Chapter 18: Gall Bladder Flashcards
What is the most common congenital anomaly of the gallbladder?
Inward folded fundus –> Phrygian cap
Why is estrogen exposure a risk factor for the development of gallstones?
Because of this who is at the most risk?
- Increases expression of: hepatic lipoprotein receptors and hepatic HMG-CoA reductase activity —> enhanced cholesterol uptake and biosynthesis
- Females taking OCs and during pregnancy
Rates of cholesteorl gallstones approach 75% in persons of which cultural group?
Native Americans of the Pima, Hopi, and Navajo groups
Which specific gene and transporter have been implicated in the development of cholesterol gallstones?
- ABCG8 gene
- ATP-binding casette (ABC) transporters
Pigment stones are more commonly seen in the setting of which 3 GI disorders?
- Ileal disease (i.e., Chron disease)
- Ileal resection or bypass
- CF w/ pancreatic insufficiency
Which 4 conditions contribute to the formation of cholesterol gallstones?
1) Supersaturation of bile w/ cholesterol
2) Hypomobility of gallbladder
3) Accelerated cholesterol crystal nucleation
4) Hypersecretion of mucus in the GB –> traps nucleated crystals –> addition of more cholesterol –> stones
The development of pigment stones is associated with disorders that cause an increase in what?
List some of these disorders
- Unconjugated bilirubin
- Chronic hemolytic anemias
- Severe ileal dysfunction or bypass
- Bacterial contamination of the biliary tree
Infection of the biliary tree leads to the release of which enzyme that hydrolyzes bilirubin glucuronides?
microbial β-glucuronidases
Infection of the biliary tree by which 3 organisms increase the risk of developing pigment stones?
- E. coli
- Ascaris lumbricides = roundworm (intestinal nematode)
- Liver fluke -> C. sinensis
In general, where are black pigmented stones vs. brown pigmented stones found?
- Black are found in STERILE gallbladder bile
- Brown are found in INFECTED large bile ducts
Can black and brown pigmented stones be seen on X-ray?
- Majority of black stones are radiopaque = can see on XR (due to calcium salts)
- Brown stones are radiolucent (can’t be seen) due to calcium soaps
When symptomatic, gallstones typically produce what type of pain, which radiates where?
Commonly presents after the patient does what?
- Biliary colic that may be excruciating and is typically constant
- Pain is localized to RUQ or epigastrium that may radiate to the right shoulder or the back
- Pain typically follows a fatty meal
How does the size of the gallstone relate to the likelihood of it causing problems?
- Larger the calculi, the less likely they are to enter the cystic or common ducts to produce obstruction
- Very small stones, or “gravel,” are far more dangerous
What are complications that may arise sometimes with large gallstones?
- May erode directly into an adjacent loop of small bowel, generating an intestinal obstruction
- “Gallstone ileus” or “Bouveret syndrome”
Acute calculous cholecystitis is typically caused by an obstruction of which 2 areas by a stone?
Neck or cystic duct
What is the primary complication of gallstones and the most common reason for emergency cholecystectomy?
Acute Cholecystitis
How do bacterial infections contribute to the initiating events of Acute Calculous Cholecystitis?
These events occur in the absence of bacterial infections; only later in the course may a bacterial infection occur
Patients with which metabolic disorder + symptomatic gallstones frequently develop acute calculous cholecystitis?
Diabetes mellitus
Acute acalculous cholecystitis, without stone involvement, is thought to result from what?
Ischemia
Which artery is implicated in Acute Acalculous Cholecystitis?
Cystic artery = end artery w/ no collateral circulation
Acute Acalculous Cholecystitis most frequently occurs in patients who are hospitalized for unrelated conditions, such as (list 5 common settings)?
- Sepsis w/ hypotension and multisystem organ failure
- Immunosuppression
- Major trauma and burns
- Diabetes mellitus
- Infections
When the exudate inside the gallbladder lumen is virtually pure pus, the condition is referred to as?
Gallbladder empyema
In the acute cholecystitis, the GB is typicall enlarged and the serosal covering is frequently covered by what type of exudate?
Fibrinopurulent exudate
In severe cases of acute cholecystitis the GB may be transformed into a green-black necrotic organ w/ small-to-large perforations and this condition is known as?
Gangrenous cholecystitis
Invasion of the GB w/ gas-forming organisms, such as clostridia and coliforms, may cause a condition known as?
Acute “emphysematous” cholecystitis
How does acute calculous cholecystitis typically present clinically?
Associated sx’s?
- Progressive RUQ or epigastric pain lasting for >6 hours
- Associated w/: mild fever, anorexia, tachycardia, sweating, N/V
Presence of hyperbilirubinemia/jaundice in a patient presenting w/ suspected acute calculous cholecystitis suggests what kind of obstruction?
Obstruction of common bile duct
Acute calculous cholecystitis may present with mild to moderate leukocytosis and be accompanied with what serum finding?
Mild elevations in alkaline phosphatase
In some cases acute calculous cholecystitis may appear with remarkable suddenness and this must be dealt with how in the clinic?
Acute surgical emergency
The incidence of gangrene and perforation are much higher in which type of acute cholecystitis?
Acute acalculous cholecystitis
Which 2 organisms can give rise to acute acalculous cholecystitis?
- Salmonella typhi
- Staphylococci
In 90% of cases Chronic Cholecystitis is associated with?
In 33% of cases which 2 organisms may be culutred from the bile?
- 90% of cases = associated w/ cholelithiasis (gallstones)
- 33% contain E. coli and enterococci
In Chronic Cholecystitis the serosa is typically smooth and glistening, but may be dulled by?
Subserosal fibrosis
Outpuchings of the mucosal epithelium through the wall of the GB may be quite prominent in Chronic Cholecystitis and is known as?
Rokitansky-Aschoff sinuses
In some cases of Chronic Cholecystitis, extensive dystophic calcification may yield what?
Porcelain gallbladder
Porcelain gallbladder caused by extensive dystrophic calcification is associated with an increased risk for?
Cancer
What is seen in Xanthogranulomatous cholecystitis, describe the morphology.
Characteristic cell type?
- GB has massively thickened wall and is shrunken, nodular, and chronically inflammed w/ foci of necrosis + hemorrhage
- Macrophages w/ ingested biliary phospholipids = foamy cytoplasm = xanthoma cells
What triggers xanthogranulomatous cholecystitis?
Rupture of Rokitansky-Aschoff sinuses into the wall of the GB –> accumulation of macrophages that have ingested bilirary phospholipids
Chronic cholecystitis does not have the striking clinical manifestations of acute forms and is usually characterized by what symptoms?
- Recurrent attacks of either steady epigastric or RUQ pain
- N/V and intolerance for fatty foods are common findings
The diagnosis of both acute and chronic cholecystitis is important to avoid which complications?
- Bacterial superinfections w/ cholangitis or sepsis
- GB perforation and local abscess formation
- GB rupture w/ diffuse peritonitis
- Biliary enteric fistula w/ drainage of bile into adjacent organs –> air and bacteria into biliary tree or gallstone induced intestinal obstruction
- Aggravation of preexisting med condition
- Porcelain GB w/ increased risk of cancer
What is the most common malignancy of the extrahepatic biliary tree?
Carcinoma of the GB
Which areas of the world have the highest incidence of GB carcinoma?
Where in the US?
- Chile, Bolivia, and Northern India
- In the US, the areas w/ highest #’s of Native Americans or Hispanics, such as the SW
What is the prognosis of GB carcinoma?
5-year survival is 10% = poor
What is the major risk factor for carcinoma of the GB; due to?
Gallstones —> chronic inflammation
Which oncoprotein is often seen overexpressed in carcinoma of the GB?
Also, which chromatin remodeling genes?
- ERBB2 (Her-2/neu)
- Chromatin remodeling genes PBRM1 and MLL3
What are the 2 patterns of growth seen in carcinomas of the GB?
Which is most common?
- Infiltrating = most common
- Exophytic
What are the morphological characteristics of the more common infiltrating growth pattern seen in carcinoma of the GB?
- Poorly defined area of diffuse mural thickening and induration
- Deep ulceration –> direct penetration of liver or fistula formation to adjacent viscera
- Scirrhous w/ firm consistency
What are the morphological characteristics of the exophytic growth pattern displayed by some carcinomas of the GB?
- Irregular, CAULIFLOWER mass
- Invades the underlying wall
Most carcinomas of the GB are what type of carcinoma?
Adenocarcinomas
Carcinomas of the GB of which type generally have a better prognosis?
Papillary tumors
Where are the most common sites for seeding by carcinomas of the GB?
- Liver –> extension into cytic duct and adjacent bile ducts
- Peritoneum
- GI tract
- Lungs
Why are carcinomas of the GB typically of poor prognosis?
- Typically are detected late
- Presenting sx’s are indistinguishable from those associated with cholelithiasis
What are 3 major risk factors/underlying diseases that cause pigment stones?
1) Chronic hemolytic syndromes
2) Biliary infection
3) GI disorders –> ileal disease (Chron), ileal resection or pass; CF w/ pancreatic insufficiency
