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.
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.
- Small ridges (microvillus architecture).
- 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
- Due to high RBC turnover, e.g. sickle cell disease, thalassemia.
- Radio-opaque.[4]
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.
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:
- Presence of goblet cells -/+ paneth cells.[8]
Antral type metaplasia
General
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.
- These glandular cells are not as columnar and have less well-defined cell borders.
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.[10]
- 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
- ↑ URL: http://www.whonamedit.com/synd.cfm/983.html. Accessed on: 29 October 2011.
- ↑ 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.
- ↑ STC. 25 February 2009.
- ↑ 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.
- ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 172. ISBN 978-0470519035.
- ↑ 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.
- ↑ 7.0 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.
- ↑ 8.0 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.
- ↑ EC. 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.