Diffuse Gallbladder Wall Thickening Research Articles

Primary Gallbladder B-Cell Lymphoma as a Finding in Post Cholecystectomy with Diffuse Gallbladder Wall Thickening: A Case Report

Primary Gallbladder B-Cell Lymphoma as a Finding in Post Cholecystectomy with Diffuse Gallbladder Wall Thickening: A Case Report

Early diagnostic markers in predicting the severity of dengue disease

The aim of the present study was to determine whether the serum ferritin, the biomarker of an acute phase reactant and the gall bladder wall edema, an early indicator of capillary leakage can predict the severity of dengue fever. This study included 131 patients, who were between the age group of 18–80 years. The patients presented to our department with an acute illness, within the first four days of high temperature. The statistical analysis of this study was performed by using the Chi-square and independent Student’s t tests. The diagnostic markers are considered statistically significant, if the serum ferritin level is higher than 500 ng/ml and the gall bladder wall thickness is more than 3 mm. The present study observed that, 39 patients (89%) who had severe dengue (n = 44) revealed a significant gall bladder wall thickening, and this correlation was significant statistically (p < 0.000). It was also observed that, the ferritin levels have a highly significant positive correlation with the severity of dengue. The severe dengue patients had a mean ferritin level of 9125.34 μg/l, whereas the non-severe group had 4271 μg/l. This comparison was also statistically significant, as the p value was 0.003. We report that the serum ferritin levels have a highly significant positive correlation with the severity of dengue. The gall bladder wall edema during the third and fourth day of the illness was also associated with severe dengue. However, diffuse gall bladder wall thickening and high serum ferritin levels are also reported in various other conditions and their exact cause have to be determined by the correlation of associated clinical findings and imaging features.

Multimodality approach to gallbladder cancer: our experience at a tertiary care centre in Northern India

Introduction: This study was done to assess the varied presentations in patients with gallbladder cancer (GBC), outcome following radical surgery and various modalities of palliation and to assess the survival of these patients. Methods: Retrospective analysis of the data of all GBC patients over 4 years. Outcome was assessed during follow-up visits and telephonic interviews. Patients with metastatic disease at presentation were not included. Results: 140 cases of GBC were analysed, with a 1:2 male to female ratio. Three most common modes of presentation were weight loss (55.7%), upper abdominal pain (45%) and jaundice (40%). Seven patients were diagnosed with incidental GBC following cholecystectomy. Most common radiological findings suggestive of GBC were focal or diffuse thickening of gallbladder wall (37 and 76 patients respectively), IHBRD (65), presence of regional/distant lymph nodes (34) and local infiltration (28). Majority of patients were admitted for palliation of jaundice for hilar blocks (52 patients). 46 patients were found to be resectable and underwent radical cholecystectomy. The average survival of patients at the end of 1 year was 45% following radical surgery and 10% following palliative modalities. Conclusions: Although GBC is an uncommon disease worldwide, it has a high incidence in Northern India, an endemic zone of gallstone disease. Patients usually have an advanced disease at presentation. However, patients with focal masses were found to benefit from surgery the most and had better survival. A greater awareness of the early symptoms of GBC and a screening programme is needed for early detection of GBC.

Masquerading as Malignancy: A Case of a Misleading Gallbladder Abscess

Introduction: A gallbladder mass should always concern a clinician for malignancy. However, clinical and radiologic data are surprisingly similar for benign and malignant disease. A few cases of gallbladder abscesses mimicking cancer have been described in the setting of cholecystitis or as a complication of spilled gallstones after laparoscopic cholecystectomy. Our case is unique, as our patient had no known risk factors for abscess formation. Case: A 64-year old male presented with intermittent abdominal pain and fevers, night sweats, and 30-pound weight loss over 2 months. Physical exam was unremarkable. Lab studies showed mild leukocytosis with WBC 13.6 and normal LFTs. CT scan revealed a gallbladder mass with pneumobilia. MRI showed a diffusely thickened gallbladder with fistulization to the transverse colon, suspicious for malignancy. CA-19-9 was normal. PET-CT depicted increased uptake in the area of the gallbladder and hepatic flexure. Pre-operative diagnosis of gallbladder cancer was made and a radical en bloc cholecystectomy with partial hepatectomy and partial transverse colectomy was performed. Post-operative pathology revealed no malignancy, but rather an abscess involving the liver, gallbladder, and colon. Discussion: Diagnosis of gallbladder pathology is challenging due to nonspecific clinical and radiologic findings. The four distinct radiologic patterns are polypoid gallbladder mass, focal or diffuse gallbladder wall thickening, polypoid bile duct mass, and focal bile duct stricture. These can occur with benign or malignant lesions. Specificity of US, CT and MRI to distinguish benign from malignant gallbladder lesions is poor. Additionally, PET yields false positives in inflammation. Known masqueraders in the gallbladder are adenomyomatosis, xanthogranulomatous cholecystitis, and tuberculoid granulomatosis. Our patient had an intact gallbladder with no signs of cholelithiasis, cholecystitis, or other chronic process. Further review of his case revealed hepatic flexure diverticula on CT and foreign body giant cells in the abscess on pathology suggesting a possible perforated diverticulitis with fistulization to the gallbladder as the etiology of our patient's abscess. The best means of accurately diagnosing gallbladder pathology remains to be determined. Clinicians must beware of radiologic limitations and hold a high index of suspicion for malignancy in the right clinical context, but be mindful of mimicry as well.Figure 1Figure 2

Ultrasound-guided fine needle aspiration cytology of gallbladder lesions: a study of 596 cases.

Fine needle aspiration (FNA) is not a commonly performed procedure for gallbladder lesions for fear of causing biliary peritonitis; hence data on gallbladder cytology is scarce. The aims of the present study were to evaluate the diagnostic application of ultrasound-guided (US) FNA cytology in the pre-operative diagnosis of neoplastic as well as non-neoplastic lesions of the gallbladder and to review the cytomorphological spectrum of gallbladder lesions encountered along with various diagnostic difficulties that can arise during reporting. The study was carried out on 596 patients with gallbladder lesions in whom US-guided FNA was performed over a 5-year period. In 130 cases, simultaneous aspirations from other organs were done. The histological correlation was available in 32 cases. No major complications such as haemorrhage, peritonitis, etc. were encountered related to the procedure. The majority were mass lesions whereas in 73 cases (12.2%) only focal or diffuse gallbladder wall thickening was present. Cytological examination of 596 cases revealed malignancy in 462 (77.6%), 26 (4.4%) suspicious of malignancy, 23 (3.8%) inflammatory lesion, 29 negative (4.8%) and 56 cases showed necrosis only or were inadequate for any definite opinion. The lesions diagnosed on FNA cytology included carcinoma (predominantly adenocarcinoma), xanthogranulomatous cholecystitis (XGC), acute suppurative inflammation and tuberculosis. Of 26 with adequate cytology, 24 were accurate with respect to malignant (including one suspicious FNA) versus benign: one false positive and one false negative both involved xanthogranulomatous change. The present study is the largest series evaluating the role of US-guided FNA in the diagnosis of gallbladder lesions. It is a safe, rapid, reliable, cost-effective and reasonably accurate method for diagnosing gallbladder lesions. FNA should always be attempted in cases with a mass lesion.

Disseminated Blastomycosis Dermatitidis Causing Hepatitis in an Immunocompromised Patient

We present a case of disseminated blastomycosis causing acute hepatitis in an immunocompromised patient. A 46 year-old female with Crohn's disease on adalimumab and methotrexate presented with chest pain, shortness of breath and fevers for one week. Physical examination revealed anicteric sclera, normal heart, lung, and abdominal examinations. Labs on admission showed a total serum bilirubin of 0.7 mg/dl, alkaline phosphatase (ALP) of 313units/L, and a serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of 655units/L and 961units/L, respectively. Computer tomography scan of the chest, abdomen and pelvis revealed mild fatty liver and diffuse gallbladder wall thickening, but also a right lower lobe infiltrate and mild effusion. A hepatobiliary iminodiacetic acid scan was normal. Autoimmune liver and viral hepatitis panels were negative. Urine histoplasma antigen was positive. The patient had a bronchoscopy with bronchoalveolar lavage with cultures sent. She was started on liposomal amphotericin B. Adalimumab and methotrexate were not continued. Her AST, ALT and conjugated bilirubin continued to increase to 1361, 914 and 7.5 respectively. She clinically improved despite the increasing transaminases. Blastomyces dermatitidis antigen was positive and cultures eventually grew blastomyces dermatitidis. Amphotericin B was changed to oral itraconazole. She was discharged home with improved transaminases. Our patient presented with mild flu like symptoms, which is a common presentation for blastomycosis, but she also had markedly elevated transaminases. The most common extra-pulmonary sites of blastomyces in humans are skin, skeleton, male genitourinary system, and central nervous system. Liver involvement is rare. A far more common infectious source of both lung and liver is histoplasmosis, however this was not the cause in our patient. A false positive histoplasma urine antigen can occur secondary to cross reactivity with blastomyces. The initial treatment for disseminated blastomycosis is IV amphotericin B. Two other cases of patients presenting with acute blastomycosis pneumonia and elevated transaminases are reported, however the transaminase elevation was not attributed to the infection. The first is a case of a 44 year-old white female who presented with fever, cough and alcoholic hepatitis and ultimately died of delirium tremens. Her transaminase elevation was attributed to the alcoholic hepatitis. The second case involves a seventeen-year-old male who presented with cough, hemoptysis, weight loss, and skin lesions and developed elevated transaminases following treatment with amphotericin B. To our knowledge, this is the first reported case of acute hepatitis caused by disseminated blastomycosis.

A Case of Xanthogranulomatous Cholecystitis Decreased in Size after Steroid Treatment and Avoided Extended Resection

Xanthogranulomatous cholecystitis is an uncommon destructive inflammatory disease with accumulation of lipid-laden macrophages, fibrous tissue, and inflammatory cells. It is often mistaken for gallbladder cancer due to diffuse wall thickening of gallbladder and infiltration into neighboring organs. And it is usually difficult to distinguish xanthogranulomatous cholecystitis from gallbladder cancer based on clinical, radiographic, or laboratory testing. Patients with xanthogranulomatous cholecystitis often undergo cholecystectomy to confirm the diagnosis, and to exclude gallbladder cancers. We report a case of 69-year-old woman with xanthogranulomatous cholecystitis who had been treated with steroid and avoided extended resection. Korean J Pancreatobiliary 2015;20(1):37-41

Case report: an unrecognized etiology of transient gallbladder pain in heart failure diagnosed with internist-performed point-of-care ultrasound

The excellent sensitivity and specificity of right upper quadrant (RUQ) ultrasound for gallbladder pathology in patients with abdominal pain is heavily relied upon in routine diagnostic evaluation. The hour-to-hour timing of this test in a patient with fluctuating symptoms is not widely recognized as having a significant impact on its sensitivity. However, we present a case report describing the essential role of symptom-timed point-of-care ultrasound in making an elusive diagnosis of transient cholecystalgia in a patient with RUQ pain and congestive heart failure (CHF). This case also demonstrates an important etiology of RUQ pain in patients with CHF beyond that of congestive hepatopathy. A review of the related entities of acalculous cholecystitis, congestive hepatopathy, and diffuse gallbladder wall thickening is provided.

Primary signet-ring cell carcinoma of gallbladder resembling linitis plastica: A clinical impostor of chronic cholecystitis

Primary signet-ring cell carcinoma (SRCC) is an extremely rare and aggressive type of malignant gallbladder (GB) neoplasm, which is comprised predominantly (>50%) of signet-ring cells. Owing to its diffusely invading nature, SRCC often confers a linitis plastica like appearance to GB. Such a gross morphology in the background of nonspecific clinical presentation creates confusion with several other benign and more common pathological entities. This dilemma can effectively be settled through clinical, radiological, and pathological correlation. We, here, describe a case of SRCC affecting the GB in a 43-year-old lady. The tumor produced diffuse thickening of GB wall and infiltrated up to subserosa, but not beyond the GB parenchyma.

Xanthogranulomatous cholecystitis masquerading as gallbladder cancer: can it be diagnosed preoperatively?

Background. Xanthogranulomatous cholecystitis (XGC) is often misdiagnosed as gallbladder cancer (GBC). We aimed to determine the preoperative characteristics that could potentially aid in an accurate diagnosis of XGC masquerading as GBC. Methods. An analysis of patients operated upon with a preoperative diagnosis of GBC between January 2008 and December 2012 was conducted to determine the clinical and radiological features which could assist in a preoperative diagnosis of XGC. Results. Out of 77 patients who underwent radical cholecystectomy, 16 were reported as XGC on final histopathology (Group A), while 60 were GBC (Group B). The incidences of abdominal pain, cholelithiasis, choledocholithiasis, and acute cholecystitis were significantly higher in Group A, while anorexia and weight loss were higher in Group B. On CT, diffuse gallbladder wall thickening, continuous mucosal line enhancement, and submucosal hypoattenuated nodules were significant findings in Group A. CT findings on retrospect revealed at least one of these findings in 68.7% of the cases. Conclusion. Differentiating XGC from GBC is difficult, and a definitive diagnosis still necessitates a histopathological examination. An accurate preoperative diagnosis requires an integrated review of clinical and characteristic radiological features, the presence of which may help avoid radical resection and avoidable morbidity in selected cases.

A case of acute cholecystitis in Henoch–Schönlein purpura

A case of acute cholecystitis in Henoch–Schönlein purpura

CT and MR features of xanthogranulomatous cholecystitis: An analysis of consecutive 49 cases

ObjectiveTo study the CT and MR features of xanthogranulomatous cholecystitis (XGC). Materials and methods49 patients had pathologically confirmed XGC. All patients underwent contrast enhanced CT, and 10 patients had additional plain MRI. The CT and MRI results were retrospectively analyzed. ResultsOn CT, all patients had thickening of gallbladder wall, with 87.8% cases showed diffuse thickening. 85.7% cases had intramural hypo-attenuated nodules in the thickened wall. Continuous mucosal line and luminal surface enhancement were noted in 79.6% and 85.7% cases, respectively. Gallbladder stones were seen in 69.4% patients. The coexistence of the above 5 CT features was seen in 40% cases, and 80% cases had the coexistence of ≥4 features. Diffused gallbladder wall thickening in XGC is more likely to have disrupted mucosal line, and XGC with disrupted mucosal line is more likely to be associated with liver infiltration. In 60% patients the inflammatory process extended beyond gallbladder, with the interface between gallbladder and liver and/or the surrounding fat blurred. 40% cases had an early enhancement of liver parenchyma. Infiltration to other surrounding tissues included bowel (n=3), stomach (n=2), and abdominal wall (n=1). On MR images, 7 of 9 intramural nodules in 7 subjects with T1-weighted dual echo MR images showed higher signal intensity on in-phase images than out-of-phase images. ConclusionCoexisting of diffuse gallbladder wall thickening, hypo-attenuated intramural nodules, continuous mucosal line, luminal surface enhancement, and gallbladder stone highly suggest XGC. XGC frequently infiltrate liver and surrounding fat. Chemical-shift MRI helps classifying intramural nodules in the gallbladder wall.

Gross and histomorphological study of thickness of the gallbladder wall

Diffuse gallbladder wall thickening is a nonspecific alteration caused by both intrinsic and extracholecystic diseases. The incidence of gallbladder illness in our country is increasing day by day. Details morphological and histomorphological knowledge is essential for proper diagnosis &amp; management of the gallbladder diseases. This is a cross sectional descriptive type of study which was carried out in the Department of Anatomy, Sir Salimullah Medical College, Dhaka from July 2010 to June 2011. The number of sample was 62 postmortem human gallbladder which were collected from unclaimed dead bodies of the morgue of Dhaka Medical College and Sir Salimullah Medical College. The samples were divided into three different age groups. Morphological study was carried out on all samples by fine dissection method and histomorphological study was carried out on 18 relatively fresh samples by light microscopic method. There was statistically significant difference found when values were compared between different age groups. This study has revealed an age related change in the thickness of the gallbladder wall. DOI: http://dx.doi.org/10.3329/jdnmch.v18i1.12238 J. Dhaka National Med. Coll. Hos. 2012; 18 (01): 34-38

Role of multidetector CT (MDCT) in differentiation between adenomyomatois and gall bladder cancer

IntroductionAdenomyomatosis, or diverticular disease of the gallbladder, is an acquired hyperplastic lesion characterized by excessive proliferation of the surface epithelium with deepened invaginations extending into the thickened muscular layer of the gallbladder wall. The radiologic evidence of both adenomyomatosis and gallbladder cancer is focal or diffuse thickening of the gallbladder wall (1).Focal or diffuse gallbladder wall thickening is a relatively frequent observation on CT and is often incidental. It can be a dilemma for interpreting radiologists (2). Aim of the workThe purpose of this study is to determine the role of MDCT in differentiating adenomyomatosis from gallbladder cancer. PatientsThe study included 20 patients already pathologically diagnosed as adenomyomatosis or gall bladder cancer, and who had undergone pre-operative CT. MethodsPreoperative CT is reviewed for the presence and nature of morphologic gallbladder abnormalities, including the presence of intramural diverticula (Pearl necklace sign) and the presence of a non-interrupted mucosal enhancement line. ResultsPearl necklace sign was 80% accurate for the diagnosis of adenomyomatosis. Mucosal enhancement line was 100% accurate for the same diagnosis. ConclusionMDCT is an accurate technique for differentiating between gall bladder adenomayomatosis and cancer.

Xanthogranulomatous cholecystitis: characteristic CT findings

A 20-year-old lady presented with right-upper-quadrant pain and a palpable tender gall bladder. Laboratory parameters were normal except for alkaline phosphatase 225 IU/L. Contrastenhanced CT revealed over distended gall bladder (GB) with smooth circumferential wall thickening and preserved pericholecystic fat planes. A thick hypodense band was seen all along GB with a continuous mucosal contrast enhancement (Fig. 1). A preoperative diagnosis of xanthogranulomatous cholecystitis (XGC) was subsequently confirmed on histopathology following open cholecystectomy. XGC is an uncommon aggressive form of chronic cholecystitis characterized by intramural accumulation of lipidladen macrophages, believed to be triggered by extravasation of bile into the gall bladder wall from ruptured RokitanskyAschoff sinuses [1]. Although, it is widely accepted that the imaging features of XGC are non-specific, recent studies have reported certain specific findings favoring XGC [1, 2]. Goshima et al. reported that when at least three of the five CT findings were observed in combination, the sensitivity, specificity, and accuracy for the differentiation of XGC from GB carcinoma were 83%, 100% and 91%, respectively. These include: i) diffuse GB wall thickening; ii) a continuous mucosal contrast enhancement; iii) intramural hypo-attenuating nodules or band; iv) absence of macroscopic hepatic invasion; and v) absence of intra-hepatic bile duct dilatation [1]. The hypodense mural band represents the intramural accumulation of lipid-laden macrophages, while continuous mucosal line suggests an intact mucosa as opposed to the disrupted mucosa of GB carcinoma. References

Diffuse Gallbladder Wall Thickening on Computed Tomography in Patients With Liver Cirrhosis

The objective of the study was to retrospectively evaluate (a) which clinical/laboratory features are associated with the presence of diffuse gallbladder wall thickening (DGWT) in cirrhotic patients and (b) whether the degree of DGWT is correlated with such clinical/laboratory variables. After excluding patients with DGWT or laboratory test abnormalities from known causes unrelated to liver cirrhosis, a retrospective review of liver computed tomography obtained from 242 consecutive cirrhotic patients was performed by 2 radiologists in consensus to determine the presence of DGWT of greater than 3 mm in thickness and, if present, to measure the degree of DGWT defined as maximal thickness. Univariate and multivariate analysis were performed to evaluate association between presence/degree of DGWT and clinical/laboratory features. Of 242 patients, 73 (30.2%) had DGWT. Diffuse gallbladder wall thickening was seen in 7.6% (12/157) of patients with Child-Pugh class A, 61.1% (33/54) of class B, and 90.3% (28/31) of class C (P < 0.001). The presence of ascites, lower platelet count, and lower albumin level were independently associated with the presence of DGWT (P < 0.01, P = 0.01, and P = 0.02, respectively). However, these factors did not show significant correlation with the degree of DGWT. The presence of DGWT in cirrhotic patients is associated with the presence of ascites, lower platelet count, and lower albumin level. The degree of DGWT is not correlated with such variables.

Distinguishing Xanthogranulomatous Cholecystitis from the Wall-Thickening Type of Early-Stage Gallbladder Cancer

Xanthogranulomatous cholecystitis (XGC) mimics early-stage gallbladder (GB) cancer with wall thickening on computed tomography (CT), both clinically and radiologically. Preoperative differentiation of XGC from early-stage GB cancer is important for selecting the most appropriate surgical management. Therefore, we evaluated the clinical features and multidetector CT (MDCT) findings of XGC to determine whether it can be distinguished from early-stage GB cancer. We retrospectively evaluated 25 patients with XGC and 56 patients with the wall-thickening type of T1- and T2-stage GB cancer, where all of the diagnoses were pathologically confirmed by surgical treatment. All of the patients underwent preoperative MDCT. The clinical symptoms, laboratory findings, and CT findings were compared. Abdominal pain, fever, and jaundice were noted more frequently in the patients with XGC. Serum aspartate aminotransferase and alanine aminotransferase levels were more elevated in patients with XGC, whereas carbohydrate antigen (CA 19-9) was higher in the patients with GB cancer. When the T-category cancer staging of XGC and early-stage GB cancer were compared, diffuse GB wall thickening, intramural hypoattenuated nodule, gallstone, and pericholecystic infiltration were consistent significant findings associated with XGC, regardless of the cancer staging. MDCT findings such as diffuse GB wall thickening, intramural hypoattenuated nodule, gallstone, and pericholecystic infiltration together with the clinical symptoms, can provide clues for physicians to differentiate XGC from early-stage GB cancer with wall thickening on CT.

Xanthogranulomatous cholecystitis: Diagnostic performance of CT to differentiate from gallbladder cancer

Purpose To retrospectively evaluate CT findings of xanthogranulomatous cholecystitis (XGC) and to measure diagnostic performance for distinguishing it from gallbladder (GB) cancer. Methods and materials Our institutional review board approved this retrospective study. Three blinded radiologists, first independently and then in consensus, retrospectively evaluated postcontrast CT images of 35 patients with histopathologically proved XGC and GB cancer, all of whom subsequently had cholecystectomy. These included 18 patients with XGC (13 male, 5 female; age range, 35–84, mean 63 years) and 17 with GB cancer (6 male, 11 female; age range, 45–95, mean 69). Differences in CT findings between XGC and GB cancer and diagnostic performances for each CT finding were calculated. Sensitivity, specificity, and accuracy were calculated for each radiologist and observer performance was also determined by receiver-operating-characteristic curve analysis. Results Five CT findings showed significant differences between XGC and GB cancer. Sensitivity, specificity, and accuracy of each finding for the differentiation of XGC were 89%, 65%, 77% with diffuse GB wall thickening, 67%, 82%, 74% with a continuous mucosal line, 61%, 71%, 66% with intra-mural hypo-attenuated nodules, 72%, 77%, 74% with absence of macroscopic hepatic invasion, and 67%, 71%, 69% with absence of intra-hepatic bile duct dilatation, respectively. When at least three of these five CT findings were observed in combination, sensitivity, specificity, and accuracy were 83%, 100% and 91%, respectively. Sensitivities, specificities and Az values for the differentiation of XGC from GB cancer were 83%, 88%, 0.94 for reader 1, 78%, 88%, 0.93 for reader 2, and 78%, 82%, 0.84 for reader 3. Conclusions The combination of three of the five CT findings that are common with XGC can provide excellent accuracy for the differentiation of XGC and GB cancer.