Difference between revisions of "Gallbladder"

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*Glands in muscularis propria of the gallbladder wall.
*Glands in muscularis propria of the gallbladder wall.


==Polyps==
==Gallbladder polyps==
*Polyps - significant as they may be adenomatous, i.e. pre-cancerous.
===General===
*Polyps are significant as they may be adenomatous, i.e. pre-cancerous.
*These are similar to [[intestinal polyps|polyps]] found elsewhere GI tract.
===Microscopic===
:See ''[[intestinal polyps]]''.


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


=Premalignant lesions - metaplasia/dysplasia=
=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>
*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>


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*[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>


==Dysplasia==
==Gallbladder dysplasia==
===General===
*Premalignant lesion.
*Premalignant lesion.


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*Like in the colon.
*Like in the colon.


=Carcinoma=
=Gallbladder carcinoma=
===General===
===General===
====Epidemiology====
====Epidemiology====
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Notes:
Notes:
*Calcification of gallbladder wall aka "Porcelain gallbladder" -- '''not''' associated with carcinoma.<ref>{{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>
*Calcification of gallbladder wall, [[AKA]] "porcelain gallbladder" -- '''not''' associated with carcinoma.<ref>{{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>
*[[Cholangiocarcinoma]] is dealt with in the ''[[liver neoplasms]]'' article.
*[[Cholangiocarcinoma]] is dealt with in the ''[[liver neoplasms]]'' article.


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Features:
Features:
*Usually adenocarcinoma.
*Usually adenocarcinoma.
**Mimics appearance of pancreatic ductal adenocarcinoma-- but less cellular mucin.<ref name=Ref_DCHH174>{{Ref DCHH|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 00:45, 30 October 2011

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:

Overview

Most common:

  • Cholelithiasis with cholecystitis.

Common:

  • Antral-type metaplasia.

Uncommon:

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

Common

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

Chronic cholecystitis

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.

Acute cholecystitis

  • Neutrophils - usually secondary to necrosis/ulceration or infection.[2]
    • Not essential for the Dx of cholecystitis.

Gangrenous cholecystitis

Cholesterolosis

  • Formally gallbladder cholesterolosis.
  • Informally known as strawberry gallbladder.

General

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

Gross

Features:

  • Mucsoa has strawberry-like appearance.

Microscopic

Features:

  • Foamy macrophages.

Image:

Cholelithiasis

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".

Cholesterol stones

  • More common than pigment stone.

Appearance:

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

Pigment stones

Appearance:

  • Black - key feature.
  • Dull.

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???

Microscopic

Features:

  • Glands in muscularis propria of the gallbladder wall.

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:[5]

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

Premalignant lesions

General

  • Metaplasia associated with carcinoma.[6]

Hypothesis:[7]

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

Intestinal metaplasia

General

Significance:

  • Increased risk of carcinoma.[6]

Microscopic

Features:

Antral type metaplasia

General

  • AKA pyloric metaplasia, pseudopyloric metaplasia, mucous gland metaplasia.[8]

Microscopic

Features:[8]

  • 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[8] and common bile duct.[9]
    • 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

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

Notes:

Microscopic

Features:

Notes:

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

See also

References

  1. ↑ URL: http://www.whonamedit.com/synd.cfm/983.html. Accessed on: 29 October 2011.
  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. ↑ STC. 25 February 2009.
  4. ↑ 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.
  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. ↑ 7.0 7.1 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.
  8. ↑ 8.0 8.1 8.2 8.3 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.
  9. ↑ EC. 3 March 2011.
  10. ↑ 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.
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