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Histopathology of chronic cholecystitis (include h & e slide)

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Excellent - I have both H&E slides. Now I have all the material needed for a comprehensive answer.

Histopathology of Chronic Cholecystitis

Overview

Chronic cholecystitis is the most common disorder of the gallbladder and is almost always associated with gallstones (>90% of cases). The morphologic changes are extremely variable and sometimes subtle - the diagnosis is ultimately a pathologic one made on the resected specimen.

Gross Morphology

  • The gallbladder may be contracted, normal-sized, or enlarged
  • The serosa is usually smooth and glistening but may be dulled by subserosal fibrosis
  • Dense fibrous adhesions may be present (sequelae of prior acute inflammation)
  • On section, the wall is variably thickened with an opaque gray-white appearance
  • The lumen typically contains green-yellow mucoid bile and gallstones
  • The mucosa itself is generally preserved

H&E Histology - Key Features

Figure A - Chronic inflammatory infiltrate:

Chronic cholecystitis (A): gallbladder mucosa infiltrated by chronic inflammatory cells with preserved mucosal architecture.
Chronic cholecystitis H&E - (A) chronic inflammatory cell infiltrate in mucosa, (B) Rokitansky-Aschoff sinus with fragmented bile pigment stone
Fig. 14.43 - Robbins & Kumar Basic Pathology: (A) Gallbladder mucosa infiltrated by chronic inflammatory cells. (B) Rokitansky-Aschoff sinus containing a fragmented bile pigment stone.
Chronic cholecystitis H&E - (A) inflammatory infiltrate, (B) Rokitansky-Aschoff sinus with bile
Fig. 18.63 - Robbins, Cotran & Kumar Pathologic Basis of Disease: (A) Mucosa infiltrated by inflammatory cells. (B) Outpouching of mucosa through the wall forming a Rokitansky-Aschoff sinus (contains bile).

Microscopic findings in detail:

FeatureDetail
Inflammatory cellsScattered lymphocytes, plasma cells, and macrophages in mucosa and subserosal fibrous tissue (mildest cases)
FibrosisMarked subepithelial and subserosal fibrosis in more advanced cases
Mononuclear infiltrationChronic inflammatory cells throughout the wall; in the absence of superimposed acute cholecystitis, lymphocytes alone may be the only sign
Mucosal changesReactive proliferation of mucosa; fusion of mucosal folds; buried crypts of epithelium within the gallbladder wall
Rokitansky-Aschoff sinusesOutpouchings of mucosal epithelium through the muscular wall - a hallmark feature (Fig. B above)

Special Variants (also seen on H&E)

  1. Porcelain gallbladder - Extensive dystrophic calcification of the wall (rare); associated with increased risk of carcinoma
  2. Hyalinizing cholecystitis - Complete replacement of the wall and mucosa by dense fibrosis, with or without calcification; also linked to gallbladder carcinoma
  3. Xanthogranulomatous cholecystitis - Rupture of Rokitansky-Aschoff sinuses leads to accumulation of lipid-laden foamy macrophages (xanthoma cells) in the wall; massively thickened, shrunken, nodular gallbladder
  4. IgG4-related sclerosing cholecystitis - A manifestation of IgG4-related fibrosing disease; storiform fibrosis with IgG4+ plasma cell infiltrates

Key Diagnostic Points

  • The hallmark of uncomplicated chronic cholecystitis on H&E is lymphocytic infiltration of the mucosa and submucosa with subepithelial and subserosal fibrosis
  • Rokitansky-Aschoff sinuses (mucosal herniations through the muscularis) are highly characteristic
  • No neutrophils in pure chronic cholecystitis (their presence suggests superimposed acute-on-chronic disease)
  • Microorganisms (E. coli, enterococci) can be cultured from bile in ~1/3 of cases

Clinical Significance

  • Chronic cholecystitis does not have the dramatic presentation of acute forms
  • Characterized by recurrent right upper quadrant or epigastric pain, nausea, vomiting, and fatty food intolerance
  • The main importance lies in the association with gallstones + chronic inflammation → gallbladder carcinoma
Sources: Robbins & Kumar Basic Pathology, p. 633 | Robbins, Cotran & Kumar Pathologic Basis of Disease, p. 813
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