Difference between revisions of "Gallbladder"

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(split 'cholecystitis' -- into 'chronic' and 'acute')
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=Common=
=Common=
==Cholecystitis==
==Chronic cholecystitis==
===General===
===General===
====Epidemiology====
====Epidemiology====
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===Microscopic===
===Microscopic===
====Chronic cholecystitis====
Features:
Features:
*Rokitansky-Aschoff sinuses.<ref>URL: [http://www.whonamedit.com/synd.cfm/983.html http://www.whonamedit.com/synd.cfm/983.html]. Accessed on: 29 October 2011.</ref>
*Rokitansky-Aschoff sinuses.<ref>URL: [http://www.whonamedit.com/synd.cfm/983.html http://www.whonamedit.com/synd.cfm/983.html]. Accessed on: 29 October 2011.</ref>
Line 51: Line 50:
*Chronic inflammatory cells (lymphocytes - most common).
*Chronic inflammatory cells (lymphocytes - most common).
*Fibrotic thickening of the gallbladder wall.
*Fibrotic thickening of the gallbladder wall.
====Acute cholecystitis====
*[[Neutrophils]] - usually secondary to [[necrosis]]/ulceration or infection.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref>
**Not essential for the Dx of cholecystitis.


====Gangrenous cholecystitis====
====Gangrenous cholecystitis====
*[[Necrosis]] of gallbladder wall (muscularis propria).<ref>STC. 25 February 2009.</ref>
*[[Necrosis]] of gallbladder wall (muscularis propria).<ref>STC. 25 February 2009.</ref>
==Acute cholecystitis==
===General===
*Less common than ''chronic cholecystitis''.
*Usually due to gallstones.<ref name=Ref_Sternberg5_1606>{{Sternberg5|1606}}</ref>
*Classically older individuals (50s and 60s) with a slight female predominance.<ref name=Ref_Sternberg5_1606>{{Sternberg5|1606}}</ref>
===Gross===
Features:<ref name=Ref_Sternberg5_1606>{{Sternberg5|1606}}</ref>
*Wall thickening - due to edema and hemorrhage.
*Gallstone(s) - classically obstructing the gallbladder neck.
===Microscopic===
Features:<ref name=Ref_Sternberg5_1606>{{Sternberg5|1606}}</ref>
*Edema.
*Hemorrhage.
*+/-Fibrin thrombi in small veins.
*+/-Mucosal erosions.
*+/-[[Neutrophils]].
**Not essential for the Dx of ''acute cholecystitis''.
**Neutrophils usually secondary to [[necrosis]]/ulceration or infection.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref>


==Gallbladder cholesterolosis==
==Gallbladder cholesterolosis==

Revision as of 00:35, 12 August 2012

The gallbladder, in pathology (and general surgery), is a growth industry... due to the worsening obesity epidemic.

Normal histology

  • No muscularis mucosae.
  • Small amount of lymphocytes in the lamina propria.

Image:

Note:

  • As there is no muscularis mucosae, the cancer staging is different; pT1a is lamina propria invasion. pT1b is muscle layer invasion.

Overview

Most common:

  • Cholelithiasis with cholecystitis.

Common:

  • Antral-type metaplasia.

Uncommon:

  • Intestinal metaplasia.
  • Gallbladder dysplasia.
  • Gallbladder carcinoma.

Common

Chronic cholecystitis

General

Epidemiology

  • Female, fat, fertile, family history, forty (though now getting younger... as people get fatter).

Etiology

  • Cholelithiasis.
  • Thick bile (acalculous cholecystitis).

Clinical (classic)

  • Constant right upper quadrant pain after a fatty meal.
  • Positive Murphy's sign (physical exam, with ultrasound).

Gross

  • Strawberry-like appearance - common (due to cholesterolosis -- see below)
    • Small ridges (microvillus architecture).
      • Normal gallbladder mucosa = smooth.
  • Congestion/erythema.

Microscopic

Features:

  • Rokitansky-Aschoff sinuses.[1]
    • Entrapped epithelial crypts -- pockets of epithelium in the wall of the gallbladder.
  • +/-Foamy macrophages in the lamina propria (cholesterolosis of the gallbladder).
  • Chronic inflammatory cells (lymphocytes - most common).
  • Fibrotic thickening of the gallbladder wall.

Gangrenous cholecystitis

Acute cholecystitis

General

  • Less common than chronic cholecystitis.
  • Usually due to gallstones.[3]
  • Classically older individuals (50s and 60s) with a slight female predominance.[3]

Gross

Features:[3]

  • Wall thickening - due to edema and hemorrhage.
  • Gallstone(s) - classically obstructing the gallbladder neck.

Microscopic

Features:[3]

  • Edema.
  • Hemorrhage.
  • +/-Fibrin thrombi in small veins.
  • +/-Mucosal erosions.
  • +/-Neutrophils.
    • Not essential for the Dx of acute cholecystitis.
    • Neutrophils usually secondary to necrosis/ulceration or infection.[4]

Gallbladder cholesterolosis

  • AKA cholesterolosis.
  • Informally known as strawberry gallbladder.

General

  • Common in cholecystitis.
  • Associated with yellow gallstones (cholesterol type gallstones).

Gross

Features:

  • Mucosa has strawberry-like appearance.

Microscopic

Features:

  • Foamy macrophages in the lamina propria.

Image:

Cholelithiasis

  • AKA gallstones.

General

  • Often accompanies cholecystitis/contributes and/or causes cholecystitis.

The two types of gallstones:

  • Cholesterol stones.
  • Pigment stones.

Note:

  • Most stones technically speaking are a mix, i.e. cholesterol and pigment. Many call yellow stones that are a mix "cholesterol stones".

Epidemiology

Classic risk factors for gallstones - 4 Fs:[5]

  • Female.
  • Fat.
  • Forty.
  • Fertile.

Additional:

  • Family history.

Cholesterol stones

  • More common than pigment stone.

Appearance:

  • Clear or yellow.
  • Opaque or translucent.
  • Sometimes shinny.

Image:

Pigment stones

Appearance:

  • Black - key feature.
  • Dull.

Less common pathologic diagnoses

Adenomyoma of the gallbladder

  • AKA gallbladder adenomyosis.
  • AKA adenomyomatosis of the gallbladder.

General

  • Glands in muscle.
  • Analogous to what happens in the uterus.
  • Significance - may mimic malignant tumours of the gallbladder.[7][8]
  • Uncommon.

Gross

  • Cystic spaces (Rokitansky-Aschoff sinuses) - may be seen on imaging.[9][10]
  • Gallbladder wall thickening.

Microscopic

Features:

  • Glands in muscularis propria of the gallbladder wall.
  • No nuclear atypia.

DDx:

Image:

Gallbladder polyps

General

  • Polyps are significant as they may be adenomatous, i.e. pre-cancerous.
  • These are similar to polyps found elsewhere GI tract.

Microscopic

See intestinal polyps.

Flat dysplasia:[11]

  • Nuclear changes.
    • Increased NC ratio.
    • Hyperchromasia (essential).
    • +/-Intestinal metaplasia --> goblet cells.

Premalignant lesions

General

  • Metaplasia associated with carcinoma.[12]

Hypothesis:[13]

  • Antral type metaplasia --> intestinal metaplasia --> dysplasia --> carcinoma.

Intestinal metaplasia

General

Significance:

  • Increased risk of carcinoma.[12]

Microscopic

Features:

Antral type metaplasia

General

  • AKA pyloric metaplasia, pseudopyloric metaplasia, mucous gland metaplasia.[14]

Microscopic

Features:[14]

  • Columnar cells with:
    • Abundant, pale, apical mucin.
    • Small basal nucleus.
  • Cells often in nests -- below luminal surface.
  • Cells vaguely resemble foveollar epithelium of the stomach.

Notes:

  • May look similar to cells of the gallbladder neck[14] and common bile duct.[15]
    • These glandular cells are not as columnar and have less well-defined cell borders.
      • Cells with antral type metaplasia >2:1 (height:width), benign mucosal glands <2:1.

Images:

Gallbladder dysplasia

General

  • Premalignant lesion.

Microscopic

Features:

  • Nuclear crowding.
  • Nuclear hyperchromasia.

Notes:

  • Like in the colon.

Gallbladder carcinoma

General

Epidemiology

Notes:

  • Diffuse calcification of gallbladder wall, AKA "porcelain gallbladder" is not associated with carcinoma - based on a series of 10,741 cholecystectomies.[16]
    • Focal mucosal calcification is associated with malignancy.[17]
  • Cholangiocarcinoma is dealt with in the liver neoplasms article.

Gross

  • Classically mass projects into the lumen.

Image:

Microscopic

Features:

Notes:

  • May be very subtle, i.e. difficult to differentiate from normal glands.

DDx:

See also

References

  1. ↑ URL: http://www.whonamedit.com/synd.cfm/983.html. Accessed on: 29 October 2011.
  2. ↑ STC. 25 February 2009.
  3. ↑ 3.0 3.1 3.2 3.3 Template:Sternberg5
  4. ↑ 4.0 4.1 Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 174. ISBN 978-0470519035.
  5. ↑ Szwed, Z.; Zyciński, P. (2007). "[4F's--still up to date risk factors of cholelithiasis].". Wiad Lek 60 (11-12): 570-3. PMID 18540184.
  6. ↑ URL: http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20%28General%20Monographs-%20U%29/URSOFALK.html. Accessed on: 29 October 2011.
  7. ↑ Saul, WM.; Herrmann, PK. (1988). "[Adenomyoma of the gallbladder].". Dtsch Z Verdau Stoffwechselkr 48 (2): 112-6. PMID 3168899.
  8. ↑ Sasatomi, E.; Miyazaki, K.; Mori, M.; Satoh, T.; Nakano, S.; Tokunaga, O. (Oct 1997). "Polypoid adenomyoma of the gallbladder.". J Gastroenterol 32 (5): 704-7. PMID 9350002.
  9. ↑ Ching, BH.; Yeh, BM.; Westphalen, AC.; Joe, BN.; Qayyum, A.; Coakley, FV. (Jul 2007). "CT differentiation of adenomyomatosis and gallbladder cancer.". AJR Am J Roentgenol 189 (1): 62-6. doi:10.2214/AJR.06.0866. PMID 17579153.
  10. ↑ 10.0 10.1 Boscak, AR.; Al-Hawary, M.; Ramsburgh, SR.. "Best cases from the AFIP: Adenomyomatosis of the gallbladder.". Radiographics 26 (3): 941-6. doi:10.1148/rg.263055180. PMID 16702464.
  11. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 172. ISBN 978-0470519035.
  12. ↑ 12.0 12.1 Duarte I, Llanos O, Domke H, Harz C, Valdivieso V (September 1993). "Metaplasia and precursor lesions of gallbladder carcinoma. Frequency, distribution, and probability of detection in routine histologic samples". Cancer 72 (6): 1878–84. PMID 8364865.
  13. ↑ 13.0 13.1 Mukhopadhyay S, Landas SK (March 2005). "Putative precursors of gallbladder dysplasia: a review of 400 routinely resected specimens". Arch. Pathol. Lab. Med. 129 (3): 386–90. PMID 15737036. http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2.
  14. ↑ 14.0 14.1 14.2 14.3 Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Oberman, Harold A; Reuter, Victor E (2004). Sternberg's Diagnostic Surgical Pathology (4th ed.). Lippincott Williams & Wilkins. pp. 1789. ISBN 978-0781740517.
  15. ↑ EC. 3 March 2011.
  16. ↑ Towfigh S, McFadden DW, Cortina GR, et al (January 2001). "Porcelain gallbladder is not associated with gallbladder carcinoma". Am Surg 67 (1): 7?0. PMID 11206901.
  17. ↑ Stephen, AE.; Berger, DL. (Jun 2001). "Carcinoma in the porcelain gallbladder: a relationship revisited.". Surgery 129 (6): 699-703. doi:10.1067/msy.2001.113888. PMID 11391368.
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