Gallbladder

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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.

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

Features:

  • Rokitansky-Aschoff sinuses.[1]
    • Entrapped epithelial crypts -- pockets of epithelium in the wall of the gallbladder.
  • +/-Foamy macrophages in the lamina propria.
  • Inflammatory cells.

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???

Microscopic

Features:

  • 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 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]

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

Images:

Dysplasia

  • Premalignant lesion.

Microscopic

Features:

  • Nuclear crowding.
  • Nuclear hyperchromasia.

Notes:

  • Like in the colon.

Carcinoma

General

Epidemiology

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

Notes:

  • Calcification of gallbladder wall aka "Porcelain gallbladder" -- not associated with carcinoma.[9]
  • Cholangiocarcinoma is dealt with in the liver neoplasms article.

Microscopic

Features:

  • 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 February 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. ↑ 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 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. ↑ 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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