Block 7 (GI) - Gallbladder Module

Question 1

What is inflammation of the gallbladder (acute or chronic)?

Answer 1

Cholecystitis

Question 2

What is presence of stones within the biliary tree?

Answer 2

Choledocholithiasis

Question 3

What is the presence of gallstones in the gallbladder lumen?

Answer 3

Cholelithiasis

Question 4

What is acute inflammation of the wall of bile ducts?

Answer 4

Cholangitis

Question 5

What are the 2 types of gallstones?

Answer 5

1. Cholesterol stones

2. Pigmented bilirubin stones

Question 6

Compare the color of cholesterol and pigmented stones.

Answer 6

Cholesterol: yellow to tan
Pigmented: black or brown

Question 7

What are the components of cholesterol stones?

Answer 7

Mostly cholesterol + some calcium salts and mucin

Question 8

What are the components of black stones?

Answer 8

Calcium bilirubinate, phosphate, carbonate, mucin

Question 9

What are the components of brown stones?

Answer 9

Calcium bilirubinate, fatty acids, some cholesterol

Question 10

Which type of stone is most common?

Answer 10

Cholesterol (up to 80%)

Question 11

Who is at risk for cholesterol stones?

Answer 11

Female
>40 y/o
Fertile
Fat
Flatulant
History of intestinal disease or malabsorption
Familial

Question 12

Who is at risk for black stones?

Answer 12

Patients with chronic hemolytic anemias

Question 13

Who is at risk for brown stones?

Answer 13

Bacterial cholangitis

Question 14

How do cholesterol stones develop?

Answer 14

Bile formation is the only significant pathway to eliminate excess cholesterol from the body. When secreted by hepatocytes into bile, cholesterol is held in solution by bile acids and lecithin. If it contains too much cholesterol, it supersaturates and precipitates out.

Question 15

How is obesity related to development of cholesterol gallstones?

Answer 15

Obesity increases hepatic cholesterol secretion, leading to supersaturation of bile with cholesterol

Question 16

How is estrogen related to the development of cholesterol gallstones?

Answer 16

Estrogen increases hepatic cholesterol uptake and synthesis.

Question 17

How is hypomotility related to development of cholesterol gallstones?

Answer 17

A sluggish gallbladder promotes bile sludging and formation of tiny stones (nucleation) which develop into macroscopic stones.

Question 18

How do black stones develop?

Answer 18

Unconjugated bilirubin is insoluble in bile and is normally present only in trace amounts. In diseases where there is increased unconjugated bilirubin, increased unconjugated bilirubin is secreted by hepatocytes. This precipitates as calcium bilirubinate, probably around a small focus of mucinous proteins, and grows into macroscopic black pigmented stones.

Question 19

How do brown stones develop?

Answer 19

These stones form in the course of bacterial infections, causing deconjugation of bilirubin and in prolonged biliary stasis

Question 20

Most gallstones are ___.

Answer 20

Asymptomatic

Question 21

What is the most common manifestation of symptomatic gallstones?

Answer 21

Biliary colic

Question 22

What are the symptoms of biliary colic?

Answer 22

Episodic abdominal pain in the epigastrum and/or RUQ, often radiating to the right shoulder and scapula; may have associated nausea or vomiting

Pain tends to intensify over ~15 minute, then decreases over the course of hours

Question 23

Biliary colic often develops after what?

Answer 23

Large or fatty meal

Question 24

Why does biliary colic develop?

Answer 24

1. CCK released
2. Gallbladder contracts
3. Stone moves
4. Stone blocks gallbladder outlet
5. Increase in gallbladder pressure
6. Pain

Question 25

Why does biliary colic resolve?

Answer 25

1. Gallbladder relaxes 2. Stones fall back into gallbladder 3. Pressure relieved 4. Pain resolves

Question 26

What causes 90% of acute cholecystitis?

Answer 26

Unrelieved obstruction fo the gallbladder by a gallstone

Question 27

What are the symptoms of acute cholecystitis?

Answer 27

Acute onset of RUQ pain, fever, leukocytosis, pain may radiate to right shoulder, lasts over 3 hours

Question 28

What may be seen on physical exam in acute cholecystitis?

Answer 28

Murphy Sign - arrest in inspiration during direct palpation of RUQ

Question 29

How is acute cholecystitis treated?

Answer 29

Cholecystectomy

Question 30

In 90% of cases of acute cholecystitis, gallstones obstruct the ___.

Answer 30

Cystic duct

Question 31

How does the gross gallbladder appear in acute cholecystitis?

Answer 31

Thickened wall, hyperemic, edematous, some necrosis

Question 32

What are potential complications of acute cholecystitis?

Answer 32

Bacterial superinfection, sepsis, perforation, cholecystoenteric fistula, bile stone ileus (impaction of a gallstone in the intestine)

Question 33

How does chronic cholecystitis present?

Answer 33

Vague, indistinct RUQ pain 1-2 hours after meals

Question 34

What are symptoms of choledocholithiasis?

Answer 34

Obstructive jaundice, abdominal discomfort, pruritis

Question 35

What is the typical set of symptoms seen in acute cholangitis?

Answer 35

Charcot triad - fever, jaundice, RUQ

Question 36

What is the definitive treatment for acute cholangitis?

Answer 36

Establish biliary drainage (relieve obstruction) with ERCP

Question 37

How do cholesterol stones appear on X-ray?

Answer 37

Radiolucent (cannot be seen on x-ray)

Question 38

What is the diagnostic study of choice when evaluating bilairy colic or cholecystitis?

Answer 38

Ultrasound

Question 39

What causes the other 10% of acute cholecystitis cases?

Answer 39

Acalculous cholecystitis (no gallstones, results from ischemia)

Question 40

Who tends to get acalculous cholecystitis?

Answer 40

People hospitalized with serious conditions (burns, sepsis, immunosuppression, major trauma, ischemia)

Question 41

What is a porcelain gallbladder?

Answer 41

Calcified gallbladder wall caused by long-standing inflammation; prone to developing gallbladder cancer

Question 42

What are the symptoms of gallbladder cancer?

Answer 42

Non-specific, may be similar to those of gallstone disease

Question 43

How does gallbladder cancer appear on histology?

Answer 43

Malignant glands infiltrate deeply into the muscularis

Question 44

Gallbladder cancer is usually infiltrative, leading to a ___ gallbladder wall.

Answer 44

Thickened and leathery

Question 45

What is a cholangiocarcinoma?

Answer 45

Cancer of the biliary tree

Question 46

___% of cholangiocarcinoma are intrahepatic; ___% are extrahepatic.

Answer 46

10; 90

Question 47

The majority of cholangiocarcinomas are ___.

Answer 47

Adenocarcinomas

Question 48

What is the most common clinical presentation of extra-hepatic cholangiocarcinomas?

Answer 48

Jaundice caused by complete obstruction of the biliary tree

Question 49

Periampullary tumors may present with what symptoms?

Answer 49

Obstructive jaundice, acute pancreatitis

Question 50

What is one of the most common micro-organisms cultured from bile in the setting of acute cholangitis?

Answer 50

E. coli

Question 51

Gallstones may serve as a persistent nidus of infection and risk for chronic carriage of this organism.

Answer 51

S. typhi

Question 52

Risk factor for cholangiocarcinoma, particularly in Asia (Thailand)

Answer 52

Chlonorchis sinensis