Gall Bladder Flashcards
What is cholelithiasis? What is the pathogenesis of the different types? What is the most common type in the west? What is it like? What are some risk factors? What is the other type? What are they like? Risk factors? What are some complications? Diagnosis? Treatment?
II. C H O L E L I T H I A S I S (GALLSTONES )
A. Solid, round stones in the gallbladder
B. Due to precipitation of cholesterol (cholesterol stones) or bilirubin (bilirubin stones) in bile
I. Arises with (I) supersaturatio n of cholesterol or bilirubin, (2) decreased phospholipids (e.g., lecithin) or bile acids (normally increase solubility), or (3) stasis
C. Cholesterol stones (yellow) are the most commo n typ e (90%), especially in the West (Fig. 1L2A),
1 , Usually radiolucent (10% are radiopaque due to associated calcium)
2. Risk factors include age (40s), estrogen (female gender, obesity, multiple pregnancies and oral contraceptives), clofibrate, Native American ethnicity,
Crohn disease, and cirrhosis.
D. Bilirubin stones (pigmented) are compose d of bilirubin (Fig. 11.2B).
1 . Usually radiopaque
2. Risk factors include extravascular hemolysis (increased bilirubin in bile) and biliary tract infection (e.g., E coli, Ascaris lumbricoides, and Clonorchis sinensis).
i. Ascitris lumbricoides is a c o m m o n roundworm that infects 25% of the world’s population, especially in areas with poo r sanitatio n (fecal-oral transmission) ; infects the biliary tract, increasing the risk for gallstones
ii. Clonorchis sinensis is endemi c in China, Korea, and Vietnam (Chines e liver fluke); infects the biliary tract, increasing the risk for gallstones, cholangitis, and cholangiocarcinoma
E. Gallstones are usually asymptomatic ; complications include biliary colic, acute and chronic cholecystitis, ascending cholangitis, gallstone ileus, and gallbladder
cancer
4) Diagnosis: ultrasound, some stone are radiopaque (10-20% cholesterol, 50-75% black pigment)
6) Treatment: Cholecytectomy (laparoscopic) if significant symptoms or complications
Describe biliary colic. Describe gallstone ileus.
III. B I L I A R Y C O L I C
A. Waxing and waning right upper quadrant pain
B. Due to the gallbladder contracting against a stone lodged in the cystic duct
C. Symptoms are relieved if the stone passes.
D. C o m m o n bile duct obstructio n may result in acute pancreatitis or obstructive jaundice.
VIE G A L L S T O N E ILEUS
A. Gallstone enters and obstructs the small bowel
B. Due to cholecystitis with fistula formation between the gallbladder and small bowel
What is acute cholocystitis? What are the results? HOw does a patient present? What is the gross and micro path? Complications? Treatment? What is acute acalculous cholecystitis? When does it occur?
IV. ACUT E CHOLECYSTITI S
A. Acute inflammatio n of the gallbladder wall
B. Impacted stone in the cystic duct results in dilatation with pressure ischemia, bacterial overgrowth (E coli), and inflammatio n
C. Presents with right upper quadrant pain, often radiating to right scapula, fever with incr. VVBC count, nausea, vomiting, and incr. serum alkaline phosphatase (fro m duct damage)
D. Risk of rupture if left untreate d
3) Pathology:
a) Gross: congested, boggy, fibrous exudates, hemorrhagic mucosa, stones, check cystic duct
b) Micro: edema, hemorrhage, neutriphils, ulceration, venous congestion may lead to transmural hemorrhagic infarction (gangrenous cholecystitis)
4) Complications: impaired function as gallbladder becomes fibrotic with healing, chronic cholecystitis, perforation, bile peritonitis
5) Treatment: systemic antibiotics, and cholecystectomy. If not a surgical candidate consider cholecystostomy
o Acute acalculous cholecystitis
Possibly ischemia of cystic artery
Risk factors: Sepsis with hypotension, multisystem organ failure, Immunosuppression, major trauma and burns, diabetes mellitus, infections
What is chronic cholecystitis? How is it characterized? How does it present? What is porcelain gallbladder? Why is it significant? Complications? Treatment?
V. C H R O N I C C H O L E C Y S T I T I S
A. Chronic inflammatio n of the gallbladder
B . Due to chemical irritation fro m longstanding cholelithiasis, with or without superimposed bouts of acute cholecystitis
C. Characterized by herniation of gallbladder mucosa into the muscular wall (Rokitansky-AscholT sinus. Fig. 11.ЭА)
D. Presents with vague right upper quadrant pain, especially after eating
E. Porcelain gallbladder is a late complication (Fig. 11.3B).
1 . Shrunken, hard gallbladder due to chronic inflammation, fibrosis, and dystrophic calcification
↑ risk of cancer
2. Increased risk for carcinoma
F. Treatment is cholecystectomy, especially if porcelain gallbladder is present,
What is cholesterolosis? What does it look like? Describe gallbladder dyskinesia. Describe sphincter of oddi dysfunction.
- Cholesterolosis: yellow speckling of red-tan mucosa, strawberry gallbladder due to lipid-laden macrophages
GALLBLADDER DYSKINESIA
Delayed emptying of the gallbladder in the absence of stones or sludge,
Questionable cause of biliary pain
Many surgeons offer laparoscopic cholecystectomy despite the lack of strong evidence
SPHINCTER OF ODDI DYSFUNCTION (SOD)
benign, noncalculous obstructive disorder that occurs at the level of the SO. The pathogenesis of SOD can be either stenosis/fibrosis, inflammation, or both; and dyskinesia.
Can cause biliary type pain, biliary obstruction, and abnormal liver enzymes
Possible cause of recurrent acute pancreatitis
Biliary and pancreatic manometry help in confirming the diagnosis
Treatment is sphincterotomy mainly in type I and II
Describe choledocholithiasis. Symptoms? Pathogenesis?
- Choledocholithiasis: the presence of stones within the bile ducts of the biliary tree
o Higher incidence in Asia
o Symptoms, related to obstruction, pancreatitis, cholangitis, hepatic abscess, secondary biliary cirrhosis, acute calculous cholecystitis
1) Almost all stones form in the gallbladder, compilations include obstruction, cholangitis, pancreatitis, hepatic abscess, secondary biliary cirrhosis, cyholecystitis
Describe ascending cholangitis.
VI, A S C E N D I N G C H O L A N G I T I S
A. Bacterial infection of the bile ducts
B. Usually due to ascending infection with enteric gram-negative bacteria
C. Presents as sepsis (high fever and chills), jaundice, and abdominal pain
D. Increased incidence with choledocholithiasis (stone in biliary ducts)
What is biliary atresia? How does it present?
I. BILIARY ATRESI A
A. Failure to form or early destructio n of extra hepatic biliary tree
B. Leads to biliary obstructio n within the first 3 months of life
C. Presents with jaundic e and progresses to cirrhosis
Describe choledochal cysts. What do they predispose to?
- Choledochal Cysts: congenital dilations of the common bile duct
o Female: male 3-4:1
o Predispose to stone formation, stenosis, stricture, pancreatitis, obstructive biliary complications
o Elevated risk of bile duct carcinoma in older patients
What is gallbladder carcinoma? What are some risk factors? How does it classically present? How is the prognosis?
GALLBLADDE R C A R C I N O M A
A. Adenocarcinoma arising fro m the glandular epithelium that lines the gallbladder wall (Fig. 11.4)
B. Gallstones are a majo r risk factor, especially when complicated by porcelain
gallbladder.
C. Classically presents as cholecystitis in an elderly woman
D. Poor prognosis
