Cholecystoses (Bệnh lý lành tính của thành túi mật không do viêm và sỏi).pptx

THS.BS. ĐẶNG THỊ KIM LIÊN
(CHOLESTEROLOSIS, POLYPOSIS,
ADENOMYOMATOSIS AND CHOLECYSTITIS
GLANDULARIS PROLIFERANS)
holecystoses

Cholecystosis
• A generic term introduced by Colesson & Jutras
• Describe a group of noninflammatory, nonlithiasic benign diseases of the gallbladder
(GB) wall
• A chronic aspecific inflammatory process much more frequent & associated with lithiasis
1. Helmberger, T., Bartolozzi, C., Vagli, P. (2008). Cholecystoses. In: Baert, A.L. (eds) Encyclopedia of
Diagnostic Imaging. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-35280-8_480

Cholecystosis
• Classified into:
⎻ The hyperplastic forms - normal growth with hyperplasia of the cellular wall components,
include limited (focal and segmental) & more extensive thickening: adenomyomatosis &
cholesterolosis
⎻ The accumulating forms - overload of the wall with organic substances or minerals such as
lipids or calcium salts (thesaurismosic forms): calcified/porcelain GB
• The clinical picture resembles that of inflammation of the GB caused by stones.
1. Helmberger, T., Bartolozzi, C., Vagli, P. (2008). Cholecystoses. In: Baert, A.L. (eds) Encyclopedia of
Diagnostic Imaging. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-35280-8_480

1. Cholesterolosis
• Benign condition, a type of hyperplastic cholecystosis
• Macrophage accumulation of triglycerides, cholesterol esters mainly in the
submucosal layer or lamina propria
• Etiology of cholesterolosis remain unclear
• Association with cholesterol gallstones, super saturation of bile with
cholesterol, hyperlipidemia, obesity, atherosclerosis remains unconfirmed
• Gallbladders often contains stones
• 2 types: a diffuse form ( “strawberry” GB) & a polypoid form
1. Helmberger, T., Bartolozzi, C., Vagli, P. (2008). Cholecystoses. In: Baert, A.L. (eds) Encyclopedia of Diagnostic Imaging.
Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-35280-8_480

Cholesterolosis (“strawberry gallbladder”)
• “Strawberry GB”
o Diffuse thickening
o The presence of yellowish, diffuse, granular, lipid deposits
o Varying in distribution & size
o In the GB mucosa
• Polypoid form
o Single or multiple, small (up to 1 cm in some cases)
o Discrete polypoid excrescences composed of cholesterol-filled macrophages
1. Helmberger, T., Bartolozzi, C., Vagli, P. (2008). Cholecystoses. In: Baert, A.L. (eds) Encyclopedia of Diagnostic Imaging.
Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-35280-8_480

Cholesterolosis (“strawberry GB”)
• Accumulation of lipids (triglycerides, cholesterol precursors & cholesterol
esters) in the mucosa
• 2/3 of cases: < 1 mm
• 1/3 of cases: larger & polypoid in appearance (polypoid form)
• Creates yellow deposits on a background of hyperaemic mucosa
(“strawberry GB”)
• Associated with cholesterol stones
The interior of a strawberry GB (cholesterosis)
Courtesy of Dr Sanjay P Thakur, Patna, India
1. O'Connell, P. R., McCaskie, A. W., & Sayers, R. D. (2023). Bailey & Love's short practice of surgery

Cholesterol polyposis
• USG: non-mobile defect, brightly echogenic
without shadowing (1,2)
• Interval follow-up is indicated to ensure
stability (1)
• Surgery is advised only if there is a
diagnostic dilemma(1)
2. Jarnagin, W. R. (Ed.). (2022). Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set-E-Book. Elsevier Health Sciences
• Women aged 40 - 50 years(2)
• Single/multiple, generally are < 10 mm(2)
• Non-neoplastic collections of lipid laden
macrophages covered in normal GB epithelium (2)
• Smooth/lobulated, attached to the GB wall by a stalk(2)
• Differentiate large cholesterol polyps from
adenomas/adenocarcinomas (2)

Cholesterol polyposis
Cholesterol polyp
A, B: Ultrasound images
C: MRI T2-weighted sequence
D: MRI venous phase
Jarnagin, W. R. (Ed.). (2022). Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume
Set-E-Book. Elsevier Health Sciences

2. Cholecystitis glandularis proliferans
(Adenomyomatosis)
• Benign condition, with tumor-like features, hyperplastic changes of the wall
• Overgrowth of the surface epithelium, glandular formation & out-pouching into or through the
thickened muscular wall => intramural diverticula or sinus tracts termed Rokitansky–Aschoff
sinuses
• Focal, segmental, or diffuse form
• Differentiate from a congenital fold of the GB wall (Phrygian cap: thinner, smoother & localized to
the fundus)
• Involve any portion of the GB
• Middle-aged females
1. Helmberger, T., Bartolozzi, C., Vagli, P. (2008). Cholecystoses. In: Baert, A.L. (eds) Encyclopedia of Diagnostic Imaging. Springer, Berlin, Heidelberg.
https://doi.org/10.1007/978-3-540-35280-8_480

(adenomyomatosis)
• Overgrowth of the mucosa & thickening of the muscle wall (Adenomyomatous
hyperplasia)(1,2)
• 8% - 10% of cholecystectomy specimens, 1/4 of cases of GB wall thickening(2)
• Associated with chronic inflammation of the GB(2)
• A clear association with cholelithiasis (1)
• Leading to: (1)
o Cyst-like structures in the GB wall
o Polypoid projections from the mucosa
o Intramural diverticulae (difuse adenomyomatosis)
o Complicated by intramural, later extramural, abscess & potentially fistula formation
Types of cholecystitis glandularis
proliferans (polyps, intramural or
diverticular stones and fstula)

(adenomyomatosis)
• 3 variants(2)
o Localized (30%): a mass in the GB fundus, ≈ 11% of GB polyps
o Segmental (> 60%): focal, circumferential GB wall thickening
o Diffuse (< 5%): diffuse GB wall thickening & intramural diverticulae
• Histology: epithelial & smooth muscle proliferation, causing epithelial invaginations, or
Rokitansky-Aschoff sinuses(2)
• US: comet-tail artifacts
• Dysplasia, carcinoma in situ, and invasive adenocarcinoma can form within the
epithelium, BUT it is a benign lesion & not a malignant precursor
• Cholecystectomy: symptomatic cases, neoplastic thickening is a concern
Jarnagin, W. R. (Ed.). (2022). Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set-E-Book. Elsevier Health Sciences
O'Connell (2023)

2. Adenomyomatosis
Adenomyomatosis
Characteristic “comet tail” artefact is
depicted by the arrow in image A
A – C: Ultrasound images
D: MRI T2-weighted sequence
E: CT scan venous phase
F: MRI T2weighted sequence
Jarnagin, W. R. (Ed.). (2022). Blumgart's Surgery of the Liver, Biliary
Tract and Pancreas, 2-Volume Set-E-Book. Elsevier Health Sciences
“Comet tail” artefact: resulting from acoustic
reverberations from calcium deposits trapped in
the Rokitansky-Aschoff sinuses

3. Porcelain gallbladder
• A male-to-female ratio of 1:5(2)
• Calcified GB/calcifying cholecystitis/cholecystopathia chronica calcarean
• The term “porcelain gallbladder”: brittle consistency & blue discoloration of these
calcifications in the muscularis
• Secondary to the chronic inflammation of the GB wall due to cholecystitis
• Intramural hemorrhage & an imbalance in calcium metabolism
• Gallstones are documented in 90% of cases(2)
• Low prevalence but association with GB carcinoma especially in cases
 More recent reports: risk may be lower, probably < 10%, related to the type of
calcification (lower risk with complete calcification compared with selective
calcification)(1)
1. Jarnagin, W. R. (Ed.). (2022). Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set-E-Book. Elsevier Health Sciences
2. Helmberger, T., Bartolozzi, C., Vagli, P. (2008). Cholecystoses. In: Baert, A.L. (eds) Encyclopedia of Diagnostic Imaging. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-35280-8_480

3. Porcelain gallbladder

4. Diverticulosis
• As black pigment stones impacted in the outpouchings of the
lacunae of Luschka
• Be demonstrated by cholecystography, especially when the GB
contracts after a fatty meal
• Small dots of contrast medium within & outside the GB wall
• The treatment is cholecystectomy

5. Typhoid infection
• Salmonella Typhi or Salmonella Typhimurium can infect the GB
• Acute/chronic cholecystitis (more frequently)
=> patient become a typhoid carrier excreting the bacteria in the
bile
• Gallstones may be present => should not give patients their
stones if there is any suspicion of typhoid
• Treatment: ampicillin + cholecystectomy are indicated
• In the case of penicillin allergy, a quinolone antibiotic can be used
https://www.researchgate.net/publication/232232512_Host-
Pathogen_Interaction_in_Invasive_Salmonellosis/figures?lo=1

6. Xanthogranulomatous cholecystitis
• Uncommon infammation of the GB
• More frequently seen in India & Japan
• More common in females
• Caused by
o Extravasation of bile into the GB wall from rupture of the
Rokitansky–Aschof sinuses
o Mucosal ulceration as a result of a focal or difuse destructive
infammatory process
• Accumulation of lipid-laden macrophages (xanthoma cells), fibrous
tissue, acute & chronic infammatory cells
Xanthogranulomatous cholecystitis.
Infltrates in the wall of the gallbladder show
foamy macrophages (arrow), giant cells and
lymphoplasma cells in the background
(courtesy of Dr Amita Joshi, Mumbai, India).

• USG shows:
o GB wall thickening (difuse or focal, with intact mucosal lining)
o Intramural hypoechoic nodules or bands
o Often the presence of gallstones
• CT shows: 5 – 20 mm intramural hypoattenuating nodules &
poor/heterogeneous contrast enhancement
• As with acute cholecystitis, early enhancement of the adjacent liver
parenchyma may occur
• Extension into the liver along with enlarged hepatoduodenal lymph
nodes closely mimics GB carcinoma

• Diagnosis is difcult & depends on pathological examination
• Intraoperatively, frozen-section examination: diferentiate
xanthogranulomatous cholecystitis from carcinoma
=> coexistence of GB cancer 2.3 – 13.3%
• Preoperative suspicion of xanthogranulomatous cholecystitis:
open cholecystectomy

7. Granular cell tumors
• Nonepithelial tumors, occur throughout the body
• 1% in the biliary tract, 4% of these biliary granular cell tumors occur in the GB => very rare tumors
• 90% women, the average age of presentation is 34 years, African Americans
• Symptoms: biliary colic or acute cholecystitis
• Are thought to be of Schwann cell origin
• S-100 positive on immunohistochemical staining
• US: heterogeneous, mildly hyperechoic, poorly defined masses
• CT: nonspecific soft tissue masses
• Cholecystectomy: symptomatic lesions or difficulty distinguishing it from a neoplastic polyp
Jarnagin, W. R. (Ed.). (2022). Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set-E-Book. Elsevier Health Sciences

olyps
P
Quay lại Trang Chương trình
Gallbladder

8. Gallbladder polyps
• Incidental findings during radiological imaging of the abdomen
• More often benign: cholesterol polyps, adenomyomas,
infammatory, adenomas or miscellaneous
• May be malignant: adenocarcinoma (80%), squamous cell
carcinoma, or cystadenomas
• A majority of polyps remain stable

Gallbladder polyps
• Pseudopolyps: cholesterol polyps, focal adenomyomatosis, hyperplastic polyps,
inflammatory polyps
• True polyps:
+ Adenomas, adenocarcinomas
+ Rare types: mesenchymal tumours, lymphoma, metastases
• Nonneoplastic polyps: cholesterol polyps (60–90%), adenomyomas (25%–40%),
inflammatory polyps (10%), fibromyoglandular
• Neoplastic polyps: adenomas, intracholecystic papillary neoplasms, adenocarcinoma

ESGAR/EAES/EFISDS/ESGE Guidelines for Gallbladder Polyps
2017 2021
1
Cholecystectomy if patient is
fit for & accepts surgery
Polypoid lesion ≥ 10 mm Polypoid lesion ≥ 10 mm
2 Symptoms + no alternative cause for the patient’s symptoms
Symptoms + no alternative cause for the patient’s symptoms
Regarding the benefit of cholecystectomy vs the risk of persistent
symptoms
3 6 – 9 mm + risk factors 6 – 9 mm + risk factors
4 During follow-up gallbladder polyp reaches 10 mm
During follow-up gallbladder polyp reaches 10 mm
Grows by ≥ 2 mm
Risk factor
• Age > 50
• PSC
• Indian ethnicity
• Sessile polyp (including focal GB wall thickening >4 mm)
• Others: solitary polyps, East Asians, presence of gallstones
• Age > 60
• PSC
• Asian ethnicity
• Sessile polyp (including focal GB wall thickening >4 mm)

ESGAR/EAES/EFISDS/ESGE Guidelines for Gallbladder Polyps
2017 2021
5
6 – 9 mm + no risk factors
Follow-up US at 6 months, 1 year and then yearly up to 5
years
Follow-up US at 6 months, 1 year 2 years
Discontinue after 2 years in the absence of growth
≤ 5 mm + risk factors
6 ≤ 5 mm + no risk factors Follow-up is advised at 1 year, 3 years and 5 years Follow-up is not required
7 During follow-up GB polyp disappears Discontinue follow-up Discontinue follow-up
8
- Primary investigation should be with TAUS
- Endoscopic ultrasound) may be useful to aid decision-
making in difficult cases
- Primary investigation should be with TAUS
- Endoscopic ultrasound) may be useful to aid decision-
making in difficult cases

 Cholesterolosis
• There is a diagnostic dilemma
 Adenomyomatosis
 Porcelain GB
 Diverticulosis
 Typhoid infection
 Xanthogranulomatous cholecystitis
 Granular cell tumors
• Symptomatic lesions, difficulty distinguishing from a
neoplasm
 Gallbladder polyps
1. Symptomatic patients
2. Prophylaxis: gallstones, PSC, biliary colic, pancreatitis,
patients > 50 years, sessile polyps with wall thickening > 4
mm, polyps > 10 mm, the size is increasing
SURGERY

BENIGN TUMORS OF THE GALLBLADDER
GALLBLADDER POLYPS
3 - 7% of abdominal ultrasound examinations
2 - 12% of cholecystectomy specimens Adenomyomatosis Granular Cell Tumors
Cholesterol polyps Adenomatous polyps
• 50 – 80% of polypoid
lesions
• Women aged 40 to 50
years
• Single or multiple
• Generally are < 10 mm
• Nonneoplastic collections
of lipid laden macrophages
covered in normal GB
epithelium
• 15% of GB polyps
• Commonly found in
women
• Neoplastic lesions derived
from the GB epithelium.
• Typically asymptomatic
• Chronic RUQ abdominal
pain if large/obstructing the
cystic duct
• Associated with
cholelithiasis
• Histology: tubular,
papillary, or tubulopapillary;
sessile or pedunculated
• Adenomyomatous
hyperplasia, 8% - 10% of
cholecystectomy specimens
• Associated with chronic
inflammation
• 3 variants: localized,
segmental, diffuse
• 1/4 of cases of GB wall
thickening
• A benign lesion
• Histology: epithelial &
smooth muscle proliferation,
=> epithelial invaginations, or
Rokitansky-Aschoff sinuses
• Nonepithelial tumors
• 1% in the biliary tract, &
4% of these biliary granular
cell tumors occur in the GB
• 90% women, the average
age is 34 years, African
Americans
• Symptoms of biliary colic
or acute cholecystitis.
• Histology: Schwann cell
origin & are S-100 positive on
immunohistochemical
staining.

BENIGN TUMORS OF THE GALLBLADDER
GALLBLADDER POLYPS
Adenomyomatosis Granular Cell Tumors
Cholesterol polyps Adenomatous polyps
• US: brightly echogenic
without shadowing
• Differentiate large
cholesterol polyps from
adenomas or
adenocarcinomas
• US: smooth intraluminal
masses; lobulated or
cauliflower-like
• The adjacent GB wall
maintains a normal
thickness (< 3 mm)
• US: comet-tail artifacts,
resulting from acoustic
reverberations from
calcium deposits trapped
in the Rokitansky-Aschoff
sinuses
• Radiography:
heterogeneous, mildly
hyperechoic, poorly
defined masses on US
• Nonspecific soft tissue
masses on CT
• Safely observed as long
as they are < 10 mm in
size
• Risk factors for GB
cancer: > 50 years,
presence of gallstones,
larger polyp size ( > 10
mm), GB wall thickening,
primary sclerosing
cholangitis, local GB wall
invasion, & polyp
vascularity
• Cholecystectomy:
symptomatic cases,
differentiation from
neoplastic thickening is a
concern.
• Cholecystectomy:
symptomatic lesions,
difficulty distinguishing it
from a neoplastic polyp

Cholecystoses (Bệnh lý lành tính của thành túi mật không do viêm và sỏi).pptx

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