Gallbladder and Biliary Tract

Question 1

What is biliary atresia? What does it lead to? How does it present?

Answer 1

Failure to form or early destruction of the extrahepatic biliary tree. Leads to biliary obstruction within the first 2 months of life. Presents with jaundice and progresses to cirrhosis.

Question 2

What are the three causes of gall stones?

Answer 2

1. Supersaturation of cholesterol or bilirubin
2. decreased phospholipids (e.g. lecithin) or bile acids
3. Stasis

Question 3

What are the most common type of gallbladder stones? Can you see them on X-ray? What are the risk factors?

Answer 3

Cholesterol stones (yellow) 90% of cases. Usually radiolucent so can’t be seen. (10 % radiopaque due to associated calcium). Risk factors include age (40s), estrogen (female gender, obesity, multiple pregnancies,oral contraceptives), Clofibrate, Native American Ethnicity, Crohn disease, cirrhosis

Question 4

What are the risk factors for Bilirubin stones? What do they look like? Can you see them on X-ray?

Answer 4

Pigmented stones composed of bilirubin. Usually radiopaque so can be seen. Risk factors include extravascular hemolysis and biliary tract infection.

Question 5

Which two organisms are implicated in biliary tract infection?

Answer 5

Ascaris lumbrioides and Clonoris sinensis

Question 6

Where is Ascaris lumbricoides found? What does it do and what does it increase the risk of?

Answer 6

Common roundworm that infects 25% of the world population especially in areas of poor sanitation (fecal-oral transmission). Infects the biliary tract, increasing the risk for gallstones.

Question 7

Where is Ascaris lumbricoides found? What does it do and what does it increase the risk of?

Answer 7

Common roundworm that infects 25% of the world population especially in areas of poor sanitation (fecal-oral transmission). Infects the biliary tract, increasing the risk for gallstones.

Question 8

Where is Clonoris sinensis endemic? What does it do and what does it increase the risk of?

Answer 8

China, Korea, Vietnam. Infects the biliary tract, increasing the risk for gallstones, cholangitis and cholangiocarcinoma.

Question 9

Where is Clonoris sinensis endemic? What does it do and what does it increase the risk of?

Answer 9

China, Korea, Vietnam. Infects the biliary tract, increasing the risk for gallstones, cholangitis and cholangiocarcinoma.

Question 10

What symptoms do gallstones present with? What complications do they lead to?

Answer 10

Usually asymptomatic. Complications include biliary colic, acute an chronic cholecystitis, ascending cholangitis, gallstone ileus and gallbladder cancer.

Question 11

A patient presents with right upper quadrant pain which he describes as waxing and waning. What could be causing this and why? How will his symptoms go away? What might be some complications?

Answer 11

Biliary colic due to gallbladder contracting against a stone lodged in the cystic duct. Symptoms are relieved if the stone passes. Common bile duct obstruction may result in acute pancreatitis or obstructive jaundice.

Question 12

A patient presents with

Answer 12

a

Question 13

A patient presents with right upper quadrant which radiates to the right scapula. He has a fever with elevated WBC count and elevated serum alkaline phosphatase. He has been nauseous and vomiting for the past two days. What does he have and what can it lead to? What would happen if he is not treated?

Answer 13

He has acute cholecystitis which is an acute inflammation of the gallbladder wall. Impacted stone in the cystic duct results in dilatation with pressure ischemia, bacterial overgrowth (E coli) and inflammation. Risk of rupture if left untreated.

Question 14

A patient presents with right upper quadrant especially after eating. Imaging shows a calcified border on the upper right quadrant. What is this indicative of? What causes this? What explains the imaging finding?

Answer 14

This is chronic cholecystitis which is chronic inflammation of the gallbladder. Due to chemical irritation from longstanding cholelithiasis with or without superimposed bouts of acute cholecystitis. Porcelain gallbladder which a late complication and is a shrunken, hard gallbladder due to chronic inflammation, fibrosis and dystrophic calcification.

Question 15

A patient presents with right upper quadrant especially after eating. Imaging shows a calcified border on the upper right quadrant. What is this indicative of? What causes this? What explains the imaging finding?

Answer 15

This is chronic cholecystitis which is chronic inflammation of the gallbladder. Due to chemical irritation from longstanding cholelithiasis with or without superimposed bouts of acute cholecystitis. Porcelain gallbladder which a late complication and is a shrunken, hard gallbladder due to chronic inflammation, fibrosis and dystrophic calcification.

Question 16

What does the gallbladder mucosa do in chronic cholecystitis? What is it called? What does this increase the risk of? How is chronic cholecystitis treated?

Answer 16

Gallbladder herniates into the muscular wall (Rokitansky-Aschoff sinus). Increased risk for carcinoma. Treatment is cholecystectomy, especially if porcelain gallbladder is present.

Question 17

A patient presents with sepsis, jaundice and abdominal pain. Lab results show that he has a bacterial infection of the bile ducts. What does he have and what causes this? What increases the incidence of this disease?

Answer 17

Ascending cholangitis which is a bacterial infection of the bile ducts due to ascending infection with enteric gram-negative bacteria. Increased incidence with choledocholithiasis (stone in biliary ducts).

Question 18

What is a gallstone ileus? What causes it?

Answer 18

Gallstone enters and obstructs the small bowel. Due to cholecystitis with fistula formation between the gallbladder and small bowel.

Question 19

An 80 year old woman presents with cholecystitis? What disease are you most worried about? What is a major risk factor? What is the prognosis?

Answer 19

Gallbladder carinoma which is adenocarcinoma arising from the glandular epithelium that lines the gallbladder wall. Gallstones are a major risk factor. Poor prognosis.