Ch 14- Liver tumors, gallbladder, and more! Flashcards
This tumor arises from the submucosa of the gallbladder, and may lead to obstructive jaundice through blockage of the extrahepatic biliary tree. Fibrosis and glandular structures are associated histologic features.
Carcinoma of the gallbladder
Cholangiosarcoma: arising from the liver, what histologic features are associated:
What infection will increase its prevalence?
What complication of ulcerative colitis will increase the prevalence of cholangiosarcoma?
Substantial fibrosis, leading to its confusion with metastatic carcinoma and reactive fibrosis.
Liver fluke c sinensis, lives in biliary tree
Primary sclerosing cholangitis
Describe the histologic appearance of a hepatic adenoma
What is a risk factor for its development?
Complication?
Solitary, sharply demarcated mass -paler than surrounding liver parenchyma
Oral contraceptive use in women
Bleeding into peritoneal cavity, inducing hypovolemic shock, requiring emergency treatment.
Describe the inheritance of hereditary hemochromatosis
Name a few of the characteristic complications
Malignant complication
Histologic diagnosis?
Accumulation of iron in parenchymal cells, esp. heart, pancreas, liver.
Autosomal recessive
Bronze diabetes (increased skin pigmentation with diabetes), heart failure.
Hepatocellular carcinoma
Prussian blue stain.
Describe the pathogenesis of cholethiasis, and important risk factors
Supersaturation of the bile with high cholesterol and/or bilirubin – increased concentration results in precipitation, leading to cholesterol or bilirubin stones.
Cholesterol – most common in the west, usually radiolucent –
Risk factors: Age (older), estrogen (increased HMG COA, increased cholesterol uptake)
Clofibrate (increases hmg coa, decreases conversion of cholesterol to bile acids)
Crohn’s – terminal ileum – less bile –
Cirrhosis – decreased bile salts, lack of solubility for cholesterol
Pathophys and risk factors for bilirubin stones?
Extravascular hemolysis (high unconj bili by reticuloepithelial system (splenic macrophages – heme broken down to protoporphyrin – bili))
biliary tract infection (ecoli, Ascaris lumbricoides and clonorchis sinesis) –- increase in deconjugation of bilirubin -
Stasis – increased risk of infection – decongugate bilirubin – leads to bilirubin gallstones
Pathophys and risk factors for cholesterol stones?
Can also occur due to decreased phospholipids (lecithin) or bile acids – loss of ability to solubilize cholesterol –
Cholestyramine – bind bile acids – decrease bile acids – increase cholesterol stones
Increased hepatic production of cholesterol
Your patient presents with RUQ pain and jaundice. Describe the pathophys of this, knowing from the ultrasound that this is a gallstone.
Biliary colic – waxing and waning of RUQ pain, due to gallbladder contracting against stone lodged in cystic duct – can then block common bile duct, and cause unconjugated hyperbilirubinemia (obstructive jaundice) and cholecystitis
Extrahepatic biliary obstruction
Describe the pathophys and complications for acute cholecystitis.
What clinical presentation would you expect?
Patient presents with this presentation - what’s your concern, if it’s untreated?
Acute cholecystitis – blockage in gallbladder drainage, pressure building –
Complications: ischemic gallbladder, bacterial overgrowth and inflammation.
Clinical presentation: RUQ pain, radiating to right scapula, fever with high WBC, nausea and vomiting, increased alk phos (epithelial cells damaged contain alk phos),
risk of rupture if untreated
Pathophys of chronic cholecystitis What might you see on histology? Symptoms? X ray findings? If you find the x ray findings, what's your intervention, and the rationale?
Chronic cholecystitis – chronic inflammation of the gallbladder from chemical irritation from longstanding cholethisais –
Formation of Rokitansky aschoff sinus – outpouchings of gallbladder mucosa in the smooth muscle
Vague RUQ pain after eating – porcelain gallbladder (dystrophic calcification)
Take out a porcelain gallbladder – risk for gallbladder cancer
Pathophys of ascending cholangitis?
How will it present?
What’s an important risk factor?
Ascending choloangitis – Bacterial infection of bile ducts – usually due to ascending infection with enteric gram negative bacteria –
Presents as sepsis, jaundice, and abdominal pain – increased incidence with choledocholethiasis (free flowing bile will kill ascending bacteria normally, so an obstruction will increase likelihood of infection)
Pathophys of a gallbladder ileus?
Gallstone ileus – stone enters and obstructs small bowel – due to cholecystitis with fistula formation between gallbladder and small bowel
Gallbladder carcinoma - histology, major risk factor.
Presentation in an elderly woman, and prognosis
Gallbladder carcinoma – adenocarcinoma arising from glandular epithelium that lines the gallbladder wall - gallstones (porcelain gallbladder) major risk factor –
Cholecystitis in elderly women – poor prognosis
Dr. Sattar’s theme for this chapter seems to be looking for symptoms outside their demographic group, and using it as a clue to a malignancy. Here’s some quick associations:
Cholecystitis in an elderly woman?
Diabetes, new onset, in an elderly woman?
Cholecystitis in an elderly woman? Carcinoma of the gallbladder (cholecystitis usually in 40s and 50s)
Diabetes, new onset, in an elderly woman? Pancreatic carcinoma
Diabetes usually in 40s and 50s if type 2
Serum markers for disease process:
AFP
CEA
Alkaline phosphatase
AFP: Hepatocellular carcinoma, testicular cancer
CEA -GI cancers
Hepatobiliary disease
