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SHORT COMMUNICATION
Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 203-206

A retrospective histopathological study of cholecystectomies


Department of Pathology, Prasad Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication16-Jul-2015

Correspondence Address:
Nidhi Awasthi
521/177, Bhairon Prasad Marg, Bara Chand Ganj, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.160902

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  Abstract 

Background: Gall bladder diseases are prevalent worldwide and present with a diverse clinical and histopathological spectrum. Cholelithiasis is associated with inflammatory as well as neoplastic diseases of the organ. This study was undertaken with a purpose to determine the demographic profile along with the diverse spectrum of histopathological lesions encountered in electively resected cholecystectomy specimens in this part of the world. Materials and Methods: This is a retrospective study conducted on 732 cholecystectomy specimens received in the Department of Pathology of a Hospital Associated with a Medical College in Lucknow, over a period of 28 months from February 2012 to June 2014. Clinical details and histopathological data were retrieved from the hospital records. Results: There were 732 cases in total, consisting of 205 males (28.0%) and 527 females (72.0%). Male: female ratio was 1:2.6. Age of the patients ranged from 12 to 81 years with a mean age of 43.2 ± 13.3 years. Maximum number of patients were in fourth decade of life (27.2%). Cholelithiasis was present in 697 (95.2%) patients in total. Microscopically, the most common pathology noted was chronic cholecystitis, seen in 711 cases (97.1%). However, no cases of gall bladder carcinoma were evident. Conclusion: This study emphasizes the need of a meticulous intra-operative as well as macroscopic examination to rule out gall bladder malignancy. It, however, in no way undermines the importance of a routine histopathological examination of all electively resected cholecystectomy specimens.

Keywords: Cholelithiasis, chronic cholecystitis, histopathological, retrospective


How to cite this article:
Awasthi N. A retrospective histopathological study of cholecystectomies. Int J Health Allied Sci 2015;4:203-6

How to cite this URL:
Awasthi N. A retrospective histopathological study of cholecystectomies. Int J Health Allied Sci [serial online] 2015 [cited 2020 Apr 8];4:203-6. Available from: http://www.ijhas.in/text.asp?2015/4/3/203/160902


  Introduction Top


The gall bladder is one of the most frequently surgically resected organs and presents with a varied spectrum of diseases ranging from congenital anomalies, cholelithiasis, inflammatory and noninflammatory diseases to noninvasive and invasive neoplastic diseases. Cholelithiasis is a common disorder afflicting 10-20% of adult populations in developed countries. [1] It can manifest clinically and histologically as a myriad of disorders encompassing acute cholecystitis, chronic cholecystitis (CC), metaplasias, hydrops, mucocele, empyema, and gall stone ileus. The risk factors for the development of gall stone disease can be categorized as non-modifiable and modifiable. Non-modifiable factors include ethnic background, increasing age, female gender, and family history or genetics whereas, the modifiable ones are obesity, rapid weight loss, and a sedentary lifestyle. [2] Several studies have shown a definite epidemiologic parallel between gall bladder carcinoma and cholelithiasis. [3],[4],[5] There has been a recent upsurge in studies focusing on the need of routine or selective histopathology of electively resected gall bladders. This study was undertaken with a purpose to determine the demographic profile along with the diverse spectrum of histopathological lesions encountered in electively resected cholecystectomy specimens in this part of the world.


  Materials and methods Top


This is a retrospective study conducted on 732 cholecystectomy specimens received in the Department of Pathology of a Hospital Associated with a Medical College in Lucknow, over a period of 28 months from February 2012 to June 2014. Clinical details and histopathological data were retrieved from the hospital records. The surgically resected cholecystectomy specimens were examined macroscopically and two full thickness sections taken from fundus, body and neck of gall bladder. In cases with any evidence of gross abnormality, additional sections were taken. These tissue sections were subjected to routine processing and staining by hematoxylin and eosin stain. Microscopic examination was done to assess the type of histopathological lesions present. Statistical analysis of the data was done using (IBM SPSS Statistical software, version 22 for Windows).


  Results Top


During the 28 months period, a total of 1015 specimens were received in the histopathology laboratory out of which 732 were cholecystectomies. This represents 72.1% of the total histopathological specimens reviewed during the study period. Overall, there were 732 cases consisting of 205 males (28.0%) and 527 females (72.0%). Male: Female ratio was 1:2.6. Age of the patients ranged from 12 to 81 years with a mean age of 43.2 ± 13.3 years. Maximum number of patients were between 41 and 50 years (27.2%) [Table 1]. Abdominal pain of variable severity and duration was the most common presenting symptom.{Table 1}

On macroscopic examination, wall thickness was increased in 199 cases (27.2%). All cases were classified microscopically on the basis of the predominant pattern seen [Table 2]. Most common pathology noted in this study was CC, seen in 711 cases (97.1%). Follicular variant was seen in 22 (3.1%) cases of CC. Cholesterolosis, focal cholesterolosis, antral metaplasia and adenomatous hyperplasia were associated with CC in 44 (6.2%), 37 (5.2%), 2 (0.3%) and 1 (0.1%) cases respectively. Active inflammation was superimposed on CC in 23 (3.2%) cases. Other histomorphological lesions seen were acute cholecystitis in 6 (0.8%), xanthogranulomatous cholecystitis in 13 (1.8%) and empyema in 2 (0.3%) cases respectively. However, no malignant lesions were detected on histopathology.{Table 2}

Cholelithiasis was present in 697 (95.2%) patients in total. Acute and CC were a calculus in 50% and 4.5% of cases respectively. The data were analyzed using SPSS version 22.0 for Windows.


  Discussion Top


Gall Bladder disease is frequently encountered pathology in the biliary tract. The estimated prevalence of gallstone disease in India is reported as between 2% and 29% with the disease being 7 times more common in North than in South India. [4],[6] According to a study by Unisa et al. the prevalence of gall bladder disease in North India is 6.2%, 4.4% in males and 7.3% in females. Prevalence of gall stones is 4.1%, 1.9% in males and 5.5% in females. [7] The present study was carried out on 732 cholecystectomy specimens retrospectively to determine the demographic profile and variable histopathological spectrum of lesions encountered in these electively resected gall bladders.

In this study, of total 732 cholecystectomies, gall stones were present in 697 (95.2%) patients, finding that was consistent with other studies. [6] Females accounted for 72% of total patients with male to female ratio being 1:2.6. This was consistent with studies of Damor et al. [8] and Ozgur et al. [9] Other studies have also reported a preponderance of females among patients of gall bladder disease but the ratio has been higher compared to this study. [4],[6],[10],[11],[12] Reasons for this female predominance have been attributed to female sex hormones, sedentary habits and genetic factors in various studies. [4]

In this study, age of the patients ranged from 12 to 81 years. Maximum number of patients were in the fourth decade of life, with a mean age of 43.2 ± 13.3 years. This was in accordance with few studies, [5],[8],[9],[12],[13] but was higher than that reported in several other studies. [4],[6],[10] [Table 3] shows comparative analysis between different studies quoted in this article and the present study with regard to gender ratio, mean age of patients and incidence of gall bladder carcinoma.{Table 3}

On gross examination normal wall thickness was seen in 533 cases (72.8%). Increased wall thickness (>3 mm) was evident in 199 cases (27.2%). All 13 cases of xanthogranulomatous cholecystitis along with 72.7% of follicular cholecystitis and 23.8% of CC cases showed a thickened wall. Xanthogranulomatous cholecystitis is known to present with increased wall thickness and mimic carcinoma on gross examination. [4],[6] A prospective study by Srikanth et al. showed gall bladder carcinoma in only 2 out of 60 (3.3%) cases of patients presenting with thickened gall bladder wall (>4 mm). They found no statistically significant difference between the incidence of malignancy in patients with or without thick-walled gall bladder. [14]

The most common histopathological finding in this study was CC, seen in 711 cases out of 732 (97.1%), which is consistent with various other studies. [9],[10],[11],[12],[13] Follicular change, cholesterolosis, focal cholesterolosis, active inflammation and antral metaplasia were associated with CC in 3.1%, 6.2%, 5.2%, 3.2% and 0.3% cases. Xanthogranulomatous change, acute cholecystitis and empyema were seen in 1.8%, 0.8% and 0.3% cases respectively.

Chronic cholecystitis was associated with adenomatous hyperplasia in a single patient (0.1%). This case showed macroscopic abnormalities in form of nodular thickenings of the wall at the neck and fundus region, cut surface of which showed grayish white areas with tiny cystic spaces. It reaffirmed the importance of a detailed gross examination and indicated that even incidentally detected malignancies must present with macroscopic abnormalities, no matter how subtle they are.

Multiple studies have been conducted in the recent past focusing on whether gall bladder histopathology must be done routinely or selectively. Gall bladder carcinoma always presents with some gross abnormalities and therefore selective histopathology sent after intra-operative inspection of the mucosa and wall by the operating surgeon would save time and cost is supported by multiple studies. [5],[13],[15] Other studies however, state that detection of incidental gall bladder carcinomas on microscopy, with no evidence of gross abnormalities is not rare and therefore they advocate routine histopathology of all electively resected cholecystectomy specimens. [10],[11],[16] In this series however, no case of incidental gall bladder carcinoma was seen.

Multiple studies and some excellent review articles have studied the natural history of asymptomatic gall stone for the development of gall bladder carcinoma. All have agreed that the incidence is very low [17],[18] and is increased in presence of certain high-risk conditions like porcelain gall bladder, large sessile polyp, large gall stone, gall bladder packed with stones and anomalous pancreaticoabiliary ductal union. [2],[19] A lack of these high risk conditions, increased awareness in the general population leading to early surgery and some preoperative selection bias might account for the absence of malignant cases in this series. There is a need of more prospective studies on these patients to determine the factors responsible for this low rate of carcinoma in this high prevalence zone.


  Conclusion Top


Gall bladder diseases can have a varied presentation both clinically and histopathologically. The present study, in accordance with other studies showed a female predominance. Majority of patients were in fourth decade of life. Cholelithiasis proved to be a major risk factor for inflammatory diseases of this organ. The most common histopathological diagnosis was CC, which was associated with a variety of other mucosal lesions like cholesterolosis, metaplasia, empyema and adenomatous hyperplasia. Despite of the setting of the study in North India, no malignant lesions were however seen. This study wishes to emphasize on the need of a meticulous macroscopic examination to rule out malignancy. It also supports the view that a careful and detailed gross examination is an indispensable tool. It however in no way undermines the importance of a routine histopathological examination of electively resected cholecystectomy specimens.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bladder G. Extrahepatic biliary tree and ampulla. In: Mills SE, editor. Sternberg′s Diagnostic Surgical Pathology. 5 th ed., Vol. II. Wolters Kluwer, 2010. p. 1600-51.  Back to cited text no. 1
    
2.
Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87.  Back to cited text no. 2
    
3.
Giang TH, Ngoc TT, Hassell LA. Carcinoma involving the gallbladder: A retrospective review of 23 cases - Pitfalls in diagnosis of gallbladder carcinoma. Diagn Pathol 2012;7:10.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Mittal R, Jesudason MR, Nayak S. Selective histopathology in cholecystectomy for gallstone disease. Indian J Gastroenterol 2010;29:211.  Back to cited text no. 5
    
6.
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.  Back to cited text no. 6
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7.
Unisa S, Jagannath P, Dhir V, Khandelwal C, Sarangi L, Roy TK. Population-based study to estimate prevalence and determine risk factors of gallbladder diseases in the rural Gangetic basin of North India. HPB (Oxford) 2011;13:117-25.  Back to cited text no. 7
    
8.
Damor NT, Chauhan HK, Jadav HR. Histological study of human gallbladder. Int J Biomed Adv Res 2013;4:9.  Back to cited text no. 8
    
9.
Ozgur T, Toprak S, Koyuncuer A, Guldur M, Bayraktar G, Yaldiz M. Do histopathologic findings improve by increasing the sample size in cholecystectomies? World J Surg Oncol 2013;11:245.  Back to cited text no. 9
    
10.
Siddiqui FG, Memon AA, Abro AH, Sasoli NA, Ahmad L. Routine histopathology of gallbladder after elective cholecystectomy for gallstones: Waste of resources or a justified act? BMC Surg 2013;13:26.  Back to cited text no. 10
    
11.
Ghimire P, Yogi N, Shrestha BB. Incidence of incidental carcinoma gall bladder in cases of routine cholecystectomy. Kathmandu Univ Med J (KUMJ) 2011;9:3-6.  Back to cited text no. 11
    
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Arathi NA, Awasthi S, Kumar A. Pathological profile of cholecystectomies at a tertiary centre. Natl J Med Dent Res 2013;2:28-38.  Back to cited text no. 12
    
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Bawahab MA, Maksoud WM, Amri FS, Ali HF, Salman AN. Does routine histopathological examination of gallbladder after simple cholecystectomy add in additional value? Bahrain Med Bull 2013;35:193-5.  Back to cited text no. 13
    
14.
Srikanth G, Kumar A, Khare R, Siddappa L, Gupta A, Sikora SS, et al. Should laparoscopic cholecystectomy be performed in patients with thick-walled gallbladder? J Hepatobiliary Pancreat Surg 2004;11:40-4.  Back to cited text no. 14
    
15.
Jamal K, Ratansingham K, Siddique M, Nehra D. Routine histological analysis of a macroscopically normal gallbladder - A review of the literature. Int J Surg 2014;12:958-62.  Back to cited text no. 15
    
16.
Jayasundara JA, de Silva WM. Histological assessment of cholecystectomy specimens performed for symptomatic cholelithiasis: Routine or selective? Ann R Coll Surg Engl 2013;95:317-22.  Back to cited text no. 16
    
17.
Attili AF, De Santis A, Capri R, Repice AM, Maselli S. The natural history of gallstones: The GREPCO experience. The GREPCO Group. Hepatology 1995;21:655-60.  Back to cited text no. 17
    
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Ransohoff DF, Gracie WA. Treatment of gallstones. Ann Intern Med 1993;119:606-19.  Back to cited text no. 18
    
19.
Kapoor VK. Cholecystectomy in patients with asymptomatic gallstones to prevent gall bladder cancer - The case against. Indian J Gastroenterol 2006;25:152-4.  Back to cited text no. 19
    




 

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