|Year : 2013 | Volume
| Issue : 2 | Page : 102-105
Spectrum of histopathological lesions in cholecystectomy specimens: A study of 360 cases at a teaching hospital in South Delhi
Sabina Khan1, Sujata Jetley1, Musharraf Husain2
1 Department of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
2 Department of Surgery, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
|Date of Web Publication||13-Dec-2013|
Department of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi - 110 062
Source of Support: None, Conflict of Interest: None
Background: Gallstone disease is a common surgical problem requiring cholecystectomy. It is known to produce diverse histopathological changes in the gallbladder ranging from acute or chronic inflammation to metaplasias and even malignancies. The aim of this study was to emphasize the importance of a detailed microscopic examination and to study the diverse range of histopathological lesions in cholecystectomy specimens.
Materials and Methods: This is a retrospective study of 360 cholecystectomy specimens received in the Department of Pathology over a period of 2 years from November 2010 to October 2012. Clinical details and histopathological data were retrieved from the records. The variety of morphological changes in the diseased gall bladder were correlated with the clinical findings.
Results: Overall, there were 360 cases consisting of 74 (21%) males and 286 (79%) females. Maximum number of patients was between 31 and 40 years (30.2%). Most common pathology noted in our study was chronic cholecystitis seen in 280 cases (77.7%). Other benign lesions were cholesterosis in 36 (10%) and acute cholecystitis in 10 (2.7%). Various other associated lesions and variants of cholecystitis were also encountered. A total of nine malignant lesions of gallbladder were observed, which included eight cases of incidental adenocarcinomas and one case showing lymphomatous involvement.
Conclusion: Our study emphasizes that a routine cholecystectomy performed for a common condition like gallstone disease can result in a diverse and wide spectrum of histopathological lesions ranging from benign diagnosis to an unexpected gallbladder malignancy.
Keywords: Cholecystectomy, gallstone disease, histopathology
|How to cite this article:|
Khan S, Jetley S, Husain M. Spectrum of histopathological lesions in cholecystectomy specimens: A study of 360 cases at a teaching hospital in South Delhi. Arch Int Surg 2013;3:102-5
|How to cite this URL:|
Khan S, Jetley S, Husain M. Spectrum of histopathological lesions in cholecystectomy specimens: A study of 360 cases at a teaching hospital in South Delhi. Arch Int Surg [serial online] 2013 [cited 2019 Dec 15];3:102-5. Available from: http://www.archintsurg.org/text.asp?2013/3/2/102/122927
| Introduction|| |
Gallstone is the most common disease of the gallbladder. The prevalence of gallstone disease varies with age, sex and ethnic group. In India, gallstone disease is 7 times more common in the north as compared to the south. 
Laparoscopic cholecystectomy is the treatment of choice done routinely for gallstone disease. Gallbladder is one of the most frequently received specimens in any histopathology laboratory. Usually, the diagnosis given in most of the cholecystectomy specimens is quite straight forward; that is, chronic cholecystitis. However, other diverse, but benign histopathological changes of gallbladder mucosa are also seen namely acute inflammation, cholesterosis, metaplasia and hyperplasia. Very rarely cholecystectomy specimen may reveal an unexpected gallbladder carcinoma. It is a rare malignancy with overall poor prognosis especially if diagnosed late in the course of the disease. Hence, the histopathological examination of every cholecystectomy specimen is of utmost importance.
The purpose of this study was to determine the histopathological pattern of gallbladder lesions in cholecystectomy specimens in a South Delhi hospital and thus contribute in understanding of its etiopathogenesis.
| Materials and Methods|| |
A retrospective study was conducted on 360 cholecystectomy specimens received in the Department of Pathology of a teaching hospital over a period of 2 years from November 2010 to October 2012. Clinical details were retrieved from hospital records and histopathological data were obtained from the original pathology reports. Cholecystectomy specimens received in the laboratory were fixed in 10% formalin and submitted to detailed gross examination. Three full thickness sections were obtained from fundus, body and neck of the gall bladder. Additional sections were taken from any grossly abnormal area if present. Sections were then stained with H and E stain and examined microscopically for a variety of morphological changes in the diseased gall bladder.
| Results|| |
During the 2 year period, a total of 1,858 specimens were received in the histopathology laboratory out of which 360 were cholecystectomies. This represents 19.4% of the total histopathological specimens reviewed during the study period. The age of the patients ranged from 14 to 70 years. Mean age of the patients was 37 years. Maximum number of patients was between 31 and 40 years (30.2%). There were 74 (21%) males and 286 (79%) females with M:F ratio of 1:4.7 [Table 1].
Almost all patients (99.2%) had gallstones according to the retrieved clinical data. Abdominal pain (68.2%) was the most common presenting symptom followed by dyspepsia (21.4%) and jaundice (10.3%). Most common clinical diagnosis was chronic cholecystitis in 283 patients (78.6%) followed by biliary colic in 54 patients (15%). 18 (5%) patients were operated for acute cholecystitis and two patients were having gall bladder polyp on ultrasound which on histopathology turned out to be cholesterosis. Only three patients were having acalculous cholecystitis. None of the patients had pre-operative diagnosis of malignancy.
All cases were examined microscopically and categorized according to their predominant microscopic pattern [Table 2]. Chronic cholecystitis alone was the most common pathology reported in 280 cases (77.7%). Other benign lesions were cholesterosis in 36 (10%), acute cholecystitis in 10 (2.7%) and metaplasia in 4 (1%) cases. There were two cases (0.5%) each of eosinophilic cholecystitis, adenomyoma and empyema. Xanthogranulomatous cholecystitis was seen in 13 cases (3.6%).
A total of nine cases of malignant lesions were found in the specimens. 8 (2.2%) were diagnosed as adenocarcinoma of the gallbladder while in one patient the gall bladder wall showed lymphomatous infiltration [Table 3]. All cases of malignancy were diagnosed incidentally during the gross or microscopic examination. Another isolated rare case of chronic cholecystitis was seen showing ectopic liver tissue attached to the body of gall bladder. Microscopically, liver tissue showed fatty change and triaditis.
| Discussion|| |
Gallstone disease is the most common surgical disorder requiring cholecystectomy. The estimated prevalence of the disease in India is reported to be between 2 and 29% with the disease being 7 times more common in the North than in South India.  The present study was carried out on 360 cholecystectomy specimens to determine the histopathological spectrum of gallbladder diseases. Histopathology not only establishes a tissue diagnosis in gallstone disease, but also contributes towards understanding its etiopathogenesis and can help in planning future treatment modality.
In our study, the age of the patients ranged from 14 to 70 years. Maximum number of patients was in the third decade of their life. The average age of these patients in India is a decade younger than in the west.  The exact cause of this is not known although may be due to genetic predisposition. Male to female ratio is 1:4.7, which is consistent with findings of Zahrani and Mansoor.  Other studies have also shown female predominance among patients of gallstone disease. However, they have reported a slightly higher female to male ratio as compared to our study. , Female sex hormones and sedentary habits of most women in India expose them to factors that possibly promote the formation of gallstones. ,,
Gallstones were present in almost all cases of cholecystectomy according to the retrieved clinical data and intra-operative findings provided by the operating surgeon on the histopathology form. However, all of them were not received in the laboratory as most of the time the stones are handed over to the patients' relatives after the surgery. Gallstones are described to be present in almost all the cases diagnosed as chronic cholecystitis, which was the commonest lesion in our study.  Acute cholecystitis was seen in 2.7% of patients which was consistent with another study from middle east.  Reports from the west have reported variable rates of acute cholecystitis in cholecystectomy cases, but overall 5-10% is reported by the majority of reports.  The rate of operation in acute cholecystitis is much less as compared to the western world because many of these patients reported very late, usually after 72 h.
Cholesterosis was the most common change noticed in our study (10%). Our results are in conformity with the findings of Mohan et al.  Metaplasia (pyloric or intestinal) was noted in four cases (1%), which is almost similar to a study from the middle-east.  However, few reports have shown that pyloric gland metaplasia is most common and found in 66-84% of cholecystectomy specimens.  This might be explained by the fact that most metaplastic changes occur focally and mild changes are often not reported by the pathologists. A more thorough sampling and careful interpretation is needed for the accurate rates of metaplasia in gallbladder specimens.
Xanthogranulomatous cholecystitis was reported in 13 cases (3.6%). Importance of recognizing this variant lies in the fact that they usually present with increased wall thickness and can mimic carcinoma on gross examination. Our incidence was slightly higher compared to the study by Mohan et al.  who reported an incidence of 2.3%. However, the above study reported a higher number of chronic follicular cholecystitis of 2.3% as compared to 0.5% in our study. This could be due to the underreporting by the pathologists as heavy lymphoid hyperplasia in the gallbladder wall is usually reported as chronic cholecystitis.
There were eight cases of carcinoma of the gallbladder in our study. All of these were incidental carcinomas with no radiological or pre-operative suspicion of malignancy. All the carcinoma cases were seen in females. Youngest patient diagnosed with malignancy was a 25-year-old female. The incidence of gallbladder carcinoma diagnosed during or after a laparoscopic cholecystectomy has been reported to be between 0.19% and 3.3%.  Despite advances in diagnostic and surgical modalities, gallbladder cancer is still characterized by late diagnosis and poor prognosis except when incidentally diagnosed at an early stage after cholecystectomy for cholelithiasis. 
One case of ectopic liver nodule attached to gallbladder wall was found incidentally in a cholecystectomy specimen. Fatty change was also seen in this ectopic liver tissue which was an interesting, but rare finding. Literature search showed less than 30 examples of ectopic liver associated with the gallbladder. 
| Conclusion|| |
The histopathological spectrum of gallbladder disease after cholecystectomy was found to be quite diverse. The most common histopathological diagnosis in gallstone disease was chronic cholecystitis, which was associated with a variety of mucosal alterations and lesions like cholesterosis, metaplasia and adenomyoma. Variants of chronic cholecystitis such as xanthogranulomatous, eosinophilic and follicular cholecystitis were also noted. Malignancies of the gallbladder included incidental adenocarcinomas and an isolated case showing lymphomatous infiltration. Increased rate of incidental carcinomas was also seen in our study, which reinforces the importance of histopathological examination in all routine cholecystectomy specimens.
| References|| |
|1.||Mohan H, Punia RP, Dhawan SB, Ahal S, Sekhon MS. Morphological spectrum of gallstone disease in 1100 cholecystectomies in North India. Indian J Surg 2005;67:140-2. |
|2.||Tandon RK. Pathogenesis of gallstones in India. Trop Gastroenterol 1988;9:83-9. |
|3.||Zahrani IH, Mansoor I. Gallbladder pathologies and cholelithiasis. Saudi Med J 2001;22:885-9. |
|4.||Tyagi SP, Tyagi N, Maheshwari V, Ashraf SM, Sahoo P. Morphological changes in diseased gall bladder: A study of 415 cholecystectomies at Aligarh. J Indian Med Assoc 1992;90:178-81. |
|5.||Baig SJ, Biswas S, Das S, Basu K, Chattopadhyay G. Histopathological changes in gallbladder mucosa in cholelithiasis: Correlation with chemical composition of gallstones. Trop Gastroenterol 2002;23:25-7. |
|6.||Weedon D. Diseases of the gallbladder. In: Mac Sween RM, Anthony PP, Scheuer PJ, Bun AD, Portman BC, editors. Pathology of the Liver. 3 rd ed. New York: Churchill Livingstone; 1994. p. 513-34. |
|7.||Sternberg SS. Diagnostic Surgical Pathology. 3 rd ed. Philadelphia (PA): Lippincott Williams and Wilkins; 1999. |
|8.||Zhang WJ, Xu GF, Zou XP, Wang WB, Yu JC, Wu GZ, et al. Incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy. World J Surg 2009;33:2651-6. |
|9.||Memon W, Khanzada TW, Samad A, Kumar B. Histopathological spectrum of gall bladder specimens after cholecystectomy. Pak J Med Sci 2011;27:553-6. |
|10.||Kyeong HE, Park Y, Park S. Ectopic liver associated with the gallbladder. A brief case report. Korean J Pathol 2008;42:128-30. |
[Table 1], [Table 2], [Table 3]