Gallbladder

Commonly removed for chronic cholecystitis with cholelithiasis. Tumors are uncommon, usually associated with gallstones. Commonly torn during a surgical procedure since the procedure is laparoscopic. Note should be made if the specimen is intact or if perforations and tears are present.

Processing the Specimen

1. Describe the serosal appearance.

   1. Normal: Smooth and Glistening.

   2. Adhesions and/or portion of Attached Liver: Normally found at the attachment of the gallbladder to the liver capsule. Fibrous scar tissue bands connecting the gallbladder serosa to nearby tissues.

   3. Inflammation: dull and irregular, subserosal fibrosis, fat necrosis (very firm yellow hemorrhagic soft tissue, may indicate pancreatitis), fibrinous or purulent exudates. Thickening and reddening, exudate or fibrin deposits.

   4. Tumor implants: firm tan/white nodules.

   5. Necrosis: Blue/black discoloration (gangrene) associated with possible perforations.

   6. Porcelain gallbladder: wall may be markedly thickened in chronic cholecystitis. Extensive calcification of the gallbladder may take on the appearance of “porcelain” (shiny hard and white).

   7. Intact with perforations and tears or previously opened.

      1. Look for lymph nodes, commonly near the cystic duct.

2. Open the gallbladder longitudinally, starting away from the cystic duct. The cystic duct is tortuous and need not be opened completely

3. Record length, circumference, and wall thickness.

4. Describe the mucosa.

   1. Normal: tan/green and velvety with a honeycomb pattern, thin, pliable wall.

   2. Cholesterolosis (“, size in Gallbladder”): speckled yellow mucosa due to aggregates of foamy histiocytes in the mucosa.

   3. Inflammation: ulcerated, friable, flattened, and white (atrophy), wall thickened and fibrotic or edematous. Acute acalculous cholecystitis (without gallstones) is a life-threatening disease which may be apparent on examination of the serosa. This wall may be very thin and friable [easily crumbled, fragile, prone to break apart].

   4. Polyps: usually small and papillary, uncommon.

   5. Carcinoma: rare, appears as solid white mass infiltrating the wall or as an exophytic [growing outward], soft, fronded [fingerlike, leaflike, or feathery projections], intraluminal tumor. The wall may be slightly thickened with effacement of the normal tissue. If present, document invasion through the wall (including serosa and adjacent liver if possible), and submit the cystic duct margin.

5. Record the number, size in aggregate, and range of sizes, color, quality and shape (ovoid or faceted) or gallstones present.

   1. Cholesterol calculi: green/yellow/black, hard and crystalline.

   2. Pigment calculi: black, soft, and crumbly.

   3. Note if the stones are lodged in the isthmus or cystic duct.

   4. Note if the luminal contents include bile (viscous green/black fluid) or clear watery mucin.

6. Submit one cassette of gallbladder with sections demonstrating":

   1. Cross-section of fundus.

   2. Neck with serosa.

   3. Cystic duct (Inked).

      1. Lymph node may be present next to cystic duct, must submit.

Gross Differential

1. Adenocarcinomas: Rare, and grossly inapparent. One third of tumors are exophytic and grow into the lumen as a mass. Porcelain gallbladders are associated with increased risk of carcinoma.

2. Metastatic Carcinoma: Usually to serosal surface, is rare. Lymph node near cystic duct will reveal metastasia.

3. Acute Calculous or Acalculous Cholecystitis: Enlarged and firm and bright red, green-black, or violaceous [purple in color]. Lumen may be filled with cloudy hemorrhagic purulent fluid. Wall may be thickened and edematous. In gangrenous cholecystitis, the entire glad is necrotic with multiple perforations. Serosal surface is often covered with fibrinous or purulent exudate.

4. Chronic Cholecystitis: Wall may be thickened and fibrotic. Mucosa is usually preserved. Serosal adhesions may be present/ If wall is thickened with multiple calcifications it may give appearance of porcelain gallbladder. Xanthogranulomatous cholecystitis has the appearance of a small shrunken nodule gallbladder and can be mistaken for malignancy; wall gets thickened, yellow-tan, nodular (xantho = yellow, granulmatous = granuloma-like inflammation, cholecystitis = inflammation of gallbladder).

5. Mucocele: Can be mistaken for mucinous carcinoma, muciphages may resemble signal ring cells on the wall.

6. Infections.