View source for Gallbladder

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|author1=[[User:Mikael Häggström|Mikael Häggström]]
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==Common requests==
*'''[[Cholecystitis]]'''
*'''[[Gallbladder polyp]]'''
{{Comprehensiveness|otherlegend=yes}}
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==Gross processing==
===Cholecystectomy grossing===
*Describe the '''serosa''' (smooth and intact versus disrupted, adhesions, inflammation, tumor implants, necrosis, porcelain).
*{{Moderate-begin}}Inspect the '''adventitia''' (the roughened juxtahepatic surface), where disruptions are generally iatrogenic and optional to report.{{Moderate-end}}
*Cut off the '''cystic duct margin''' and submit
*Look for any cystic duct '''lymph node''', describe and submit if present
*'''Open''' the gallbladder longitudinally on the serosal surface. Do not open along the adventitia.<ref group=note>If a tumor is found, then the adventitial surface is likely the closest surgical margin, and should therefore be spared during initial opening in order to allow for optimal sections later.</ref>
*{{Moderate-begin}}Estimate the amount of '''bile'''.{{Moderate-end}}
*{{Finding-begin}}Estimate the number and describe '''gallstones'''.{{Finding-end}}
*Describe the '''mucosa''' (such as velvety, granular, trabeculated, and/or with cholesterol stippling)
<gallery mode=packed heights=180>
File:Gross pathology of cholesterolosis.jpg|thumb|Cholesterol stippling (cholesterolosis): yellow streaks of cholesterol deposition, a frequent incidental finding.<ref>{{cite journal|last1=Talwar|first1=OP|last2=K.C.|first2=Geetika|title=Histomorphological changes in gall bladder diseases and its association with helicobacter infection|journal=Journal of Pathology of Nepal|volume=4|issue=8|year=2014|pages=617–622|issn=2091-0908|doi=10.3126/jpn.v4i8.11607}}<br>- "Figures - available via license: CC BY 4.0"</ref>
File:Gross pathology of a trabeculated gallbladder, with enlarged inset.jpg|Trabeculated gallbladder.
File:Photograph of a hyperplastic polyp of the gallbladder.jpg|'''[[Gallbladder polyp]]'''
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*Look for any '''[[gallbladder polyps]] or tumors'''. Tumors will usually be hard.
*Open the '''spiral neck''', and look for lesions and gallstones therein
*Cut through the '''wall''', and look for any tumors or Rokitansky-Aschoff sinuses
*Look for gallstones in the '''container'''

;Gross report:
{|class=wikitable
| {{Comprehensive-begin}}Labeled - gallbladder. The specimen is received in formalin and consists of a resected{{Comprehensive-end}} {{Finding-begin}}
*previously opened?
*focally disrupted {{Moderate-begin}}on the juxtahepatic avdentitial surface only{{Moderate-end}}?
*edematous?{{Finding-end}}
gallbladder measuring __ cm in length and __ cm in maximum diameter. The serosa is 
*{{Finding-begin}}(mottled) tan / pink / red (generally combinations thereof) and{{Finding-end}}
*smooth {{Finding-begin}}/ with patchy adhesions{{Finding-end}}
Upon opening, the lumen contains {{Comprehensive-begin}}__ {{Comment-begin}}volume in cc/cm<sup>3</sup>{{Comment-end}}{{Comprehensive-end}}
*green {{Finding-begin}}/ brown / blood-tinged / yellow-white and chalky / clear colorless
*viscid / sludge-like / thick{{Finding-end}}
bile {{Finding-begin}}and
*(approximately) __ (number) / multiple
*black / brown / green / yellow / tan / white (generally combinations thereof)
*irregular / multifaceted / spiculated / ovoid / mulberry-like / barrel-like
gallstones measuring up to __ cm in greatest dimension.{{Finding-end}}
The mucosa is 
*green {{Finding-begin}}/ tan / yellow-red / brown / pink{{Finding-end}}
*and velvety {{Finding-begin}}/ granular / trabecular
*with diffuse cholesterol stippling?{{Finding-end}}
The spiral neck is patent {{Finding-begin}}/ obstructed by one additional similar gallstone measuring __ cm{{Finding-end}}. The wall measures up to __ cm in thickness. {{Finding-begin}} Rokitansky-Aschoff sinuses are present within the fundus. There is a __ (color) cystic duct lymph node present measuring __ cm in greatest dimension. {{Finding-end}} {{Comprehensive-begin}}Representative sections are submitted for microscopic examination in __ cassette(s). {{Comprehensive-end}}
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'''Rifts''' on the adventitial side that are consistent with surgical trauma need mentioning only in tumor cases.

====Carcinoma====
Pathology trainees that find an unsuspected tumor should generally '''notify''' a senior before continuing.
*State whether the gallbladder is '''intact''' when you received it.
*'''Ink the surgical margin''' (adventitial surface). 
*'''Ink the cystic duct margin''' (lightly) and put in a separate cassette. Notify the lab to have it submitted {{en face}}
*Look for any cystic duct '''lymph nodes'''. If found, bisect and submit.
*'''Measure the tumor''' in greatest dimension and thickness and state where in the gallbladder it is located (fundus, body, etc and whether it is on the peritoneal or hepatic side). 
*Measure the '''margin''' to the cystic duct resection
*State all '''other abnormalities''' including stones, Rokitansky-Aschoff sinuses etc.

Take sections from:
*Cystic duct margin, en face
*Cystic duct lymph node if present
*Sections of tumor, full thickness
*Sections of unaffected gallbladder

===Autopsy grossing===
[[File:Gross pathology of gallbladder carcinoma.jpg|thumb|Gross pathology of gallbladder carcinoma, with a prominent nodule.]]
The gallbladder and biliary tract may be cut open from either end:
*Starting from the gallbladder: Cut the gallbladder open and from there dissect the cystic duct and common bile duct through the ''ampulla of Vater''.
*Starting from the duodenum: Identify the ''ampulla of Vater'', possibly by bile flow when squeezing the gallbladder. Dissect the common bile duct, cystic duct and thereafter the gallbladder. If the cystic duct is difficult to find, transverse cuts may be performed at its presumed location.
*In the gallbladder, inspect the contents and the appearance of the wall. Look mainly for signs of carcinoma. Optionally, estimate the volume of bile therein. 
*In the biliary tract, look mainly for stones and stenosis.
{{Further|Autopsy}}
{{Fixation - standard}}
{{Fixation - general notes}}

==Microscopic evaluation==
Look at least at the epithelial lining, for '''atypia''' and '''inflammation''' (such as edema and inflammatory cells, {{Further|cholecystitis|linebreak=no}}).
<gallery mode=packed heights=200>
File:Histopathology of lamina propria edema and hemorrhage in acute cholecystitis.jpg|thumb|Acute '''[[cholecystitis]]'''.
File:Histopathology of gallbladder carcinoma.jpg|Histopathology of gallbladder '''carcinoma''', with marked nuclear pleomorphism
File:Histopathology of cholelithiasis.jpg|Look in the '''gross report''' for '''gallstones''', which is generally reported or commented in the microscopy diagnosis as well.
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===Other findings===
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File:Histopathology of cholesterolosis, with annotated foam cell.jpg|Report a substantial amount of '''foam cells''' within lamina propria, conferring a diagnosis of '''cholesterolosis'''.
File:Histology of liver tissue from a gallbladder resection.jpg|'''Liver''' tissue in the periphery of a gallbladder resection, does not need to be reported.
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==Report==
Example:
{|class=wikitable
|{{Moderate-begin}}Gallbladder, resection:{{Moderate-end}}
*Gallbladder with no significant histopathologic changes
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In '''[[cholecystitis]]''':
{|class=wikitable
| {{Moderate-begin}}Gallbladder, cholecystectomy:{{Moderate-end}} <br><<Acute and/or chronic>> cholecystitis. <br>{{Finding-begin}}Cholelithiasis.{{Finding-end}}
|}
{{CAP}}
<noinclude>{{Reporting}}
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