Extrahepatic Bile Duct برای بزرگنمایی عکسها کلیک را روی ان نگه دارید..... Figure 21.1 The gallbladder is divided into the fundus, body, and neck; the portion of the body adjoining the neck is referred to as the infundibulum. A small bulge in this portion is known as Hartmann pouch, notable because gallstones may become lodged here Figure 21.2 The gallbladder wall contains three layers: mucosa, muscularis propria, and serosa on the free surface. There is no muscularis mucosae or submucosa, thus the lamina propria abuts directly onto the muscularis propria. The mucosa is composed of variably sized branching folds consisting of a core of lamina propria lined by a single layer of columnar epithelium Figure 21.3 Gallbladder epithelial cells have eosinophilic cytoplasm with basally located nuclei. Smaller, darkly staining columnar cells known as penciloid cells are interspersed within the epithelium (arrow), as well as basal cells that are often inconspicuous (arrowhead) Figure 21.4 The ducts of Luschka are normal small accessory bile ducts typically located in the perimuscular connective tissue on the hepatic surface of the gallbladder. There is a distinctive ring of surrounding connective tissue, which helps distinguish them from carcinoma, particularly on frozen section evaluation Figure 21.5 Normal and Anomalous Arrangements of Extrahepatic Bile Ducts and Their Adjoining Arteries. 1, Normal arrangement. 2, Caudad origin of cystic artery (frequent variation). 3, Placement of cystic artery posterior to common hepatic duct. 4, Long cystic duct attached to common hepatic duct for some distance before confluence to form common bile duct. 5, Long cystic duct passing behind common hepatic duct and joining it medially at lower level. 6, Normal ductal system with anomalous right hepatic artery reaching the gallbladder wall, where it gives off cystic artery and then turns into liver. In this anomaly, which is not rare, the right hepatic artery is often ligated either with the cystic duct or as a separate structure erroneously identified as the cystic artery. 7, Anomalous right hepatic artery in posterior position presenting the same dangers mentioned in 6. 8, Very dangerous anomaly of entire hepatic artery that follows cystic duct to gallbladder before turning into liver. Accidental ligation of entire hepatic artery was almost always fatal before the advent of antibiotics, and it is still hazardous. 9, Anomalous bile duct entering gallbladder through its bed in liver. Cholecystectomy in such instances is usually followed by profuse drainage of bile and is likely to result in fatal peritonitis unless external drainage is afforded. 10, Anomalous insertion of cystic duct into right hepatic duct. The section of right hepatic duct caudad to its junction with cystic duct can easily be mistaken for cystic duct and ligated, thus shutting off drainage of right lobe of liver into intestine. 11, Anomalous arrangement of right hepatic duct in which it enters gallbladder so that all the bile from right lobe of liver must drain through cystic duct Figure 21.6 The epithelium within all the extrahepatic bile ducts is made up of a single layer of columnar cells resting on dense connective tissue Figure 21.7 Cross section through a congenitally duplicated gallbladder showing duplication of all layers of the gallbladder wall Figure 21.8 Island of heterotopic pancreas adjacent to gallbladder Figure 21.9 This section of the porta hepatis in an infant with biliary atresia shows extensive fibrosis and inflammation and severely damaged, atrophic biliary epithelium with a nearly obliterated lumen (arrow) Figure 21.10 Choledochal Cyst in a 5-Year-Old Female. The structure to the left is the attached gallbladder. (Courtesy of Dr. R.A. Cooke, Brisbane, Australia; from Cooke RA, Stewart B. Colour Atlas of Anatomical Pathology. Edinburgh: Churchill Livingstone; 2004.) Figure 21.11 The Todani classification of choledochal cysts includes types I (segmental or diffuse dilatation of the common bile duct); II (isolated supraduodenal diverticulum); III (choledochocele, usually within duodenal wall); IVa (extrahepatic cysts and Caroli disease-like cystic dilatation of intrahepatic ducts); IVb (multiple extrahepatic cysts); and V (multiple intrahepatic cysts, equivalent to Caroli disease). Type I is the most common, accounting for 75%-90% of cases. (From Lamps LW, Kakar S. Diagnostic Pathology: Hepatobiliary and Pancreas. Salt Lake City: Amirsys; 2011.) Figure 21.12 A, Choledochal cyst with an overall intact epithelial lining and minimal chronic inflammation. B, In contrast, this section from another case shows a completely denuded epithelial lining with underlying acute and chronic inflammation Figure 21.13 A, This gross photograph of an opened gallbladder shows the linear yellow streaks characteristic of cholesterolosis (arrow), as well as larger polypoid projections indicative of cholesterol polyps. B and C, Histologically, cholesterolosis features foamy, lipid-filled macrophages within the lamina propria. D, When one or more of the deposits grows larger and protrudes into the lumen, it is referred to as a cholesterol polyp. (A, Courtesy of Dr. George F. Gray Jr.) Figure 21.14 Numerous mixed cholesterol gallstones in a background of acute and chronic cholecystitis. (Courtesy of Dr. George F. Gray Jr.) Figure 21.15 Dilated gallbladder containing multiple black (calcium bili- rubinate) gallstones. (Courtesy of Dr. George F. Gray Jr.) Figure 21.16 This opened gallbladder with hydrops features a very thin wall, abundant watery secretions, and numerous cholesterol stones within the lumen of the gallbladder. (Courtesy of Dr. George F. Gray Jr.) Figure 21.17 Acute Cholecystitis. A, Both the external surface and the mucosa have a characteristic "angry red" color; the mucosa also appears hemorrhagic. This example of acute calculous cholecystitis contains cholesterol stones. B, At low power, the mucosa has been replaced by a fibrinous exudate, and the wall contains extensive hemorrhage and necrosis. C, Another case of acute cholecystitis, later in the course of disease, shows mural edema, hemorrhage, and a fibroblastic response. Note that neutrophils are not prominent. D, This case of acute emphysematous cholecystitis shows both necrosis and gas bubbles in the wall of the gallbladder. (A, Courtesy of Dr. George F. Gray Jr. D, Courtesy of Dr. Jose Jessurun.) Figure 21.18 A, Gallbladder containing numerous mixed cholesterol stones. The wall is mildly thickened due to chronic cholecystitis. B, The wall of this gallbladder with chronic cholecystitis is markedly thickened, and it contains numerous bilirubin gallstones. C, This section of a case of chronic cholecystitis shows a markedly thickened wall with muscle hypertrophy and numerous Rokitansky-Aschoff sinuses, some of which contain inspissated thick bile. D, Chronic cholecystitis featuring a thickened fibrotic wall and mononuclear inflammation within the mucosa. E, Intestinal metaplasia is common in chronic cholecystitis; this case shows areas of intestinal metaplasia as well as epithelial dysplasia. F, Florid pyloric metaplasia in a case of chronic cholecystitis. (B, Courtesy of Dr. George F. Gray Jr.) Figure 21.19 This case of follicular cholecystitis shows lymphoid follicles, many with germinal centers, throughout the wall of the gallbladder Figure 21.20 A, This case of xanthogranulomatous cholecystitis features a nodular collection of ceroid-laden histiocytes and cholesterol crystals with foreign body giant cell reaction in the wall of the gallbladder. B, Another case shows a more spindled nodule of histiocytes, with associated ceroid pigment and mural fibrosis (B inset) Figure 21.21 This gallbladder wall is almost completely replaced by calcification, known as porcelain gallbladder Figure 21.22 Hyalinizing cholecystitis features replacement of the gallblad- der wall by dense hyaline fibrosis, with minimal inflammation and denuding of epithelium Figure 21.23 "Pure" eosinophilic cholecystitis contains an inflammatory infiltrate composed almost entirely of eosinophils Figure 21.24 This case of diffuse lymphoplasmacytic cholecystitis contained numerous IgG4-positive plasma cells on immunostaining. (Courtesy of Dr. Rhonda K. Yantiss.) Figure 21.25 Hemorrhagic necrosis and mucosal ulceration in a case of gallbladder ischemia that occurred during liver transplant surgery Figure 21.26 Fibrinoid necrosis in a medium-sized artery in a case of polyarteritis nodosa. At the time of cholecystectomy, the vasculitis was limited to the gallbladder Figure 21.27 A, Common hepatic duct in primary sclerosing cholangitis shows a lymphoplasmacytic infiltrate underlying epithelium that is primarily intact. B, A more advanced case shows dense lymphoplasmacytic inflammation with fibrosis, epithelial disarray, and compromise of the duct lumen Figure 21.28 A, Section of common hepatic duct in IgG4 disease, showing a dense lymphoplasmacytic infiltrate, fibrosis, and perineural inflammation deep within the wall of the duct. B, Higher power view shows numerous plasma cells, which were positive with IgG4 immu- nostain. C, Perivenular lymphoplasmacytic inflammation and obliterative fibrosis (arrow) are also characteristic features. (Case courtesy of Dr. Keith K. Lai.) Figure 21.29 A, This ampullary biopsy shows round, basophilic organisms typical of Cryptosporidia within the apical cytoplasm of the epithelial cells. B, A gallbladder biopsy from a patient with microsporidiosis shows an increased mononuclear cell infiltrate in the lamina propria and increased intraepithelial lymphocytes. C, Modified trichrome stain highlights red-staining Microsporidia within the epithelium (arrows). D and E, This gallbladder contains numerous Cystoisospora within parasitophorous vacuoles, with minimal inflammatory reaction (arrows; Case courtesy of Dr. Keith K. Lai) Figure 21.30 A, An autopsy specimen shows a fluke within a large intrahepatic bile duct (arrow). B, Liver flukes are flat, slightly transparent, and tapered anteriorly with prominent oral and ventral suckers. C, Clonorchis within a large intrahepatic bile duct with associated cholangiocarcinoma (D). (A and B, Courtesy of Dr. Jason Doss, C and D, Courtesy of Dr. Dan Milner.) Figure 21.31 A, This gross specimen shows diffuse adenomyomatosis, characterized by a markedly thickened wall and grossly visible dilated glands filled with inspissated bile. B, This fundic adenomyoma shows hypertrophic, branching glands with prominent smooth muscle extending deeply into the wall of the gallbladder. C, Inspissated bile is a common finding. (A, Courtesy of Dr. George F. Gray Jr.) Figure 21.32 A and B, Intracholecystic papillary-tubular neoplasms (ICPNS) show a wide spectrum of papillary and tubular patterns and are often detached from the underlying gallbladder mucosa when the specimen is opened. The case illustrated in B would likely have been called an adenoma using previous terminology. C and D, This large ICPN has a gastric or pyloric cell type. E, This papillary lesion contained extensive high-grade dysplasia/carcinoma in situ and consisted of a mixture of cell types Figure 21.32, cont'd F, This ICPN also contains extensive high-grade dysplasia/carcinoma in situ; the original cell type is difficult to discern given the extensive dysplasia Figure 21.33 A, Flat dysplasia can have a flat or papillary growth pattern; the latter is seen here. Note involvement of a Rokitansky-Aschoff sinus. B, Flat, low-grade dysplasia with elongated, hyperchromatic, pseudostratified cells but no architectural complexity or loss of nuclear polarity. High-grade dysplasia in flat dysplasia with a biliary phenotype (C) and intestinal phenotype (D) Figure 21.33, cont'd E, Extension of dysplasia into a Rokitansky-Aschoff sinus. F, Small focus of invasive adenocarcinoma arising beneath an area of flat dysplasia Figure 21.34 A, Grossly, gallbladder adenocarcinomas may have a polypoid, papillary, or diffuse configura- tion. This adenocarcinoma of the gallbladder has a predominantly papillary appearance. B, This tumor is growing in diffuse fashion in the distal wall of the gallbladder, associated with extensive involvement of the liver. C, This tumor has both polypoid and diffuse growth patterns; note the large polypoid tumor in the center, but the near-circumferential tumor visible around it. D, This tumor has a papillary component with admixed stones but a diffuse component indicated by the friable, thickened folds on the right (arrow). It may be difficult to distinguish a diffuse pattern tumor from chronic cholecystitis. E, In this case, the adenocarcinoma appears as rough, thickened mucosa beneath three large stones (arrow). F, The markedly thickened wall represents diffuse adenocarcinoma rather than chronic cholecystitis, and no distinct mass is easily identified. (C-E, Courtesy of Dr. George F. Gray Jr.) Figure 21.35 A, Pancreatobiliary-type gallbladder adenocarcinoma, featuring well-formed, irregular, widely spaced, infiltrative glands, is the most common pattern among gallbladder carcinomas. B, Although well differentiated, glands that lie parallel to the muscularis propria are a clue to neoplasia (arrow). C, At higher power, these well-differentiated neoplastic glands have nuclear anisocytosis, irregular nuclear mem- branes, uneven chromatin distribution, and loss of nuclear polarity. D, Prominent desmoplastic stroma is a characteristic feature, as seen here in a more poorly differentiated adenocarcinoma. E, Intraneural and perineural invasion is also common Figure 21.36 A, A low-power section from a case of hyalinizing chole- cystitis with widely spaced, well-differentiated malignant glands with attenuated epithelium and prominent luminal debris (arrows). Note that the overlying gallbladder epithelium is denuded. B, A higher-power view shows malignant glands lying parallel to the muscularis propria within densely hyalinized gallbladder wall Figure 21.37 Micropapillary variant with clusters of cells in a papillary configuration within artifactual clefts Figure 21.38 Adenosquamous carcinoma with overlying surface ulceration Figure 21.39 A, Mucinous adenocarcinoma of the gallbladder features abundant extracellular mucin. Clusters of malignant cells and individual signet ring cells float in the mucin. B, Primary signet ring cell carcinoma of the gallbladder. The majority of the malignant cells are in the lamina propria Figure 21.40 A, Adenocarcinoma of the gallbladder with intestinal features, including "dirty" luminal necrosis. Note the overlying dysplasia. B, This pancreatobiliary gallbladder carcinoma has both goblet cells (arrow) and a cribriform growth pattern in numerous foci Figure 21.41 This undifferentiated adenocarcinoma shows a sarcomatoid epithelial component, along with scattered multinucleate giant cells. (Courtesy of Dr. Volkan Adsay.) Figure 21.42 A, Neuroendocrine carcinoma of the gallbladder with overlying flat dysplasia. B, Higher-power view shows speckled chromatin, scant cytoplasm, and numerous mitoses. Synaptophysin and chromogranin were strongly positive Figure 21.43 A, Incidental well-differentiated neuroendocrine tumor (carcinoid, arrows) within gallbladder wall. B, Another case, at higher power, shows uniform cells with a "salt and pepper" chromatin pattern. C, Synaptophysin highlights the tumor cells within the wall of the gallbladder Figure 21.44 A, Granular cell tumor of the common bile duct from a young African-American woman. B and C, Some cases of granular cell tumor in the biliary tree are associated with hyperplasia of the overlying epithelium, similar to other organs. (B and C, Courtesy of Dr. Richard Eisen.) Figure 21.45 A, A noninvasive papillary neoplasm (IPNB) is present within the common bile duct. B, At higher power, there are architectural and nuclear features of high-grade dysplasia. C, This intraductal papillary neoplasm has more of an intestinal phenotype, but again harbors high-grade dysplasia. D, A focus of solid-pattern invasive carcinoma is present at the base (arrows) Figure 21.46 High-Grade Nontumoral Dysplasia. A, Although there are some small papillae, this lesion was found incidentally and did not form a mass. B, Another example shows fusion of the delicate epithelial projections, as well as oncocytic features. C, This example is virtually flat but shows enlarged, hyperchromatic nuclei with pseudostratification Figure 21.47 A, This Whipple resection shows a longitudinally opened common bile duct that contains a nodular tumor extending deeply into the wall (arrows). B, Hilar cholangiocarcinoma with intraductal spread. Figure 21.48 A, A focus of well-differentiated adenocarcinoma beneath flat dysplasia in the common bile duct. B, In this case, the infiltrative neoplastic glands are well differentiated, but the concentric layering of desmoplastic stroma around them is a clue to the diagnosis Figure 21.48, cont'd C, This more poorly differentiated example of adenocarcinoma of the extrahepatic bile duct has overlying dysplasia and associated lymphovascular invasion. D, Heterogeneity of cells within the same gland, increased nucleocytoplasmic ratio, nucleolar prominence, and loss of nuclear polarity are cytologic clues to the diagnosis of malignancy within this relatively well-formed gland. E, Perineural and intraneural invasion are frequent findings in adenocarcinomas of the bile ducts Figure 21.49 A and B, Clear cell well-differentiated neuroendocrine tumor (carcinoid) of the cystic duct Figure 21.50 Malignant Melanoma Metastatic to the Gallbladder. A, The tumor nodules are heavily pigmented. B, Microscopic appearance of malignant melanoma metastatic to gallbladder mucosa Figure 21.51 Diffuse large B cell lymphoma of the gallbladder, involving the entire thickness of the wall Figure 21.52 Embryonal Rhabdomyosarcoma of Botryoid Subtype. A, There is a prominent cambium layer beneath the biliary epithelium. B, High-power view of undifferentiated spindle cells Figure 21.53 A and B, Solitary fibrous tumor of the gallbladder Figure 21.54 A, Gallbladder with metastatic breast carcinoma presenting in the form of multiple nodules protruding through the mucosa and associated with inflammatory changes. B, Metastatic renal cell carcinoma appears as multiple polypoid red nodules in the common bile duct. C, Metastatic lobular breast carcinoma is difficult to appreciate except for the prominent surrounding reactive stroma (low power; inset, high power) Figure 21.54, cont'd D, Metastatic endometrial cancer mimics a high-grade carcinoma of the gallbladder. (B, Courtesy of Dr. George F. Gray Jr.)
