Evaluation of Gall Bladder Mucosal Changes in Relation to the Type of Stones in Patients Undergoing Laparoscopic Cholecystectomy: A Retrospective Study of 394 Patients

Cholelithiasis induces diverse histopathological changes in the gallbladder mucosa e.g. acute & chronic inflammation, hyperplasia, granulomatous inflammation, cholesterosis, dysplasia, and carcinoma ^{1, 2}. The overall incidence of Cholelithiasis in India is between 2% to 29% and mostly occurs in north than south India ³. Gall bladder mucosal changes depend upon the duration of cholelithiasis, size, number, stone type and gender of the patient ⁴. Coexistence of gallstones with cholecystitis, hyperplasia, intestinal metaplasia, and carcinoma is well known in literature ⁵. Incidental gallbladder (GB) carcinoma is revealed in 1% of all cholecystectomies done for benign conditions ⁶.Pathological stage of the disease decides the prognosis of the disease. Gall bladder metaplasia is characterized by intestinal or pyloric type epithelium found in association with cholelithiasis ⁷. Histopathological changes in the tissue can predict the chances of gall bladder cancer formation.

In a recent paper ⁸, it is found that as gallstone size increases, the response in gallbladder mucosa changes from cholecystitis, hyperplasia, and metaplasia to carcinoma. The Gallstone number and type are less important variables associated with these changes. In another study ⁹, the rate of incidental gallbladder carcinoma was found low in histopathological examination of cholecystectomies specimens. In India, the histopathological examination of Gallbladder specimens in Kumaon Region of Uttarakhand state has been completed ¹⁰.

Etiology and pathogenesis of GB cancer is not well known. The main difficulty in studying the precursor lesions of this disease is the fact that it is impossible to perform follow-up, because the diagnosis is established during surgery or after the cholecystectomy.

Therefore, the evidence relating these lesions to the cancer is determined indirectly. A better understanding of the risk factors for gall bladder cancer and premalignant lesions of the gall bladder could help in selection of prophylactic cholecystectomies and thus reduction in mortality ¹¹. In the current study, we planned to correlate various gallstone characteristics (number and morphological type) with the type of mucosal response in gallbladder mucosa (inflammation, hyperplasia, metaplasia, and carcinoma).

We examined the 438 cholecystectomy specimens, in which 394 cases (90%) belonged to gallstones and the rest 44 cases (10%) belonged to acalculous cholecystitis. We examined the mucosal changes in gallbladder for 394 cases to identify the correlation between mucosal changes and number and type of observed gallbladder stone. Out of 394 patients, 78 were males and 316 were females with M/F ratio 1:4. The observed mucosal changes in male and female patients are shown in Table 1. Figure 1, Figure 2, Figure 3.

Figure 1.Photomicrographs showing A, Rokitansky agghste sinuses characteristic of chronic cholecystitis; B, Acute on Chronic Cholecystitis; C, Follicular Cholecystitis; D, Foamy macrophages admixed with mcaumulaig inflammatory infiltrate seen in Zbanikagmapincitma Cholecystitis (H&E)

Figure 2.Photomicrograph showing A, cib;k%=Ss in low power; B, High power view of CiNk%=1%us showing lipid laden macrophages; C,ggtj of Gall Bladder; D, Pyloric Metaplasia Gall Bladder (H&E)

Figure 3.Photomicrograph showing A, Low power view of Adenocarcinoma Gall bladder; B, High power view shows attempted gland formation with moderate pleomorphismmoderately differentiated adenocarcinoma Gall Bladder; C, Low power view of Papillary carcinoma GB; D, High power view showing papillae with fibrovascular cores lined by malignant cells- Papillary carcinoma GB (H&E)

(Table 2) shows the type and number of stones observed in total 394 patients. Mixed type of stone was the most frequently encountered stone present in 276 cases (70.05%), which was predominantly multiple in numbers; followed by pigmented type around 77 cases (19.54%). Cholesterol stones were present in only 41 cases (10.40%). A total of 285 patients had multiple stones, while 109 patients had single stone.

(Table 3) shows the various types of the mucosal changes observed in terms of number of stones. We studied the gall bladder mucosa microscopically and observed the most common change in chronic cholecystitis with cholelithiasis (341 cases, 86.54%). Xanthogranulomatous Cholecystitis was present in 16 cases (4%). Chronic Cholecystitis with metaplasia was present in 14 cases (3.55%), followed by Chronic Cholecystitis with focal cholesterosis in 9 cases (2.28%) Gall bladder carcinoma was found in 1 case (0.25%).

(Table 4) shows the correlation between mucosal changes and morphology of stones. We found that almost all the lesions were more common in gall bladders with multiple number of stones. It might be due to the fact that multiple stones are far more common than single (63.47%) and irritation of mucosa is greater with higher number of stones. Among the other changes, multiple stones were more associated with cholecystitis, xanthogranulomatous cholecystitis, in both gastric and intestinal metaplasia, as shown in Table 4.

In the current work, a retrospective study on 394 patients was carried out to find the correlation between gallstones (number and morphology) with mucosal changes that occur in the gall bladder. It is already known that cholecystolithiasis is associated with GB cancer, as cholecystolithiasis is observed in 80% of all GB cancer cases ¹². In one study, incidence of GB cancer is about 1.68%, whereas it is 3.5% in another study in which multiple histopathological sections of GB was examined ¹³. Coexistence of cholecystolithiasis with xantho granuloma to us cholecystitis, adenomyomatosis, pyloric and intestinal metaplasia is well known in literature ¹⁴. In our study, majority of patients were aged between 30 to 39 years. The females are more sufferers than males, as 1:4 (Male/Female) GB stone incidence is observed in various studies ^{15, 16}. 

Mixed stones incidence (70.05%) was most commonly observed gallstone in North India and also observed in our study ^{15, 17}.  We observed 19.54% (77/394) pigmented stones, 10.40% (41/394) cholesterol stones, 72.33% (285/394) multiple mixed stones and 27.66% (109/394) single stones, as observed in other reports ^{11, 18, 19}.  These data indicate that cases with multiple stones are more symptomatic (cholecystitis) than single stone and mucosal changes e.g. hyperplasia, metaplasia, and carcinoma are more common with multiple mixed stones. Dysplasia and carcinoma in situ were detected in 16/394 (4%) and 1/394 (0.25%) patients, when we examined the multiple sections of gall bladder from fundus, body, and neck.

Precancerous gall bladder mucosal changes are important clinically as well as pathologically, however not studied carefully by pathologist earlier ²⁰. We observed gall bladder mucosal hyperplasia in 6/394 (1.5%) cases in females only. The primary cholelithiasis causes mechanical mucosal irritation and results in hyperplasia. Intestinal metaplasia was detected in only 14/394 cases (3.5%).

Higher incidence of cholecystolithiasis was observed in females compared to males, which causes increased risk of gall bladder cancer. This may be due to decrease in activity of cholesterol reductase and increase in activity of HMG-CoA reductase with age, resulting in increased cholesterol secretion and saturation of bile. The female sex hormones may also expose them to factors that possibly promote the formation of gallstones. Early menarche, early first pregnancy, multiple pregnancies, and delayed menopause may increase the risk of gall bladder carcinoma ¹². 

An earlier study ²⁵ suggested that gallbladder metaplasia changes are found commonly in patients with multiple mixed stones. This association seems to be relative and statistical association could not be demonstrated between number of stones and mucosal response ²⁶. Xanthogranulomatous cholecystitis is an uncommon inflammatory and destructive gall bladder process that can spread to adjacent structures and could be confused with cancer. This histological alteration occurs in approximately 2.9% of all cholecystectomies, affects men and women equally and is frequently associated with gallstones. The occurrence of cancer in gall bladders with xanthogranulomatous cholecystitis has been reported and has been observed in 9-12% of these cases. Similarly, xanthogranulomatous cholecystitis presented a higher incidence within elderly individuals in this study and, interestingly, occurred more often among women.

In our study, the incidence of acute cholecystitis was higher in males as observed in other study ²⁷.  The incidence of cholecystolithiasis and GB cancer increases with age. An estimated 0.25% of the patients above 65 with cholecystolithiasis may develop GB carcinoma, that depends upon the duration of gallstone disease than the age of patient ²⁸.  We observed 1/394 case of GB carcinoma.

Adenomatoid hyperplasia, a non-inflammatory benign gall bladder alteration, mostly occurred in middle aged patients and increased with age. It is presently identified as a precancerous lesion, and cancer cases associated with adenomyomatosis have been reported in literature ²⁹. 

In our study, we observed that metaplasia and dysplasia increased with age and the metaplastic alterations and dysplasia are taken as precancerous lesions. The gall bladder cancer is an extremely slow progressive disease and prolonged follow up may be needed ¹⁸.  Ransohoff and Gracie ³⁰ performed the follow-up of 123 patients with asymptomatic cholecystolithiasis for seven years without any symptoms of GB cancer. Maringhini and associates performed follow-up on 2,583 patients for 13 years, however five patients (0.2%) developed cancer in this period.

Whether prophylactic cholecystectomy should be performed in asymptomatic gallstones is a matter of debate. However, an Indian study recommends prophylactic cholecystectomies for asymptomatic gallstones in young patients with thickened GB wall (greater than 3 mm), with large gallstones (greater than 3 cm), patients with porcelain GB, sessile polyps (greater than 1 cm) and in people from areas with high incidence rates of GB cancer ³¹. 

Our study advocates that there is correlation between gall bladder stones and gall bladder histological changes. Nonetheless, further work is needed to understand about various risk factors of gall bladder cancer. Our data is crucial to establish the surgical treatment for various pathological gall bladder conditions e.g. symptomatic or asymptomatic calculous cholecystitis.

Our study showed that patients with multiple gallstones were more symptomatic (cholecystitis) than with single stone. The mucosal changes like hyperplasia, metaplasia, and carcinoma were also more common in cases with multiple mixed type of stones. Etiology or pathogenesis of multiple stones were more symptomatic (cholecystitis) than with single stone and mucosal changes like hyperplasia, metaplasia, and carcinoma were also more common in cases with multiple mixed type of stone. Still, we require further studies to understand gall bladder stones leading to carcinogenesis and risk factors.

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