Ch. 18 7-9 (Dobson) Flashcards
This is the standard therapy for many liver diseases. It is indicated for severe acute or chronic liver disease where the limits of medical therapy have been reached. If successful, it results in prolonged survival and improves quality of life of recipients.
Liver transplantation
39,718 transplants were performed in 2019, a new record high for the seventh consecutive year. Each day, about ______ people receive organs.
80
Rejection is a process in which ________ and _______ produced against graft antigens react against and destroy tissue grafts, and the major antigenic differences between a donor and recipient that result in rejection of transplants are differences in ______ alleles.
T lymphocytes
Antibodies
HLA
Following transplantation, the recipient’s T cells recognize donor HLA antigen from the graft (allogeneic antigens) by two pathways. These are…
1) Graft antigens are presented directly to recipient T cells by graft APCs
OR
2) Graft antigens are picked up by host APCs, processed (like any other foreign antigen), and presented to host T cells
The frequency of T cells that can recognize the foreign antigens in a graft is much higher than the frequency of T cells specific for any microbe. For this reason, immune responses to allografts are stronger than responses to pathogens. These strong reactions can destroy grafts rapidly, so their control requires powerful…
Immunosuppressive agents
After liver transplant, recipient T cells are activated directly (acute rejection) or indirectly (chronic rejection), and proliferation of T cells and activation of effector cells by ________ occur.
CD4+ T cells
_________ and effector cells infiltrate and injure the graft developing rejection signs. Depending on the cytokine environment, activated CD4+ T cells can transform into graft-destructive or graft-tolerance phenotypes which balance the immune response.
CD8+ T cells
CD4+ T cells can also activate B cells, which can develop a further Ab-mediated response against antigens in the graft and generate _______.
AMR (Ab-mediated rejection)
Liver damage is predominantly a ________ reaction after bone marrow transplantation, but a ________ in liver transplantation.
GVH (Graft-versus-Host)
HVG (Host-versus-Graft)
(ACUTE/CHRONIC) rejection is mediated by T cells and Abs that are activated by alloantigens in the graft. It occurs within days or weeks after transplantation and is the principal cause of early graft failure. It may also appear suddenly much later after transplantation if immunosuppression is tapered or terminated.
Acute
In acute cellular rejection, ________ may directly destroy graft cells, or ________ secrete cytokines and induce inflammation, which damages the graft. They may also act against graft vessels, leading to vascular damage.
CD8+ CTLs
CD4+ T cells
In acute AMR (Ab-mediated rejection), Abs bind to vascular endothelium and activate complement via the classical pathway. The resultant inflammation and endothelial damage leads to ischemic changes in the liver parenchyma. This includes destruction of bile ducts resulting in the…
Vanishing bile duct syndrome
Chronic rejection is an indolent form of graft damage that occurs over months or years, leading to progressive loss of graft function. Chronic rejection manifests as interstitial _______ and gradual narrowing of graft blood vessels (graft arteriosclerosis).
Fibrosis
In chronic rejection, the culprits are believed to be T cells that react against graft alloantigens and secrete cytokines, which stimulate the proliferation and activities of ________ and _______ _______ _______ cells in the graft.
Fibroblasts
Vascular smooth muscle
Chronic rejection has resultant inflammation and endothelial damage that leads to ischemic changes in the liver parenchyma. This includes destruction of bile ducts resulting in the…
Vanishing bile duct syndrome
***Also occurs in acute rejection!
The _______ is a common site of complication stemming from transplantation for bone marrow, kidney, and other solid organs. Common themes are toxic or immunologically mediated _______ damage, opportunistic infections related to immune suppression, post transplant lymphoproliferative processes, or recurrent primary disease.
Liver
Liver
Some forms of hepatic disease may be exacerbated by…
Pregnancy
This is the most common cause of jaundice in pregnancy.
Viral hepatitis
While these women require careful clinical management, pregnancy does not specifically alter the course of viral hepatitis, with the exception of _______ infection. For unknown reasons, this runs a more severe course and has a fatality rate approaching 20% in pregnant patients.
HEV
The liver may also be secondarily involved by other infections during pregnancy. These include hepatitis caused by ______, a rare cause of ALF in pregnancy, and liver abscess caused by ________ ________, an organism that thrives in placental tissue, from where it may seed the liver.
HSV
Listeria monocytogenes
In a very small subgroup of pregnant women (0.1%), more serious hepatic complications develop. These disorders include…
- Preeclampsia and Eclampsia
- Acute Fatty Liver of pregnancy
- Intrahepatic Cholestasis of pregnancy
***In extreme cases, eclampsia and acute fatty liver of pregnancy may be fatal!
This occurs in 10% of pregnancies and is characterized by maternal HTN, proteinuria, peripheral edema, and coagulation abnormalities.
Preeclampsia and eclampsia
Subclinical hepatic disease may be the primary manifestation of preeclampsia, as part of a syndrome called the HELLP syndrome. What does this stand for?
H = Hemolysis E = Elevated; L = Liver enzymes L = Low; P = Platelets
In addition to the HELLP syndrome of preeclampsia, when ________ and ________ occur, the condition is called eclampsia and may be life-threatening.
Hyperreflexia
Convulsions
Hepatic involvement in preeclampsia may show modest to severe elevation of serum aminotransferases and mild elevation of serum bilirubin. Hepatic dysfunction sufficient to cause a _________ signifies advanced and potentially lethal disease. This is why the liver can appear with a black pigment, and it is important to obtain a thorough history to not misdiagnose with ________ ________.
Coagulopathy
Dubin-Johnson Syndrome
While this condition most commonly runs a mild course, women with _______ _______ _______ of pregnancy can progress within days to hepatic failure and death.
Acute Fatty Liver
Women with Acute Fatty Liver of pregnancy will present in the latter half of pregnancy, usually the 3rd trimester. Symptoms are directly attributable to incipient hepatic failure, including…
- Bleeding
- N/V
- Jaundice
- Coma
20-40% of pregnant women with Acute Fatty Liver have presenting symptoms that are coexistent with…
Preeclampsia
What is the primary treatment for acute fatty liver of pregnancy?
Termination of pregnancy (meaning give birth)
This disorder is the onset of pruritus in the second or third trimester, followed in some cases (10-25%) by darkening of the urine, and occasionally light stools and jaundice. Resolves within 2-3 weeks of delivery.
Intrahepatic Cholestasis of Pregnancy
With intrahepatic cholestasis of pregancy, total bilirubin is usually ________ and ALP can be positive or negative. Biopsy will also show canalicular cholestasis. Modest risk of fetal loss.
<5 mg/dL
T/F. Intrahepatic Cholestasis of pregnancy can recur in subsequent pregnancies.
True
(Pearl #1) Liver infarcts are rare due to the dual blood supply of 1/3 Hepatic A. and 2/3 Portal V. The only exception to this is what?
Hepatic A. thrombosis in liver transplant as major bile ducts have only arterial supply.
(Pearl #2) Portal V. occlusion can lead to…
Esophageal varices
(Pearl #3) What is the most common cause of intrahepatic blood flow obstruction?
Cirrhosis
(Pearl #4) What is the most common cause of small portal vein branch obstruction?
Schistosomiasis
(Pearl #5) This is a hepatic disorder often seen in HIV patients.
Obliterative portal venopathy
(Pearl #6) This disorder is caused by sinusoidal dilation and forms “blood lakes” in the liver.
Peliosis hepatis
(Pearl #7) This disorder is caused by Hepatic V. obstruction/thrombosis.
Budd-Chiari Syndrome
(Pearl #8) This disease is caused by Jamaican bush tea, and can occur 3 weeks after stem cell transplant. Also can cause cancer.
Veno-Occlusive disease
(Pearl #9) This can occur due to right-sided heart failure or a terminal event.
Passive congestion
(Pearl #10) For this type of rejection disease, acute can occur in 10-50 days while chronic types are 100+ days.
GVHD
(Pearl #11) For transplant rejection, it can either be acute which is _______, or chronic which is _______.
Cellular
Vascular
(Pearl #12) This is the end-point of passive hepatic congestion due to chronic congestive heart failure.
Cardiac Sclerosis (or cardiac cirrhosis)
(Pearl #13) This is what the liver can appear like due to hypoperfusion and retrograde congestion.
Nutmeg liver
What are the benign hepatic neoplasms discussed?
- Nodular hyperplasias (2)
- Hemangiomas
- Adenomas (3)
What are the malignant hepatic neoplasms discussed?
- Hepatoblastoma
- Hepatocellular carcinoma
- Cholangiocarcinoma
- Angiosarcoma
- Lymphoma
- Metastatic
What are the 2 types of nodular hyperplasias?
Focal Nodular Hyperplasia (FNH)
Nodular Regenerative Hyperplasia (NRH)
This type of benign hyperplasia is an incidental finding in an otherwise normal liver in young to middle age adults. It usually has a single well-demarcated lesion with a central scar, this is highly characteristic. “Map-like pattern”.
Focal Nodular Hyperplasia (FNH)
This type of benign hyperplasia consists of multiple nodules that looks like cirrhosis, but has no fibrous septa.
Nodular Regenerative Hyperplasia (NRH)
Nodular Regenerative Hyperplasia can develop _______ _______, and has associations with HIV and rheumatologic disease.
Portal HTN
This is the most common benign neoplasm of the liver (20%) and occurs more in females than males.
Cavernous hemangioma of liver
This is usually asymptomatic and an incidental discovery, but can present as life threatening intraabdominal emergency from hemorrhage due to subcapsular location. Often mistaken for malignancy.
Cavernous hemangioma of liver
This is a benign neoplasm that typically occurs in young women and is strongly associated with use of oral contraceptives and anabolic steroids.
Hepatocellular Adenoma
Hepatocellular Adenomas have three molecular subtypes that have are each associated with distinct clinicopathologic features and varying risk of transformation into HCC. What are the subtypes?
1) HNF1-a inactivated adenomas
2) Inflammatory adenomas
3) B-Catenin activated adenomas
This type of hepatocellular adenoma accounts for 40-50% of cases, has a strong female predilection, and is associated with minimal risk of transformation to HCC. It is fatty with no atypia.
HNF1-a inactivated adenomas
This type of hepatocellular adenoma accounts for 40-50% of cases, is more common in women, and is associated with obesity and metabolic syndrome. It mimics FNH, overexpress CRP and amyloid A.
Inflammatory adenomas
________-activating mutations are also present in 10% of Inflammatory Hepatocellular Adenomas, and these tumors have a higher risk of malignant tranformation.
B-catenin
This type of hepatocellular adenoma contains tumors at high risk of malignant transformation to HCC and are associated with oral contraceptive and anabolic steroid use. Nearly 40% occur in men.
B-Catenin activated adenomas
Malignant tumors in the liver can be primary or metastatic. Among primary epithelial tumors, the most common are…
HCC
Intrahepatic Cholangiocarcinoma
This is the most common liver tumor of early childhood. It rarely occurs over the age of 3 years, and its incidence is increasing.
Hepatoblastoma
Primary hepatic lymphoma is a rare type of liver malignancy. The most common subtype is _______ _______ _______ _______, a form of non-Hodgkin lymphoma that frequently occurs at extranodal sites.
Diffuse large B-cell lymphoma
Another rare subtype of primary hepatic lymphoma is ________ _______ ________, most common in young adult males, which has a predilection for growth within the sinusoids of the liver, spleen, and bone marrow.
Hepatosplenic T-cell lymphoma
What are the other disease associations with Hepatoblastoma?
- Familial Adenomatous Polyposis (FAP)
- - Beckwith-Wiedemann Syndrome
The ________ type of Hepatoblastoma is composed of small polygonal fetal cells or smaller embryonal cells forming acini, tubules, or papillary structures vaguely recapitulating liver development.
Epithelial
This type of Hepatoblastoma contains foci of mesenchymal differentiation that may consist of primitive mesenchyme, osteoid, cartilage, or striated muscle.
Mixed epithelial and mesenchymal
Hepatoblastoma usually comes to clinical attention due to abdominal swelling in an asymptomatic infant or child. About 20% of tumors will have metastasized to the _______ by the time of diagnosis. Untreated, the tumor is usually fatal within a few years, but therapy has raised the 5-year survival to 80%.
Lungs
This is the most common primary malignancy of hepatocytes and accounts for approximately 5.4% of all cancers worldwide.
HCC
More than 85% of HCC cases occur in countries in Asia (southeast China, Korea, Taiwan) and sub-Saharan Africa, where chronic _______ infection is common. The peak incidence is between 20-40 yo, and males are more likely than females (8:1).
HBV
The incidence of HCC in western countries is rising due to _______ and ______ ______.
HCV
Metabolic syndrome
What is the next leading cause of HCC after HBV and HCV?
Alcohol use – because they develop cirrhosis, and this greatly increases risk of HCC
These are a family of toxins produced by certain fungi that are found on agricultural crops such as maize, peanuts, cottonseed, and tree nuts. They increase the risk of HCC.
Aflatoxins
The main fungi that produce aflatoxins are _______ _______ and _______ _______, which are abundant in warm and humid regions of the world.
Aspergillus flavus
Aspergillus parasiticus
Most HCCs occur in the setting of chronic liver disease with ________, while 15-20% arise in ________ livers (ie, adenomas, aflatoxin).
Cirrhosis
Noncirrhotic
This is a distinctive variant of HCC that constitutes less than 5% of all types of HCC. 85% of this variant occurs under the age of 35 years and without gender predilection or identifiable pre-disposing conditions. It usually presents as a single large, hard “scirrhous” tumor with fibrous bands coursing through it.
Fibrolamellar Carcinoma
Microscopically, Fibrolamellar Carcinoma is composed of large polygonal cells with granular cytoplasm due to abundant ________. There is vesicular nuclei with a prominent nucleolus and a parallel lamellae of dense collagen bundles.
Mitochondria
What is the treatment of choice for HCC?
Noncirrhotic livers and cirrhotic livers with adequate function = Surgical resection
Advanced cirrhosis = Liver transplantation
Image-guided tumor ________ with alcohol or radiofrequency waves can be done for unresectable tumors or those that do not meet criteria for transplantation.
Ablation
For HCC, hematogenous metastases, especially to the _______, tend to occur late in the disease. _______ ______ metastases occur in <5% of cases (worsen prognosis).
Lung
Lymph node
Overall outcomes in HCC are poor due to underlying liver disease and the intrinsic resistance of HCC to conventional chemotherapy. The overall 5-year survival rate is ______ for tumor confined to the liver and only ______ for cases with extrahepatic spread. Outcomes are better for the unusual fibrolamellar variant, with up to 40% of patients surviving 10 years or longer.
30%
5-10%
Adenocarcinomas arising from the intrahepatic biliary tree are referred to as _________ _________, while similar tumor arising from the extrahepatic bile ducts are referred to as _______ _______.
Intrahepatic Cholangiocarcinoma
Biliary Adenocarcinoma
This is the most common primary malignant tumor of the liver after HCC. Its incidence is rising in the US, and accounts for 7.6% of cancer deaths worldwide and 3% of cancer deaths in the US.
Intrahepatic Cholangiocarcinoma
Intrahepatic Cholangiocarcinoma is very common in Southeast Asian countries such as Thailand, Laos, and Cambodia, where ______ ______ infestation is endemic.
Liver fluke
***Particularly Opisthorchis and Clonorchis species
60-70% of Cholangiocarcinoma are located at the _________ of the biliary system, called _______ tumors.
Bifurcation
Klatskin
What are risk factors for developing Cholangiocarcinoma?
- Fibropolycystic liver disease
- PSC
- Liver flukes
- Hepatolithiasis
Chronic liver disease that predispose to HCC, such as _______, _______, and ________, also increase the risk for intrahepatic cholangiocarcinoma.
HBV
HCV
NAFLD
Microscopically, both intrahepatic and extrahepatic tumors show features of adenocarcinomas. Most are well to moderately differentiated and are arranged in clearly defined glandular/tubular structures lined by malignant epithelial cells embedded in an abundant fibrous stroma. ________ and ________ invasion are common.
Lymphovascular
Perineural
Intrahepatic Cholangiosarcoma may be detected incidentally on imaging or may present with a cholestatic picture or symptomatic liver mass, whereas extrahepatic adenocarcinoma typically presents with symptoms related to…
Biliary obstruction
***Overall prognosis is poor due to common recurrences.
This malignant tumor of the liver is historically associated with vinyl chloride, arsenic, or Thorotrast although with reduced exposures to these compounds in recent decades, this malignancy is becoming very rare.
Angiosarcoma
Hepatic _________ are primarily diseases of middle-aged men and are seen, albeit rarely, in association with HBV, HCV, HIV, and PBC.
Lymphomas
Most hepatic lymphomas are what types?
Diffuse Large B-cell Lymphomas
followed by
MALT Lymphomas
Involvement of the liver by _________ malignancy is far more common than primary hepatic neoplasia. Although the most common primary sources are the colon, breast, lung, and pancreas, any cancer in any site of the body may spread to the liver.
Metastatic
What are common symptoms of liver metastatic malignancy?
- Anorexia
- Fevers
- Jaundice
- Nausea
- RUQ pain
- Sweats
- Weight loss
The gallbladder and biliary system develop from the foregut. By the end of the 4th week of embryogenesis, a structure called the _______ _______ appears. This goes on to become the liver, extrahepatic biliary system, and portion of the pancreas. The superior bud of it develops into the gallbladder.
Hepatic diverticulum
As much as ______ of bile is secreted by the liver per day. Between meals, bile is stored in the gallbladder, where it is concentrated. The adult gallbladder has a capacity of about _______.
1 L
50 mL
The function of the gallbladder is to store and concentrate bile, which is released into the ________ during digestion.
Duodenum
Following a meal rich in fats, a peptide hormone called _______ is released by cells in the duodenum.
CCK (cholecystokinin)
What are the 2 main functions of CCK pertaining to the gallbladder?
1) Stimulate smooth muscle of gallbladder to contract and release bile into biliary tree.
2) Signal muscular sphincter of Oddi to relax.
The gallbladder may be congenitally absent, or there may be gallbladder duplication with conjoined or independent ______ ______.
Cystic ducts
A longitudinal or transverse septum may create a bilobed gallbladder, called…
Vesical fellea divisum
Aberrant locations of the gallbladder occur 5-10% of the population, most commonly partial or complete embedding in the _______ substance.
Liver
________ of all or any portion of the hepatic or common bile ducts and hypoplastic narrowing of biliary channels (true “_______ _______”) may also occur.
Agenesis
Biliary atresia
________ ________ may be isolated findings in the gallbladder or associated with other cysts in the extrahepatic biliary tree or with fibropolycystic disease.
Choledochal Cysts
This is the most common congenital anomaly of the gallbladder, and consists of a folded fundus.
Phrygian cap
More than 95% of biliary tract disease is attributable to…
Cholelithiasis
***10-20% of adult population is afflicted!
Gallstones affect 20 million people in the US, and more than 700,000 cholecystectomies are performed annually at a cost of approximately ________.
$6 billion
What are the major risk factors associated with the development of gallstones?
- Age and sex
- Environmental factors
- Acquired disorders
- Hereditary factors
What are the 2 general classes of gallstones?
Cholesterol stones
Pigment stones
This type of gallstone are more prevalent in the US and Western Europe (90%) and uncommon in low income countries. The prevalence rates approach 75% in Native Americans of the Pima, Hopi, and Navajo groups.
Cholesterol gallstones
This is the predominant type of gallstone in non-Western populations, and arise primarily in the setting of bacterial infections or parasitic infections of the biliary tree, and as well as in individuals with diseases that lead to chronic red cell hemolysis.
Pigment gallstones
Cholesterol stones arise exclusively in the gallbladder and range from 100% pure (which is rare) down to around 50% cholesterol. With increasing proportions of calcium carbonate, phosphates, and bilirubin, the stones take on a gray-white to black color and may be lamellated. Stones composed largely of cholesterol are __________. Sufficient calcium carbonate is found in 10-20% of cholesterol stones to render them _________.
Radiolucent
Radiopaque
In general, (BROWN/BLACK) pigment stones are found in sterile gallbladder bile, and (BROWN/BLACK) stones are found in infected large bile ducts.
Black
Brown
_______ stones contain oxidized polymers of calcium salts of unconjugated bilirubin, small amounts of calcium carbonate, calcium phosphate, mucin glycoprotein, and some cholesterol monohydrate crystals.
Black
________ stones contain similar compounds along with some cholesterol and calcium salts of palmitate and stearate.
Brown
Approximately 50-75% of (BROWN/BLACK) stones are radiopaque due to calcium salts, while (BROWN/BLACK) stones, which contain calcium soaps, are radiolucent.
Black
Brown
What are the 6 F’s for Cholelithiasis (cholesterol stones)?
- Family hx
- Female
- Fair
- Fat
- Forty
- Fertile
What are the usual culprits of biliary infection leading to pigment stones?
- Clinorchis sinensis
- Ascaris lumbricoides
- E. coli
For Cholelithiasis, 70-80% of patients remain asymptomatic throughout their lives, but convert to being symptomatic at an average rate of up to 4% per year, although the risk diminishes with time. Pain is the major symptom, and is often initiated by a…
Fatty meal
Pain with cholelithiasis is localized to RUQ or epigastrium and may radiate to the ______ ______ or ______. Inflammation of the gallbladder (cholecystitis) in association with stones also generates pain.
Right scapula
Back
More severe complications of Cholelithiasis include empyema, perforation, fistula, inflammation of the biliary tree (cholangitis), obstructive cholestasis, and pancreatitis. The larger the stone, the less likely they are to enter the cystic or common ducts to produce obstruction. It is the very small stones, or “_______”, that are most dangerous.
Gravel
Occasionally a large stone may erode directly into an adjacent loop of small bowel, generating intestinal obstruction. This is called…
Gallstone ileus or Bouveret Syndrome
Gallstones are also associated with an increased risk of what cancer?
Gallbladder Carcinoma
Inflammation of the gallbladder can be what forms?
- Acute
- Chronic
- Acute superimposed on chronic
This type of cholecystitis is precipitated in 90% of cases by obstruction of the neck of the gallbladder or the cystic duct by a stone. There can be a +/- history of prior attacks.
Acute Cholecystitis
Acute Cholecystitis consists of RUQ or epigastric pain for 6 hours that is progressive. Frequently associated with mild fever, anorexia, tachycardia, sweating, N/V. Most patients are free of ________, because the presence of hyperbilirubinemia suggests the obstruction of the common bile duct.
Jaundice
Acute Cholecystitis has mild to moderate _________ which may be accompanied by mild elevations in serum ________ values.
Leukocytosis
ALP
Acute calculous cholecystitis may appear with remarkable suddenness and constitute an acute _______ _______ or may present with mild symptoms that resolve without medical intervention.
Surgical emergency
Clinical symptoms of acute ________ cholecystitis tend to be more insidious, since they are obscured by the underlying conditions precipitating the attack. A higher proportion of patients have no symptoms referable to the gallbladder, so diagnosis therefore rests on a high index of suspicion.
Acalculous
With Acute Acalculous Cholecystitis, early recognition is crucial for a severely ill patient. Failure to do so almost ensures a _______ outcome. As result in either delay in diagnosis or the disease itself, the incidence of ________ and ________ is much higher in acalculous cholecystitis than in calculous cholecystitis.
Fatal
Gangrene
Perforation
In rare instances, primary bacterial infection by agents such as ________ and _______ can give rise to acute acalculous cholecystitis.
Salmonella typhi
Staphylococci
A more indolent form of acute acalculous cholecystitis may occur in the setting of….
- Systemic vasculitis
- Severe atherosclerotic ischemic disease in elderly
- AIDS (usually related to Cryptosporidium infection)
- Ascending biliary tract infection
________ Cholecystitis may be a sequel to repeated bouts of mild to severe Acute Cholecystitis, but in many instances it develops in the apparent absence of antecedent attacks.
Chronic
Chronic Cholecystitis can lead to this, which consists of a calcified gallbladder.
Porcelain Gallbladder
Chronic Cholecystitis can lead to this, which is an overdistended gallbladder filled with mucoid or clear and watery content.
Hydropic (Mucocele) Gallbladder
Diagnosis of both acute and chronic cholecystitis is important because of what possible complications?
– Bacterial superinfection with cholangitis or sepsis.
– Gallbladder perforation and local abscess formation.
– Gallbladder rupture with diffuse peritonitis.
– Biliary enteric (cholecystenteric) fistula (could cause ileus)
– Aggravation of preexisting medical illness
This complication of cholecystitis can cause drainage of bile into adjacent organs, entry of air and bacteria into the biliary tree, and potentially, gallstone-induced intestinal obstruction (ileus).
Biliary enteric (cholecystenteric) fistula
This is the most common malignancy of the extrahepatic biliary tract. Approximately 6,000 new cases are diagnosed each year in the US. Twice as common in women than men.
Gallbladder Carcinoma
The most important risk factor gallbladder cancer (besides gender and ethnicity) is ________, which are present in 95% of cases. However, it should be noted that only 1-2% of patients with these actually develop gallbladder cancer.
Gallstones
In Asia, what have been implicated as risk factors for gallbladder cancer?
Chronic bacterial or parasitic infections
Most carcinomas of the gallbladder are __________, and are most often detected in the ________. By the time these neoplasms are discovered, most have invaded the liver centrifugally, and many have extended to the cystic duct and adjacent bile ducts and portal-hepatic lymph nodes. The peritoneum, GI tract, and lungs are common sites of seeding. Prognosis is poor.
Adenocarcinomas
Fundus
