Gallbladder

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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.

General

  • Often accompanies cholecystitis/contributes and/or causes cholecystitis.
  • The gallbladder is removed following biliary pancreatitis (gallstone pancreatitis) to reduce recurrence risk.[2][3]
  • Gallstones may compress the common bile duct - known as Mirizzi Syndrome.[4]
    • Can be associated with jaundice.[5]

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:[6]

  • Female.
  • Fat.
  • Forty.
  • Fertile.

Additional:

  • Family history.

Cholesterol stones

  • More common than pigment stone.

Appearance:

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

  • Yellow gallstones. (WC)

Pigment stones

Appearance:

  • Black - key feature.
  • Dull.

Microscopic

  • Not routinely done on gallstones.

Sign out

GALLBLADDER CHOLECYSTECTOMY:
- CHOLELITHIASIS.
- MILD CHRONIC CHOLECYSTITIS.

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.[8][9]
  • Uncommon.

Gross

  • Cystic spaces (Rokitansky-Aschoff sinuses) - may be seen on imaging.[10][11]
  • Gallbladder wall thickening.

Microscopic

Features:[12]

  • 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:[14]

  • 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.[15]

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

Premalignant lesions

General

  • Metaplasia associated with carcinoma.[16]

Hypothesis:[17]

  • 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.[18]

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.

Images:

Gallbladder adenoma

Gallbladder dysplasia redirects here.

General

Microscopic

Features:

  • Gallbladder epithelium with:
    • Nuclear atypia - key feature.
      • Nuclear hyperchromasia.
      • Nuclear crowding (pseudostratification) or round enlarged nuclei.
    • +/-Goblet cells.

Architectural subclassification:[21]

  • Papillary ~ 45%.
  • Tubulopapillary ~ 30%.
  • Tubular ~ 25%.

Notes:

  • All of the gallbladder should be submitted prior to sign out to exclude non-sampled adenocarcinoma.

DDx:

Images

Sign out

GALLBLADDER, CHOLECYSTECTOMY:
- BILIARY TYPE TUBULAR ADENOMA WITH HIGH GRADE DYSPLASIA.
- MARGINS CLEAR OF ADENOMA (NEAREST MARGIN 1.0 CM).

Intracholecystic Papillary Neoplasm[22]

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. ↑ Bouwense, SA.; Besselink, MG.; van Brunschot, S.; Bakker, OJ.; van Santvoort, HC.; Schepers, NJ.; Boermeester, MA.; Bollen, TL. et al. (2012). "Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial.". Trials 13: 225. doi:10.1186/1745-6215-13-225. PMID 23181667.
  3. ↑ van Baal, MC.; Besselink, MG.; Bakker, OJ.; van Santvoort, HC.; Schaapherder, AF.; Nieuwenhuijs, VB.; Gooszen, HG.; van Ramshorst, B. et al. (May 2012). "Timing of cholecystectomy after mild biliary pancreatitis: a systematic review.". Ann Surg 255 (5): 860-6. doi:10.1097/SLA.0b013e3182507646. PMID 22470079.
  4. ↑ Khalid, S.; Bhatti, AA.. "Mirizzi's syndrome: an interesting on table finding.". J Ayub Med Coll Abbottabad 26 (4): 621-4. PMID 25672201.
  5. ↑ Elhanafy, E.; Atef, E.; El Nakeeb, A.; Hamdy, E.; Elhemaly, M.; Sultan, AM.. "Mirizzi Syndrome: How it could be a challenge.". Hepatogastroenterology 61 (133): 1182-6. PMID 25513064.
  6. ↑ Szwed, Z.; Zyciński, P. (2007). "[4F's--still up to date risk factors of cholelithiasis].". Wiad Lek 60 (11-12): 570-3. PMID 18540184.
  7. ↑ 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.
  8. ↑ Saul, WM.; Herrmann, PK. (1988). "[Adenomyoma of the gallbladder].". Dtsch Z Verdau Stoffwechselkr 48 (2): 112-6. PMID 3168899.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 11.0 11.1 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.
  12. ↑ 12.0 12.1 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.
  13. ↑ URL: http://radiopaedia.org/articles/phrygian_cap. Accessed on: 16 May 2014.
  14. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 172. ISBN 978-0470519035.
  15. ↑ 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/.
  16. ↑ 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.
  17. ↑ 17.0 17.1 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.
  18. ↑ 18.0 18.1 18.2 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.
  19. ↑ Cutz, E. 3 March 2011.
  20. ↑ 20.0 20.1 Levy, AD.; Murakata, LA.; Abbott, RM.; Rohrmann, CA.. "From the archives of the AFIP. Benign tumors and tumorlike lesions of the gallbladder and extrahepatic bile ducts: radiologic-pathologic correlation. Armed Forces Institute of Pathology.". Radiographics 22 (2): 387-413. PMID 11896229. http://radiographics.rsna.org/content/22/2/387.full.
  21. ↑ 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.
  22. ↑ 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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