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Liver Changes Associated with Cholecystitis J Clin Pathol 1994;47:457-460 457 Liver changes associated with cholecystitis J M Geraghty, R D Goldin J Clin Pathol: first published as 10.1136/jcp.47.5.457 on 1 May 1994. Downloaded from Abstract Previous studies correlating the presence of Aims-To investigate the histopathologi- gall stones with changes in liver histology have cal changes in the livers of patients given conflicting results.49 In particular, the undergoing cholecystectomy and to relate reported incidences of portal tract fibrosis dif- these changes to the underlying biliary fered considerably, and its association with tract pathology. the localisation of gall stones has been poorly Methods-Liver changes in 67 patients defined. More importantly, the histological undergoing cholecystectomy were inves- changes have not been described in detail. tigated. Sixty three had gall stones, one The aim of this study, therefore, was to cholesterolosis only, and there were three determine the prevalence and extent of liver cases of acute acalculous cholecystitis. disease, and to assess the value ofperoperative Results-Only 34% of the patients had liver biopsy specimens in patients undergoing completely normal liver biopsy speci- cholecystectomy for gall stones and cholecys- mens. The most clinically important titis. Clinical assessment, liver function tests pathology was found in 11 of the 14 and biliary microbiology were correlated with patients with choledocholithiasis: three liver and gall bladder histology and the distrib- of these had cholangitis and eight had ution of gall stones in the biliary tree. features of large bile duct obstruction (four also had chronic cholestasis and portal-portal linking fibrosis). Non-spe- Methods cific reactive hepatitis was the most com- Peroperative protocol liver biopsy specimens mon abnormality in the remaining 53 distal to the gall bladder bed were obtained patients with cholecystitis alone, and was from 67 consecutive patients undergoing found in 18. A further four patients had cholecystectomy at St Mary's Hospital, chronic cholestasis without fibrosis and London, between January 1984 and March early primary biliary cirrhosis was a 1989. The series included 41 women, mean coincidental finding in another. Clinical age 47.6 years (range 18 to 83 years), and 26 http://jcp.bmj.com/ symptoms were poorly correlated with men, mean age 57.6 years (range 32 to 75 gall bladder and liver pathology apart years), a distribution similar to that expected from an association between jaundice for the British population.' 01' and choledocholithiasis. Liver function Forty patients presented with acute symp- tests of obstructive pattern were noted in toms and underwent emergency cholecystec- 23 of 58 patients, most of whom had tomy. Twenty one of these had had a history choledocholithiasis or non-specific reac- of gall stone related disease of between four on September 25, 2021 by guest. Protected copyright. tive hepatitis. Bile cultures were positive weeks' and 10 years' duration. Elective in 10 of 42 patients, predominantly in surgery was carried out in the remaining 27 cases of cholangitis and acute chole- patients, who had histories of gall stone cystitis. related disease of between eight weeks and 15 Conclusions-Cholangitis and extensive years. None of the patients was alcoholic, had fibrosis associated with large bile duct viral hepatitis, or was known to be taking obstruction are common findings in drugs associated with liver damage. The patients with choledocholithiasis. The results of preoperative liver function tests liver disease may progress to secondary (serum bilirubin, aspartate amino transferase, biliary cirrhosis if the obstruction is not and alkaline phosphatase), taken within three relieved, emphasising the need for early days before surgery, were available in 53 surgery. A peroperative liver biopsy may patients. be useful to exclude cirrhosis in these The distribution of gall stones within the patients, but is unlikely to be informative biliary tree was determined by a combination in those with cholecystitis alone. of radiological and ultrasound findings before Department of surgery and those at surgery including per- Histopathology, St ( Clin Pathol 1994;47:457-460) operative cholangiography and exploration of Mary's Hospital the common bile duct. Peroperative bile Medical School, Norfolk Place, London swabs from the gall bladder and common bile W2 IPG Liver damage in patients with gall stones is duct were cultured aerobically and anaerobi- J M Geraghty thought to be the result of chronic extra- cally by standard methods, and results were R D Goldin hepatic large bile duct obstruction with or available for 42 patients. Correspondence to: 2 Dr R D Goldin without repeated episodes of cholangitis" The liver biopsy specimens (stained with Accepted for publication and may ultimately progress to secondary haematoxylin and eosin, reticulin, and orcein 25 November 1993 biliary cirrhosis.' stains) and blocks from the gall bladders 458 Geraghty, Goldin T;able 1 Gall bladder histology in 67patients undergoing CORRELATION BETWEEN LIVER AND cholecystectomy, with percentages ofthe total in GALL BLADDER HISTOLOGY parentheses Normal liver histology and reactive hepatitis Normal 2(3 0) were common in all categories of gall bladder Acute cholecystitis 8(11 9) J Clin Pathol: first published as 10.1136/jcp.47.5.457 on 1 May 1994. Downloaded from Acute-on-chronic 22(32-8) disease. Large droplet fatty change and acute cholecystitis or chronic large duct obstruction were seen Chronic cholecystitis 34(50 7) Cholesterolosis only 1(1.5) mainly in cases of acute-on-chronic or chronic cholecystitis. All those patients with cholangitis or reactive hepatitis with acute inflammatory cells in portal tracts had either acute or acute- (fundus, neck, and body) were assessed on-chronic cholecystitis. independently by both authors and designated histological categories according to standard CLINICAL SYMPTOMS texts.'12 Discrepancies were settled by con- The most common symptoms were abdomi- sensus. nal pain with or without jaundice. There was no correlation between the timing of the pain and gall bladder or liver histology. Results Thirteen (19%) patients presented with GALL BLADDER HISTOLOGY AND DISTRIBUTION acute abdominal pain and jaundice, with the OF GAIL STONES following liver histology: acute cholangitis (n = Histological changes in the gall bladder are 3); acute large duct obstruction (n = 4); acute documented in table 1. Cholelithiasis was pre- large duct obstruction with chronic cholestasis sent in 63 patients, 14 of whom also had (n = 2); non-specific reactive hepatitis (n = choledocholithiasis. Three had acute acalcu- 1); and cholestasis only (n = 3). None had lous cholecystitis and another only choles- normal liver histology. All three patients with terolosis. The distribution of stones and the cholangitis had swinging fever in addition to gall bladder histology were similar in men and abdominal pain and jaundice. women (results not shown). Forty two patients had no history of jaun- dice, including two with the changes of acute LIVER HISTOLOGY (TABLE 2) large duct obstruction with chronic cholesta- Although minor differences were seen in the sis, both of whom had histories of abdominal frequency of histological changes between pain of more than two years. men and women, these were not significant All four patients with only chronic cholesta- (results not shown). Liver histology was nor- sis had histories of recurrent abdominal pain, mal in 23 (34%) patients. The commonest of at least three months' duration, but none abnormalities were non-specific reactive had had jaundice before. hepatitis and large droplet fatty change. Of In general, there was poor correlation the 18 patients (27%) with reactive hepatitis between symptoms and gall bladder pathol- http://jcp.bmj.com/ seven also had acute inflammatory cells in ogy. portal tracts not involving the bile ducts. More clinically important pathology in the CHOLEDOCHOLITHIASIS form of cholestasis, cholangitis, or large duct The results of liver histology for the 14 obstruction was present in 18 patients. patients with choledocholithiasis are given in Extensive fibrosis with portal-portal linking table 3. was confined to the four patients with acute on September 25, 2021 by guest. Protected copyright. large duct obstruction who also showed fea- LIVER FUNCTION TESTS tures of chronic cholestasis, including the Abnormal preoperative liver function tests are accumulation of copper associated protein in correlated with liver histology in table 4. periportal hepatocytes."3 None of the patients Twenty eight of the 53 (53%) patients in had secondary biliary cirrhosis. The liver whom results were available had abnormal biopsy specimen from one woman displayed liver function tests. The most sensitive indica- the features of primary biliary cirrhosis (stage tor of clinically important liver pathology was a 2), subsequently confirmed by a positive test raised serum alkaline phosphatase value, pre- for serum mitochondrial antibodies. sent in 23 (43%) patients. None of the A frequent observation was the presence of patients with acalculous cholecystitis had a focal necroses and collections of neutrophils raised alkaline phosphatase activity. in the sinusoids, which are generally accepted to be the result of surgery and anaesthesia.' BILJARY MICROBIOLOGY Of the 42 patients in whom the results of peroperative bile swab microbiology were Table 2 Liver histology in 67patients undergoing cholecystectomy with percentages
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