morphometric analysis of histoarchitectural changes...
TRANSCRIPT
MORPHOMETRIC ANALYSIS OF HISTOARCHITECTURAL
CHANGES IN CHOLECYSTITIS
DISSERTATION
SUBMITTED TO THE TAMILNADU DR.M.G.R. MEDICAL
UNIVERSITY
CHENNAI
In partial fulfillment of
the requirements for the degree of
M.D. (PATHOLOGY)
BRANCH – III
DEPARTMENT OF PATHOLOGY
TIRUNELVELI MEDICAL COLLEGE HOSPITAL
TIRUNELVELI – 627011
APRIL-2017
CERTIFICATE
This is to certify that the dissertation titled “MORPHOMETRIC
ANALYSIS OF HISTOARCHITECTURAL CHANGES IN
CHOLECYSTITIS” is a bonafide work done by Dr.R.PRIYADARSHINI,
Department of Pathology, Tirunelveli Medical College, Tirunelveli – 627011,
during her post graduate degree course from 2014 to 2017. This work has not
formed the basis for previous award of any degree.
Prof. Dr. K. SITHY ATHIYA MUNAVARAH, MD.,
Dean,
Tirunelveli Medical College,
Tirunelveli – 627011
CERTIFICATE
I hereby certify that this dissertation entitled “MORPHOMETRIC
ANALYSIS OF HISTOARCHITECTURAL CHANGES IN
CHOLECYSTITIS” is arecord of work done by Dr.R.PRIYADARSHINI,
Department of Pathology, Tirunelveli Medical College & Hospital, Tirunelveli, in
partial fulfilment of university rules and regulations for the award of M.D.
DEGREE in PATHOLOGY BRANCH III,under my guidance and
supervisionduring the academic period from 2014 to 2017.
Prof. Dr.K. SHANTARAMAN,MD.,
Professor and Head,
Tirunelveli Medical College
Tirunelveli-627011.
Prof. Dr. S. VASUKI,MD.,
Department of pathology,
Tirunelveli Medical College
Tirunelveli-627011.
DECLARATION
I solemnly declare that the dissertation titled “MORPHOMETRIC
ANALYSIS OF HISTOARCHITECTURAL CHANGES IN
CHOLECYSTITIS” was done by me at Tirunelveli Medical College, Tirunelveli
– 627011, during the period of 2014 to2017 under the guidance and supervision of
Prof. S. VASUKI.MD, to be submitted toThe Tamil Nadu Dr. M.G.R. Medical
University towards thepartial fulfilment of requirements for the award of MD
DEGREE in PATHOLOGY BRANCH-III.
Place : Tirunelveli
Date :
Dr.R.PRIYADARSHINI,
Post Graduate Student,
Department of Pathology
Tirunelveli Medical College,
Tirunelveli – 627011.
ACKNOWLEDGEMENT
This thesis owes its existence to the help, support and inspiration of several
people. First, I thank Professor Dr. K. SITHY ATHIA MUNAVARAH, M.D.
Dean, Tirunelveli Medical College, for having permitted me to conduct the study
and use the hospital resources in the study.
I would like to express my sincere and heartfelt gratitude to Professor Dr.
SHANTARAMAN. K. MD, Professor and Head, Department of Pathology, for
his guidance, inspiration and suggestions for the development of this thesis
context.
I would like to express my special appreciation and thanks to my mentor
Professor Dr. S. VASUKI.M.D., and Professors DR. SWAMINATHAN.K.
M.D., DR.SURESH DURAI. J. M.D., DR. ARASI RAJESH.M.D., Department
of Pathology, for guiding me during the period of study.
I am extremely thankful to Professor DR. A.SELVAMURUGAN,
Professor and Head,Department of Forensic Medicinefor supporting me
academically and professionally during the period of study.
I also thank all the lab technicians especially Mrs. Veeralakshmi for their
valued assistance and my fellow postgraduates for their cooperation which
enormously helped me in the study.
Finally, but by no means least, my deepest gratitude goes to my husband
Dr. N. KARTHIKEYAN, mom and dad for their unflagging love and
unconditional support throughout my life and my studies.
ABBREVIATIONS
GB – Gall bladder
EHBD – Extra hepatic bile duct
IHBD – Intra hepatic bile duct
CBD – Common bile duct
LMW – Low Molecular weight keratin
EMA – Epithelial Membrane Antigen
CEA – Carcino Embryonic Antigen
R.A sinus – Rokitansky Aschoff sinus
DM – Diabetes Mellitus
Ca(HUCB)2 – Calcium monohydrogen bilirubinate
HPE – Histopathological Examination
MALT – Mucosa Associated Lymphoid Tissue
CLL – Chronic Lymphocytic Leukemia
SLL – Small Lymphocytic Lymphoma
IgG 4 – Immunoglobulin G 4
HMG- COA - 3-Hydroxy 3- Methyl Glutaryl Coenzyme A
TPN - Total Parenteral Nutrition
CONTENTS
1. INTRODUCTION 1
2. AIMS OF THE STUDY 3
3. REVIEW OF LITERATURE 4
4. MATERIALS AND METHODS 45
5. OBSERVATIONS AND RESULTS 49
6. DISCUSSION 69
7. SUMMARY 75
8. BIBILIOGRAPHY
9. ANNEXURES
INTRODUCTION
1
INTRODUCTION
Cholecystitis is often thought to be a major ailment in modern society.
Gallstones are more likely associated with humans from antique era, since they
have been found in the gallbladders of Egyptian mummies dating back to 1000
BC. Historical evidence suggests that Alexander The Great had suffered from
acute gall bladder infection[1]. Nowadays, it is a worldwide medical problem, with
wide areas of geographical distribution.
Recently, gallstones are becoming increasingly common due to sedentary
lifestyle and socio economic status. Its frequency has been strongly integrated
with the epidemics of obesity and the metabolic syndrome[2].
Risk factors associated with cholecystitis are multifactorial. Many risk
factors for gallstone formation are not modifiable such as ethnicity, older age,
female sex and family history or genetics. On contrary, modifiable factors like
diet, drugs, physical activity also contributes for stone formation. Other
attributable risk factors related to biliary sludge include pregnancy, drugs and total
parenteral nutrition or starvation.
Certain diseases like cirrhotic liver, chronic hemolytic diseases and ileal
Crohn’s disease are more prone for black pigment stones. Gallstone disease in
childhood, was once considered rare but its occurrence has been increased these
days because of lifestyle modification particularly childhood obesity[3].
Population-based surveys have uncovered an overall increase in mortality
in co-morbidance with cardiovascular disease and cancer. Due to this increased
2
incidence of gallstone disease, there is a concomitant increase in certain
complications like gallstone-related pancreatitis[4].
Gall bladder is one of the commonest specimens received in the
histopathology laboratory. Cholecystitis is classified based on the presence of
stones as calculous (cholelithiasis) and acalculous cholecystitis. Both are
associated with significant macroscopic and microscopic changes.
Histopathological alterations such as epithelial hyperplasia, dysplasia with
erosion of mucosa and inflammatory cellular infiltrates were encountered in both
cholelithiasis and acalculous cholecystitis. Therefore it will automatically warrant
a study to distinguish and estimate the changes evident in both types. In the recent
decades,morphometrictechniques have been developed rapidly which permits
quantification of structural data facilitating correlation with functional studies.
Morphometry is a field concerned with studying variations and alterations
in forms such as size and shape. It can be used to assess the malignant nature of
cells and its classification by quantitative measurements of nuclei such as density,
area, etc. For example, in uveal melanoma, the nuclear perimeter shows good
correlation with prognosis[5]. In addition, it can also be used to estimate the
predominant alteration with statistical evidence. With the recent advent of
personal computers, morphometric measurement could be easily merged with the
computer for rapid and better analysis.
This article gives a valuable audit on calculous and acalculous cholecystitis
and spotlights current information about the pathogenesis, risk factors,
histopathological changes and morphometric analysis of the predominant
alterations.
AIMS OF THE STUDY
3
AIMS OF THE STUDY
The aim of this study is
1) To morphometrically analyse the histomorphological pattern in the wall
of human gall bladder in cholecystitis.
2) To compare them statistically with normal human gall bladder through
routine histopathological approach.
REVIEW OF LITERATURE
4
REVIEW OF LITERATURE
HISTORY :
Cholecystectomy is the commonest operative procedure of biliary tract and
second most common surgery performed today[6]. History of surgery is weighed
down with names of well known German specialists like Kocher, Czerny,
Courvoisier and Mikulicz.In 1687,Stal Pert Von Der Weil while operating a
patient with purulent peritonitis inadvertently discovered gall stones[1]. But Carl
Langenbuch spearheaded the idea and executed first gall bladder (GB) extraction
in 1882 [7].
In 1987, Philippe Mouret in France did the first laparoscopic
cholecystectomy which immediately reformed the treatment of gall stones[8].
Today laparoscopic cholecystectomy is the preferred treatment for symptomatic
gall stones.
EMBRYOLOGY :
Embryologically, GB and biliary tree anlage begins around fourth week of
gestation. They are endodermal in origin and develop as a ventral bud known as
hepatic diverticulum[9]. It stretches out into septum transversum as rapidly
multiplying cell strands and partitioned into two parts(FIG. 1) - a larger cranial
part pars hepatica which is the liver primordium and smaller caudal part pars
cystica[10].
5
At 29 days of gestation, pars cystica will start protruding as anterolateral
dilatation which later develops into GB along with a cystic duct visible at 34
days[11]. Initially GB is an empty organ however as a consequence of multiplying
strands of epithelial lining, it turns out to be briefly solid. Further recanalization
happens by vacuolation of epithelium .
FIG.1 – Diaphragmatic representation of hepatic diverticulum.
The external layers of GB wall and cystic duct develop from consolidating
mesenchyme around the epithelial mass. Myoblasts develop around 30mm stage
resulting in establishment of each of the three layers of wall of future gall bladder
– mucosa, muscular and serosa[12].
6
For up to 56 days of gestation, the extra hepatic biliary tree (EHBD)
develops from extension of the caudal part of the hepatic diverticulum. From the
beginning, it remains patent and in coherence with the developing liver at all
stages.By 12 weeks of gestation, tubular structures are formed from the distal part
of right and left hepatic ducts.
The intra hepatic bile ducts (IHBD) require finely tuned epithelial –
mesenchymal interactions for its developement, which continue from the hilum of
the liver toward its fringe along the branches of the developing portal vein[12].
ANATOMY :
Gall bladder is a pear shaped organ that lies in the shallow fossa on visceral
surface of liver[13].It usually lies at junction of right lobe and medial lobe of left
lobe[14] (FIG. 2). In adult, it measures 7 to 10 cm in length, 3 to 4 cm in width and
thickness of 1 to 2 mm[15].
Its capacity is usually 40 to 70 ml [15]. But when obstructed, it can distend
markedly and contain upto 300 ml[16]. It is divided into four anatomic areas
(FIG. 3) – fundus, corpus (body) and neck [17].
7
FIG. 2 – showing anatomy of gall bladder and its relations.
FUNDUS :
It is the rounded blind end that usually extends 1 to 2 cm beyond hepatic margin.
It contains most of the smooth muscles of all layers. [14]
8
FIG. 3 – Parts of gall bladder – fundus, body and neck.
CORPUS :
The body extends from fundus and tapers into neck connecting with the
cystic duct. It contains most of the elastic tissue and therefore serves as the main
storage area.
NECK :
The neck lies in the most profound part of GB fossa and extends into free
portion of hepatoduodenal ligament. True glands are present only in the neck.
INFUNDIBULUM :
The infundibulum or Hartmann’s pouch is an out pouching of wall in the
region of neck. It is the result of some pathological conditions such as dilatation
or presence of stones[18].
9
BLOOD SUPPLY
ARTERIAL SUPPLY :
GB is supplied by cystic artery, usually given off in Calot’s triangle. It is a
branch of right hepatic artery. The course of cystic artery may vary and enters GB
in the body or neck[17]. It is divided into anterior and posterior branches.
VENOUS DRAINAGE:
It is carried through small veins that enter directly into liver. Rarely, a large
cystic vein carries blood back to portal vein [19].
LYMPHATIC DRAINAGE:
Lymphatics drain into nodes present at the neck of GB. From here it flows
to nodes near hepatic hilum and in inferior portion of hepato– duodenal ligament
reaching the nodes on celiac axis[20] .
NERVE SUPPLY :
Nerves of GB arises from vagus and from sympathetic branches T8 &
T9 that pass through the celiac plexus[21] .
BILE DUCT:
Bile duct comprises intra hepatic and extra hepatic bile duct (EHBD).
The EHBD consists of right hepatic and left hepatic duct, common hepatic duct,
cystic duct, common bile duct (CBD) or choledochus. The CBD enters second
portion of duodenum through muscular structure called Sphincter of Oddi [22].
10
HISTOLOGY :
GB is a muscular sac. The wall of GB is composed of mucosa comprising
surface epithelium & lamina propria (LP), smooth muscle – tunica muscularis,
perimuscular subserosal connective tissue&serosa. There is no submucosa or
muscularis mucosa (FIG. 4). True glands are present only in the neck and are of
tubulo-alveolar type[23].
MUCOSA :
The mucosa is thrown into variably sized branching folds lined by single
layer of columnar cells(FIG. 4) having pale cytoplasm with occasional small
apical vacuoles & basally located nuclei . Ultra structurally, these cells have
abundant micro villi with filamentous glycocalyx on apical surfaces and core
rootlets. Small darker staining columnar cells called pencillate cells are scattered
among columnar cells.Tubulo alveolar mucous glands are seen only in the neck of
GB.
Histochemically, the epithelial cells contain mainly sulfomucin in contrast
to metaplastic glands which contains neutral and sialomucin[24].
11
FIG 4 – showing normal histology of GB, mucosa thrown into folds, lamina
propria and tunica muscularis.
IMMUNO HISTOCHEMISTRY :
By IHC, the epithelial cells are reactive to both Low molecular weight
keratin (LMW) and Epithelial membrane antigen (EMA). Carcino embryonic
antigen (CEA) positivity is confined to apical cells[23].
LAMINA PROPRIA :
It lies between surface epithelium and muscularis and fills the cores of
mucosal folds. It is composed of loose connective tissue, lymphocytes, plasma
cells & macrophages. Nerve fibers, small blood vessels and lymphocytes are also
present. Neutrophils and eosinophils are usually absent[23].
12
MUSCULAR LAYER :
It is made up of haphazardly arranged bundles of smooth muscle
fibers.Unlike in GI tract, the GB has only one muscle layer, tunica muscularis.
They are highly porous, allowing numerous invaginations from the mucosa.
Mucosal invaginations known as RokitanskyAschoff (R.A) sinuses (FIG. 13) may
be seen in normal GB but more prone in inflammation[25].
PERIMUSCULAR LAYER :
This sub serosal layer contains variable amount of fibro elastic & adipose
tissueas well as nerve cells. Bile ductules also known as Luschka ductules (FIG.
5) which are thought to be remnants of primordium liver may likewise be seen [26].
They are lined by cuboidal epithelium alike intra hepatic bile duct surrounded by
collar of fibrous tissue. They have no relation with R.A sinuses. They have been
seen in 10 % of cholecystectomy specimens[23].
SEROSA :
It covers the entire unattached GB surface. When GB is attached to liver
surface, the connective tissue is called adventitia.
13
FIG 5– Luschka ductules seen in perimuscular layer at the hepatic surface of
gall bladder.
EHBD :
It is lined by single layer of tall epithelium similar to GB.The epithelium
invaginates into the stroma known as Sacculi of Beale surrounded by mucinous
glands[27].
CHOLECYSTITIS :
It is defined as inflamed GB in which inflammation may be acute, acute on
chronic, or chronic. 90% cases involve stones in GB i.e calculous cholecystitis
while 10 % of cases represent acalculous cholecystitis[28].
14
GALL STONES :
EPIDEMIOLOGY :
Gall stone is a vital problem affecting 5 – 20% of adults[29].The prevalence
ranges widely across ethnicities and approximately twice as high in women as in
men[30]. It is considered as one of the leading causes of gastrointestinal
problems[31].They are often asymptomatic but 1- 3% of patients per annum may
present with symptoms[32].
RISK FACTORS :
Risk factors are multifactorial and classified as modifiable and non –
modifiable factors[33]. (Table 1)
1) ETHNICITY :
Geography and particularly ethnicity contribute to prevalence of gallstone
disease and also the type of stones. Cholesterol gallstones are more common in
the developed countries of the Western world while brown pigment stones in the
bile ducts in Asia[29]. White Americans show an overall predominance of 16.6% in
women and 8.6% in men[34]. Intermediate prevalence rates occur in Asian[35]and
Black Americans while Sub-Saharan Black Africans have very low frequencies
(<5%) [36].
15
Table 1 – Risk factors of gall stones.
NON MODIFIABLE MODIFIABLE
GENETICS OBESITY
ETHINICITY REDUCED ACTIVITY
FEMALE TPN
FAMILY HISTOTY DIET
AGE DRUGS
2) GENETICS :
Genetic susceptibility is a key factor in gallstone formation. Familial
studies reveal an increased frequency of nearly five times increased risk in the
relatives of gallstone patients. These rates are even higher in monozygotic twins
than dizygotic twins[37].
3) AGE :
The frequency of gallstones markedly increases with age which are 4 to 10
times more likely in older individuals[38]. It also corresponds with the type of
stone formation initially being composed predominantly of cholesterol but later
having a tendency more towards black pigment stone[39]
16
4) GENDER :
Women show increased frequency for gall stones formation among which
premenopausal are at higher risk[33]. Risk factors include parity, oral
contraceptives and estrogen replacement therapy[40]. Female sex hormones show
strong association with GB function and bile secretion. Estrogen acts by
augmenting the secretion of cholesterol and decreases bile salt formation, whereas
progestins reduces bile salt secretion impeding GB emptying leading to stasis[39].
5) OBESITY :
Obesity, in particular, centripetal obesity, is a common risk factor for gall
stone disease[41]. It affects the rate limiting step in cholesterol synthesis by
enhancing HMG COA reductase activity. It eventually promotes increased
cholesterol synthesis in the liver and its secretion into bile[42].
6) DYSLIPIDEMIA & DIABETES MELLITUS :
Gallstone disease is a metabolic problem, in association with lipid
abnormalities & diabetes mellitus. A low HDL cholesterol[43] and
hypertriglyceridemia[44] carry an increased risk of developing stones. In DM,
insulin resistance alters cholesterol and bile salt metabolism predisposing to gall
stone formation[45].
7) DIET & TOTAL PARENTERAL NUTRITION :
Diets rich in cholesterol[46], fatty acids[47], carbohydrates[48] and legumes[49]
are associated with the risk of development of cholelithiasis whereas unsaturated
fats[50], coffee[51], fiber[52], ascorbic acid[53]& calcium[54] reduce the risk. TPN, on
17
the other hand, is a risk factor for developing microlithiasis and gallstone disease
besides acute acalculous cholecystitis[55].It may be due to loss of the enteric
stimulation of the GB which occurs as a result of starvation, prompting
gallbladder stasis[56].
8) LIFESTYLE :
The relationship between socioeconomic status and gallstones is still
controversial[33]. Reduced physical activity increases the risk of gallstone disease
and increased physical activity helps in preventing cholelithiasis[55].
9) DRUGS :
Certain medications like estrogen therapy, thiazide diuretics[57],
ceftriaxone[42] and octreotide[58] show predilection for gall stone formation
whereas statins reduces the risk[59].
10) UNDERLYING ILLNESS :
Advanced cirrhosis[60], Crohn’s disease[61], cystic fibrosis[62] and other
injuries such as spinal cord injuries[63] are well known risk factors.
PATHOGENESIS :
Gall stones are formed of abnormal constituents of bile. Biliary sludge
precedes stone formation which contains mucous gel, hydrophobic bile pigments,
cholesterol lecithin liquid crystals and solid cholesterol mono hydrate crystals[64].
First, cholesterol precipitates into crystals when its concentration in bile exceeds
the solubilizing ability of bile salts and phospholipids. Biliary accumulation along
with sluggish motility of gallbladder advances nucleation of cholesterol crystals
18
and mucous hypersecretion facilitating stone formation[65]. There are two different
types of stones - cholesterol stones and pigment stones.(Table 2)
CHOLESTEROL STONES :
Cholesterol stones comprises of 70% of gall stones in western countries[66].
Its formation is related to super saturation of bile with cholesterol and rapid
nucleation of cholesterol crystals[67]. Other mechanisms include GB hypomotility
resulting in stasis.More than 80% of cholesterol stones lack calcium carbonate and
hence radiolucent[23].
MORPHOLOGY :
Pure cholesterol stones accounts for 10% of gall stones. They are
yellowish to white, round to ovoid, crystalline or laminated cut surface measuring
upto 4 cm[23] (FIG. 6).
Stones with lower cholesterol level are designated as mixed. Depending on
the proportion of calcium carbonate, bilirubin and phosphates, mixed stones may
be lamellated, greyish white to black in colour. They are usually smaller and
multifaceted[23].
19
Table.2 – Classification of stones.
PIGMENT STONES :
It is classified as black stones which are hard in consistency and brown
stones which are soft.
BLACK STONES :
Black stones form in sterile GB bile. It contains enough calcium carbonates
and phosphates to render them radiopaque[68].It is associated with states of
hyperbilirubinemia [69],all hemolytic anemias like spherocytosis[70],sickle cell
disease[71], thalassemia[72], malaria[73]and foot trauma in long distance runners[74].
GALL STONES
PIGMENT STONES
BLACK STONES
BROWN STONES
CHOLESTEROL STONES
20
FIG. 6 – showing multiple cholesterol stones each measuring less than 4 cm.
MORPHOLOGY:
Black stones are black or deep brown, (FIG 7) relatively small measuring
about 2-5 mm. They are brittle and sometimes spiculated. On fracturing, these
stones have a glass like appearance[23].
BROWN STONES :
Brown stones are more common in Asia[33]. It forms secondaryto stasis,
anaerobic bacterial infection and parasitic infestation from nematodes and flukes
in any part of biliary tree rarely GB.
21
FIG. 7 – showing multiple black pigment stones.
It contains unpolymerized Ca(HUCB)2 and calcium soapscontaining
amorphous calcium salts of palmitate and stearate rendering them as
radiolucent[68].Parasites in the bile duct may induce stone formation by the
calcified overcoat of parasite’s egg which serves as a nidus and enhance
precipitate of calcium bilirubinate[66].
MORPHOLOGY :
These stones are much softer, laminated and may have soap like or greasy
consistency[75] (FIG. 8)
CLINICAL PRESENTATION :
Majority of patients have silent stones without any symptoms and may not
require treatment[76].But patients with symptomatic stones often present with
22
repeated episodes of right upper quadrant or epigastric pain accompanied by
nausea or vomiting [77]. Often attacks occur after fatty meals and almost at
night[78].
FIG. 8 – shows multiple soft brown pigment stones.
Sometimes, patients may experience referred pain between the shoulder
blades or below right shoulder region (Boas sign)[79]. On examination, there will
be tenderness in right quadrant (Murphy’s sign)[80]. Occasionally, gall stone ileus
may occur by a large stone eroding the adjacent loop of small bowel which in turn
results in intestinal obstruction (Bouverets syndrome) [81].
ACALCULOUS CHOLECYSTITIS :
Cholecystitis can occur without the evidence of gall stones. It is
predominantly seen in critically ill patients receiving parenteral
23
hyperalimentation. Extensive burns, sepsis, major operations and multiple trauma
are at higher risk. Decreased GB perfusion and ischemia caused by shock,
congestive cardiac failure and arteriosclerosis are the contributing mechanisms[82].
It usually presents with nonspecific clinical features similar to gall stone disease.
Microscopically, it shows leukocyte margination of blood vessels,
lymphatic dilatation and bile infiltrating deeper into the muscular layer[83]. There
will be associated edema of serosa and muscular layers with patchy thrombi of
arterioles and venules[14]. Due to nonspecific presentations, diagnosis will be
delayed and tends to have fulminant complications such as gangrene, perforation
and empyema. Majority of the patients will improve by percutaneous
cholecystostomy.
ACUTE CHOLECYSTITIS :
It is an acute inflammation of GB.It is more often a clinical entity and does
not necessarily imply acute inflammation of GB i.e. neutrophils are often
lacking[23].
It is precipitated by obstruction of stones in neck or cystic duct (90%) and
rest includes acute acalculous cholecystitis[84]. Its etiology may not be
demonstrable but it is typically seen in debilitating patients[85].
PATHOLOGIC FINDINGS :
The gross and histopathological findings of GB wall in both acute
calculous and acalculouscholecystitis are similar[23].
24
GROSS FINDINGS :
GB is usually enlarged, tense and external surface shows bright red or
green black discolouration[75].
HISTOPATHOLOGY :
In acute cholecystitis, the mucosa is often eroded and shows prominent
edema, congestion, hemorrhage and fibrin deposition in all layers(FIG. 9). In
extreme cases, necrosis and neutrophils are seen[23]. Sometimes fibrin thrombi
may be seen in small veins[20].On addition, the adventitia shows activated myo
fibroblastic cells in a loosely edematous stroma which is considered as one of the
hallmarks of acute cholecystitis[23]. (FIG. 10)
FIG. 9– shows mucosal erosion, marked congestion, edema and fibrin
deposits on the wall with perimuscular thickening.
25
VARIANTS :
The variants of acute cholecystitis are :
1) Empyema of GB
2) Acute emphysematous cholecystitis.
EMPYEMA OF GB :
It is a severe form of acute calculous cholecystitis with superadded
suppuration[86]. In other words, it is an inflammation of GB with contained pus.
The presentation is often atypical[87]. Microscopically, the mucosa is often
extensively ulcerated and contains numerous neutrophils[23]. Laparoscopic
cholecystectomy is contra indicated because of fear of life threatening
complications[88]. It carries high mortality rate[87].
FIG. 10 – shows activated myofibroblasts in a edematous stroma.
26
ACUTE EMPHYSEMATOUS CALCULOUS CHOLECYSTITIS :
It is a life threatening form of acute calculous cholecystitis caused by
presence of gas on GB lumen or wall[89]. Clostridium species, Escherchia coli,
streptococcus and Klebsiella are the most common gas forming organism[90]. It is
a consequence of ischemic injury associated with predisposing conditions like
atherosclerosis, arterial embolism, vasculitis[91]. It is more common in older
patients with DM[89]. On HPE, the inflammatory reactions are histologically
indistinct and consists of usual pattern of acute inflammatory changes[75] and
ischemic changes formed by progressive vascular incompetence leading to
necrosis and perforationof GB wall. It is associated withcomplications like
perforation and abscess formation leading to peritonitis and carries high mortality
rate[92].
CHRONIC CHOLECYSTITIS :
ETIOLOGY :
It is often associated with cholelithiasis. It occurs as a result of chronic
irritation of GB wall by recurrent attacks of cholecystitis secondary to transient
obstruction by gallstones[93].
EPIDEMOLOGY :
Women are more affected than men. It usually occurs in 5th to 6th
decade. It is strongly associated with GB cancer with an incidence ranging from
12-61%[93].
27
CLINICAL FEATURES:
Intermittent or constant pain in right upper quadrant is the most specific
symptom. Many patients have nausea with colic pain. Other non-specific
symptoms are belching, bloating, flatulence or upper abdomen fullness. A
palpable GB mass in upper abdomen can sometimes be seen on clinical
examination suggesting chronic hydrops[94].
PATHOPHYSIOLOGY :
Characteristic finding of chronic calculous cholecystitis is fibrosis which leads
to shrunken or contracted GB[93].
GROSS :
Calculi are present in greater than 90% of cases.GB is itself normal or
show thickening of wall. In more severe cases the GB may be shrunken with
marked fibrosis, thickening and serosal scarring [23].
PORCELAIN GB :
Long standing chronic calculous cholecystitis may develop mural
calcification and referred as porcelain GB. Its prevalence is 1 – 2% in chronic
choloecystitis specimens. It is strongly associated with GB cancer with an
incidence ranging from 12-61%. Grossly, it appears bluish and brittle in
consistency[94] (FIG. 11).
28
FIG. 11– porcelain GB with brittle in nature.
HISTOPATHOLOGY :
On HPE, the epithelium may be relatively normal, atrophic and show
hyperplastic or metaplastic changes[95]. Metaplasia can be of intestinal with goblet
cell (FIG. 12) or pyloric (antral), the former being accompanied by paneth cells
and endocrine cells. Of these, pyloric metaplasia is more common[96].R.A sinuses
(FIG.13) results from increased intra luminal pressure. It is a pseudo diverticula
formed by deeply invaginating mucosa without a complete muscular coat. It is
common finding and more prominent in severe cases[23]. Luschka’s ducts are
sometimes found in the subserosal layer usually on hepatic side[97].
29
Fig.12– shows intestinal metaplasia of GB with paneth cells.
The degree of chronic inflammation varies with predominance of
lymphocytes and some plasma cells, macrophages and occasionally eosinophils.
When neutrophils are present, a diagnosis of chronic active cholecystitis may be
preferable.
30
FIG. 13– showing R.A sinuses associated with thickened wall and
inflammatory cells
In some cases, there will be collection of macrophages containing bile and
lipofuschin which is termed as cholegranulomatous cholecystitis[23].The different
variants of chronic cholecystitis and are as follows:
31
VARIANTS :
1) Xanthogranulomatouscholecystitis.
2) Hyalinisingcholecystitis.
3) Follicular cholecystitis.
4) Diffuse lymphoplasmacyticcholecystitis.
5) Eosinophiliccholecystitis.
6) IgG4 related sclerosingcholecystitis
1) XANTHOGRANULOMATOUS CHOLECYSTITIS :
It is considered as an uncommon variant and clinically similar to acute or
chronic cholecystitis. Grossly there is large or small contracted GB usually
associated with cholelithiasis and greyish yellow nodules in outer layers.
Recurrent inflammation and calculi incite degeneration and necrosis of GB wall
which subsequently leads to intra mural abscess and eventual replacement by
xantho granulomas(FIG.14). Open cholecystectomy is the preferred treatment[98].
32
FIG.14 – shows foamy macrophages containing bile and cholesterol clefts.
2) FOLLICULAR CHOLECYSTITIS :
It is an extremely rare entity seen in older age group usually in mid
60s[99]. Originally described in typhoid fever, it is now known to occur in gram
negative infections[100]. In normal GB mucosa, lymphoid tissue is very sparse.
Some intra epithelial lymphocytes may be evident among surface columnar cells
but lymphoid follicles are never seen[101]. In this variant, there is widespread
formation of lymphoid follicles(FIG.15) in all layers of GB[102]. It is
associatedwithlymphoidmalignancy[103]. The most common lymphoma
33
masquerading as cholecystitis are MALT, follicular lymphoma, mantle cell
lymphoma, CLL / SLL[104].
FIG.15 – shows prominent lymphoid follicles in lamima propria.
3) DIFFUSE LYMPHOPLASMACYTIC CHOLECYSTITIS :
It occurs sporadically in almost 7% of GB resected for cholecystitis[105].It
was initially related with chronic inflammation in patients with primary sclerosing
cholangitis[106]. On HPE, it shows triad of diffuse chronic inflammatory infiltrate
with predominant plasma cells accompanied by nodules of mucosal lymphocytes
(FIG.16) sometimes with germinal centers[107]
34
It is a unique form of cholecystitis charcterised by diffuse inflammatory infiltrates
confined to lamina propria not extending to deeper layers[23].
FIG.16 - shows mixture of lymphocytes and plasma cells forming a band in
mucosa sparing the deeper layers.
4) EOSINOPHILIC CHOLECYSTITIS :
It is an uncommon condition first described in 1949[108]. Histologically,
eosinophilic cholecystitis is distinguished by a dense transmural infiltration of
eosinophils without evidence of any infestation[109]. The eosinophilic infiltrates
are most evident in subserosal and muscularis sparing the mucosa[110]. (FIG.17)
35
It may be associated with parasitic infestations of liver and biliary tract.
It should be distinguished from Churg Strauss syndrome in which gall bladder is
involved in addition to granulomatous angitis and eosinophilia[23].
FIG.17 - shows predominantly esosinophilic infiltrates.
5) HYALINISING CHOLECYSTITIS :
It is a recently described rare subtype clinically referred as porcelain GB. It
is characterised by dense pauci cellular collagenous transmural fibrosis(FIG.18)
replacing the mucosa and muscularis propria[111]. It is often associated with
carcinoma and prone to misdiagnosis because they can be fairly subtle[112]. Clear
36
cell cytology, nuclear enlargement and nuclear axis parallel to surface helps in
distinguishing from their malignant counterpart[23].
FIG.18 – shows hyalinization entirely replacing the gall bladder wall.
6) IgG4 RELATED SCLEROSING CHOLECYSTITIS :
In IgG4 related sclerosing pancreatitis, patients may also show changes in
gall bladder in addition to duodenum and pancreas[113]. On HPE, it shows a band
of characteristic basophilic wavy sclerosis with plasma cells lying individually in
lacunae which are formed within the sclerosis[23].
37
MORPHOMETRIC ANALYSIS :
HISTORY :
Since ancient era, the human body has been measured for several purposes.
In the older days, human body was measured for figurative arts. Eventually, the
methodology was trailed by the naturalist field and then by anthropologists to
identify basic morphological characteristics of human. The term anthropometria
dates back to the 17th century in the naturalist field, and was initially mentioned
in the short manual of Anthropometria by Johann Sigismund Elsholtz. It is the
first recorded material that researched the human body for scientific and medical
purposes. Elsholtz proposed that anthropometry could be applied in various fields
such as medical practices, physiognomy, the arts, and ethics[114]. By the
application of mathematics, geometry, and statistics, anthropologists proposed
human investigation methodologies.
MORPHOMETRY :
Morphometrics is a branch of anthropometry, which deals with the study of
size and shape of the components of various biological forms. It can also be
characterised as the quantitative analysis of organic structures. It focuses on
studying the variations and changes in forms (i.e., size and shape) of organisms.
The field has emerged rapidly over the last two decades. It is classified into
traditional and modern morphometrics[115].
38
TRADITIONAL MORPHOMETRICS :
It comprises multivariate statistical tools to characterise shape by analysing
conventional estimations between points with biological and anatomical
implications to characterize shapes called landmarks. These measurements usually
depictsthe lengths and widths of various parameters and the distances between
specific landmarks, within and between various populations.[116]
METHOD :
It was done by measuring linear distances such as length, width, and
height. Multiple statistical tools were used to describe patterns of variation in
shape within and among groups. Occasionally,counts, ratios, areas and angles can
be measured.
MERIT :
The advantage of this technique was that it was extremelyfundamental and
simple, however it had certain challenges.
DEMERITS:
1. It is impossible to recoup the shape of the original form using the data
matrices of distance measurements. The overall form is neither archived
nor used in the analysis[117].
2. Linear distance measurements are usually analogous with size and this
makes shape analysis troublesome.
39
3. In this technique, the data did not include the area from which the
measurements were taken. Therefore possibility of same results could be
generated from the measurements taken from two different shapes.
4. It was likewise impractical to restore graphical representation of shape
from the taken measurements[118].
MODERN MORPHOMETRICS :
Later, in 1960s, biometricians started applying multivariate statistical tools
to sets of traditional measurements. They used a set of landmarks to describe
shape. Landmark is described as a two or three-dimensional point by a tightly set
of rule. It is considered as more substantial than traditional morphometric methods
in ensuring morphological information and permitting for further analysis of this
information.These information might be two dimensional (2D) or three-
dimensional (3D) organizing with morphological point of interest[117].
It includes the development of powerful statistical methods based on
models that are used to examine the shape variation of all configurations that
correspond to morphologic landmark locations. Indeed, in many biological or
biomedical studies, the most efficient way to analyze the forms of biological
organs or organisms is by registering landmarks[115].
MERIT :
It records the geometry of surveyed objects, and preserves the information
throughout the analysis.
40
DEMERIT :
Disadvantage is that a number of landmarks available can sometimes be
insufficient to capture the shape of an object.
PRINCIPLE :
The fundamental principles of morphometric measurements are :
1. Linear measurements determine the distance between two landmarks by
using an eyepiece graticule with an engraved scale or alternatively with a
ruler on a projected microphotograph.
2. Stereology based on geometric probabilityhighlights the features of
twodimensional images in three dimensions.
3. Computerized image processing and analysis system allows image capture,
stockpiling and analysis using specialized software and hardware.
APPLICATIONS :
Morphometric methods can be applied in creating methods for
identification of tumor in diagnostic context and in characterizing diagnostic
histopathology. In conventional method of subjective diagnostic histopathology,
reproducibility can be defined adequately but the definition of precision is
ambiguous. The pathologists may be interested in morphometry for checking an
intuitive and subjective evaluation of a diagnostic feature on microscopic section
by making measurements[5].
41
A) STUDIES ON CLASSIFICATION OF TUMOR :
It is used to create a classification basis for diagnostic decisions through
two approaches :
1) Initially, it correlates the obtained morphometric information with
traditional tumor classification taking into account of subjective
histopathology.
2) Secondly, by attempting a classification by reviewing the morphometric
data.
It may include correlation of morphometric data with prognostic
parameters like life expectancy, response to therapy and metastasis prediction.
B) STUDIES ON DIAGNOSTIC HISTOPATHOLOGY :
In this technique, the morphometric descriptors are defined to identify
certain type of tumor. It also includes the search for relevant morphometric
parameters.
MORPHOMETRIC HISTOPATHOLOGY :
It deals with the study of certain parameters measured from tissue sections
or derived from the primary measurements estimated through calculations. For
example, in tumor, certain parameters such as nuclear density, nuclear area,
perimeters, cellularity and number of mitosis per area are measured. For rational
application of morphometric methods,it is very important to make distinction
between group morphometry and diagnostic morphometry.
42
GROUP MORPHOMETRY :
It includes the study of multiple samples from different specimens.Then
the pathologist tries to achieve classifications by using obtained morphometric
methods.Finally based on the data from various samples, the results are
interpreted. This method is controlled and the measurements are mostly carried
out by one and the same investigator who is acquainted with the technique
involved.
DIAGNOSTIC MORPHOMETRY :
On the other hand,it is a process that takes place in a number of different
labs. It is carried out by many investigators and various techniques. This results in
variation in tissue processing, section thickness, and staining intensity[119].
MORPHOMETRIC PARAMETERS :
In HPE, the sections studied are usually two dimensional. Indeed there are
certain conditions in which one may need to characterize the tissue in three
dimensional evaluation. It involves volumetric measurements of tissue,
parameters per tissue volume or 3D structure of tissue. For these, stereological
parameters are recommended. But stereological parameters are always not
necessary for diagnostic context.
REPRODUCIBILITY AND ACCURACY :
In morphometric methods, both reproducibility and accuracy can be
estimated. By estimating reproducibility, we can compare the results of subjective
and morphometric assessments. It can also be made with standardized outside
43
reference by standard units of measurements to estimate the accuracy. However
morphometric methods do not give diagnosis directly[5].
COMPUTER ASSISTED MORPHOMETRY :
With the approach of computers, applications for morphometric analysis
became simpler. Compared to conventional methods, computer-assisted
morphometry is exponentially quicker, more accurate, meticulous, and efficient in
providing a broad scope of estimations of morphological parameters. Using this
methodology, subjective, perception based interpretation have been replaced by
objective quantification. It depends on various factors such as image acquisition,
image display,transmission of images, storage and retrieval of images[120].
A) IMAGE ACQUISITION :
In this technique, the microscopic image is connected to the capturing
device. Devices for acquisition images range from electronic still to video
cameras which obtain electronic images directly in real time. It converts
photographs to digital data suitable for display and storage by computer.
B )IMAGE DISPLAY :
Captured images are usually displayed on computer display monitors. It
depends on the screen size, dot pitch and pixel resolution of the video output card.
C) IMAGE ANALYSIS :
It involves two distinct activities – image processing and morphometry.
Image processing may be either hardware based ie. incorporated into cameras,
scanners or software based. It also provides editing capabilities like sizing,
44
cropping, rotation, labeling, arrows, horizontal and vertical reflection. Further it
allows for quantification studies like morphometric analysis using the processed
digital data. Some microscope manufacturers like Zeiss and Olympus are offering
image analysis packages interpreted with their microscope.
CASE CONTROL STUDY :
To conduct case control study, the control should be free of disease. If the
study involves a large number, then one control should be used for each case. If
the study group is small, then 2 or more controls can be selected for each study
subject. In order toavoidselection bias, some epidemiologists prefer case from one
source and control from more than one source[121].
MATERIALS AND METHODS
45
MATERIALS AND METHODS
This study deals with the methodology and comparative study on
morphometric analysis of histoarchitectural changes in cholecystitis. The present
study was carried out at the Department of Pathology at Tirunelveli Medical
College and Hospital during October 2014 to August 2016. The study population
includes case and control groups. Cases include gall bladder specimen operated
for cholecystitis received from Department of Surgery in our hospital. Control
groups include normal human gall bladder obtained from autopsy subjects from
Department of Forensic Medicine in our hospital.
Inclusion criteria
This study includes
A. Cases with clinical diagnosis of cholecystitis and cholelithiasis irrespective
of age and sex.
B. Control group includes autopsy gall bladder specimens with no obvious
gross changes irrespective of age and sex.
Exclusion criteria
1) Autolysed specimens
2) All the cases of malignant gall bladder lesions
3) Autopsy gall bladder specimens with gross pathological changes.
46
Age and Sex :
The age of case and control groups varied from 15 to 80 years. Study
populations were grouped into 4 groups as ≤ 20, 21- 40, 41 – 60, and > 60 based
on age and sex. The male patients were 25 and the remaining 50 were female with
male and female ratio of 1: 2.
In our case control study, 75 normal gall bladders (controls) and 75
cholecystitis specimens (cases) were studied. From each specimen, three sections
were taken from neck, body and fundus. After sectioning, tissues were processed
in an automated tissue processor and paraffin blocks were made. Tissue sections
of 3 mm were cut and stained with hematoxylin and eosin. Then the slides were
examined under light microscope and estimation was done in microns using IS
capture software to find out the predominant histopathological alterations in each
layers of gall bladder.
The predominant histopathological alterations observed in this study were
as follows:
HISTOPATHOLOGICAL ALTERATIONS:
EPITHELIUM:
Intact epithelium
Mucosal erosion
Epithelial distortion
Metaplasia
47
LAMINA PROPRIA:
Thickness
Irregularity and gap
Lymphocytes
Macrophages
Plasma cells
MUSCULAR LAYER:
Rokitansky Aschoff sinuses
Macrophages
Plasma cells
Lymphocytes
SEROSAL LAYER:
Macrophages
Plasma cells
Lymphocytes
In epithelial layer, intactness and erosion of mucosa were measured in
microns. In addition to these, epithelial distortion like hyperplasia and metaplastic
changes like gastric and intestinal metaplasia were observed and estimated.
Thickness of lamina propria andirregularity and gap between the lamina propria
and mucosal layer were also measured in microns.
48
To count the number of inflammatory cells in each layers such as lamina
propria, muscular and serosal layer, 10 high power fields were chosen. In each
areas, the inflammatory cells such as lymphocytes, plasma cells and macrophages
were counted using 40 X magnification and average was taken.
Control specimens were grouped based on their age and gender. An
average value was calculated from the groups and considered as control values for
that particular age and gender.
RESULTS AND OBSERVATIONS
49
RESULTS AND OBSERVATIONS
In our case control study, 75 normal gall bladders(controls) and 75
cholecystectomy specimens such as calculous and acalculous (cases) were
studied. Out of 75 cholecystectomy specimens, 56 specimens i.e 74.66% were
associated with gall stones. Among these, 2 were reported as chronic follicular
cholecystitis(2.67%), 2 asacute on chronic cholecystitis(2.67%) and 52 as chronic
calculous cholecystitis(69.33%). Remaining 19 specimens(25.34%) were not
associated with stones, in which 2 were reported as chronic follicular
cholecystitis(2.67%) and 3 as acute on chronic cholecystitis(4%) and 14 as
chronic cholecystitis(18.67%).
With regards to gallstones, 36 were black stones(73.33%), 19 were
cholesterol stones(25.33%) and remaining one case comprised of both black and
cholesterol stones(1.33%). The age of case and control groups varied from 15 to
80 years with maximum frequency of 36 falls in age group of 41 – 60 years.
The mean age for calculous cholecystitis was 44.79 with SD of 13.53 and
for acalculous cholecystitis, it was 46.37 with SD of 11.24.
50
TABLE 2 :AGE GROUP 1 : ≤ 20, GROUP 2 : 21 – 40, GROUP 3 : 41 – 60,
GROUP 4 : ≥60.
Age
group
1 2 3 4 Total p value
Control 2 23 35 15 75 <0.0001 pearson
chi square test
Calculous 2 21 25 8 56
Acalculous 7 0 11 1 19
11 44 71 24
In our study, various histopathological alterations were observed in each
layers of calculous and acalculous cholecystitis and compared with control. In
both calculous and acalculous cholecystitis, epithelial hyperplasia, intactness,
minimum and maximum erosion were noted. Thickness of lamina propria and
mucosal invaginations called Rokitansky aschoff sinuses were found and
estimated. Maximum to minimum inflammatory infiltrates such as lymphocytes,
plasma cells and macrophages were estimated in each successive layers.
51
CHART NO. 1: GENDER DISTRIBUTION AMONG CASE GROUP
CHANGES IN EPITHELIUM :
In epithelial layer of calculous cholecystitis, predominant histopathological
alterations were estimated. Maximum epithelial erosion was calculated as 95.94%,
minimum epithelial erosion as 12.66%, maximum epithelial hyperplasia as
16.67% and maximum intactness as 87.33%. Epithelial metaplasia such as goblet
and intestinal type were not observed. Compared to control groups, it showed a
significant p value of < 0.0001.
In case of acalculous cholecystitis, maximum and minimum epithelial
erosion were calculated as 93.79% and 15.45% respectively. Epithelial distortion
like hyperplasia was noted and estimated as 1.44% and maximum intactness as
84.55%. Epithelial metaplasia was not found. It showed a significant p value of <
0.0001 when compared to control groups.
66.67%
33.33%
Gender
Females
Males
52
CHART NO. 2: CHANGES SEEN IN EPITHELIUM OF CALCULOUS
CHOLECYSTITIS
47.6852.32
3.544.06
12.66
0.60
87.33
95.94
16.67
0.00
20.00
40.00
60.00
80.00
100.00
120.00
INTACT EROSION HYPERPLASIA
Axi
s Ti
tle
Epithelium
Mean Minimum Maximum
53
CHART NO. 3: CHANGES SEEN IN EPITHELIUM OF ACALCULOUS
CHOLECYSTITIS.
CHANGES IN LAMINA PROPRIA :
Predominant histopathological alterations of lamina propria were found
and estimated. In calculous cholecystitis, maximum irregularity and gap between
the lamina propria and mucosal layer were estimated as 21.59% and maximum
lymphocytic infiltration as 94%. Percentage of plasma cells and macrophages
54.07
6.21
84.55
45.94
15.45
93.79
2.26 1.443.60
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Mean Minimum Maximum
Axi
s Ti
tle
Epithelium
INTACT EROSION HYPERPLASIA
54
were estimated as 24% and 15 % respectively. Compared to control groups, it
showed a significant p value of < 0.0001.
CHART NO.4: CHANGES SEEN IN LAMINA PROPRIA OF
CALCULOUS CHOLECYSTITIS.
14.30
71.70
6.11 7.727.73
16
1 1
21.59
98
24
15
0.00
20.00
40.00
60.00
80.00
100.00
120.00
IRREGULARITY & GAP LYMPHOCYTES PLASMA MACROPHAGES
Axi
s Ti
tle
Lamina propria
Mean Minimum Maximum
55
CHART NO.5 : CHANGES SEEN IN LAMINA PROPRIA OF
ACALCULOUS CHOLECYSTITIS.
In acalculous cholecystitis, maximum irregularity and gap between the
lamina propria and mucosal layer were estimated as 63.63% and maximum
lymphocytic infiltration as 98%. Percentage of plasma cells and macrophages
were estimated as 7% and 14% respectively. On comparison with control
groups,it showed a significant p value of < 0.0001.
38.76
62.42
4.83 5.42
13.34
32
2 1
66.63
94
7
14
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
IRREGULARITY & GAP LYMPHOCYTES PLASMA MACROPHAGES
Axi
s Ti
tle
Lamina propria
Mean Minimum Maximum
56
CHART NO. 6: COMPARISON OF LAMINA PROPRIA THICKNESS IN
CALCULOUS AND ACALCULOUS CHOLECYSTITIS.
In addition to the above criteria, thickness of lamina propria was estimated
and found to be an average of 332.16 microns in calculous cholecystitis whereas
367 microns in acalculous cholecystitis.
332.16
367
310.00
320.00
330.00
340.00
350.00
360.00
370.00
Calculus Acalculous
Axi
s Ti
tle
Thickness of lamina propria
LAM_THIC
57
CHART NO. 7: CHANGES SEEN IN MUSCULAR LAYER OF
CALCULOUS CHOLECYSTITIS.
CHANGES IN MUSCULAR LAYER :
Predominant changes in muscular layer were observed and found. In
calculous cholecytitis, R.A sinuses were calculated as a maximum of 27.56%.
Infiltrates such as lymphocytes, plasma cells and macrophages were estimated as
maximum of 98%, 11% and 12% respectively.
7.64
66.02
4.74 5.563.06
26
1 1
27.56
98
11 12
0.00
20.00
40.00
60.00
80.00
100.00
120.00
R.A SINUS LYMPHOCYTES PLASMA MACROPHAGES
Axi
s Ti
tle
Muscular layer
Mean Minimum Maximum
58
CHART NO. 8: CHANGES SEEN IN MUSCULAR LAYER OF
ACALCULOUS CHOLECYSTITIS.
In acalculous cholecytitis, R.A sinuses were calculated as a maximum of
4.14%. Inflammatory infiltrates such as lymphocytes, plasma cells and
macrophages were estimated in muscular layer as maximum of 86%, 8% and 9%
respectively.
3.76
53.26
4.22 5.173.37
16.00
1.00 1.004.14
86.00
8.00 9.00
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
R.A SINUS LYMPHOCYTES PLASMA MACROPHAGES
Axi
s Ti
tle
Muscular layer
Mean Minimum Maximum
59
CHART NO. 9: CHANGES SEEN IN SEROSA OF CALCULOUS
CHOLECYSTITIS.
CHANGES IN SEROSAL LAYER :
Predominant alterations of serosal layer were found in calculous
cholecystitis and estimated as 88% maximum infiltration of lymphocytes. Others
like plasma cells and macrophage showed maximum infiltration of 12% and 24%
respectively.
47.25
10
88
4.941
127.42
1
24
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Mean Minimum Maximum
Serosa
LYMPHOCYES PLASMA MACROPHAGES
60
CHART NO. 10: CHANGES SEEN IN SEROSA OF ACALCULOUS
CHOLECYSTITIS.
In acalculous cholecytitis, inflammatory infiltrates such as lymphocytes,
plasma cells and macrophages were estimated in serosal lasyer as maximum of
79%, 4% and 9% respectively.
43.84
11.00
79.00
2.25 1.004.005.00
2.00
9.00
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
Mean Minimum Maximum
Axi
s Ti
tle
Serosa
LYMPHOCYTES PLASMA MACROPHAGES
61
TABLE 3 : SHOWS DESCRIPTIVES
Descriptives
N
Mean S.D Min Max
EPI_INTA Control 75 100.00 0.00 100 100
Calculous 56 47.68 22.19 4.06 87.33
Acalculous 19 54.07 24.45 6.21 84.55
PI_EROS Control 0 . . . .
Calculous 56 52.32 22.19 12.66 95.94
Acalculous 19 45.94 24.45 15.45 93.79
EPI_DIST Control 0 . . . .
Calculous 28 3.54 3.69 0.6 16.67
Acalculous 7 2.26 0.78 1.44 3.6
LAM_THIC Control 75 203.01 62.10 110.8 410.1
Calculus 56 332.16 180.51 63.77 875.2
Acalculus 19 367.00 169.79 58.21 748.7
LAM_IR Control 0 . . . .
Calculous 6 14.30 5.38 7.73 21.59
Acalculous 4 38.76 29.11 13.34 66.63
LAM_LYM Control 23 38.52 15.28 10 63
62
Calculous 56 71.70 18.98 16 98
Acalculous 19 62.42 16.05 32 94
LAM_PL Control 0 . . . .
Calculous 36 6.11 4.70 1 24
Acalculous 12 4.83 1.64 2 7
LAM_MAC Control 0 . . . .
Calculous 39 7.72 3.27 1 15
Acalculous 12 5.42 4.36 1 14
MUSC_RA Control 0 . . . .
Calculous 14 7.64 6.32 3.06 27.56
Acalculous 2 3.76 0.54 3.37 4.14
MUSC_LYM Control 0 . . . .
Calculous 56 66.02 18.95 26 98
Acalculous 19 53.26 19.92 16 86
MUSC_PL Control 0 . . . .
Calculous 31 4.74 2.71 1 11
Acalculous 9 4.22 2.28 1 8
MUSC_MAC Control 0 . . . .
Calculous 32 5.56 3.04 1 12
63
Acalculous 12 5.17 3.10 1 9
SER_LYM Control 0 . . . .
Calculous 56 47.25 21.65 10 88
Acalculous 19 43.84 19.74 11 79
SER_PL Control 0 . . . .
Calculous 18 4.94 3.04 1 12
Acalculous 4 2.25 1.26 1 4
SER_MAC Control 0 . . . .
Calculous 24 7.42 5.06 1 24
Acalculous 5 5.00 2.92 2 9
EPI – Epithelium, INTA - intact, EROS – erosion, DIST – distortion, LAM
– lamina propria, THIC – thickness, IR – irregularity & gap, LYM – lymphocytes,
PL – plasma cells, MAC – macrophages.
The average values for each statistical criteria in both calculous and
acalculous cholecystitis were compared in the following charts:
64
CHART NO. 11 : COMPARISION OF EPITHELIAL CHANGES
BETWEEN CALCULOUS AND ACALCULOUS CHOLECYSTITIS.
47.68
52.32
3.54
45.94
2.26
0.00
10.00
20.00
30.00
40.00
50.00
60.00
INTACT EROSION HYPERPLASIA
Axi
s Ti
tle
Epithelium
Calculous Acalculous
65
CHART NO. 12 : COMPARISION OF CHANGES IN LAMINA PROPRIA
BETWEEN CALCULOUS AND ACALCULOUS CHOLECYSTITIS
14.30
71.70
6.117.72
38.76
62.42
4.83 5.42
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
IRREGULARITY & GAP LYMPHOCYTES PLASMA MACROPHAGES
Axi
s Ti
tle
Lamina propria
Calculous Acalculous
66
CHART NO. 13 : COMPARISION OF CHANGES IN MUSCULAR LAYER
BETWEEN CALCULOUS AND ACALCULOUS CHOLECYSTITIS
7.64
66.02
4.74 5.563.76
53.26
4.22 5.17
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
R.A SINUS LYMPHOCYTES PLASMA MACROPHAGES
Axi
s Ti
tle
Muscular
Calculous Acalculous
67
CHART NO. 14 : COMPARISION OF CHANGES IN SEROSAL LAYER
BETWEEN CALCULOUS AND ACALCULOUS CHOLECYSTITIS
47.25
4.947.42
43.84
2.255.00
0.00
10.00
20.00
30.00
40.00
50.00
60.00
LYMPHOCYTES PLASMA MACROPHAGES
Axi
s Ti
tle
SEROSA
Calculous Acalculous
68
TABLE 4 : STATISTICAL COMPARISON BETWEEN THE STUDY
GROUPS
Multiple Comparisons
Bonferroni
Dependent
Variable
(I) GROUP (J) GROUP SIG
EPI_INTA Control Calculous <0.0001
Acalculous <0.0001
Calculous Control <0.0001
Acalculous 0.408
Acalculous Control <0.0001
Calculous 0.408
LAM_THIC Control Calculous <0.0001
Acalculous <0.0001
Calculous Control <0.0001
Acalculous 0.975
Acalculous Control <0.0001
Calculous 0.975
LAM_LYM Control Calculous <0.0001
Acalculous <0.0001
69
EPI - Epithelium, INTA – Intact, LAM – Lamina propria,THIC – Thickness,
LYM- Lymphocytes
Based on statistical evidence, the present study showed a significant p
value of < 0.0001 between control group and calculous cholecystitis. Similarly,
control group and acalculous cholecystitis also showed a significant p value of <
0.0001.
Calculous Control <0.0001
Acalculous 0.152
Acalculous Control <0.0001
Calculous 0.152
70
FIG.19 :A case of calculous cholecystitis showing mucosal erosions and
lamina propria thickness with dense inflammatory cells in lamina propria and muscular layer (10X).
FIG. 20: A case of acalculous cholecystitis showing mucosal erosions and dense inflammatory cells in lamina propria and muscular layer. (10X)
71
FIG. 21: Photomicrograph showing mucosal hyperplasia and dense
inflammatory cells in lamina propria and muscular layer (10X).
FIG. 22: Photomicrograph showing mucosal erosions withR.A sinus
ifiltrating into the muscular layer and inflammatory cells in lamina propria (10X).
72
FIG. 23: Photomicrograph showing inflammatory infiltrates predominantly
lymphocytes, few macrophages and plasma cells in muscular layer(40X).
FIG. 24: Photomicrograph showing inflammatory cellular infiltrates composed of lymphocytes and few plasma cells in serosal layer(40X).
DISCUSSION
73
DISCUSSION
The study was conducted in Tirunelveli medical college hospital,
Tirunelveli, southern Tamilnadu on operated specimens of gall bladder for both
calculous and acalculous cholecystitis. A total number of 75 cholecystectomy
specimens and 75 controlspecimens obtained from autopsy subjects were
subjected to the histopathological examination and morphometric analysis of
predominant histoarchitectural changes.
In our study, majority of patients were between age group of 41 and 60
years with mean age being 45.58 with S.D of 12.38. The mean ageof the calculous
and acalculous patientswere 44.79 and 46.37 respectively. Tyagi SP et
al[122]studied morphological changes of GB in 415 cholecystectomy specimens at
Aligarh and showed the mean age was 43.6% with most of the cases were seen in
the 4th and 5th decades of life.
With regards to gender, there was a female preponderance in our study
with male to female ratio ratio of 1:2. Of the 75 patients, 66.67% were females
and 33.33% were male. Santhosh Upadhyaya Kafle[123] showed female
predominance in his study conducted in Nepal with male to female ratio of 1:7.16.
In the present study which includes 75 cholecystectomy specimens, 56 specimens
showed the presence of gall stones accounting for 74.66% whereas acalculous
cholecystitis constituted of remaining 25.34% specimens. Among the gall stones,
25.33% were cholesterol stones, 73.33% were black stones and 1.33% comprised
74
of mixed stones. Tadashi Terada[124] in his study showed 96% among the 540
cholecystectomy specimens in the population of Japan had gall stones among
which 47% were black stones, 19% were cholesterol stones and 33% were having
mixed stones.
In the present study, routine histopathological examination showed the
following lesions : chronic calculous cholecystitis(69.33%), chronic cholecystitis
without gall stones(18.67%), chronic follicular cholecystitis with gall
stones(2.67%), chronic follicular cholecystitis without gall stones(2.67%), acute
on chronic calculous cholecystitis (2.67%) and acute on chronic acalculous
cholecystitis(4%).
Santhosh Upadhyaya Kafle[123] in his study on the population of Nepal
observed acute on chronic cholecystitis without cholelithiasis (8%), chronic
acalculous cholecystitis with cholesterosis(22%), chronic cholecystitis without
cholelithiasis (50%), chronic cholecystitis with cholelithiasis (8%),
follicularcholecystitis (4%), xanthogranulomatous calculous cholecystitis(2%)
and without stones(6%).
In the present study, all the specimens were then subjected to
morphometric analysis using IS capture software to find out the histopathological
alterations in calculous and acalculous cholecystitis. Finally the results were
compared with age and gender based control specimens.
In our study, we observed that the predominant histopathological
alterations in epithelium were found to be erosion and hyperplasia. Maximum
epithelial erosion of 95.94% was seen in calculous cholecystitis whereas 93.79%
75
in acalculous cholecystitis. In calculous cholecystitis, the epithelium was exposed
to concentrated biliary solutes and toxic hydrophobic bile salts, resulting in
erosion[125].
Maximum epithelial hyperplasia was noted as 16.67% in calculous
cholecystitis and 1.44% in acalculous cholecystitis. Putz and Willens et al[126]
stated that cholelithiasis produces chronic irritation inducing active proliferation
of the epithelium so that surface epithelial cells look more crowded, taller than
normal and have pseudostratified appearance.
In our study, metaplastic changes were not observed. Jyoti Prakash Pani[127]
in his study observed absolute absence of metaplasia in cholelithiasis whereas
9.1% metaplasia in acalculous cholecystitis. Hence cholelithiasis produces a series
of epithelial pathological changes such as hyperplasia, dysplasia and metaplasia
which could be precursor lesions of gallbladder cancer[128].
In our study, an average thickness of lamina propria observed was 332.16
microns in calculous cholecystitis whereas 367 microns in acalculous
cholecystitis. Badke A, Bohm B et al studied histological changes in calculous
cholecystitis and found inflammatory changes in some and fibrotic changes in
others[129].
Irregularity and gap between the former layer was found to be 21.59% in
calculous cholecystitis whereas 66.63% in acalculous cholecystitis. Jyoti Prakash
Pani[127] studied histological changes in gall bladders of North Indian
population and showed an irregularity and gap of 100 % in cholelithiasis and
90.09 % in acalculous cholecystitis.
76
In our study, R.A sinuses were observed as a maximum of 27.56% in
calculous cholecystitis and 4.14% in acalculous cholecystitis. Jyoti Prakash Pani
et al[131] showed 50% in calculous whereas 40.9% in acalculous cholecystitis.
These sinuses were associated with inward proliferation of the mucosa due to
increase in the intraluminal pressure and weakening of the wall by distension
caused by the stone[133].
In our study, lymphocytic infiltrates were predominant in all three layers
such as lamina propria, muscular and serosa with maximum infiltrates of
98%,98% and 88% in calculous cholecystitis whereas 94%,86% and 79% in
acalculous cholecystitis respectively. Some of them show promiment lymphatic
follicles in lamina propria extending into muscular layer. Other infiltrates like
plasma cells and macrophages were also observed in successive layers. In addition
to these infiltrates, neutrophils were also seen in case of acute on chronic
cholecystitis.
Csendes A, Maluenda F, Smok G, Diaz JC, Burdiles P et al studied
histological findings of gall bladder mucosa in 95 control subjects with
asymptomatic gall stones. Their findings suggest that chronic inflammatory
changes can occur in gall bladder mucosa prior to appearance of macroscopic
stones[130].
Jyoti Prakash Pani[127] in his study estimated and showed that lymphocytes
were the predominant infiltrates in lamina propria, muscular and serosal layers
followed by plasma cells and macrophages. These inflammatory cells were
regarded as a part of the inflammatory process induced by the stones associated
77
with the hemorrhage and congestion of the mucosal blood vessels[131]From the
above data, the present study showed that in calculous cholecystitis, due to the
presence of gall stones and the concomitant chemical injury caused by toxic effect
of lithogenic bile leads to more irritation resulting in drastic changes in all the
layers of gall bladder. Whereas in acalculous cholecystitis, due to absence of
stones, there will be relatively less chronic reaction when compared to calculous
cholecystitis.
The present study showed a statistically significant p value between control
and calculous cholecystitis. Similarly, control groups and acalculous cholecystitis
comparison were also highly statistically significant. But comparison of both
calculous and acalculous cholecystitis showed an insignificant p value which
warrants more gall bladder specimens to be morphometrically analysed and
studied.
SUMMARY AND CONCLUSION
78
SUMMARY AND CONCLUSION
In the present case control study, a group of 75 cholecystectomy specimens
and 75 normal human gall bladder from autopsy subjects were included. Three
sections from each gall bladder specimens were taken, processed, paraffin
embedded and stained with haematoxylin and eosin. Then the slides were
routinely examined and subjected to morphometric analysis using IS capture
software.
In our study, the predominant histopathological alterations seen in
epithelium such as epithelial erosion and hyperplasia were found in both calculous
and acalculous cholecystitis. Both thickness of lamina propria and gap between its
former layer were observed in both calculous and acalculous cholecystitis and
analysed in comparison to control groups. Both calculous and acalculous
cholecystitis showed mucosal invaginations through the muscular layer known as
R.A sinus.
Our study showed that the predominant inflammatory infiltrates in all the
layers such as lamina propria, muscular and serosa were found to be lymphocytes
followed by plasma cells and macrophages in varying proportions in calculous
and acalculous cholecystitis.
In the present morphometric study, an attempt was made to analyse the
predominant histopathological changes in calculous and acalculous cholecystitis
in comparison to control groups. Further study is needed to demonstrate the other
79
subsidiary histopathological changes occurring in the variants of cholecystitis and
to find out the metaplastic changes by mucin studies.
Our study provides an insight into the morphometric analysis of
predominant histopathological alterations in both calculous and acalculous
cholecystitis in comparison to normal human gall bladders obtained from autopsy
cases. Epithelial erosion, hyperplasia, Rokitansky Aschoff sinuses and
inflammatory infiltrates like lymphocytes, plasma cells and macrophages in all the
layers such as lamina propria, muscularis and serosa were observed and
morphometrically analysed. All the above changes observed were found to be
relatively more in calculous than acalculous cholecystitis whereas control groups
showed significantly minimal alterations.
Histopathological changes like epithelial hyperplasia and metaplasia which
are considered as premalignant conditions may alert both the pathologists and
clinicians. Certain variants like follicular cholecystitis may rarely masquerade an
underlying lymphoma which warrants a more detailed study and accurate
classification of cholecystitis.
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ANNEXURES
ANNEXURE
PROFORMA
NAME
AGE
SEX
HPE NO
PM NO
SPECIMEN
STONES
TYPE OF STONES
HPE DIAGNOSIS
STATISTICAL CRITERIA
EPITHELIUM
Intactness
Erosion
Hyperplasia
Metaplasia
LAMINA PROPRIA
Thickness
Irregularity and gap
Lymphocytes
Plasma cells
Macrophages
MUSCULAR LAYER
R.A sinus
Lymphocytes
Plasma cells
Macrophages
SEROSA
Lymphocytes
Plasma cells
Macrophages
TOTAL(µ) INTACT (µ)EROSION
(µ)DIST(µ) META (µ) THICK (µ)
IR & GAP(µ)
LYM PL MAC R.A LYM PL MAC LYM PL MAC
1 50 F 36/15 GB YES CHOL CH.C.CC 4421.75 3773 648.75 463.92 NIL 198.84 NIL 600 70 30 NIL 550 50 40 400 50 100
2 65 F 413/15 GB YES BLACK CH.C.CC 11O75.12 8737.48 2337.64 551.34 NIL 312.12 43.15 690 45 86 NIL 330 16 60 520 5 43
3 63 M 1512/15 GB YES BLACK CH.C.CC 13727.15 9729.9 3997.25 NIL NIL 164.99 NIL 720 22 78 NIL 610 70 32 480 13 39
4 48 F 1167/15 GB YES BLACK CH.C.CC 40394 28908 11486 535.7 NIL 442.85 NIL 640 26 66 NIL 550 9 36 310 40 65
5 65 M 1287/15 GB YES BLACK CH.C.CC 16682 10605 6077 446.8 NIL 245.32 NIL 550 40 5 NIL 360 4 60 780 NIL 9
6 40 M 2177/15 GB YES BLACK CH.C.CC 16378 9240 7138 NIL NIL 450.42 NIL 620 18 82 NIL 340 30 63 880 40 80
7 34 M 656/15 GB YES BLACK CH.C.CC 15907 6845 9062 443.41 NIL 119.64 NIL 460 110 43 NIL 820 70 110 590 88 120
8 60 M 996/15 GB YES BLACK CH.C.CC 14662 13893.1 2013.9 NIL NIL 675.93 NIL 850 24 72 NIL 720 40 69 490 70 33
9 47 F 489/15 GB YES BLACK CH.C.CC 19022 13372 5650 NIL NIL 267.91 NIL 770 20 43 NIL 730 50 22 820 18 NIL
10 35 F 3419/15 GB YES CHOL CH.C.CC 5381.21 4481.75 899.46 NIL NIL 324.98 NIL 790 60 71 NIL 810 30 16 600 50 85
11 70 F 3515/15 GB YES BLACK CH.C.CC 11664.35 7411.05 4253.3 NIL NIL 363.27 NIL 490 30 89 NIL 650 80 27 700 NIL 20
12 47 F 1319/15 GB YES BLACK CH.C.CC 10994.62 7896.76 3097.91 NIL NIL 297.29 52.09 740 70 80 NIL 510 50 44 750 30 22
13 43 F 2953/15 GB YES BLACK CH.C.CC 15270.2 7668.3 7601.9 NIL NIL 272.62 NIL 470 23 67 NIL 730 70 20 430 20 55
14 34 F 104/16 GB YES BLACK CH.C.CC 10951.35 3077.96 7873.39 127.75 NIL 141.08 NIL 420 70 150 NIL 950 NIL 60 240 NIL 30
15 33 F 149/16 GB YES CHOL CH.C.CC 9689.51 4287.5 5402.01 1017.39 NIL 702.07 NIL 810 140 90 840.97 840 20 70 430 60 150
16 50 M 229/16 GB YES BLACK CH.C.CC 9152.48 1663.3 7489.18 1526.31 NIL 175.84 NIL 940 40 20 719.99 450 20 40 100 NIL NIL
17 15 F 380/16 GB YES BLACK CH.C.CC 16699.25 10850.03 5849.22 343.66 NIL 479.6 NIL 210 15 40 687.46 510 NIL NIL 260 NIL NIL
18 52 F 393/16 GB YES BLACK CH.C.CC 9909.73 3816.1 6093.63 NIL NIL 240.21 51.88 530 10 80 328.42 260 8 40 220 NIL NIL
19 62 F 443/16 GB YES BLACK CH.C.CC 16009.05 10123.96 5885.09 NIL NIL 261.39 43.3 750 20 NIL NIL 700 50 40 840 NIL NIL
20 50 F 551/16 GB YES BLACK CH.C.CC 12987.09 4296.84 8690.25 NIL NIL 875.22 75.47 160 70 110 NIL 340 20 40 210 NIL NIL
21 51 F 592/16 GB YES BLACK CH.C.CC 11067.81 5284.43 5783.38 NIL NIL 419.51 NIL 980 20 NIL NIL 660 NIL NIL 220 NIL NIL
22 53 M 596/16 GB YES BLACK CH.C.CC 21256.93 8396.01 12860.92 NIL NIL 738.16 57.113 540 20 30 NIL 610 NIL 22 220 NIL NIL
23 66 F 644/16 GB YES CHOL CH.C.CC 33538.85 23382.54 10156.31 NIL NIL 423.95 NIL 980 NIL NIL NIL 910 NIL 40 110 40 NIL
24 28 F 667/16 GB YES CHOL CH.C.CC 8807.39 2601.58 6205.81 NIL NIL 151.88 NIL 640 NIL 100 1085.62 420 NIL NIL 560 NIL 80
25 32 F 309/16 GB YES BLACK CH.C.CC 10658.76 1725.85 8932.91 NIL NIL 505.59 NIL 910 NIL 100 619.56 360 20 80 260 NIL NIL
26 67 M 692/16 GB YES CHOL CH.C.CC 4551.73 184.72 4367.01 NIL NIL 773.6 NIL 350 NIL 70 1254.59 580 60 50 320 80 70
27 34 F 732/16 GB YES CHOL CH.C.CC 13972.39 5634.02 8338.37 NIL NIL 263.07 NIL 740 30 60 NIL 480 10 90 280 30 40
28 58 M 749/16 GB YES CHOL CH.C.CC 6474.31 1105.16 5369.15 NIL NIL 241.8 NIL 810 NIL 100 NIL 420 60 40 280 NIL 70
29 35 F 845/16 GB YES CHOL CH.C.CC 11926.93 7656.02 4270.91 185.86 NIL 282.13 NIL 920 NIL NIL NIL 680 NIL NIL 140 NIL NIL
30 35 F 803/16 GB YES CHOL CH.C.CC 15046.7 5526.73 9519.97 198.11 NIL 386.99 NIL 910 NIL 40 NIL 960 NIL NIL 110 NIL NIL
31 40 F 1117/16 GB YES BLACK CH.C.CC 14494.08 9729.01 4765.07 373.37 NIL 368.71 NIL 440 NIL 100 NIL 310 NIL NIL 220 NIL NIL
32 49 F 1138/16 GB YES BLACK Ac on Ch 15432.88 3263.2 12169.68 NIL NIL 336 NIL 810 NIL 50 NIL 920 40 NIL 380 NIL NIL
33 59 M 1051/16 GB YES BLACK CH FOLL 13498.45 5404.15 8094.3 NIL NIL 565.17 NIL 960 NIL NIL NIL 980 NIL NIL 240 NIL NIL
34 46 F 1075/16 GB YES CHOL CH.C.CC 4899.63 4160.99 738.64 NIL NIL 322.22 NIL 890 40 110 NIL 780 NIL 90 490 NIL NIL
35 45 F 1182/16 GB YES BLACK CH.C.CC 16212.22 3015.52 13196.7 NIL NIL 99.24 NIL 840 NIL NIL NIL 710 90 NIL 740 NIL NIL
36 55 F 1241/16 GB YES MIXED CH.C.CC 13467.04 5783.97 7683.07 480.82 NIL 487.51 NIL 490 NIL 120 NIL 520 NIL NIL 440 NIL NIL
37 56 M 1346/16 GB YES BLACK CH.C.CC 14282.31 6716.32 7565.99 1096.21 NIL 163.74 NIL 780 NIL 80 NIL 610 90 110 640 NIL NIL
38 55 M 1360/16 GB YES BLACK CH.C.CC 7597.63 1720.8 5876.83 NIL NIL 141.44 NIL 710 110 NIL NIL 820 NIL NIL 640 120 240
39 35 F 1363/16 GB YES CHOL CH.C.CC 14365.66 7749.91 6615.75 236.65 NIL 375.84 NIL 910 120 NIL 1202.27 710 NIL NIL 640 90 NIL
40 42 F 1500/16 GB YES BLACK CH FOLL 23031.55 1934.55 21097 NIL NIL 367.68 NIL 980 NIL NIL NIL 920 NIL NIL 840 NIL NIL
41 18 F 1506/16 GB YES BLACK CH.C.CC 54194.87 30840.45 23354.42 788.87 NIL 273.39 NIL 860 90 NIL NIL 810 NIL 120 770 NIL 80
42 41 M 3929/15 GB YES BLACK CH.C.CC 26564.02 9760.37 16803.65 381.32 NIL 492.39 NIL 720 110 90 NIL 710 NIL NIL 690 NIL 70
43 26 F 3983/15 GB YES BLACK CH.C.CC 12951.45 6165.12 6786.33 403.93 NIL 427.56 NIL 810 NIL 140 535.98 770 NIL 110 650 NIL 90
44 29 F 1759/16 GB YES BLACK Ac on Ch 8304.58 5448.19 2856.39 485.85 NIL 63.77 NIL 520 240 NIL NIL 570 110 NIL 510 40 70
45 50 F 1789/16 GB YES CHOL CH.C.CC 10082.63 3758.82 6323.81 349.68 NIL 125.27 NIL 790 110 NIL NIL 810 NIL NIL 620 NIL 140
EPITHELIUM LAMINA PROPRIA MUSCULAR SEROSA
MASTER CHART - CASE GROUP
S. No AGE SEX HPE NO SPE STO TYPE HPE DIAG
46 33 F 1848/16 GB YES BLACK CH.C.CC 32909.39 26443.13 6466.26 198.35 NIL 336.93 NIL 800 NIL 110 NIL 810 50 NIL 740 NIL NIL
47 50 F 2476/16 GB YES BLACK CH.C.CC 34233.45 19258.17 14975.28 378.65 NIL 486.71 NIL 920 70 110 NIL 840 40 10 420 NIL NIL
48 31 M 2332/16 GB YES CHOL CH.C.CC 17376.01 9651.18 7724.83 400.1 NIL 290.37 NIL 790 NIL NIL NIL 890 NIL NIL 740 NIL NIL
49 28 F 2350/16 GB YES CHOL CH.C.CC 38897.57 13604.35 25293.22 NIL NIL 245.93 NIL 840 NIL 90 1194.06 820 NIL NIL 460 NIL NIL
50 58 M 2347/16 GB YES BLACK CH.C.CC 9998.37 3252.44 6745.93 NIL NIL 100.86 NIL 760 NIL NIL 540.82 710 NIL NIL 380 NIL NIL
51 61 F 2265/16 GB YES CHOL CH.C.CC 16426.98 6585.85 9841.13 165.41 NIL 147.45 NIL 860 90 NIL 630.89 540 NIL NIL 320 NIL NIL
52 38 F 2286/16 GB YES CHOL CH.C.CC 8835.12 995.83 7839.29 79.8 NIL 122.31 NIL 710 80 40 741.69 740 80 90 490 NIL NIL
53 28 F 2024/16 GB YES BLACK CH.C.CC 16180.99 6591.8 9589.19 579.36 NIL 370.23 NIL 760 NIL NIL NIL 510 NIL NIL 480 NIL NIL
54 24 F 2421/16 GB YES CHOL CH.C.CC 16243.71 11930.49 4313.22 213.07 NIL 231.99 NIL 810 90 NIL 691.93 790 NIL NIL 640 NIL NIL
55 31 M 2332/16 GB YES CHOL CH.C.CC 21589.63 7744.51 13845.12 344.17 NIL 262.1 NIL 760 80 110 NIL 810 60 NIL 320 NIL NIL
56 58 F 2130/16 GB YES BLACK CH.C.CC 16677.66 1059.33 15618.33 NIL NIL 197.86 NIL 640 70 50 NIL 720 60 40 410 NIL NIL
57 48 M 145/16 GB NO NIL Ac on Ch 16004.62 12321.57 3683.05 NIL NIL 346.5 NIL 640 25 110 NIL 560 50 90 710 40 70
58 30 F 317/16 GB NO NIL CH.C.CC 14606.65 906.36 13700.29 NIL NIL 339.36 NIL 780 NIL NIL NIL 360 10 NIL 150 NIL NIL
59 42 M 188/16 GB NO NIL CH.C.CC 11682.19 4449.68 7232.51 NIL NIL 334.04 NIL 320 40 NIL 484.77 240 NIL NIL 320 20 NIL
60 39 M 2570/16 GB NO NIL CH.C.CC 29019.86 6992.08 22027.78 NIL NIL 298.97 NIL 620 NIL NIL NIL 840 NIL NIL 320 NIL NIL
61 36 F 216/16 GB NO NIL CH.C.CC 39546.56 20505.88 19040.68 593.97 NIL 738.64 NIL 320 NIL NIL NIL 160 NIL 80 200 NIL NIL
62 32 M 852/16 GB NO NIL CH.C.CC 29834.09 16201.29 13632.8 804.98 NIL 474.2 NIL 790 NIL 100 NIL 310 NIL NIL 110 NIL NIL
63 47 F 1312/16 GB NO NIL CH.C.CC 13480.85 8143.4 5337.45 NIL NIL 384.98 NIL 610 NIL NIL NIL 440 NIL 90 360 NIL NIL
64 55 F 1428/16 GB NO NIL CH.C.CC 19181.97 4202.44 14979.53 382.28 NIL 428.86 NIL 600 70 90 NIL 590 75 50 490 NIL NIL
65 48 M 1520/16 GB NO NIL CH.C.CC 15647.72 13229.36 2418.36 NIL NIL 350.49 214.33 510 40 20 NIL 490 NIL NIL 360 NIL 40
66 38 F 1678/16 GB NO NIL CH FOLL 28264.85 17516.14 10748.71 407.12 NIL 748.71 NIL 940 NIL 140 NIL 860 NIL NIL 680 NIL 90
67 58 M 89/15 GB NO NIL CH.C.CC 22767 16394 6373 NIL NIL 478.72 63.9 540 50 40 NIL 650 20 30 410 NIL 20
68 52 M 1555/16 GB NO NIL CH.C.CC 6301 3673.31 2627.69 NIL NIL 188.26 NIL 560 40 40 NIL 530 40 20 700 20 NIL
69 35 F 1079/15 GB NO NIL CH.C.CC 8813 6218.38 2594.62 319.18 NIL 283.67 NIL 860 20 10 NIL 810 40 10 490 NIL 30
70 60 F 1251/15 GB NO NIL CH.C.CC 42555 35972 6583 NIL NIL 142.3 9.8 550 60 30 NIL 450 20 50 450 10 NIL
71 55 M 3045/15 GB NO NIL CH.C.CC 21839.56 16524.49 5315.07 NIL NIL 310.11 206.64 640 40 30 NIL 380 60 20 490 NIL NIL
72 42 M 2623/15 GB NO NIL CH.C.CC 10201.94 8311.85 1890.09 NIL NIL 412.39 NIL 680 50 20 NIL 730 60 NIL 240 NIL NIL
73 73 F 2529/15 GB NO NIL CH.C.CC 5190.31 2969.7 2220.31 NIL NIL 384.68 NIL 570 NIL NIL NIL 530 NIL 20 790 NIL NIL
74 36 F 1888/16 GB NO NIL CH.C.CC 19417.6 3318.86 16098.74 384.73 NIL 58.21 NIL 540 70 NIL NIL 480 NIL 80 420 NIL NIL
75 55 F 2039/16 GB NO NIL Ac on Ch 14411.67 4309.49 10102.18 390.68 NIL 269.86 NIL 790 70 20 486.57 710 NIL 80 640 NIL NIL
TOTAL ERO DIST META THICK IR & GAP LYM PL MAC RA LYM PL MAC LYM PL MAC
1 33 M 985/15 GB 184/15 NIL 17211.96 NIL NIL NIL 129.81 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
2 70 F 986/15 GB 185/15 NIL 14383.64 NIL NIL NIL 340.92 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
3 23 M 988/15 GB 186/15 NIL 15789.78 NIL NIL NIL 206.42 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
4 70 M 990/15 GB 187/15 NIL 18461.84 NIL NIL NIL 365.25 NIL 20 NIL NIL NIL NIL NIL NIL NIL NIL NIL
5 52 F 991/15 GB 188/15 NIL 22814.91 NIL NIL NIL 410.05 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
6 60 F 992/15 GB 189/15 NIL 12746.92 NIL NIL NIL 286.9 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
7 53 F 993/15 GB 190/15 NIL 10646.12 NIL NIL NIL 110.8 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
8 48 F 995/15 GB 191/15 NIL 19147.46 NIL NIL NIL 237.44 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
9 30 M 997/15 GB 193/15 NIL 9685.97 NIL NIL NIL 186.71 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
10 20 M 999/15 GB 194/15 NIL 11698.72 NIL NIL NIL 172.75 NIL 40 NIL NIL NIL NIL NIL NIL NIL NIL NIL
11 34 M 1001/15 GB 195/15 NIL 32862.91 NIL NIL NIL 155.26 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
12 36 F 1002/15 GB 196/15 NIL 29811.26 NIL NIL NIL 190.86 NIL 60 NIL NIL NIL NIL NIL NIL NIL NIL NIL
13 55 F 1003/15 GB 197/15 NIL 25685.72 NIL NIL NIL 174.91 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
14 60 F 1004/15 GB 198/15 NIL 30861.96 NIL NIL NIL 114.92 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
15 48 M 1005/15 GB 199/15 NIL 14895.71 NIL NIL NIL 116.76 NIL 10 NIL NIL NIL NIL NIL NIL NIL NIL NIL
16 15 F 1011/15 GB 200/15 NIL 31864.89 NIL NIL NIL 118.04 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
17 49 M 1013/15 GB 201/15 NIL 18417.76 NIL NIL NIL 197.7 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
18 44 M 1058/15 GB 202/15 NIL 17926.81 NIL NIL NIL 180.04 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
19 63 M 1062/15 GB 203/15 NIL 28725.98 NIL NIL NIL 176.84 NIL 20 NIL NIL NIL NIL NIL NIL NIL NIL NIL
20 58 M 1070/15 GB 204/15 NIL 29867.81 NIL NIL NIL 140.77 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
21 43 M 654/16 GB 88/16 NIL 27981.21 NIL NIL NIL 162.86 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
22 32 F 663/16 GB 89/16 NIL 36987.15 NIL NIL NIL 157.22 NIL 50 NIL NIL NIL NIL NIL NIL NIL NIL NIL
23 55 M 667/16 GB 90/16 NIL 31784.25 NIL NIL NIL 161.9 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
24 62 M 668/16 GB 91/16 NIL 29685.71 NIL NIL NIL 270.8 NIL 10 NIL NIL NIL NIL NIL NIL NIL NIL NIL
25 55 M 669/16 GB 92/16 NIL 13714.09 NIL NIL NIL 217.95 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
26 65 F 671/16 GB 93/16 NIL 15896.08 NIL NIL NIL 227.81 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
27 33 M 662/16 GB 94/16 NIL 31876.92 NIL NIL NIL 212.9 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
28 32 F 685/16 GB 95/16 NIL 33682.78 NIL NIL NIL 165.46 NIL 20 NIL NIL NIL NIL NIL NIL NIL NIL NIL
29 50 M 692/16 GB 96/16 NIL 38748.74 NIL NIL NIL 214.78 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
30 54 M 695/16 GB 97/16 NIL 22714.99 NIL NIL NIL 226.91 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
31 51 M 723/16 GB 98/16 NIL 16142.81 NIL NIL NIL 179.86 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
32 53 M 729/16 GB 99/16 NIL 9284.71 NIL NIL NIL 180.07 NIL 30 NIL NIL NIL NIL NIL NIL NIL NIL NIL
33 36 M 732/16 GB 100/16 NIL 12876.42 NIL NIL NIL 210.01 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
34 60 F 728/16 GB 102/16 NIL 8974.72 NIL NIL NIL 168.49 NIL 40 NIL NIL NIL NIL NIL NIL NIL NIL NIL
35 53 M 729/16 GB 103/16 NIL 18742.16 NIL NIL NIL 201.91 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
36 36 M 733/16 GB 104/16 NIL 30782.78 NIL NIL NIL 117.81 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
37 60 M 734/16 GB 105/16 NIL 17112.04 NIL NIL NIL 386.14 NIL 10 NIL NIL NIL NIL NIL NIL NIL NIL NIL
38 30 F 736/16 GB 106/16 NIL 17094.78 NIL NIL NIL 239.46 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
39 55 F 739/16 GB 107/16 NIL 30586.11 NIL NIL NIL 281.91 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
40 37 F 743/16 GB 108/16 NIL 27876.48 NIL NIL NIL 149.96 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
41 65 M 747/16 GB 109/16 NIL 14891.07 NIL NIL NIL 156.81 NIL 50 NIL NIL NIL NIL NIL NIL NIL NIL NIL
42 65 F 748/16 GB 110/16 NIL 21998.03 NIL NIL NIL 274.9 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
43 60 M 750/16 GB 113/16 NIL 27864.78 NIL NIL NIL 216.81 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
GR CHAN
MASTER CHART - CONTROL GROUP
S NO
EPITHELIUM LAMINA MUSCULAR SEROSA
AGE SEX PM NO SPE FP NO
44 65 M 754/16 GB 114/16 NIL 22789.11 NIL NIL NIL 161.94 NIL 30 NIL NIL NIL NIL NIL NIL NIL NIL NIL
45 31 M 756/16 GB 115/16 NIL 19876.95 NIL NIL NIL 178.77 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
46 65 F 757/16 GB 116/16 NIL 14714.01 NIL NIL NIL 116.27 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
47 42 M 760/16 GB 117/16 NIL 32117.84 NIL NIL NIL 278.68 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
48 46 M 762/16 GB 118/16 NIL 30982.41 NIL NIL NIL 210.09 NIL 60 NIL NIL NIL NIL NIL NIL NIL NIL NIL
49 42 M 763/16 GB 119/16 NIL 29876.04 NIL NIL NIL 196.81 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
50 46 M 765/16 GB 120/16 NIL 27774.09 NIL NIL NIL 198.91 NIL 20 NIL NIL NIL NIL NIL NIL NIL NIL NIL
51 80 M 761/16 GB 121/16 NIL 13112.08 NIL NIL NIL 141.69 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
52 52 M 768/16 GB 130/16 NIL 27418.77 NIL NIL NIL 248.16 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
53 32 M 773/16 GB 131/16 NIL 37864.19 NIL NIL NIL 156.71 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
54 53 M 776/16 GB 132/16 NIL 33781.67 NIL NIL NIL 298.04 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
55 59 M 780/16 GB 133/16 NIL 19117.04 NIL NIL NIL 186.41 NIL 40 NIL NIL NIL NIL NIL NIL NIL NIL NIL
56 78 M 788/16 GB 134/16 NIL 13674.08 NIL NIL NIL 179.86 NIL 20 NIL NIL NIL NIL NIL NIL NIL NIL NIL
57 63 M 796/16 GB 135/16 NIL 18969.78 NIL NIL NIL 148.76 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
58 65 F 787/16 GB 136/16 NIL 31878.41 NIL NIL NIL 205.71 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
59 32 M 1084/16 GB 173/16 NIL 27319.02 NIL NIL NIL 142.7 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
60 45 F 1085/16 GB 174/16 NIL 9997.81 NIL NIL NIL 176.85 NIL 40 NIL NIL NIL NIL NIL NIL NIL NIL NIL
61 60 F 1088/16 GB 175/16 NIL 14474.7 NIL NIL NIL 191.44 NIL 50 NIL NIL NIL NIL NIL NIL NIL NIL NIL
62 40 M 1092/16 GB 176/16 NIL 16718.09 NIL NIL NIL 206.78 NIL 50 NIL NIL NIL NIL NIL NIL NIL NIL NIL
63 65 F 1093/16 GB 177/16 NIL 29414.71 NIL NIL NIL 191.6 NIL 30 NIL NIL NIL NIL NIL NIL NIL NIL NIL
64 39 M 1095/16 GB 178/16 NIL 32786.2 NIL NIL NIL 126.8 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
65 40 M 1096/16 GB 179/16 NIL 17146.09 NIL NIL NIL 200.98 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
66 38 M 1105/16 GB 180/16 NIL 24096.84 NIL NIL NIL 181.25 NIL 40 NIL NIL NIL NIL NIL NIL NIL NIL NIL
67 50 M 1107/16 GB 181/16 NIL 36819.09 NIL NIL NIL 241.81 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
68 39 M 1108/16 GB 182/16 NIL 32724.06 NIL NIL NIL 169.86 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
69 65 M 1069/16 GB 171/16 NIL 14876.96 NIL NIL NIL 211.79 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
70 53 M 1080/16 GB 172/16 NIL 29874.8 NIL NIL NIL 294.86 NIL 50 NIL NIL NIL NIL NIL NIL NIL NIL NIL
71 44 M 1129/16 GB 183/16 NIL 27119.04 NIL NIL NIL 267.64 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
72 40 M 1130/16 GB 184/16 NIL 28069.85 NIL NIL NIL 199.14 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
73 51 M 1127/16 GB 185/16 NIL 22786.05 NIL NIL NIL 260.11 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
74 27 F 769/16 GB 128/16 NIL 34468.95 NIL NIL NIL 199.14 NIL 40 NIL NIL NIL NIL NIL NIL NIL NIL NIL
75 22 F 785/16 GB 129/16 NIL 32814.9 NIL NIL NIL 260.11 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
SPE - SPECIMEN , STO - STONES , GR CHAN - GROSS CHANGES , ERO - EROSION , DIST - DISTORTION, META - METAPLASIA,
THICK - THICKNESS ,IR & GAP - IRREGULARITY & GAP , LYM -LYMPHOCYTES , PL - PLASMA CELLS , MAC - MACROPHAGES