Cholecystectomy specimen

Question 1

Describe the case for your specimen?

Answer 1

Case: 44-year-old woman who had been diagnosed with acute cholecystitis (RUQ pain, anorexia, nausea and fever, positive Murphy’s sign). The gallbladder was removed by a laparoscopic cholecystectomy. The specimen was fixed in 10% formalin and sent to pathology.

Question 2

Describe the external macroscopic features?

Answer 2

External exam:
o intact gallbladder measured 75 x 30 mm
o with the attached cystic duct measuring 1cm
o gallbladder appeared enlarged
o serosal surface showed signs of acute inflammation; hyperaemic, subserosal haemorrhage

Question 3

Describe the internal macroscopic features?

Answer 3

Internal exam:
o opened lengthwise; from fundus
o wall was slightly thickened and oedematous, measuring 3mm (normal)
o muscosa was green and granular
o bile within was green and tubid (likely containing fibrin, pus and haemorrhage)
o contained was a bile forming nodule, measuring 25 x 15 x 18 mm (likely the early formation of a gall stone)
-> brown colour (ca bilirubinate pigment stone?, infection)
o no evidence of malignancy; neoplastic growths/polyps/chronic inflam/ulceration

Question 4

Describe the histological changes seen in acute vs chronic cholestasis?

Answer 4

Acute:
• Normal GB wall thickness
• Patchy ulceration 
• Congestion -> haemorrhagic inner wall
• Neutrophil infiltration- slough on luminal surface
• Adhesions with hepatic surface
• Possible stones
Chronic:
• Thickened wall due to inflam and fibrosis of muscularis and serosa -> scarring (fibrotic wall)
• Omental tethering
• Possible stones

Question 5

Describe the microscopic abnormalities of the specimen?

Answer 5

Microscopic abnormalities:
• Acute cholecystitis is characterised by acute inflammatory changes;
o Inflammatory infiltrate (including PMNs)
o BV dilation and congestion
o Tissue damage (mucosal necrosis).

Question 6

Describe the pathogenesis of cholecystitis?

Answer 6

1) Obstruction
- stone formation (90%)
- stone impacts cystic duct
- cholecystokinin (CKK) released after fatty meal -> gallbladder contraction (colic)
2) Inflammation/ infection
- lecithin (bile component) converte to lysolecithin (by phospholipase A) -> mucosal damage
- inflammation predisposes infection (esp gram neg, E. coli or Klebsiella)
3) Ischaemia
- inflammation -> reduced organ perfusion (despite collateral) -> ischaemia

Question 7

How does a gallstone form?

Answer 7

Stone formation:

• supersaturation of bile with cholesterol/pigment
• > not enough bile salts
• > cholesterol crystalizes into gallstones (around nidus)
• > gallbladder contracts (colic)
• > incomplete emptying

Question 8

What are the causes of cholecystitis?

Answer 8

• 90% gallstones (cholesterol, pigment, mixed)

- 10% acalculi (in critically due to stasis- trauma, burns, infection, ischaemia, neoplasia)

Question 9

List the different types of calculi?

Answer 9

1) Cholesterol stones (80%)
• large, solitary, white
• 80% radiolucent, 20% opaque due to calcifications
• Risk factors: 4Fs (female, fat, fair, fecund, forty), hyperlipidaemia, DM, genetics, CD, advanced age, HRT, multiparity, weight loss, Native American

2) Pigment stones
• contain calcium bilirubinate
• Black = sterile stone, Ca2+, Br, haemolysis -> radiopaque
• Brown = infection -> radiolucent

3) Mixed
• most common
• 1-3cm, faceted
• Contains calcium salts, cholesterol (mostly), pigment

Question 10

What are some acalculi causes of cholecystitis?

Answer 10

o Acute- ischaemia due to major surgery, trauma, burns, septic shock
o Chronic- cholesterolosis, adenomyomatosis, cholesterol polyposis, biliary sludge
o Infective- enteric gram negative cocci, Salmonella typhi

Question 11

Name some complications of cholecystitis?

Answer 11

• Sepsis: necrotic gallbladder prone to perforation -> peritonitis -> septicaemia -> death
• Local abscess formation
• Cholangitis
• Biliary enteric fistula
• Chronic cholecystitis -> increases risk cholangiocarcinoma