|Year : 2021 | Volume
| Issue : 2 | Page : 95-101
A Study of Helicobacter pylori in chronic cholecystitis and gallbladder carcinoma
Saba Bashir, Prema Saldanha
Department of Pathology, Yenepoya Medical College, University Road, Deralakatte, Mangalore, Karnataka, India
|Date of Submission||02-Feb-2021|
|Date of Acceptance||09-Mar-2021|
|Date of Web Publication||02-Jun-2021|
Dr. Prema Saldanha
Department of Pathology, Yenepoya Medical College, University Road, Deralakatte, Mangalore 575018, Karnataka.
Source of Support: None, Conflict of Interest: None
Background: Chronic cholecystitis (CC) accounts for more than 90% of cholecystectomies. Some recent work has demonstrated the presence of Helicobacter pylori in bile and the gallbladder of more than three-fourths of the patients with gallbladder carcinoma (GBC) and in more than half of the patients with CC. Objective: To study the histopathological findings and to demonstrate the presence of H. pylori in CC and GBC in our region. Materials and Methods: One hundred fifty cholecystectomy specimens received during two years were examined after obtaining ethical clearance for the study. The specimens were received in 10% neutral buffered formalin. The specimens were processed, paraffin-embedded, and stained with Hematoxylin and Eosinand Giemsa stain, for the detection of H. pylori. Immunohistochemistry (IHC) for H. pylori was done on 35 cases. Results: Of the 150 cases of cholecystectomy specimens, the majority of the patients were in the age group of 41–50 years, with the male:female (M:F) ratio being 1:1.9. The most common lesion was chronic calculous cholecystitis (76%). The spectrum of lesions in our study included chronic acalculouscholecystitis (1.3%), follicular cholecystitis (4.6%), xanthogranulomatous cholecystitis (3.3%), acute over CC (2.6%), eosinophilic cholecystitis (2%), cholesterolosis (2%), choledochal cyst (1.3%), acute calculous cholecystitis (1.3%), empyema (0.66%), and gallbladder carcinoma (GBC; 3.3%). Giemsa stain on 150 cases was negative for H. pylori. On 35 cases an IHC was done; none detected H. pylori, indicating that H. pylori infection does not contribute to the development of gallstones in this region.
Keywords: Carcinoma, chronic cholecystitis, gallbladder, Helicobacter pylori, immunohistochemistry
|How to cite this article:|
Bashir S, Saldanha P. A Study of Helicobacter pylori in chronic cholecystitis and gallbladder carcinoma. MGM J Med Sci 2021;8:95-101
|How to cite this URL:|
Bashir S, Saldanha P. A Study of Helicobacter pylori in chronic cholecystitis and gallbladder carcinoma. MGM J Med Sci [serial online] 2021 [cited 2021 Oct 21];8:95-101. Available from: http://www.mgmjms.com/text.asp?2021/8/2/95/317455
| Introduction|| |
Chronic cholecystitis (CC) is the most commonly encountered disease of the gallbladder; the overwhelming majority of cholecystectomies are performed for CC. It is associated with cholelithiasis in more than 90% of the cases. It may also develop as a sequela of recurrent acute cholecystitis.
Cholelithiasis produces diverse histopathological changes in gallbladder mucosa, namely acute inflammation, glandular hyperplasia, granulomatous inflammation, cholesterolosis, dysplasia, and carcinoma. Gall stones mainly injure the mucosal columnar epithelium and, thus, cause changes such as metaplasia, dysplasia, and neoplasia.,, Gallbladder carcinoma (GBC) is an extremely rare though lethal malignancy. It has been linked to various genetic and environmental factors.,
Helicobacter pylori is known to cause chronic gastritis, gastric ulcers, duodenal ulcers, and gastric mucosa-associated lymphoid tissue lymphoma (MALToma). Recent work has demonstrated the presence of H. pylori in the bile and gallbladder of 80% of patients with GBC and in more than 45% of patients with CC undergoing surgery.
| Materials and methods|| |
A total of 150 specimens of cholecystectomy were examined from October 2017 to June 2019 after Institutional Ethical Review Committee approval. The gallbladder specimens, fixed in 10% formalin, were received in the Pathology Department. Gross findings were recorded; the tissue bits were processed according to the standard protocol and thereafter stained with Hematoxylin and Eosin; and the histopathological findings were recorded. Then, all the cases were subjected to Giemsa stain for demonstration of H. pylori. Thirty-five cases showing moderate to severe inflammation, cases with follicular cholecystitis and adenocarcinoma were selected for immunohistochemistry (IHC) for H. pylori antigen detection. The primary antibody used was a Polyclonal Rabbit antibody-Helicobacter pylori Code IR523 from DAKO. The IHC detection system used was DAKO Real Envision.
| Results|| |
Out of the 150 cases of cholecystectomy specimens, the majority of the patient’s age group ranged from three years to 74 years with a sex predilection toward females, with the F:M ratio being 1.9:1. Multiple stones were the most common in 77.33% of the cases, with a maximum number of stones measuring 0.2cm. Mixed types of stones were the most common stones seen in 82.73% of the cases, followed by pure pigment stones seen in 10.79% of the cases and pure cholesterol stones seen in 6.4% of the cases.
The most common lesion was chronic calculous cholecystitis (76%), and the spectrum of lesions in our study included chronic acalculouscholecystitis (1.3%), follicular cholecystitis (4.6%), xanthogranulomatous cholecystitis (3.3%), acute over CC (2.6%), eosinophilic cholecystitis (2%), cholesterolosis (2%), choledochal cyst (1.3%), acute calculous cholecystitis (1.3%), empyema (0.66%), and GBC (3.3%).
The microscopic findings in different gallbladder diseases are summarized in [Table 1] and shown in [Figure 1][Figure 2][Figure 3][Figure 4]. Chronic calculous cholecystitis was the most common lesion encountered in our study and it was seen in 76% of the cases (n = 115). Out of the 150 cases, 148 cases showed chronic lymphocytic inflammatory infiltrate, ranging from mild (82 cases) to moderate (61 cases) and severe (6 cases), respectively.
|Figure 1: Follicular cholecystitis showing lymphoid follicles with germinal centers. (H&E 10X)|
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GBC was seen in five cases (3.3%): two were adenosquamous, two were adenocarcinoma, and one was squamous cell carcinoma, and all were associated with stones[Figure 5][Figure 6][Figure 7][Figure 8].
|Figure 5: Gross specimen of GBC showing thickened wall and loss of velvety mucosa|
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|Figure 6: Gallbladder adenocarcinoma, showing closely packed tumour cells composed of irregular glands. (H&E 4x)|
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|Figure 8: Squamous cell carcinoma of gallbladder showing tumour cells composed of nests of polygonal cells with abundant eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli (H&E 40x)|
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In all cases, Giemsa stain was negative for H pylori. Out of these, 35 cases that were selected were negative for H pylori by IHC. The results are shown in [Table 2] and [Figure 9] and [Figure 10].
|Table 2: Spectrum of lesions in our study and the prevalence of H. pylori|
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|Figure 9: Giemsa stain negative for H. pylori in gallbladder mucosa (H&E 10x)|
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|Figure 10: Immunohistochemistry negative for H. pylori in gallbladder mucosa (10x)|
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| Discussion|| |
Cholecystectomy specimens are one of the most common samples received in the histopathology department; 90% of cholecystectomies were performed for CC, and 10% of cases represented as calculous cholecystitis.
Cholelithiasis can manifest clinically and histologically as a myriad of disorders encompassing acute cholecystitis, CC, metaplasias, hydrops, mucocele, empyema, gallstone ileus, and carcinoma.
The risk factors for the development of gallstone disease can be categorized as non-modifiable and modifiable. Non-modifiable factors include ethnic background, increasing age, female gender, and family history or genetics; whereas the modifiable ones are obesity, rapid weight loss, and a sedentary lifestyle. Cholecystitis and cholelithiasis appear to be increasing in incidence over the past couple of decades in India and the Western world due to the increased intake of a fatty and high-calorie diet and increased consumption of alcohol. In India, the disease is seven times more common in the North than in South India. Dietary differences in the two regions are suspected to be responsible for the difference in the prevalence rate.,
Helicobacter pylori is a gram-negative, S-shaped microorganism that can cause chronic gastritis, gastric ulcers, duodenal ulcers, and gastric malignancies. In recent literature, there is an increasing description of H. pylori in extra-gastric locations and its association with many diseases. Helicobacter species that may colonize the biliary tract have been implicated as a possible cause of hepatobiliary diseases, ranging from CC and primary sclerosing cholangitis to gall bladder carcinoma and primary hepatic carcinoma. Multiple researchers have demonstrated the presence of H. pylori in the bile and gallbladder of more than 75% of patients with GBC and in more than 45% of patients with CC undergoing surgery., Many studies from different parts of the world and India have explored the possibility of Helicobacter infection in gallbladder diseases by identifying H. pylori on H&E, Giemsa stains, Warthin-starry silver stain, IHC, serology, PCR, ELISA, etc.
Gallbladder disease is more common in the middle age group, with female preponderance. In the present study, the youngest age at presentation was three years and the most common age range was between 41 and 50 years. According to a study conducted by Mohan et al, they observed that the age ranged from 10 to 90 years. Kaur et al. showed that age ranged from 31 to 50 years, and Kala et al. found that age ranged from 10 to 69 years. Our study showed that the age ranged between 3 and 74 years. In our study, we had 98 females and 52 males with an F:M ratio of 1.9:1. An almost similar M:F ratio was found in a study conducted by Narayanasamy et al.and Sreeramulu et al.
Chronic calculous cholecystitis was the most common lesion encountered in our study and it was seen in 115 cases (76%), similar to other studies conducted by Kaur et al., Selvi et al., Mathur et al., and Kumar et al. ranging from 45% to 87%. Acute over CC was seen in 2.6% of the cases in our study. This was similar to studies by Kaur et al., and Mathur, which found 12% of these cases. Follicular cholecystitis and xanthogranulomatous cholecystitis were observed in 4.6% and 3.3%, which was almost similar to the studies conducted by Mathur et al. and Kafle et al. Carcinoma of the gallbladder was seen in 3.33% of the cases. Other studies also showed a lower incidence of carcinoma ranging from 0.78% to 6%.,,,[20-22]
The present study was conducted to ascertain whether H. pylori could be identified in resected gallbladder tissue. However, a few studies from different parts of the world showed that there may be an association between the presence of Helicobacter species and the development of gallbladder diseases. The incidence ranges from 5.8% to 33% [Table 3].,,,,,, Our study did not find the presence of H. pylori in gallbladder mucosa by using Giemsa stain and IHC.
|Table 3: Frequency of H. pylori in gallbladder disease in various countries|
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In India, numerous studies were conducted to ascertain the relationship between the gallbladder and H. pylori. In North India, studies conducted by Misra et al. and Bansal et al. detected H. pylori in 45% and 32.6% of gallbladder samples, respectively [Table 4]. They have suggested that H. pylori colonization in the gallbladder is possible and may play an important role in the pathogenesis of gallbladder diseases. Similar results as ours were seen in one study conducted by Choudhary et al. in 2015, and they could not demonstrate H. pylori in gallbladder mucosa using Giemsa staining.
In South India, a few studies demonstrated the presence of H. pylori in gallbladder tissue with an incidence ranging from 4.6% to 22.22%,,[33-35] and they concluded that H. pylori is a pathogenic entity in gallbladder disease in this population as well. One study conducted by Hedge et al. from Bangalore was not able to find H. pylori in any of their cases by using the PCR technique [Table 5].
Helicobacter species present in the human biliary tree may play a significant role in the pathogenesis of malignancies of the biliary tract, especially GBC. Bulajic et al., Kobayashi et al., Mishra et al., and Parajuli et al. have shown a higher incidence of Helicobacter species in hepatobiliary malignancy with 80%, 71.24%, 44.44%, and 71.24%, respectively [Table 6].
|Table 6: Frequency of H. pylori in gallbladder carcinoma in various countries|
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There was no evidence of H. pylori infection of the gallbladder on histopathological examination using H&E, Giemsa stain, and IHC in our study, which was similar to two studies conducted in India. The results are conflicting, as some investigators have detected the presence of H. pylori in gallbladder tissues whereas others have not. Accordingly, whether H. pylori participates in the pathogenesis of gallbladder diseases is a question that remains unresolved. Further studies are needed to determine whether Helicobacter spp. is a causative agent of biliary diseases or a cofactor.
| Conclusion|| |
Gallbladder disease is one of the most common problems affecting the digestive tract, especially chronic calculous cholecystitis. The prevalence of gallbladder disease is related to many factors. The colonization of bacteria in the human gastrointestinal tract has been a subject of study for decades. The relationship between H. pylori and gallstones has been investigated; however, it is not demonstrated. Helicobacter species detection in human bile has encouraged a growing interest as to whether these organisms truly colonize the biliary tract of humans and can cause hepatobiliary diseases. The pathogenicity of helicobacter species in hepatobiliary disease and carcinogenesis has not been fully elucidated. This study did not find H. pylori in gallbladder diseases in our region.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]