Difference between revisions of "Gallbladder"

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(redo refs)
Line 33: Line 33:
*+/-Foamy macrophages in the lamina propria.
*+/-Foamy macrophages in the lamina propria.
*Inflammatory cells.  
*Inflammatory cells.  
**[[Neutrophils]] are not essential for the Dx - usually secondary to necrosis/ulceration or infection.<ref>DCHHP P.174</ref>
**[[Neutrophils]] are not essential for the Dx - usually secondary to necrosis/ulceration or infection.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref>


==Cholesterolosis==
==Cholesterolosis==
Line 88: Line 88:
*Polyps - significant as they may be adenomatous, i.e. pre-cancerous.
*Polyps - significant as they may be adenomatous, i.e. pre-cancerous.


Flat dysplasia<ref>DCHHP P.172</ref>
Flat dysplasia:<ref name=Ref_DCHH172>{{Ref DCHH|172}}</ref>
*Nuclear changes  
*Nuclear changes.
**Incr. [[NC ratio]],
**Incr. [[NC ratio]].
**Hyperchromasia (essential),
**Hyperchromasia (essential).
**+/-Intestinal metaplasia --> goblet cells.
**+/-Intestinal metaplasia --> goblet cells.


Line 102: Line 102:
==Intestinal metaplasia==
==Intestinal metaplasia==
Definition:
Definition:
*Presence of [[goblet cell]]s -/+ paneth cells<ref>Sternberg DSP4 P.1789</ref>
*Presence of [[goblet cell]]s -/+ paneth cells.<ref>Sternberg DSP4 P.1789</ref>


Significance:
Significance:
Line 108: Line 108:


==Antral type metaplasia==
==Antral type metaplasia==
General
===General===
*[[aka]] ''pyloric metaplasia'', ''pseudopyloric metaplasia'', ''mucous gland metaplasia''.<ref>Sternberg DSP4 P.1789</ref>
*[[AKA]] ''pyloric metaplasia'', ''pseudopyloric metaplasia'', ''mucous gland metaplasia''.<ref>Sternberg DSP4 P.1789</ref>


Micro.
===Microscopic===
*Cells with...<ref>Sternberg DSP4 P.1789</ref>  
Features:<ref>Sternberg DSP4 P.1789</ref>  
*Cells with...
**Abundant, pale, apical mucin.
**Abundant, pale, apical mucin.
**Small basal nucleus.
**Small basal nucleus.
Line 141: Line 142:
===Microscopic===
===Microscopic===
*Usually adenocarcinoma.
*Usually adenocarcinoma.
**Mimics appearance of pancreatic ductal adenocarcinoma-- but less cellular mucin.<ref>DCHHP P.174</ref>
**Mimics appearance of pancreatic ductal adenocarcinoma-- but less cellular mucin.<ref name=Ref_DCHH174>{{Ref DCHH|174}}</ref>


Notes:
Notes:

Revision as of 02:41, 1 July 2010

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.

Pathology

Most common:

  • Cholelithiasis with cholecystitis.

Cholecystitis

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

  • Rokitansky-Aschoff sinuses[1]
    • Entrapped epithelial crypts -- pockets of epithelium in the wall of the gallbladder.
  • +/-Foamy macrophages in the lamina propria.
  • Inflammatory cells.
    • Neutrophils are not essential for the Dx - usually secondary to necrosis/ulceration or infection.[2]

Cholesterolosis

General

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

Gross

Features:

  • Mucsoa has strawberry-like appearance.

Microscopic

Features:

  • Foamy macrophages.

Image:

Cholelithiasis

  • Often accompanies cholecystitis/contributes and/or causes cholecystitis

The two types of gallstones:

  • Cholesterol stones
    • More common than pigment stone.
    • Appearance:
      • Clear or yellow.
      • Opaque or translucent.
      • Sometimes shinny.
  • Pigment stones
    • Due to high RBC turnover, e.g. sickle cell anemia, thalassemia.
    • Appearance:
      • Black - key feature.
      • Dull.

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

Crystalline gallstones -- UC association (?):[3]

Less common pathologic diagnoses

Adenomyosis

General

  • Glands in muscle.
  • Analogous to what happens in the uterus.
  • Significance??? -- consequence of long standing cholecystitis/Rokitansky-Aschoff sinuses???

Histology

  • Glands in muscularis propria of the gallbladder wall.

Gangrenous gallbladder

  • Necrosis of gallbladder wall (muscularis propria).[4]

Polyps

  • Polyps - significant as they may be adenomatous, i.e. pre-cancerous.

Flat dysplasia:[5]

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

Premalignant lesions - metaplasia/dysplasia

  • Metaplasia assoc. with carcinoma.[6]

Hypothesis:[7]

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

Intestinal metaplasia

Definition:

Significance:

  • Increased risk of carcinoma.[6]

Antral type metaplasia

General

  • AKA pyloric metaplasia, pseudopyloric metaplasia, mucous gland metaplasia.[9]

Microscopic

Features:[10]

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

Dysplasia

  • Premalignant lesion.

Microscopic

Features:

  • Nuclear crowding.
  • Nuclear hyperchromasia.

Notes:

  • Like in the colon.

Carcinoma

Epidemiology

  • Associated with gallstones.
  • Sex: female > male.
  • Location: usually fundus, sometimes body.

Notes:

  • Calcification of gallbladder wall aka "Porcelain gallbladder" -- not associated with carcinoma.[11]
  • Cholangiocarcinoma is dealt with in the liver neoplasms article.

Microscopic

  • Usually adenocarcinoma.
    • Mimics appearance of pancreatic ductal adenocarcinoma-- but less cellular mucin.[2]

Notes:

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

See also

References

  1. http://www.whonamedit.com/synd.cfm/983.html
  2. 2.0 2.1 Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 174. ISBN 978-0470519035.
  3. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1358536
  4. STC 25 Feb 2009.
  5. Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 172. ISBN 978-0470519035.
  6. 6.0 6.1 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.
  7. 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://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=129&page=386.
  8. Sternberg DSP4 P.1789
  9. Sternberg DSP4 P.1789
  10. Sternberg DSP4 P.1789
  11. 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.