.1%. Cholecystoduodenal fistula and gallstone ileus coexisting is rare. Parra JA et al described only one case between 26 cases of histologically confirmed XGC.
Bibliografía:
– Hale MD, Roberts KJ, Hodson J, Scott N, Sheridan M, Toogood GJ. Xanthogranulomatous cholecystitis: a European and global perspective. HPB 2014,16:448–458. – Parra JA, Acina O, Bueno J, Güezmes A, Fernández MA, Fariñas MC. Xanthogranulom