Acute cholecystitis

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Acute cholecystitis
Diagnosis in short

Acute cholecystitis. H&E stain.

LM edema, hemorrhage, +/-neutrophils, +/-reactive epithelial changes
LM DDx chronic cholecystitis, intestinal metaplasia of the gallbladder, gallbladder dysplasia, adenocarcinoma of the gallbladder. eosinophilic cholecystitis
Gross wall thickening (due to edema), gallstone(s) in the neck (classic finding), +/-mucosal erosions
Site gallbladder

Associated Dx cholelithiasis
Clinical history elderly individuals (50s and 60s)
Signs Murphy's sign present
Prevalence uncommon
Radiology wall thickening (>3 mm), gallstone(s) in the neck
Prognosis benign, good
Treatment cholecystectomy

Acute cholecystitis, abbreviated AC, is a relatively uncommon gallbladder pathology when compared to chronic cholecystitis. It is usually associated with gallstones and seen in older individuals.

General

  • Less common than chronic cholecystitis.
  • Usually due to gallstones.[1]
  • Classically older individuals (50s and 60s) with a slight female predominance.[1]

Notes:

  • Pathologic diagnosis very often discordant with clinical impression.[2]

Gross

Features:[1]

  • Wall thickening - due to edema and hemorrhage.†
  • Gallstone(s) - classically obstructing the gallbladder neck.
  • +/-Mucosal erosions.

Note:

  • † The sonographic criterium for "thick" is greater than 3 mm.[3][4]

Microscopic

Features:[1]

  • Edema.
  • Hemorrhage.
  • +/-Fibrin thrombi in small veins.
  • +/-Mucosal erosions.
  • +/-Neutrophils - useful
    • Not essential for the Dx of acute cholecystitis.
    • Neutrophils usually secondary to necrosis/ulceration or infection.[5]
  • +/-Reactive epithelial changes.[6]

Notes:

  • May see activated fibroblasts.

DDx:

Images

Special types

Gangrenous cholecystitis

General:[7]

  • Older.
  • Clinically "sicker".
  • Worse outcome than (acute) non-gangrenous cholecystitis.

Microscopic:

Sign out

Gallbladder, Cholecystectomy:
- Acute cholecystitis with cholelithiasis.
Block letters
GALLBLADDER, CHOLECYSTECTOMY: 
- ACUTE CHOLECYSTITIS.
- CHOLELITHIASIS.

Necrosis of wall

Gallbladder, Cholecystectomy:
- Acute cholecystitis with multiple mucosal erosions and focal necrosis of the gallbladder wall.
GALLBLADDER, CHOLECYSTECTOMY:
- ACUTE AND CHRONIC CHOLECYSTITIS WITH MULTIPLE MUCOSAL EROSIONS AND FOCAL 
  NECROSIS OF THE GALLBLADDER WALL.

Gangrenous cholecystitis

GALLBLADDER, CHOLECYSTECTOMY:
- GANGRENOUS CHOLECYSTITIS.
- CHOLELITHIASIS.

Xanthomatous lymph node present

GALLBLADDER, CHOLECYSTECTOMY: 
- ACUTE CHOLECYSTITIS. 
- CHOLELITHIASIS. 
- BENIGN LYMPH NODE WITH NONNECROTIZING GRANULOMAS, XANTHOMATOUS APPEARANCE. 
- NEGATIVE FOR DYSPLASIA.

Micro

The sections show gallbladder wall with hemorrhage, and activated fibroblasts. The superficial mucosa has clusters of neutrophils.

Alternate

The sections show an inflamed gallbladder wall with hemorrhage, activated fibroblasts and focal necrosis. The mucosa is partially eroded. Abundant neutrophils and eosinophils are present. No significant nuclear changes are apparent.

See also

References

  1. 1.0 1.1 1.2 1.3 Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 1606. ISBN 978-0781779425.
  2. Fitzgibbons, RJ.; Tseng, A.; Wang, H.; Ryberg, A.; Nguyen, N.; Sims, KL. (Dec 1996). "Acute cholecystitis. Does the clinical diagnosis correlate with the pathological diagnosis?". Surg Endosc 10 (12): 1180-4. PMID 8939838.
  3. Tsung, JW.; Raio, CC.; Ramirez-Schrempp, D.; Blaivas, M. (Mar 2010). "Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED.". Am J Emerg Med 28 (3): 338-42. doi:10.1016/j.ajem.2008.12.003. PMID 20223393.
  4. Kim, HJ.; Park, JH.; Park, DI.; Cho, YK.; Sohn, CI.; Jeon, WK.; Kim, BI.; Choi, SH. (Feb 2012). "Clinical usefulness of endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening.". Dig Dis Sci 57 (2): 508-15. doi:10.1007/s10620-011-1870-0. PMID 21879282.
  5. Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 174. ISBN 978-0470519035.
  6. 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.
  7. Nikfarjam, M.; Niumsawatt, V.; Sethu, A.; Fink, MA.; Muralidharan, V.; Starkey, G.; Jones, RM.; Christophi, C. (Aug 2011). "Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis.". HPB (Oxford) 13 (8): 551-8. doi:10.1111/j.1477-2574.2011.00327.x. PMID 21762298.
  8. Struetker C. 25 February 2009.