Overview of cholecystitis
Yellow granulomatous cholecystitis is a destructive inflammatory disease based on chronic inflammation of the gallbladder accompanied by the formation of yellow granulomas.This disease has been gradually emphasized since the 1980’s. It is essentially an inflammatory lesion of the gallbladder, and the clinical and surgical protocols are very different from those of gallbladder cancer, which significantly affects the prognosis of patients. The incidence of this disease is low, more females than males, more common in middle-aged women, and the clinical manifestations are not specific.
Etiology
The etiology of this disease is still unclear, and the vast majority of patients are accompanied by cholelithiasis. Most scholars believe that biliary obstruction combined with bacterial infection is the key factor leading to the development of this disease. Bile and mucus infiltrate the gallbladder wall and surrounding tissues through the ruptured sinuses and ulcerated foci, causing an inflammatory reaction. Macrophages gather and phagocytose cholesterol, phospholipids and bile pigments in the bile to form the characteristic foam cells, and with the progression of the disease, the fibrous tissues proliferate and gradually form inflammatory granulomatous structures, which leads to focal or diffuse thickening of the gallbladder wall and the formation of this disease. The pathogenesis is similar to that of chronic yellow granulomatous pyelonephritis.
Symptoms
The disease can occur in both sexes, more often in women than in men, and is more common in the age group of 50 to 60 years. Clinical manifestations are not specific, and are similar to those of chronic cholecystitis, cholelithiasis and gallbladder cancer in general. It often manifests as recurrent chronic vague pain in the right upper abdomen, with nausea, vomiting, radiating pain in the lumbar and back regions and fever during acute attacks. Jaundice may occur when the gallbladder wall is granulomatous or combined with stones, and the mass may be palpable in the right upper abdomen when it is huge. In addition, when an internal fistula is formed between the gallbladder and the surrounding organs, gangrene and perforation of the gallbladder wall are often seen.
Examination
1. Ultrasonography
Diffuse or focal thickening of the gallbladder wall, thickening of the gallbladder wall is nodular hypoechoic or irregular hypoechoic bands; the gallbladder can be seen in the border is still clear mass, the shape is more regular, moderate echo; even the gallbladder liquid cavity disappeared, and replaced by a substantial mass of echogenicity.
2.CT examination
(1) Limited thickening type: the lesion does not exceed 60% of the total gallbladder. There is limited thickening of the gallbladder wall, and low-density nodules can be seen within the wall, single or multiple, as small as a few millimeters or as large as tens of millimeters.
(2) Diffuse thickening type: the lesions cover more than 60% of the gallbladder. The gallbladder is obviously enlarged, and the wall is uniformly and diffusely thickened or mass-like thickening, and the enhancement of the mucosal and plasma layers of the gallbladder wall in the arterial phase is obvious, while the enhancement of the intermediate muscular layer is relatively weak, which is like a “sandwich cracker”-like change. The muscular layer gradually strengthens in the portal vein stage.
3. Magnetic resonance examination
The gallbladder is enlarged, the wall is irregularly thickened, and multiple stones can be seen in the gallbladder cavity; single or multiple round or round-like abnormal signal shadows of different sizes can be seen in the thickened wall of the gallbladder, which are yellow nodules, with a diameter of up to 2 cm individually, and some of them can be fused into a mass; the yellow nodules can be located in the intermural area, or protrude into the submucosal layer or the subplasma layer.
Diagnosis
According to the symptoms and signs of chronic cholecystitis, combined with the imaging manifestations of diffuse or nodular thickening of the gallbladder wall; clear or unclear borders of the gallbladder wall; and fluid accumulation around the gallbladder, etc., it can suggest the diagnosis of this disease, but the final diagnosis requires surgery or puncture biopsy for pathologic examination.
Treatment
Cholecystectomy is used, and if the inflammation has invaded the adjacent liver tissue or if gallbladder cancer cannot be excluded, part of liver tissue including the gallbladder bed can be removed. However, attention should be paid to avoiding damage to the surrounding organs, hemostasis should be thorough and a drain should be placed. This disease is benign and does not recur after resection.