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Cholecystitis Glandularis Proliferans (Cystica) (British Journal of Surgery, Vol. 19, Issue 74) (1931)
Cholecystitis Glandularis Proliferans (Cystica) (British Journal of Surgery, Vol. 19, Issue 74) (1931)
AND P. MAcCALLUM,
PROFESSOR O F PATHOLOGY. IJIIVERSITY OF NELBOURSE.
FIG.237.-Section of the nodule in the fundus of the gall-bladder shown in Fig. 236.
The connection of the epithelium of this nodule with that of the gall-bladder was shown
by serial sections. A, Peritoneal surface ; B. Fat ; C , Cavity of gall-bladder. ( X 3.)
The glandular crypts pass through the muscular coat and finally reach
the subperitoneal layer. The course followed by these crypts is often very
tortuous, and these tortuous portions cut in section give the appearance of
numerous Lglands’ (Fig. 244). The tortuosity of these crypts in the
deeper layers is of paramount importance, since it may be assumed readily
that there is no connection between the ‘ glands ’ observed in the deeper
layers and the surface epithelium.
The cystic spaces, which are found particularly in the submucous and
subperitoneal coats, are lined by a single layer of columnar cells, but in the
larger cysts these become cuboidal or even flattened. Adjacent cysts may
coalesce to form larger cysts (Fig. 238).
314 THE BRITISH JOURNAL O F SURGERY
2. Local proliferation of the epithelium results in the formation of two
or three layers. These are quite regular in
their formation, however, both with regard
t o size, shape, and position, only a few
mitotic figures being present and thc base-
ment membrane intact. Sometimes they
approximate in appearance t o squamous
epithe1i~m.l~
These changes have been regarded as
evidence of carcinomatous or, a t least, prc-
cancerous development. There is, a t present,
no evidence for this assumption.
METAPI,ASIA.-T~~ alterations of the epi-
thelium from the typical gall-bladder type
t o varieties resembling cells typical of other
portions of the bowel make the examination
of the sections of cholecystitis glandularis a
fascinating study. The types of epithelium
found arc : (1) Columnar epithelium with or
FIG. 238.-Section of a localized
without goblet cells-an epithelium of intes-
nodule which projected from the peri- tinal type ; (2) Mucous glands ; (3) ' Gastric '
toneal s'irfac'e Of the
A, Mucous membrane ; 6, Peritoneum.
glands. These structures show the alteration
( x 6.) of gall-bladder epithelium to various other
forms of alimentary canal epithelium.
1. Columnar Epithelium.--In
many of the epithelium-lined crypts
the epithelium is of a tall columnar
character, with basal nuclei (Fig. 241).
The regularity of the size and position
of these nuclei is a characteristic
feature of many of the sections.
Goblet Cells. -The cells of the
epithelium of the gall-bladder differ
from those of the intestine in that all
the cells produce mucin a t the same
time, but only in the form of small
droplets. Thus in the normal gall-
bladder goblet cells are infrequent. I n
the iriflanied organ, however, goblet
cells occur in a large proportion of
cases.14 Thcsc are t o be found in
most of the examples of cholecystitis
glandularis.
2. 1l1ucous Glands occur not un-
commonly in chronic cholecystitis,
having been found 185 times in 250
consecutive described by the a gallFIG. 239.-Portion of the thickened wall of
- bladder, showing the epithelium - lined
writer e1~ewhcre.l~They occur in the crypts and the associated glands. ( x 30.)
CHOLECY STITIS GLANDULARIS PROLIFERANS 315
majority of the examples of cholecystitis glandularis, and were described
in 1905 by Aschoff.2
They resemble mucous glands
occurring elsewhere. The epithelial
cells are arranged in small alveoli, the
nuclei are round or oval and are
situated in the middle of the cell, the
position varying with the activity of
the cells, and the protoplasm stains
deeply with mucicarmine (Figs. 240,
243). There is no doubt that these
glands arise from the surface epi-
thelium either directly or from the
crypts, since on section direct con-
tinuity of the epithelium can easily
be traced.
3. 'Gastric' Glands.-In a number
of cases of chronic cholecystitis in
which mucous glands occur, other
glands resembling the glands of the
FIG.242.-Portion of tissue from an example FIG. 243.- -An area showing niucous glands.
of eholecystitis glandularis showing a ’ lyinplioid ( x IN)).
nodule ’. ( x 110.)
FIG. 24j.--fortion of the wall similar to that shown in Fig. 246. Coiled tubules,
cut in section, are present, principally of the inucoua type, but also a few of the
' gastric ' variety.
of the cholecystitis glandularis type, but found only extreme fibrosis. Some
of these, however, may be related, since in some cases evidence of the
previous presence of glands is t o be found in the occurrence of small spaces
CHOLECYSTITIS GLANDULARIS PROLIFERANS 319
sometimes still containing a few epithelial cells or of degenerating epithelial
cells lying in the connective tissue.
The excess development of fat is striking in some organs, either as fat
purely, or with a mixture of connective tissue. This tissue sometimes merges
into lymphoid tissue, which, however,
is distinct from the lymphoid nodules
referred to above.
Any of these changes which occur
in ordinary cases of chronic chole-
cystitis may be found in the condition
described here.
Acute Inflammation.-When acute
inflammation supervenes on chronic
inflammation, the characteristic phe-
nomena appear in the subepithelial
tissues, and, depending on the degree
of the stimulus and the time at which
it was examined, hyperactivity and
then destruction of the epithelium
may be found.
The inflammation spreads down
the crypts, and similar changes occur
here. The destruction of the deeper
epithelium may be an explanation of
not finding this in cases where it was
expected* In two cases Of FIG. 249.-Higher-power view showing the
abscesses in the wall of the gall- structure of the ‘gastric’ glands. ( x 360.)
bladder, a few large epithelial cells
were found, suggesting that the site of the abscess was originally an
epithelium-lined space.
The relationship of the crypts to
the peritoneum probably affords an
explsination of the observation that
some patients with acute cholecyst-
itis have a peritonitis early, whereas
others do not do so-excluding for
the moment other factors, such as
the virulence of the organism, etc.
Other Complications. -Obstruc-
tion of the cystic duct by a peduncu-
lated ‘adenoma’ is described by the
Mayos in Keen’s Surgery. A calculus
in a cyst in the wall- of the gall-
FIG. 260.-Smell subperitoneal cysts contctining
cholesterol and bile pigment. ( x 30.) bladder may be mistaken for a calculus
in the cavitv of the =.eall-bladder.
.
Relationship to Malignancy.-This problem, as in all parts of the body,
is extremely difficult, and apparently convincing arguments may be offered
for diametrically opposed opinions.
320 THE BRITISH JOURNAL O F SURGERY
It seems t o us reasonable and probable that neoplastic development
could arise in the epithelium of cholecpstitis glandularis. On the other hand,
we have not observed, in the few examples that have come t o our notice,
any instance of changes which would withstand critical examination by the
usual criteria for malignancy. The regular arrangement of the cells, the
normal polarity and the regular charactcr of the nuclei, the presence of base-
ment membrane, the degree of differentiation of the metaplastic glands all
militate against a diagnosis of malignancy.
CLINICAL CHARACTERISTICS.
Cholecystitis glandularis presents no special clinical features. It has
been observed, in this series, in patients whose ages ranged from 38 t o 72.
All the patients were females.
I n every case the gall-bladder was removed on account of signs and
symptoms of chronic cholecystitis; in 9 of them acute inflammation had
supervened.
Gall-stones were present in 21 out of the 25 cases. In the 4 other cases,
record of the presence or otherwise of stones was absent.
I t s greatest importance rests in its possible confusion with malignant
disease. A thickening of the wall, particularly when considerable fibrosis
rendered this very hard, and nodular projection several times simulated and
CHOLECYSTITIS GLANDULARIS PROLIFERANS 321
led, at operation, to the provisional diagnosis of malignancy. Even micro-
scopically two cases were returned as carcinoma. The subsequent history
shows that the patients have had no ill effects after a period of seven years,
even though in one case the thickening in the wall, examined microscopic-
dly, extended for 2 in. along that aspect of the wall which was in contact
with the liver.
As stated, the condition was found in 9.5 per cent of 400 gall-bladders
examined, but this result cannot be accepted as an indication of the frequency
of occurrence, since the cases were, unintentionally, picked. For example,
in addition t o material derived from hospital and our own practice, a number
of the specimens were sent to the writers by colleagues (to whom they would
express their grateful appreciation) who knew of the interest evinced by us
in the subject, and other ‘less interesting’ material was not examined.
In comparison with this, there are the figures of ‘innocent tumours ’
observed by other writers :-
Mayo - 107 examples of papilloma in 2558 gall-bladders (4.21 per cent)
Irwin and McCartyIl 85 ,, ,, 2168 (3.92 ,, 1
-
9, 9,
REFERENCES.
1 ABELL,I., ‘‘ Papilloma and Adenoma of Gall Bladder ”, Ann. Of SffTg.,1923, Ixxvii, 276.
* ASCHOFF, L., “ Bemerkungen zur pathologischen Anatomie der Cholelithiasis und
Cholecystitis ”, Verhandl. d. deui. path. Gesellsch., 1905, ix, 41.
BIANCALANA, L.. “ Un Caso di Adenornioma della Cistifellea ”, Arch. ifal. di ChiT.,
1926, xvi, 539.
CHOLECYSTITIS GLANDULARIS PROLIFERA.NS 323
BISHOP,E. S., ‘.An Undescribed Innocent (?) Growth of t h e Gall-bladder ”, Lancet,
1901, ii, 72.
BODN~R L.,, “ Cholecystitis Cystica ”, Virchow’s Arch., 1922, ccxxxviii, 359.
BUZZI,A., and LASCANO GONGALEZ, J. M., ‘’ CholCcystite chronique avec AdCnome ”,
Ann. d’Anat. pathol., 1930, vii, 943.
DOMINICI,M., “ Ueber einen seltener Tumor der Gallenblase ”, Arch. f. kZin. Chir.,
1911, xcvi, 487.
EWING,J., Neoplastic Diseases, 1928. London.
HRUSKA,“ Ein Fall von krebsiger Umwandlung eines Papilloms der Gallenblase ”,
Wien. kZin. Woch., 1916, xxix, 1283.
lo IKEDA, I., Gann, 1912, quoted by Kaufmann.
l 1 IRWIN,H. C., and MACCARTY,W. C., “ Papilloma of the Gall-bladder. Report of
85 Cases”, Ann. of Surg., 1915, Ixi, 725.
l 2 .JANOWSKI, W.,‘‘ Ueber Vertlbderungen in der Gallenblase bei Vorhandenseim von
Gallensteinen ”, Zeigler’s Beitr., 1891, x, 449.
l 3 KAUFMANN, E., Lehrbuch der spaiellen pathologischen Anatomie, 1922. Berlin.
l4 KING, E. S. J . , “ Epithelial Proliferation and Metaplasia in Chronic Cholecystitis ”,
Jour. Coll. Surg. Australasia, 1930, Nov., No. 2, 245.
l 5 LASNIER, E. P., and RODRIGUEZ ESTEVAN, C. M., “ Dos Casos de Cistoadenoma biliar ”,
Ann. de Fac. de med. Monlevid., 1929,xiv, 142.
LUBARSCH, ‘‘ Ueber heterotope Epithelwucherungen und Krebs ”, Verhandl. d . deut.
path. Gesellsch., 1906, Sitz. iv, 208.
l 7 MAYER,L., “ Transformation de la VCsicule biliaire en un Kyste papillifhre ”, Jour.
mid. de Bruz., 1911, xvi, 85.
l 8 MAYO.C. H., ‘‘ Papilloma of the Gall-bladder ”, Collected Papers of the M a y o CZinic.
1915, 249.
NICIIOLSON,G. W.,“ Heteromorphosis of the Alimentary Tract ”, Jour. Pathol. and
Bacteriol., 1923, xxvi, 399.
20 NICOII,J. L., ‘‘ L’AdCnomyome du Fond de la Vesicule biliare ”, Ann. d’Anat. pathol.,
1927, iv, 133.
21 PELS-LEUSDEN, F., ‘‘ Ueber papillare Wucherungen in der Gallenblase und ihre
Beziehungen zur Cholelithiasis und zum Carcinom ”, Arch. f. klin. Chir., 1906,
Ixxx, 128.
22 RINGEL, ‘‘ Ueber Papillom der Gallenblase ”, B i d . , 1899,lix, 101.
23 ROBSON, A. W. M., .‘ Adenoma of the Gall-bladder ”, Med.-Chir. Trans., 1905,
Ixxxviii, 231.
21 ROLLESTON, H.D., Diseaws of the Liver, Gall-bladder and Bile-ducts, 1905.
2; SAND, R., and MAYER,L., ’‘ Transformation de la VCsicule biliaire tout entiere en un
Kyste papillifhe ”, Arch. de Mdd. ezpir. el d’Anat. pathol., 1911, xxiii, 523.
2 6 SAVY,P., BONNET, P., and MARTIN,J. F., ‘’ Tumenrs bCnignes des Voies biliares ”,
Lyon chir., 1913, ix, 673.
27 SLADR, G. R., Gallstones and Cancer ”, Lancef, 1905, i, 1059.
I‘
2“ SOMMER, R., Ueber papilliire Neubildungen in der Gallenblase und der Gallenwegen ”,
Beitr. z. Idin. Chir., 1926,cxxxviii. 357.
29 QUTIIERLAND, “ Small Adenomyoma of the Gall-bladder ”, Glasgow Med. Jour., 1898,
i, 216.
m VALLEE,A., ‘‘ Adeno-papillome de la Vesicule biliaire ”, Bull. mPd. de QuCbec, 1929,
xxx, 302.
31 VECCHI,A., ‘‘ Polipo adenomatose della Parete della Cistifellea di grande Volume ”,
Arch. per le S&. med.. 1929,liii, 188.
32 WEiDLiNGEn, E., ‘‘ Fibromyoadenom des Gallenblasenfundus ”, Arch. .f. klin. Chir.
1928, cliii, 180.
33 ZENKER,.‘ Der primiire Krebs der Gallenblase und seine Beziehungen zu Gallensteinen
nnd Gallensteinnarben ”,Deut. Arch. f. M i t t . Med., 1889, xliv, 159.