Difference between revisions of "Gallbladder"

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


=Normal histology=
=Normal=
==Anatomy==
*Body.
*Fundus.
*Neck.
 
Variations:
*Hartmann's pouch - invagination of the gallbladder wall at the origin of the cystic duct.
 
Image:
*[http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2020_%20Extrahepatic%20Biliary%20Tract%20and%20Gallbladder_fichiers/loadBinaryCAS7X571.jpg Hartmann's pouch (uni-plovdiv.bg)].<ref>URL: [http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2020_%20Extrahepatic%20Biliary%20Tract%20and%20Gallbladder.htm http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2020_%20Extrahepatic%20Biliary%20Tract%20and%20Gallbladder.htm]. Accessed on: 13 December 2012.</ref>
 
==Histology==
*'''No''' muscularis mucosae.
*'''No''' muscularis mucosae.
*Small amount of lymphocytes in the lamina propria.
*Small amount of lymphocytes in the lamina propria.
Image:
*[http://commons.wikimedia.org/wiki/File:Gallbladder_-_intermed_mag.jpg Normal gallbladder - intermed. mag. (WC)].


Note:
Note:
*As there is no ''muscularis mucosae'', the [[cancer staging]] is different; pT1a is lamina propria invasion. pT1b is muscle layer invasion.
*As there is no ''muscularis mucosae'', the [[cancer staging]] is different; pT1a is lamina propria invasion. pT1b is muscle layer invasion.
===Image===
<gallery>
Image:Gallbladder_-_intermed_mag.jpg | Normal gallbladder - intermed. mag. (WC/Nephron)
</gallery>


=Overview=
=Overview=
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=Common=
=Common=
==Chronic cholecystitis==
==Chronic cholecystitis==
*Abbreviated ''CC''.
{{Main|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===
*+/-[[Cholelithiasis]] - strongly associated pathology.
*+/-Strawberry-like appearance - common (due to [[gallbladder cholesterolosis]]).
**Small ridges (microvillus architecture) + yellow.
***Normal gallbladder mucosa = smooth, green.
*+/-Congestion/erythema.
*+/-Wall thickening - typically ~ 6-7 mm.<ref name=pmid21879282>{{Cite journal  | last1 = Kim | first1 = HJ. | last2 = Park | first2 = JH. | last3 = Park | first3 = DI. | last4 = Cho | first4 = YK. | last5 = Sohn | first5 = CI. | last6 = Jeon | first6 = WK. | last7 = Kim | first7 = BI. | last8 = Choi | first8 = SH. | title = Clinical usefulness of endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening. | journal = Dig Dis Sci | volume = 57 | issue = 2 | pages = 508-15 | month = Feb | year = 2012 | doi = 10.1007/s10620-011-1870-0 | PMID = 21879282 }}</ref>
 
Note:
*Wall thickening (due to congestion/edema) is the important gross finding in ''[[acute cholecystitis]]''.
*Wall thickenss greater than 10 mm should raise the suspicion of malignancy.<ref name=pmid21879282/>
 
===Microscopic===
Features:<ref name=Ref_GLP439>{{Ref GLP|439}}</ref>
*Thickening of the gallbladder wall - due to fibrosis/muscular hypertrophy - '''key feature'''.
*Chronic inflammatory cells - usu. "minimal".
**Lymphocytes - most common.
*Rokitansky-Aschoff sinuses - common.<ref>URL: [http://www.whonamedit.com/synd.cfm/983.html http://www.whonamedit.com/synd.cfm/983.html]. Accessed on: 29 October 2011.</ref>
**Entrapped epithelial crypts -- pockets of epithelium in the wall of the gallbladder.
*+/-Foamy macrophages in the lamina propria ([[cholesterolosis of the gallbladder]]).
 
DDx:
*[[Gallbladder adenocarcinoma]].
*[[Gallbladder adenomyoma]].
*[[Acute cholecystitis]] - more inflammation, lack Rokitansky-Aschoff sinuses, +/-mucosal erosions.
 
===Sign out===
<pre>
GALLBLADDER, CHOLECYSTECTOMY:
- CHRONIC CHOLECYSTITIS.
- CHOLELITHIASIS.
</pre>
 
====Micro====
The sections show gallbladder wall with hemorrhage, and activated fibroblasts.  The superficial mucosa has clusters of neutrophils.


==Acute cholecystitis==
==Acute cholecystitis==
===General===
{{Main|Acute cholecystitis}}
*Less common than ''chronic cholecystitis''.
*Usually due to gallstones.<ref name=Ref_Sternberg5_1606>{{Ref Sternberg5|1606}}</ref>
*Classically older individuals (50s and 60s) with a slight female predominance.<ref name=Ref_Sternberg5_1606>{{Sternberg5|1606}}</ref>
 
Notes:
*Pathologic diagnosis very often discordant with clinical impression.<ref name=pmid8939838>{{Cite journal  | last1 = Fitzgibbons | first1 = RJ. | last2 = Tseng | first2 = A. | last3 = Wang | first3 = H. | last4 = Ryberg | first4 = A. | last5 = Nguyen | first5 = N. | last6 = Sims | first6 = KL. | title = Acute cholecystitis. Does the clinical diagnosis correlate with the pathological diagnosis? | journal = Surg Endosc | volume = 10 | issue = 12 | pages = 1180-4 | month = Dec | year = 1996 | doi =  | PMID = 8939838 }}</ref>
 
===Gross===
Features:<ref name=Ref_Sternberg5_1606>{{Ref Sternberg5|1606}}</ref>
*Wall thickening - due to edema and hemorrhage.†
*Gallstone(s) - classically obstructing the gallbladder neck.
 
Note:
*† The sonographic criterium for "thick" is greater than 3 mm.<ref name=pmid20223393>{{Cite journal  | last1 = Tsung | first1 = JW. | last2 = Raio | first2 = CC. | last3 = Ramirez-Schrempp | first3 = D. | last4 = Blaivas | first4 = M. | title = Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED. | journal = Am J Emerg Med | volume = 28 | issue = 3 | pages = 338-42 | month = Mar | year = 2010 | doi = 10.1016/j.ajem.2008.12.003 | PMID = 20223393 }}</ref><ref name=pmid21879282>{{Cite journal  | last1 = Kim | first1 = HJ. | last2 = Park | first2 = JH. | last3 = Park | first3 = DI. | last4 = Cho | first4 = YK. | last5 = Sohn | first5 = CI. | last6 = Jeon | first6 = WK. | last7 = Kim | first7 = BI. | last8 = Choi | first8 = SH. | title = Clinical usefulness of endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening. | journal = Dig Dis Sci | volume = 57 | issue = 2 | pages = 508-15 | month = Feb | year = 2012 | doi = 10.1007/s10620-011-1870-0 | PMID = 21879282 }}</ref>
 
===Microscopic===
Features:<ref name=Ref_Sternberg5_1606>{{Ref Sternberg5|1606}}</ref>
*Edema.
*Hemorrhage.
*+/-Fibrin thrombi in small veins.
*+/-Mucosal erosions.
*+/-[[Neutrophils]] - '''useful'''
**Not essential for the Dx of ''acute cholecystitis''.
**Neutrophils usually secondary to [[necrosis]]/ulceration or infection.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref>
*+/-Reactive epithelial changes.<ref name=Ref_GLP439>{{Ref GLP|439}}</ref>
 
Notes:
*May see activated fibroblasts.
 
DDx:
*[[Chronic cholecystitis]] - has less inflammation, fibrotic wall thickening/muscular hypertrophy, may have RK sinuses.
*[[Gallbladder adenocarcinoma]].
 
====Special types====
=====Gangrenous cholecystitis=====
General:<ref name=pmid21762298>{{Cite journal  | last1 = Nikfarjam | first1 = M. | last2 = Niumsawatt | first2 = V. | last3 = Sethu | first3 = A. | last4 = Fink | first4 = MA. | last5 = Muralidharan | first5 = V. | last6 = Starkey | first6 = G. | last7 = Jones | first7 = RM. | last8 = Christophi | first8 = C. | title = Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis. | journal = HPB (Oxford) | volume = 13 | issue = 8 | pages = 551-8 | month = Aug | year = 2011 | doi = 10.1111/j.1477-2574.2011.00327.x | PMID = 21762298 }}</ref>
*Older.
*Clinically "sicker".
*Worse outcome than (acute) non-gangrenous cholecystitis.
 
Microscopic:
*[[Necrosis]] of gallbladder wall (muscularis propria).<ref>STC. 25 February 2009.</ref>
 
===Sign out===
<pre>
GALLBLADDER, CHOLECYSTECTOMY:
- ACUTE CHOLECYSTITIS.
- CHOLELITHIASIS.
</pre>


==Gallbladder cholesterolosis==
==Gallbladder cholesterolosis==
*[[AKA]] ''cholesterolosis''.
{{Main|Gallbladder cholesterolosis}}
*Informally known as ''strawberry gallbladder''.
 
===General===
*Common in [[cholecystitis]].
*Associated with yellow gallstones (cholesterol type gallstones).
 
===Gross===
Features:
*Mucosa has strawberry-like appearance.
**The similarity is in the surface texture.
**The colour (yellow) is not strawberry-like.
 
Image:
*[http://commons.wikimedia.org/wiki/File:Cholesterolosis_of_the_Gallbladder.jpg Gallbladder cholesterolosis (WC/euthman)].
 
===Microscopic===
Features:
*Numerous foamy macrophages in the lamina propria.
 
Image:
*[http://commons.wikimedia.org/wiki/File:Gallbladder_cholesterolosis_intermed_mag_cropped.jpg Cholesterolosis - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Gallbladder_cholesterolosis_micro.jpg Cholesterolosis (WC)].
 
===Sign out===
<pre>
GALLBLADDER, CHOLECYSTECTOMY:
- CHRONIC CHOLECYSTITIS WITH CHOLESTEROLOSIS.
- CHOLELITHIASIS.
</pre>


==Cholelithiasis==
==Cholelithiasis==
*[[AKA]] ''gallstones''.
*[[AKA]] ''gallstones''.
===General===
{{Main|Cholelithiasis}}
*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:<ref name=pmid18540184>{{Cite journal  | last1 = Szwed | first1 = Z. | last2 = Zyciński | first2 = P. | title = [4F's--still up to date risk factors of cholelithiasis]. | journal = Wiad Lek | volume = 60 | issue = 11-12 | pages = 570-3 | month =  | year = 2007 | doi =  | PMID = 18540184 }}</ref>
*'''F'''emale.
*'''F'''at.
*'''F'''orty.
*'''F'''ertile.
 
Additional:
*Family history.
 
====Cholesterol stones====
*More common than pigment stone.
 
Appearance:
*Clear or yellow.
*Opaque or translucent.
*Sometimes shinny.
 
Image:
*[http://commons.wikimedia.org/wiki/File:Gallensteine_2006_03_28.JPG Yellow gallstones (WC)].
 
====Pigment stones====
*Due to high [[RBC]] turnover, e.g. [[sickle cell disease]], thalassemia.
*Radio-opaque.<ref>URL: [http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20%28General%20Monographs-%20U%29/URSOFALK.html 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.</ref>
 
Appearance:
*Black - '''key feature'''.
*Dull.


=Less common pathologic diagnoses=
=Less common pathologic diagnoses=
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*[[Gallbladder carcinoma]].
*[[Gallbladder carcinoma]].
*[[Chronic cholecystitis]] - has less muscular hypertrophy; overlaps with this diagnosis.<ref name=Ref_GLP439>{{Ref GLP|439}}</ref>
*[[Chronic cholecystitis]] - has less muscular hypertrophy; overlaps with this diagnosis.<ref name=Ref_GLP439>{{Ref GLP|439}}</ref>
*Phrygian cap.<reF>URL: [http://radiopaedia.org/articles/phrygian_cap http://radiopaedia.org/articles/phrygian_cap]. Accessed on: 16 May 2014.</ref>
====Image====
*[http://pubs.rsna.org/na101/home/literatum/publisher/rsna/journals/content/radiographics/2006/radiographics.2006.26.issue-3/rg.263055180/production/images/medium/g06ma19c05x.jpeg Adenomyomatosis of the gallbladder (radiographics.rsna.org)].<ref name=pmid16702464/>


Image:
===Sign out===
*[http://radiographics.rsna.org/content/26/3/941/F10.expansion.html Adenomyomatosis of the gallbladder (radiographics.rsna.org)].<ref name=pmid16702464/>
<pre>
GALLBLADDER, CHOLECYSTECTOMY:
- CHRONIC CHOLECYSTITIS WITH MILD CHOLESTEROLOSIS AND ADENOMYOSIS (FUNDUS).
- CHOLELITHIASIS.
</pre>


==Gallbladder polyps==
==Gallbladder polyps==
Line 242: Line 101:
**+/-Intestinal metaplasia --> goblet cells.
**+/-Intestinal metaplasia --> goblet cells.


=Premalignant lesions=
==Gallbladder diverticulosis==
===General===
===General===
*Metaplasia associated with carcinoma.<ref name=pmid8364865>{{cite journal |author=Duarte I, Llanos O, Domke H, Harz C, Valdivieso V |title=Metaplasia and precursor lesions of gallbladder carcinoma. Frequency, distribution, and probability of detection in routine histologic samples |journal=Cancer |volume=72 |issue=6 |pages=1878–84 |year=1993 |month=September |pmid=8364865 |doi= |url=}}</ref>
*Uncommon.
 
*Thought to arise in the context of an outflow obstruction.<ref name=pmid4963758>{{Cite journal | last1 = Beilby | first1 = JO. | title = Diverticulosis of the gall bladder. The fundal adenoma. | journal = Br J Exp Pathol | volume = 48 | issue = 4 | pages = 455-61 | month = Aug | year = 1967 | doi = | PMID = 4963758 | PMC = 2093791 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2093791/}}</ref>
Hypothesis:<ref name=pmid15737036>{{cite journal |author=Mukhopadhyay S, Landas SK |title=Putative precursors of gallbladder dysplasia: a review of 400 routinely resected specimens |journal=Arch. Pathol. Lab. Med. |volume=129 |issue=3 |pages=386–90 |year=2005 |month=March |pmid=15737036 |doi= |url=http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2 }}</ref>
*Antral type metaplasia --> intestinal metaplasia --> dysplasia --> carcinoma.
 
==Intestinal metaplasia of the gallbladder==
*[[AKA]] ''gallbladder [[intestinal metaplasia]]''.
===General===
Significance:
*Increased risk of carcinoma.<ref name=pmid8364865/>


===Microscopic===
===Microscopic===
Features:<ref name=pmid2872152>{{Cite journal  | last1 = Albores-Saavedra | first1 = J. | last2 = Nadji | first2 = M. | last3 = Henson | first3 = DE. | last4 = Ziegels-Weissman | first4 = J. | last5 = Mones | first5 = JM. | title = Intestinal metaplasia of the gallbladder: a morphologic and immunocytochemical study. | journal = Hum Pathol | volume = 17 | issue = 6 | pages = 614-20 | month = Jun | year = 1986 | doi =  | PMID = 2872152 }}</ref>
Features:
*[[Goblet cell]]s - '''key feature'''.
*Mucosal pouch penetrating the muscularis propria of the gallbladder wall - '''key feature'''.
*+/-Paneth cells.<ref name=Ref_Sternberg4_1789>{{Ref Sternberg4|1789}}</ref>
 
Note:
*Often accompanied by antral type metplasia.
**Gastric antral-type epithelium - may form glands.


DDx:
DDx:
*[[Gallbladder adenocarcinoma]].
*[[Chronic cholecystitis]].
 
*[[Gallbladder adenomyosis]].
Image:
*[http://www.archivesofpathology.org/action/showFullPopup?id=i1543-2165-129-3-386-f01&doi=10.1043%2F1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2 IM - among other things (archivesofpathology.org)].<ref name=pmid15737036/>


===Sign out===
===Sign out===
<pre>
<pre>
GALLBLADDER, CHOLECYSTECTOMY:  
GALLBLADDER, CHOLECYSTECTOMY:
- INTESTINAL METAPLASIA OF THE GALLBLADDER, FOCAL.
- CHRONIC CHOLECYSTITIS WITH DIVERTICULOSIS.
- CHRONIC CHOLECYSTITIS.  
- CHOLELITHIASIS.
- CHOLELITHIASIS.
- NEGATIVE FOR DYSPLASIA.
</pre>
</pre>
==Xanthogranulomatous cholecystitis==
*Abbreviated ''XGC''.
{{Main|Xanthogranulomatous cholecystitis}}
==Pancreatic heterotopia==
[[File:Gallbladder mass benign A sl 1.png|Pancreatic heterotopia in 35 year old women]]
[[File:Gallbladder mass benign A sl 2.png|Pancreatic heterotopia in 35 year old women]]
[[File:Gallbladder mass benign A sl 3.png|Pancreatic heterotopia in 35 year old women]]
[[File:Gallbladder mass benign A sl 4.png|Pancreatic heterotopia in 35 year old women]]<br>
Pancreatic heterotopia near cystic duct in 35 year old women. A. The cystic duct margin is at right; the heterotopia, at left. This cannot be a portion of the pancreas because the cystic duct margin lies proximal to the common bile duct. B. Pancreatic ducts with lobular proliferation, but without the inflammation that would usually be present were this obstruction by a gallstone. C. Nuclei of the duct and the proliferated bile ductules are bland. D. Acini are unremarkable; no pancreatic islets were seen in this case.
=Premalignant lesions=
===General===
*Metaplasia associated with carcinoma.<ref name=pmid8364865>{{cite journal |author=Duarte I, Llanos O, Domke H, Harz C, Valdivieso V |title=Metaplasia and precursor lesions of gallbladder carcinoma. Frequency, distribution, and probability of detection in routine histologic samples |journal=Cancer |volume=72 |issue=6 |pages=1878–84 |year=1993 |month=September |pmid=8364865 |doi= |url=}}</ref>
Hypothesis:<ref name=pmid15737036>{{cite journal |author=Mukhopadhyay S, Landas SK |title=Putative precursors of gallbladder dysplasia: a review of 400 routinely resected specimens |journal=Arch. Pathol. Lab. Med. |volume=129 |issue=3 |pages=386–90 |year=2005 |month=March |pmid=15737036 |doi= |url=http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2 }}</ref>
*Antral type metaplasia --> intestinal metaplasia --> dysplasia --> carcinoma.
==Intestinal metaplasia of the gallbladder==
*[[AKA]] ''gallbladder [[intestinal metaplasia]]''.
{{Main|Intestinal metaplasia of the gallbladder}}


==Antral type metaplasia==
==Antral type metaplasia==
Line 299: Line 163:
*[http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2 Gallbladder metaplasias (archivesofpathology.org)].<ref name=pmid15737036>{{cite journal |author=Mukhopadhyay S, Landas SK |title=Putative precursors of gallbladder dysplasia: a review of 400 routinely resected specimens |journal=Arch. Pathol. Lab. Med. |volume=129 |issue=3 |pages=386–90 |year=2005 |month=March |pmid=15737036 |doi= |url=http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2 }}</ref>
*[http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2 Gallbladder metaplasias (archivesofpathology.org)].<ref name=pmid15737036>{{cite journal |author=Mukhopadhyay S, Landas SK |title=Putative precursors of gallbladder dysplasia: a review of 400 routinely resected specimens |journal=Arch. Pathol. Lab. Med. |volume=129 |issue=3 |pages=386–90 |year=2005 |month=March |pmid=15737036 |doi= |url=http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282005%29129%3C386%3APPOGDA%3E2.0.CO%3B2 }}</ref>


==Gallbladder dysplasia==
===Sign out===
===General===
<pre>
*Premalignant lesion.
Gallbladder, Cholecystectomy:
 
- Chronic cholecystitis with antral-type metaplasia, NEGATIVE for dysplasia.
===Microscopic===
- Cholelithiasis.
Features:
</pre>
*Gallbladder epithelium with:
**Nuclear crowding - '''key feature'''.
**Nuclear hyperchromasia.
**+/-Goblet cells.


Notes:
==Gallbladder adenoma==
*Like in the colon.
:''Gallbladder dysplasia'' is covered in ''[[gallbladder adenoma]]''.
{{Main|Gallbladder adenoma}}


DDx:
==Intracholecystic Papillary Neoplasm<ref>{{Cite journal  | last1 = Adsay | first1 = V. | last2 = Jang | first2 = KT. | last3 = Roa | first3 = JC. | last4 = Dursun | first4 = N. | last5 = Ohike | first5 = N. | last6 = Bagci | first6 = P. | last7 = Basturk | first7 = O. | last8 = Bandyopadhyay | first8 = S. | last9 = Cheng | first9 = JD. | title = Intracholecystic papillary-tubular neoplasms (ICPN) of the gallbladder (neoplastic polyps, adenomas, and papillary neoplasms that are ≥1.0 cm): clinicopathologic and immunohistochemical analysis of 123 cases. | journal = Am J Surg Pathol | volume = 36 | issue = 9 | pages = 1279-301 | month = Sep | year = 2012 | doi = 10.1097/PAS.0b013e318262787c | PMID = 22895264 }}
*[[Gallbladder adenocarcinoma]].
</ref>==


===Sign out===
*All of the gallbladder should be submitted prior to sign out to exclude non-sampled adenocarcinoma.
=Malignant=
==Gallbladder carcinoma==
*[[AKA]] ''gallbladder adenocarcinoma''.
===General===
===General===
*Uncommon.
*Probably some overlap with 'adenoma' above
*Lesion defined as being >1cm.
*Low-grade lesions previously designated “papillary adenoma”
*High-grade lesions previously designated “noninvasive papillary carcinoma.”
*Oten arise in a background of pyloric-gland metaplasia.
*May be associated with invasive adenocarcinoma, which should be reported as intracystic papillary neoplasm with an associated invasive carcinoma and staged.


Treatment:
*Population
*Cholecystectomy +/- lymph nodes +/- partial hepatectomy.<ref name=pmid20639849>{{Cite journal  | last1 = Biswas | first1 = PK. | title = Carcinoma gallbladder. | journal = Mymensingh Med J | volume = 19 | issue = 3 | pages = 477-81 | month = Jul | year = 2010 | doi =  | PMID = 20639849 }}</ref>
**Female (F/M=2:1)
**Mean age 61
*Presentations
**Pain
**Incidental
*No particular association with gallstones.


====Epidemiology====
===Microscopic===
*Associated with gallstones.
*Cell types
*Increased risk in [[primary sclerosing cholangitis]].
**Pancreatobiliary type
*Sex: female > male.
**Intestinal types with goblet, Paneth, and/or serotonin-containing cells.
*Location: usually fundus, sometimes body.
*Architecture
 
**Papillary
Notes:
**Tubulopapillary
*Diffuse calcification of gallbladder wall, [[AKA]] "porcelain gallbladder" is '''not''' associated with carcinoma - based on a series of 10,741 cholecystectomies.<ref name=pmid11206901>{{cite journal |author=Towfigh S, McFadden DW, Cortina GR, ''et al'' |title=Porcelain gallbladder is not associated with gallbladder carcinoma |journal=Am Surg |volume=67 |issue=1 |pages=7?0 |year=2001 |month=January |pmid=11206901 |doi= |url=}}</ref>
**Tubular
**Focal mucosal calcification ''is'' associated with malignancy.<ref name=pmid11391368>{{Cite journal  | last1 = Stephen | first1 = AE. | last2 = Berger | first2 = DL. | title = Carcinoma in the porcelain gallbladder: a relationship revisited. | journal = Surgery | volume = 129 | issue = 6 | pages = 699-703 | month = Jun | year = 2001 | doi = 10.1067/msy.2001.113888 | PMID = 11391368 }}</ref>
*Dysplasia - high or low grade
*[[Cholangiocarcinoma]] is dealt with in the ''[[liver neoplasms]]'' article.
 
===Gross===
*Classic: mass projecting into the lumen.
*Marked gallbladder wall thickening.
**>10 mm should be considered with suspicion.<ref name=pmid21879282>{{Cite journal  | last1 = Kim | first1 = HJ. | last2 = Park | first2 = JH. | last3 = Park | first3 = DI. | last4 = Cho | first4 = YK. | last5 = Sohn | first5 = CI. | last6 = Jeon | first6 = WK. | last7 = Kim | first7 = BI. | last8 = Choi | first8 = SH. | title = Clinical usefulness of endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening. | journal = Dig Dis Sci | volume = 57 | issue = 2 | pages = 508-15 | month = Feb | year = 2012 | doi = 10.1007/s10620-011-1870-0 | PMID = 21879282 }}</ref>


Image:
<gallery>
*[http://www.flickr.com/photos/santoshpath/5245332515/ Papillary gallbladder adenocarcinoma (flickr.com)].
Image:GallBladder IntracysticPapillaryNeoplasm WA InvasiveAdenocarcinoma LP CTR.jpg|Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - Low power (SKB)
===Microscopic===
Image:GallBladder IntracysticPapillaryNeoplasm WA InvasiveAdenocarcinoma HP CTR.jpg|Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - High power (SKB)
Features:
Image:GallBladder IntracysticPapillaryNeoplasm WA InvasiveAdenocarcinoma HP3 CTR.jpg|Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - High power (SKB)
*Usually adenocarcinoma.
Image:GallBladder IntracysticPapillaryNeoplasm WA InvasiveAdenocarcinoma HP2 CTR.jpg|Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - High power (SKB)
**Mimics appearance of [[pancreatic ductal adenocarcinoma]] -- but less cellular mucin.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref>
Image:GallBladder IntracysticPapillaryNeoplasm WA InvasiveAdenocarcinoma MP CTR.jpg|Gall Bladder - - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - Malignant gland infiltrating stroma - High power (SKB)
Image:GallBladder IntracysticPapillaryNeoplasm WA InvasiveAdenocarcinoma HP4 CTR.jpg|Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma -  - Malignant gland infiltrating stroma - Very high power (SKB)
Image:Gallbladder IntracysticPapillaryNeoplasm HighGradeDysplasia LP PA.JPG|Gall Bladder - Intracholecystic Papillary Neoplasm with high grade dysplasia - Low power (SKB)
Image:Gallbladder IntracysticPapillaryNeoplasm HighGradeDysplasia MP PA.JPG|Gall Bladder - Intracholecystic Papillary Neoplasm with high grade dysplasia - Medium power (SKB)
</gallery>


Notes:
Notes:
*May be very subtle, i.e. difficult to differentiate from normal glands.
All of the gallbladder should be submitted prior to sign out to exclude invasive adenocarcinoma.


DDx:
=Malignant=
*[[Adenomyoma of the gallbladder]].
==Gallbladder carcinoma==
*[[metastasis|Metastatic carcinoma]].
{{Main|Gallbladder carcinoma}}
**[[Cholangiocarcinoma]].


=See also=
=See also=
Line 366: Line 228:
{{reflist|2}}
{{reflist|2}}


[[Category:Gallbladder]]
[[Category:Gastrointestinal pathology]]
[[Category:Gastrointestinal pathology]]

Latest revision as of 14:06, 30 October 2017

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

Normal

Anatomy

  • Body.
  • Fundus.
  • Neck.

Variations:

  • Hartmann's pouch - invagination of the gallbladder wall at the origin of the cystic duct.

Image:

Histology

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

Note:

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

Image

  • Normal gallbladder - intermed. mag. (WC/Nephron)

Overview

Most common:

  • Cholelithiasis with cholecystitis.

Common:

  • Antral-type metaplasia.

Uncommon:

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

Common

Chronic cholecystitis

Main article: Chronic cholecystitis

Acute cholecystitis

Main article: Acute cholecystitis

Gallbladder cholesterolosis

Main article: Gallbladder cholesterolosis

Cholelithiasis

  • AKA gallstones.
Main article: Cholelithiasis

Less common pathologic diagnoses

Adenomyoma of the gallbladder

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

General

  • Glands in muscle.
  • Analogous to what happens in the uterus.
  • Significance - may mimic malignant tumours of the gallbladder.[2][3]
  • Uncommon.

Gross

  • Cystic spaces (Rokitansky-Aschoff sinuses) - may be seen on imaging.[4][5]
  • Gallbladder wall thickening.

Microscopic

Features:[6]

  • Glands in muscularis propria of the gallbladder wall - key feature.
  • Significant muscular hypertrophy - key feature.
  • No nuclear atypia.

DDx:

Image

Sign out

GALLBLADDER, CHOLECYSTECTOMY:
- CHRONIC CHOLECYSTITIS WITH MILD CHOLESTEROLOSIS AND ADENOMYOSIS (FUNDUS).
- CHOLELITHIASIS.

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:[8]

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

Gallbladder diverticulosis

General

  • Uncommon.
  • Thought to arise in the context of an outflow obstruction.[9]

Microscopic

Features:

  • Mucosal pouch penetrating the muscularis propria of the gallbladder wall - key feature.

DDx:

Sign out

GALLBLADDER, CHOLECYSTECTOMY:
- CHRONIC CHOLECYSTITIS WITH DIVERTICULOSIS.
- CHOLELITHIASIS.

Xanthogranulomatous cholecystitis

  • Abbreviated XGC.
Main article: Xanthogranulomatous cholecystitis

Pancreatic heterotopia

Pancreatic heterotopia in 35 year old women Pancreatic heterotopia in 35 year old women Pancreatic heterotopia in 35 year old women Pancreatic heterotopia in 35 year old women
Pancreatic heterotopia near cystic duct in 35 year old women. A. The cystic duct margin is at right; the heterotopia, at left. This cannot be a portion of the pancreas because the cystic duct margin lies proximal to the common bile duct. B. Pancreatic ducts with lobular proliferation, but without the inflammation that would usually be present were this obstruction by a gallstone. C. Nuclei of the duct and the proliferated bile ductules are bland. D. Acini are unremarkable; no pancreatic islets were seen in this case.

Premalignant lesions

General

  • Metaplasia associated with carcinoma.[10]

Hypothesis:[11]

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

Intestinal metaplasia of the gallbladder

Main article: Intestinal metaplasia of the gallbladder

Antral type metaplasia

General

  • AKA pyloric metaplasia, pseudopyloric metaplasia, mucous gland metaplasia.[12]

Microscopic

Features:[12]

  • 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[12] and common bile duct.[13]
    • 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:

Sign out

Gallbladder, Cholecystectomy:
- Chronic cholecystitis with antral-type metaplasia, NEGATIVE for dysplasia.
- Cholelithiasis.

Gallbladder adenoma

Gallbladder dysplasia is covered in gallbladder adenoma.
Main article: Gallbladder adenoma

Intracholecystic Papillary Neoplasm[14]

General

  • Probably some overlap with 'adenoma' above
  • Lesion defined as being >1cm.
  • Low-grade lesions previously designated “papillary adenoma”
  • High-grade lesions previously designated “noninvasive papillary carcinoma.”
  • Oten arise in a background of pyloric-gland metaplasia.
  • May be associated with invasive adenocarcinoma, which should be reported as intracystic papillary neoplasm with an associated invasive carcinoma and staged.
  • Population
    • Female (F/M=2:1)
    • Mean age 61
  • Presentations
    • Pain
    • Incidental
  • No particular association with gallstones.

Microscopic

  • Cell types
    • Pancreatobiliary type
    • Intestinal types with goblet, Paneth, and/or serotonin-containing cells.
  • Architecture
    • Papillary
    • Tubulopapillary
    • Tubular
  • Dysplasia - high or low grade

  • Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - Low power (SKB)

  • Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - High power (SKB)

  • Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - High power (SKB)

  • Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - High power (SKB)

  • Gall Bladder - - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - Malignant gland infiltrating stroma - High power (SKB)

  • Gall Bladder - Intracholecystic Papillary Neoplasm with Invasive Adenocarcinoma - - Malignant gland infiltrating stroma - Very high power (SKB)

  • Gall Bladder - Intracholecystic Papillary Neoplasm with high grade dysplasia - Low power (SKB)

  • Gall Bladder - Intracholecystic Papillary Neoplasm with high grade dysplasia - Medium power (SKB)

Notes: All of the gallbladder should be submitted prior to sign out to exclude invasive adenocarcinoma.

Malignant

Gallbladder carcinoma

Main article: Gallbladder carcinoma

See also

References

  1. ↑ URL: http://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2020_%20Extrahepatic%20Biliary%20Tract%20and%20Gallbladder.htm. Accessed on: 13 December 2012.
  2. ↑ Saul, WM.; Herrmann, PK. (1988). "[Adenomyoma of the gallbladder].". Dtsch Z Verdau Stoffwechselkr 48 (2): 112-6. PMID 3168899.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 5.0 5.1 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.
  6. ↑ 6.0 6.1 Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 439. ISBN 978-0443066573.
  7. ↑ URL: http://radiopaedia.org/articles/phrygian_cap. Accessed on: 16 May 2014.
  8. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 172. ISBN 978-0470519035.
  9. ↑ Beilby, JO. (Aug 1967). "Diverticulosis of the gall bladder. The fundal adenoma.". Br J Exp Pathol 48 (4): 455-61. PMC 2093791. PMID 4963758. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2093791/.
  10. ↑ 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.
  11. ↑ 11.0 11.1 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.
  12. ↑ 12.0 12.1 12.2 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.
  13. ↑ Cutz, E. 3 March 2011.
  14. ↑ Adsay, V.; Jang, KT.; Roa, JC.; Dursun, N.; Ohike, N.; Bagci, P.; Basturk, O.; Bandyopadhyay, S. et al. (Sep 2012). "Intracholecystic papillary-tubular neoplasms (ICPN) of the gallbladder (neoplastic polyps, adenomas, and papillary neoplasms that are ≥1.0 cm): clinicopathologic and immunohistochemical analysis of 123 cases.". Am J Surg Pathol 36 (9): 1279-301. doi:10.1097/PAS.0b013e318262787c. PMID 22895264.
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