Difference between revisions of "Gallbladder"

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|author2=
 
|author2=
 
}}
 
}}
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<noinclude>
 
==Common requests==
 
==Common requests==
*'''[[Chronic cholecystitis]]'''
+
*'''[[Cholecystitis]]'''
 
+
*'''[[Gallbladder polyp]]'''
 +
{{Comprehensiveness|otherlegend=yes}}
 +
</noinclude>
 
==Gross processing==
 
==Gross processing==
 
===Cholecystectomy grossing===
 
===Cholecystectomy grossing===
*Describe the serosa (smooth and intact, adhesions, inflammation, tumor implants, necrosis, porcelain)
+
*Describe the '''serosa''' (smooth and intact versus disrupted, adhesions, inflammation, tumor implants, necrosis, porcelain).
*Cut off the cystic duct margin and submit
+
*{{Moderate-begin}}Inspect the '''adventitia''' (the roughened juxtahepatic surface), where disruptions are generally iatrogenic and optional to report.{{Moderate-end}}
*Look for any cystic duct lymph node, describe and submit if present
+
*Cut off the '''cystic duct margin''' and submit
*Open the gallbladder longitudinally on the serosal surface. Do not open along adventitia
+
*Look for any cystic duct '''lymph node''', describe and submit if present
*Estimate the amount of bile
+
*'''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>
*Estimate the number and describe gallstones
+
*{{Moderate-begin}}Estimate the amount of '''bile'''.{{Moderate-end}}
*Describe the mucosa (velvety, granular, trabeculated, cholesterol stippling etc)
+
*{{Finding-begin}}Estimate the number and describe '''gallstones'''.{{Finding-end}}
*Look for polyps and tumors. Tumors will usually be hard.
+
*Describe the '''mucosa''' (such as velvety, granular, trabeculated, and/or with cholesterol stippling)
*Open the spiral neck, look for lesions and gallstones
+
<gallery mode=packed heights=180>
*Cut through the wall, look for tumors, Rokitansky-Aschoff sinuses
+
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>
*Look for gallstones in the container
+
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]]'''
 +
</gallery>
 +
*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}}
 +
|}
 +
'''Rifts''' on the adventitial side that are consistent with surgical trauma need mentioning only in tumor cases.
  
 
====Carcinoma====
 
====Carcinoma====
Pathology trainees that find an unsuspected tumor should generally notify a senior before continuing.
+
Pathology trainees that find an unsuspected tumor should generally '''notify''' a senior before continuing.
*Ink the surgical margin (adventitial surface). State whether the gallbladder is intact when you received it.
+
*State whether the gallbladder is '''intact''' when you received it.
*Ink the cystic duct margin (lightly) and but in separate cassette- write “enface” on the side of the cassette
+
*'''Ink the surgical margin''' (adventitial surface).
*Look for a cystic duct lymph node(s), bisect and submit.
+
*'''Ink the cystic duct margin''' (lightly) and put in a separate cassette. Notify the lab to have it submitted {{en face}}
*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)
+
*Look for any cystic duct '''lymph nodes'''. If found, bisect and submit.
*Measure how far from the cystic duct margin of resection
+
*'''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).
*State all other abnormalities including stones, Rokitansky-Aschoff sinuses etc.
+
*Measure the '''margin''' to the cystic duct resection
 +
*State all '''other abnormalities''' including stones, Rokitansky-Aschoff sinuses etc.
  
 
Take sections from:
 
Take sections from:
*Cystic duct margin, enface
+
*Cystic duct margin, en face
 
*Cystic duct lymph node if present
 
*Cystic duct lymph node if present
 
*Sections of tumor, full thickness
 
*Sections of tumor, full thickness
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*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 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.
 
*In the biliary tract, look mainly for stones and stenosis.
<gallery>
 
File:Gross pathology of cholesterolosis.jpg|thumb|Cholesterolosis (yellow streaks of cholesterol deposition) is 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>
 
</gallery>
 
 
{{Further|Autopsy}}
 
{{Further|Autopsy}}
 
{{Fixation - standard}}
 
{{Fixation - standard}}
Line 50: Line 82:
  
 
==Microscopic evaluation==
 
==Microscopic evaluation==
Look at least at the epithelial lining, for atypia.
+
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>
 
<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 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.
 
</gallery>
 
</gallery>
  
===Common findings===
+
===Other findings===
Report if incidentally discovered:
 
 
<gallery mode=packed heights=200>
 
<gallery mode=packed heights=200>
File:Histopathology of cholesterolosis, with annotated foam cell.jpg|Substantial amount of '''foam cells''' within lamina propria, conferring a diagnosis of cholesterolosis.
+
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.
 
</gallery>
 
</gallery>
  
 
==Report==
 
==Report==
{{Comprehensiveness|otherlegend=yes}}
+
Example:
 +
{|class=wikitable
 +
|{{Moderate-begin}}Gallbladder, resection:{{Moderate-end}}
 +
*Gallbladder with no significant histopathologic changes
 +
|}
  
 +
In '''[[cholecystitis]]''':
 
{|class=wikitable
 
{|class=wikitable
| {{Comprehensive-begin}}Labeled: gallbladder. The specimen is received in formalin and consists of a resected{{Comprehensive-end}} gallbladder {{Comprehensive-begin}}that measures __ cm in length and 3.0 cm in maximum diameter{{Comprehensive-end}} / {{Moderate-begin}}is of regular size{{Moderate-end}}. {{Moderate-begin}}The '''serosa''' is {{Finding-begin}}mottled tan-red and{{Finding-end}} smooth.{{Moderate-end}} Upon opening, the '''lumen''' contains {{Comprehensive-begin}}approximately __ ml {{Comment-begin}}or cc{{Comment-end}} of{{Comprehensive-end}} {{Finding-begin}}green viscid{{Finding-end}} bile {{Finding-begin}}and __ yellow-brown, mulberry-like gallstones measuring up to __ cm{{Finding-end}}. {{Moderate-begin}}The '''mucosa''' is green and velvety {{Finding-begin}}with diffuse cholesterol stippling{{Finding-end}}. The '''spiral neck''' is patent.{{Finding-end}} The '''wall''' <<is thin / {{Comprehensive-begin}}measures up to __ cm in thickness{{Comprehensive-end}}. {{Finding-begin}}A tan-pink cystic duct '''lymph node''' is present measuring __ cm in greatest dimension.{{Finding-end}} {{Moderate-begin}}Representative sections are submitted for microscopic examination in one cassette.{{Moderate-end}}
+
| {{Moderate-begin}}Gallbladder, cholecystectomy:{{Moderate-end}} <br><<Acute and/or chronic>> cholecystitis. <br>{{Finding-begin}}Cholelithiasis.{{Finding-end}}
 
|}
 
|}
 +
{{CAP}}
 +
{{Reporting}}
 
{{Bottom}}
 
{{Bottom}}

Revision as of 12:21, 6 July 2022

Author: Mikael Häggström [note 1]

Common requests

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))
Other legend

<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page

Gross processing

Cholecystectomy grossing

  • Describe the serosa (smooth and intact versus disrupted, adhesions, inflammation, tumor implants, necrosis, porcelain).
  • (Inspect the adventitia (the roughened juxtahepatic surface), where disruptions are generally iatrogenic and optional to report.)
  • 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.[note 2]
  • (Estimate the amount of bile.)
  • {{Estimate the number and describe gallstones.}}
  • Describe the mucosa (such as velvety, granular, trabeculated, and/or with cholesterol stippling)
  • 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
((Labeled - gallbladder. The specimen is received in formalin and consists of a resected)) {{
  • previously opened?
  • focally disrupted (on the juxtahepatic avdentitial surface only)?
  • edematous?}}

gallbladder measuring __ cm in length and __ cm in maximum diameter. The serosa is

  • {{(mottled) tan / pink / red (generally combinations thereof) and}}
  • smooth {{/ with patchy adhesions}}

Upon opening, the lumen contains ((__ [[volume in cc/cm3]]))

  • green {{/ brown / blood-tinged / yellow-white and chalky / clear colorless
  • viscid / sludge-like / thick}}

bile {{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.}} The mucosa is

  • green {{/ tan / yellow-red / brown / pink}}
  • and velvety {{/ granular / trabecular
  • with diffuse cholesterol stippling?}}

The spiral neck is patent {{/ obstructed by one additional similar gallstone measuring __ cm}}. The wall measures up to __ cm in thickness. {{ Rokitansky-Aschoff sinuses are present within the fundus. There is a __ (color) cystic duct lymph node present measuring __ cm in greatest dimension. }} ((Representative sections are submitted for microscopic examination in __ cassette(s). ))

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[note 3]
  • 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

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 information: Autopsy

Fixation

Generally 10% neutral buffered formalin.

  See also: General notes on fixation


Microscopic evaluation

Look at least at the epithelial lining, for atypia and inflammation (such as edema and inflammatory cells, Further information: cholecystitis ).

Other findings

Report

Example:

(Gallbladder, resection:)
  • Gallbladder with no significant histopathologic changes

In cholecystitis:

(Gallbladder, cholecystectomy:)
<<Acute and/or chronic>> cholecystitis.
{{Cholelithiasis.}}

For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.

  See also: General notes on reporting


Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. 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.
  3. En face means that the section is tangential to the region of interest (such as a lesion) of a specimen. Further information: Gross_processing#Cutting

Main page

References

  1. Talwar, OP; K.C., Geetika (2014). "Histomorphological changes in gall bladder diseases and its association with helicobacter infection ". Journal of Pathology of Nepal 4 (8): 617–622. doi:10.3126/jpn.v4i8.11607. ISSN 2091-0908. 
    - "Figures - available via license: CC BY 4.0"

Image sources