Difference between revisions of "Gallbladder"
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*+/-Fibrin thrombi in small veins. | *+/-Fibrin thrombi in small veins. | ||
*+/-Mucosal erosions. | *+/-Mucosal erosions. | ||
*+/-[[Neutrophils]] | *+/-[[Neutrophils]] - '''useful''' | ||
**Not essential for the Dx of ''acute cholecystitis''. | **Not essential for the Dx of ''acute cholecystitis''. | ||
**Neutrophils usually secondary to [[necrosis]]/ulceration or infection.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref> | **Neutrophils usually secondary to [[necrosis]]/ulceration or infection.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref> | ||
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Microscopic: | Microscopic: | ||
*[[Necrosis]] of gallbladder wall (muscularis propria).<ref>STC. 25 February 2009.</ref> | *[[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== | ||
Revision as of 15:23, 28 September 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
- +/-Cholelithiasis - strongly associated pathology.
- +/-Strawberry-like appearance - common (due to gallbladder cholesterolosis).
- Small ridges (microvillus architecture).
- Normal gallbladder mucosa = smooth.
- Small ridges (microvillus architecture).
- +/-Congestion/erythema.
- +/-Wall thickening.
- Seen in acute cholecystitis (due to congestion/edema).
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.
DDx:
Sign out
GALLBLADDER, CHOLECYSTECTOMY: - CHRONIC CHOLECYSTITIS. - CHOLELITHIASIS.
Acute cholecystitis
General
- Less common than chronic cholecystitis.
- Usually due to gallstones.[2]
- Classically older individuals (50s and 60s) with a slight female predominance.[2]
Notes:
- Pathologic diagnosis very often discordant with clinical impression.[3]
Gross
Features:[2]
- 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.[4]
Microscopic
Features:[2]
- Edema.
- Hemorrhage.
- +/-Fibrin thrombi in small veins.
- +/-Mucosal erosions.
- +/-Neutrophils - useful
Special types
Gangrenous cholecystitis
General:[6]
- Older.
- Clinically "sicker".
- Worse outcome than (acute) non-gangrenous cholecystitis.
Microscopic:
=Sign out
GALLBLADDER, CHOLECYSTECTOMY: - ACUTE CHOLECYSTITIS. - CHOLELITHIASIS.
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.
- The similarity is in the surface texture (not the colour).
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:[8]
- 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
- Due to high RBC turnover, e.g. sickle cell disease, thalassemia.
- Radio-opaque.[9]
Appearance:
- Black - key feature.
- Dull.
Less common pathologic diagnoses
Adenomyoma of the gallbladder
General
- Glands in muscle.
- Analogous to what happens in the uterus.
- Significance - may mimic malignant tumours of the gallbladder.[10][11]
- Uncommon.
Gross
- Cystic spaces (Rokitansky-Aschoff sinuses) - may be seen on imaging.[12][13]
- 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:[14]
- Nuclear changes.
- Increased NC ratio.
- Hyperchromasia (essential).
- +/-Intestinal metaplasia --> goblet cells.
Premalignant lesions
General
- Metaplasia associated with carcinoma.[15]
Hypothesis:[16]
- Antral type metaplasia --> intestinal metaplasia --> dysplasia --> carcinoma.
Intestinal metaplasia of the gallbladder
- AKA gallbladder intestinal metaplasia.
General
Significance:
- Increased risk of carcinoma.[15]
Microscopic
Features:[17]
- Goblet cells - key feature.
- +/-Paneth cells.[18]
Note:
- Often accompanied by antral type metplasia.
- Gastric antral-type epithelium - may form glands.
DDx:
Image:
Sign out
GALLBLADDER, CHOLECYSTECTOMY: - INTESTINAL METAPLASIA OF THE GALLBLADDER, FOCAL. - CHRONIC CHOLECYSTITIS. - CHOLELITHIASIS. - NEGATIVE FOR DYSPLASIA.
Antral type metaplasia
General
Microscopic
Features:[18]
- 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[18] and common bile duct.[19]
- 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.
- These glandular cells are not as columnar and have less well-defined cell borders.
Images:
Gallbladder dysplasia
General
- Premalignant lesion.
Microscopic
Features:
- Nuclear crowding.
- Nuclear hyperchromasia.
Notes:
- Like in the colon.
DDx:
Malignant
Gallbladder carcinoma
- AKA gallbladder adenocarcinoma.
General
- Uncommon.
Epidemiology
- Associated with gallstones.
- Increased risk in primary sclerosing cholangitis.
- Sex: female > male.
- Location: usually fundus, sometimes body.
Notes:
- Diffuse calcification of gallbladder wall, AKA "porcelain gallbladder" is not associated with carcinoma - based on a series of 10,741 cholecystectomies.[20]
- Focal mucosal calcification is associated with malignancy.[21]
- Cholangiocarcinoma is dealt with in the liver neoplasms article.
Gross
- Classic: mass projecting into the lumen.
Image:
Microscopic
Features:
- Usually adenocarcinoma.
- Mimics appearance of pancreatic ductal adenocarcinoma-- but less cellular mucin.[5]
Notes:
- May be very subtle, i.e. difficult to differentiate from normal glands.
DDx:
- Adenomyoma of the gallbladder.
- Metastatic carcinoma.
See also
References
- ↑ URL: http://www.whonamedit.com/synd.cfm/983.html. Accessed on: 29 October 2011.
- ↑ 2.0 2.1 2.2 2.3 Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 1606. ISBN 978-0781779425.
Cite error: Invalid
<ref>tag; name "Ref_Sternberg5_1606" defined multiple times with different content Cite error: Invalid<ref>tag; name "Ref_Sternberg5_1606" defined multiple times with different content Cite error: Invalid<ref>tag; name "Ref_Sternberg5_1606" defined multiple times with different content - ↑ Fitzgibbons, RJ.; Tseng, A.; Wang, H.; Ryberg, A.; Nguyen, N.; Sims, KL. (Dec 1996). "Acute cholecystitis. Does the clinical diagnosis correlate with the pathological diagnosis?". Surg Endosc 10 (12): 1180-4. PMID 8939838.
- ↑ Tsung, JW.; Raio, CC.; Ramirez-Schrempp, D.; Blaivas, M. (Mar 2010). "Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED.". Am J Emerg Med 28 (3): 338-42. doi:10.1016/j.ajem.2008.12.003. PMID 20223393.
- ↑ 5.0 5.1 Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 174. ISBN 978-0470519035.
- ↑ Nikfarjam, M.; Niumsawatt, V.; Sethu, A.; Fink, MA.; Muralidharan, V.; Starkey, G.; Jones, RM.; Christophi, C. (Aug 2011). "Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis.". HPB (Oxford) 13 (8): 551-8. doi:10.1111/j.1477-2574.2011.00327.x. PMID 21762298.
- ↑ STC. 25 February 2009.
- ↑ Szwed, Z.; Zyciński, P. (2007). "[4F's--still up to date risk factors of cholelithiasis].". Wiad Lek 60 (11-12): 570-3. PMID 18540184.
- ↑ 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.
- ↑ Saul, WM.; Herrmann, PK. (1988). "[Adenomyoma of the gallbladder].". Dtsch Z Verdau Stoffwechselkr 48 (2): 112-6. PMID 3168899.
- ↑ 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.
- ↑ 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.
- ↑ 13.0 13.1 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.
- ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 172. ISBN 978-0470519035.
- ↑ 15.0 15.1 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.
- ↑ 16.0 16.1 16.2 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.
- ↑ Albores-Saavedra, J.; Nadji, M.; Henson, DE.; Ziegels-Weissman, J.; Mones, JM. (Jun 1986). "Intestinal metaplasia of the gallbladder: a morphologic and immunocytochemical study.". Hum Pathol 17 (6): 614-20. PMID 2872152.
- ↑ 18.0 18.1 18.2 18.3 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.
- ↑ Cutz, E. 3 March 2011.
- ↑ 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.
- ↑ 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.