B64 inflammation and tumors of the biliary tract and gallbladder

Question 1

Classifications of cholecystitis and their causes

Answer 1

Acute calculous cholecystitis - most common in healthy patients

• gall stone obstruction

Acute non-calculous - typically occurs in seriously ill patients, post-operatively, with severe trauma or severe burns.

• infections,
• autoimmune vasculitis
• trauma

Chronic

• Is associated with gall stones co-occurence, but is not caused by gallstones or obstruction.
• Supersaturation of bile directly produces cholecystitis as well as pigment stones.

Question 2

What is cholangitis and what causes it?

Answer 2

Inflammation of the wall of the bile ducts

Almost always caused by bacterial infection of the duct

Usually results from bile duct obstructions (extrahepatic obv), especially by stones, this is specifically called choledocholelithiasis. During stasis bacteria enters and infects through the duodenum, pancreatic duct.

Question 3

How does calculous cholelithiasis cause acute cholecystitis?

Answer 3

It is not usually from bacterial infection.

Rather, the obstruction causes the accumulation of phospholipases derived from the mucosa.

These phospholipases hydrolyze bile to a toxic lysolecithin which damages the mucosa and disrupts the mucous layer, then bile salts cause mucosal damage directly.

Subsequent swelling and distention then compromises blood flow. Only after all of this does secondary bacterial infection occur, but this is not common.

Question 4

What are the main symptoms and potential consequences of acute calculous cholecystitis?

Answer 4

Symptoms:

Acute onset of pain, fever, nausea, leukocytosis, and Conjugated hyperbilirubinemia. Serousa around the gall bladder will often have a fibrinous exudate.

Consequences:

It is a medical emergency and requires cholecystectomy, but this surgery resolves the issue completely.

If not fixed, it is possible that it will self resolve, or it may become infected, ruptured, bleeding, peritonitis

Question 5

Chronic cholecystitis, causes, symptoms, consequences

Answer 5

Causes:

• Chronic supersaturation of bile, most often.
• Repeated acute cholecystitis, less

Symptoms:

• minor, often asymptomatic
• minor colicky pain in the region

Consequences:

• secondary infection, sepsis
• abscesses
  
  • rupture and peritonitis,
  • bile-enteric fistula formation

Question 6

Causes, symptoms, and consequences of Cholangitis

Answer 6

Caused by:

• any lesion obstructing bile flow, and
• subsequent bacterial infection.

Symptoms:

• fever, chills,
• regional pain,
• jaundice

Consequences:

• Ascending infection,
• suppurative cholangitis with pus formation,
• bile duct distention,
• abcess formation and potential rupture.

Question 7

Gall bladder tumors

Answer 7

Three types, all are malignant, and all are uncommon but very aggressive, and have almost always invaded the liver or portal/hepatic lymph nodes by the time of diagnosis.

Two types arise from the gall bladder epithelium:

• Adenocarcinoma is by far the most common. 95%. They can be papillary with dysplastic epithelial cells, or poorly differentiated.
  
  • These are strongly associated with gallstones, although gall stones do not strongly indicate adenocarcinoma will develop.
• Squamous cell carcinoma is rare.

Cholangiocarcinoma

• Arises from the cholangiocytes that line the intrahepatic and extrahepatic bile ducts.
• 2/3rds are extrahepatic and occur commonly at the hilum.
  
  • Extrahepatic ones are favorable because they cause obstruction sooner and present sooner.
  • Intrahepatic ones are very advanced by the time they are seen.
• Forms an adenocarcinoma with well formed tubular glands and also desmoplasia causing abundant fibrosis and eventual oclusion/obstruction of the duct.
• Transplantation is not curative, and mean survival is 6 to 18 months regardless of surgical resection.
• risk factors:
  
  • Primary sclerosing cholangitis
  • Certain liver flukes
  • Fibropolycystic disease of the biliary tree.