Gallbladder disease, particularly cholelithiasis, remains one of the most common indications for abdominal surgery globally. In India, regional and dietary differences have been shown to influence the incidence of gallstone disease, leading to the proposition that gallbladder pathology may "divide" the country epidemiologically—with northern states exhibiting a higher burden compared to southern regions【1】. The gold standard treatment for symptomatic gallstone disease is cholecystectomy, with laparoscopic techniques now dominating surgical practice due to reduced morbidity and recovery time【5】.

Despite the routine nature of cholecystectomy, the importance of detailed histopathological examination of the excised gallbladder should not be underestimated. Histological analysis not only confirms clinical diagnoses such as chronic cholecystitis but also plays a pivotal role in detecting subclinical pathologies like epithelial metaplasia, dysplasia, and even early gallbladder carcinoma—conditions that may be entirely missed intraoperatively【2】【4】. The dilemma between selective versus routine histopathological evaluation continues to generate debate, particularly in resource-limited settings【2】.

Studies have reported a diverse histopathological spectrum among cholecystectomy specimens. Chronic cholecystitis is the most frequent diagnosis, often accompanied by varying degrees of mucosal changes and gallstone-induced injury【3】【6】. However, incidental findings such as cholesterolosis, polyps, and carcinoma are not uncommon. In endemic regions, such as rural areas of West Bengal, gallbladder carcinoma has been observed even in younger patients, often in association with gallstones and mucosal ulceration【7】.

This histopathological variability underlines the diagnostic value of examining every cholecystectomy specimen. Furthermore, understanding the age and gender distribution, socioeconomic background, and gross morphological patterns (e.g., wall thickening, mucosal ulceration, presence of stones) can provide important epidemiological insights into gallbladder disease【6】.

In this context, the present study was undertaken to evaluate the histopathological spectrum of gallbladder specimens collected during cholecystectomy procedures at a tertiary care centre in Barasat, West Bengal, and to correlate histological patterns with clinical and demographic profiles.

Aims and Objectives

Aim

This study aimed to evaluate the histopathological spectrum of gallbladder lesions in cholecystectomy specimens and correlate them with clinical and demographic characteristics.

Objectives

1. To analyze the frequency and distribution of histopathological diagnoses—such as chronic cholecystitis, acute cholecystitis, cholesterolosis, metaplasia, dysplasia, and carcinoma—in gallbladder specimens.
2. To assess the demographic profile (age, sex, residence, socioeconomic status) of patients undergoing cholecystectomy.
3. To examine the association between clinical presentation and histological findings.
4. To determine the prevalence and types of gallstones and their relation to histopathological changes.
5. To identify incidental findings of premalignant or malignant lesions in routine cholecystectomy specimens.

Study Design and Setting

This was a hospital-based, cross-sectional, observational study conducted in the Department of General Surgery at North 24 Parganas District Hospital, Barasat, Kolkata, affiliated with Barasat Government Medical College and Hospital. The study was carried out over a defined period and included patients undergoing elective or emergency cholecystectomy.

Study Population

A total of 66 patients who underwent cholecystectomy for various indications were enrolled consecutively. Informed consent was obtained from all participants. Both laparoscopic and open cholecystectomy cases were included.

Inclusion Criteria

• Patients of all genders aged 18 years and above.
• Patients undergoing cholecystectomy for gallstone disease or suspected gallbladder pathology.

Exclusion Criteria

• Inadequate or autolyzed specimens unsuitable for histopathological examination.
• Patients with known primary malignancies elsewhere.

Data Collection

Demographic and clinical details such as age, sex, residential background (urban/rural), socioeconomic status, presenting symptoms, and surgical modality (laparoscopic vs. open) were recorded using a predesigned proforma.

Specimen Handling and Histopathology

Following cholecystectomy, gallbladder specimens were examined grossly for:

• Presence of stones (single/multiple)
• Wall thickening (mild: 3–5 mm; moderate: >5 mm)
• Mucosal ulceration
• Pus, fibrin, haemorrhage, or perforation
• Tumour or polypoid lesions

All specimens were fixed in 10% formalin and sent to the Department of Pathology for routine histopathological processing. Sections were stained with Haematoxylin and Eosin (H&E) and examined under light microscopy. The final diagnosis was categorized into chronic cholecystitis, acute cholecystitis, cholesterolosis, epithelial metaplasia, dysplasia, or adenocarcinoma.

Data Analysis

Data were compiled and analyzed using descriptive statistics. Results were expressed as frequencies, percentages, and proportions. Correlations between clinical-demographic variables and histopathological diagnoses were evaluated where appropriate.

1. Demographic Characteristics

The study included a total of 66 patients who underwent cholecystectomy. The most common age group was 41–60 years, accounting for 45.5% of cases (n=30), followed by the 25–40 years group (42.4%, n=28), and patients aged over 60 years made up 12.1% (n=8) of the cohort.

There was a female predominance, with 57.6% (n=38) females compared to 42.4% (n=28) males, reflecting the known gender distribution pattern of gallbladder disease. The majority of patients resided in urban areas (n=40, 60.6%), while 39.4% (n=26) were from rural backgrounds.

In terms of socioeconomic classification, the largest subset of patients belonged to the Lower Middle Class (Class III) as per the modified Kuppuswamy scale (37.9%, n=25), followed by the Upper Middle Class (Class II) (30.3%, n=20), and Upper Class (Class I) (15.2%, n=10). Smaller proportions belonged to the Upper Lower Class (Class IV) (12.1%, n=8) and Lower Class (Class V) (4.5%, n=3).

Detailed distribution is presented in Table 1.

Table 1. Demographic Profile of Study Participants (N = 66)

2. Clinical Presentation

All patients (100%, n=66) presented with abdominal pain, making it the most consistent clinical symptom in this cohort. Other commonly reported symptoms included nausea and/or vomiting in 75.8% of patients (n=50), fever in 42.4% (n=28), and jaundice in 18.2% (n=12).

These findings are consistent with the classical clinical manifestations of gallbladder disease, particularly cholelithiasis and cholecystitis. The high prevalence of abdominal pain underscores its importance as a key symptom prompting surgical intervention.

The distribution of presenting symptoms is summarized in Table 2.

Table 2. Distribution of Clinical Symptoms Among Study Participants (N = 66)

3. Surgical Approach

Out of the 66 patients included in the study, the majority (87.9%, n=58) underwent laparoscopic cholecystectomy, reflecting current trends in minimally invasive gallbladder surgery. A smaller proportion of patients (12.1%, n=8) required open cholecystectomy, likely due to complications, anatomical variations, or intraoperative conversions.

This distribution is consistent with modern surgical practices, where laparoscopic cholecystectomy is the standard approach due to its lower morbidity, shorter hospital stay, and faster recovery time.

The distribution of surgical techniques is shown in Table 3.

Table 3. Type of Cholecystectomy Performed (N = 66)

4. Gross Pathological Findings

Gross examination of the 66 gallbladder specimens revealed that gallstones were the most frequently observed feature, present in 75.8% (n=50) of cases. Among these, multiple stones were more common (45.5%, n=30) than single stones (30.3%, n=20).

Wall thickening was another prominent feature, noted in 60.6% (n=40) of specimens. Of these, mild thickening (3–5 mm) was observed in 37.9% (n=25), while moderate thickening (>5 mm) was seen in 22.7% (n=15).

Other gross pathological findings included:

• Mucosal ulceration in 15.2% (n=10)
• Empyema in 6.1% (n=4)
• Polypoid lesions in 9.1% (n=6)
• Perforation of the gallbladder in 3.0% (n=2)
• Tumour/mass lesions in 3.0% (n=2)

These findings highlight the common inflammatory and structural changes associated with gallstone disease, as well as the occasional presence of potentially malignant lesions.

Detailed gross findings are provided in Table 4.

Table 4. Gross Pathological Findings in Gallbladder Specimens (N = 66)

5. Histopathological Spectrum

Histopathological examination of the 66 gallbladder specimens revealed that chronic cholecystitis was the most common diagnosis, observed in 72.8% (n=48) of cases. This was followed by acute cholecystitis in 12.1% (n=8) and cholesterolosis in 9.1% (n=6). Importantly, premalignant and malignant lesions were also identified: dysplasia and metaplasia were each seen in 1.5% of cases (n=1 each), while gallbladder adenocarcinoma was found in 3.0% (n=2).

These findings reinforce the importance of routine histopathological evaluation of all cholecystectomy specimens, particularly in regions with known higher incidence of gallbladder cancer.

A detailed breakdown of diagnoses is presented in Table 5.

Table 5. Histopathological Spectrum of Gallbladder Lesions (N = 66)

6. Correlation Between Histopathological Diagnosis and Age Group

An age-wise distribution of histopathological diagnoses revealed that chronic cholecystitis was most prevalent across all age groups, particularly among patients aged 25–40 years (n=22, 45.8%) and 41–60 years (n=20, 41.7%), with fewer cases in the >60 years group (n=6, 12.5%).

Acute cholecystitis was more frequently observed in younger individuals, with 50.0% of cases (n=4) occurring in the 25–40 age group, 37.5% (n=3) in the 41–60 group, and 12.5% (n=1) in patients above 60 years.

Cholesterolosis was predominantly seen in the 41–60 years group (n=3, 50.0%), followed by the 25–40 (n=2, 33.3%) and >60 years (n=1, 16.7%) groups.

Notably, adenocarcinoma was detected in two patients: one in the 41–60 years group and another in the >60 years group (each 50.0% of adenocarcinoma cases), with no cases in the youngest age group. Dysplasia and metaplasia were found only in the 41–60 years group (n=1 each).

Although the data suggest a trend of increasing incidence of premalignant and malignant lesions with age, formal statistical significance was not calculated due to limited sample size within rare categories.

Detailed findings are summarized in Table 6.

Table 6. Distribution of Histopathological Diagnosis by Age Group (N = 66)

7. Correlation Between Gallstones and Histopathology

A correlation between the presence of gallstones and histopathological diagnosis was evaluated. Among the 48 cases of chronic cholecystitis, 83.3% (n=40) were associated with gallstones. A similar high association was observed in cases of cholesterolosis, where 83.3% (n=5 out of 6) had stones.

In contrast, only 50.0% of cases of acute cholecystitis (n=4 of 8) and adenocarcinoma (n=1 of 2) were associated with gallstones. Notably, neither dysplasia nor metaplasia cases (n=1 each) demonstrated the presence of gallstones.

These findings align with the well-established role of gallstones in chronic inflammatory changes and cholesterolosis, whereas their presence appears less consistent in neoplastic or premalignant lesions.

Details of gallstone presence across histopathological categories are presented in Table 7.

Table 7. Correlation Between Gallstones and Histopathological Diagnosis (N = 66)

This study analyzed the histopathological spectrum of gallbladder lesions in 66 cholecystectomy specimens, with emphasis on inflammatory, metaplastic, and neoplastic changes and their association with demographic and clinical features.

Inflammatory and Cholesterol-Related Lesions

The most frequent histological diagnosis was chronic cholecystitis, present in 72.8% of cases. This finding is in concordance with prior studies such as those by Kafle et al., who reported a 74% prevalence of chronic cholecystitis in their cohort of cholecystectomy specimens in Nepal. Similarly, Memon et al. found chronic cholecystitis in 76% of patients undergoing elective cholecystectomy. The persistent inflammation observed in these cases likely reflects long-standing gallstone irritation and repeated subclinical infections.

Cholesterolosis, another benign but histologically distinct finding, was identified in 9.1% of cases in our study. This is consistent with the 10% rate reported by Yaylak et al., who emphasized the clinical relevance of its association with cholesterol gallstones. These findings underscore the importance of identifying cholesterolosis histologically, as it may represent a precursor stage in cholesterol-mediated gallbladder pathology.

Age-Related Histological Patterns

Stratification by age revealed that chronic cholecystitis was most common in the 25–40 years group (45.8%), followed by those aged 41–60 years (41.7%). The predominance of inflammatory lesions in younger individuals is comparable to findings by Kumari et al., who also reported peak incidence in patients below 50 years. In contrast, premalignant and malignant changes were exclusive to the older age groups in our study, suggesting a possible age-linked transformation in mucosal pathology.

Malignant and Premalignant Lesions

Adenocarcinoma of the gallbladder was detected in 3.0% of specimens. This rate is comparable to the 2.7–4.5% incidence reported in large histopathological reviews from South Asia . Notably, both adenocarcinoma cases in our study occurred in patients aged above 40 years and were not clinically suspected preoperatively. This supports findings by Baseer et al., who emphasized the frequency of incidental gallbladder carcinoma discovered only after histopathological review. Similarly, Masood et al. emphasized the silent and occult nature of gallbladder carcinoma, often detected too late for curative resection.

One case each of dysplasia and intestinal metaplasia was observed, both in the 41–60 age group. While numerically few, these changes are clinically important due to their known association with the metaplasia–dysplasia–carcinoma sequence, as described in previous studies by Chen et al. and Devi et al.

Gallstone Association

Gallstones were present in 75.8% of cases, with a higher frequency among patients with chronic cholecystitis (83.3%) and cholesterolosis (83.3%). This strong correlation aligns with the findings of Mondal et al., who established gallstone irritation as a major etiologic factor in gallbladder inflammation and even neoplasia. Interestingly, only 50.0% of adenocarcinoma cases and none of the dysplasia/metaplasia cases had associated stones, suggesting that while stones are important contributors to inflammation, their absence does not rule out malignant transformation.

Implications for Surgical Practice

The predominance of incidental findings, including dysplasia and carcinoma, among asymptomatic or non-suspect cases supports the stance taken by Deng et al. and others advocating for routine histopathological examination of all cholecystectomy specimens. Despite increasing pressure for selective submission, particularly in resource-limited settings, these results reinforce that early-stage malignancy or premalignant lesions can be easily missed intraoperatively.

This was a single-centre study with a relatively small sample size, limiting generalizability to larger populations. Additionally, follow-up data were not available to assess clinical outcomes in patients with premalignant or malignant lesions. No advanced immunohistochemical or molecular studies were performed, which could have further characterized atypical or neoplastic changes.

Chronic cholecystitis remains the most prevalent histopathological finding in cholecystectomy specimens, followed by acute inflammation and cholesterolosis. A noteworthy proportion of specimens also revealed premalignant and malignant changes, often without clinical suspicion. The presence of gallstones showed strong correlation with inflammatory lesions but was inconsistently associated with neoplastic changes. These findings reaffirm the importance of routine histopathological examination of all gallbladder specimens, irrespective of gross appearance or clinical indication, particularly in regions with high biliary pathology burden.

1. Behari, A., & Kapoor, V. K. (2010). Does gallbladder divide India? Indian Journal of Gastroenterology, 29(1), 3–7.
2. Deng, Y. L., Xiong, X. Z., Zhou, Y., Shrestha, A., Li, F. Y., & Cheng, N. S. (2015). Selective histology of cholecystectomy specimens—is it justified? Journal of Surgical Research, 193(1), 196–201.
3. Gupta, K., Faiz, A., Thakral, R. K., Mohan, A., & Sharma, V. K. (2019). The spectrum of histopathological lesions in gallbladder in cholecystectomy specimens. International Journal of Clinical Diagnostic Pathology, 2(2), 146–151.
4. Singh, A., Singh, G., Kaur, K., Goyal, G., Saini, G., & Sharma, D. (2019). Histopathological changes in gallbladder mucosa associated with cholelithiasis: A prospective study. Nigerian Journal of Surgery, 25(1), 21–25.
5. Gupta, O. P., & Khan, S. (2019). Incidents and complications in laparoscopic cholecystectomy: A retrospective analysis of 336 cases. International Journal of Contemporary Medical Surgery and Radiology, 4(1), 1–5.
6. Thukral, S., Roychoudhury, A. K., Bansal, N., & Rani, E. (2018). Histopathological spectrum of gall bladder lesions in a tertiary care hospital in the Malwa belt: A hospital-based study. Annals of Pathology and Laboratory Medicine, 5(9), 878–881.
7. Mondal, B., Maulik, D., Biswas, B., Sarkar, G., & Ghosh, D. (2016). Histopathological spectrum of gallstone disease from cholecystectomy specimens in rural areas of West Bengal, India: An approach of association between gallstone disease and gallbladder carcinoma. International Journal of Community Medicine and Public Health, 3(11), 3229–3235.
8. Baseer, M., Ali, R., Ayub, M., Rashid, H., Mahmood, A., & Ahmed, S. (2019). The frequency of incidental gall bladder carcinoma after laparoscopic cholecystectomy for chronic cholecystitis with gall stones. Annals of Punjab Medical College, 13(3), 130–132.
9. Masood, I., Rasheed, H., & Raheem, A. (2016). Cohort study: Occurrence rate of occult gallbladder carcinoma and its curative strategies. Journal of Surgery, 32(4), 245–249.
10. Chen, C., Geng, Z., Shen, H., et al. (2016). Long-term outcomes and prognostic factors in advanced gallbladder cancer: Focus on the advanced T stage. PLoS ONE, 11(10), e0164457.
11. Kafle, S. U., Sinha, A. K., & Pandey, S. R. (2013). Histomorphology spectrum of gall bladder pathology in cholecystectomy specimens with clinical diagnosis of chronic cholecystitis. Journal of Nepal Medical Association, 52(192), 600–607.
12. Yaylak, F., Deger, A., Ucar, B. I., Sonmez, Y., Bayhan, Z., & Yetisir, F. (2014). Cholesterolosis in routine histopathological examination after cholecystectomy: What should a surgeon behold in the reports? International Journal of Surgery, 12(11), 1187–1191.
13. Memon, W., Khanzada, T. W., Samad, A., & Kumar, B. (2011). Histopathological spectrum of gall bladder specimens after cholecystectomy. Pakistan Journal of Medical Sciences, 27(3), 553–556.
14. Anushree, C. N., et al. (2018). Histopathological spectrum of cholecystectomy specimens in a tertiary care hospital in Bangalore. Indian Journal of Pathology and Oncology, 5(1), 145–149.
15. Kumari, M., Srivastava, D., Singh, A., et al. (2021). Spectrum of histopathological lesions of gallbladder. International Journal of Contemporary Medical Research, 8(6), 6–9.
16. Devi, B., et al. (2017). Histopathological spectrum of diseases in gall bladder. National Journal of Laboratory Medicine, 6(4), P006–P009.
17. Mondal, B., Maulik, D., et al. (2016). Histopathological spectrum of gallstone disease from cholecystectomy specimens in rural areas of West Bengal, India—An approach of association between gallstones disease and gallbladder carcinoma. International Journal of Community Medicine and Public Health, 3(11), 3229–3235.