Gallbladder And Biliary Tree Flashcards
Cholesterol stone formation is enhanced by
Hypomobility of gallbladder promoting nucleation
Mucus hypersecretion with trapping of crystals
Cholesterol exceeding solubilizing capacity of bile and crystalization
Precipitation of insoluble calcium in unconjugated bilirubinate salts
Pigment stone
Exclusive in the gallbladder
Pale yellow inc proportion of calcium carbonate, phosphates and bilirubin
gray white to black discoloration
ovoid firm radiolucent but 20% with calcium carbonate making them radiopaque
Cholesterol stone
Arise anywhere in biliary tree Black and brown Black in sterile gallbladder Brown in infected Calcium salt of inconjigated bilirubin Small fragile numerous with greasy and soaplike consistency from FA Radiopaque black, brown radiolucent
Pigment stone
red blotchy violaceous color with subserosal hemorrhage of GB
serosa covered by fibrinopurulent exudate
90% of cases stones are present often obstructing neck of bladder or cystic duct
Lumen is filled with cloudy turbid bile containing fibrin, blood and pus
Acute cholecystitis
Pus in gallbladder
Thick edematous hyperemic
empyema
Green black necrotic organ of gallbladder
Gangrenous cholecystitis
Acute inflamm of gallbladder with stones by obstruction of neck or cystic duct
Due to chemical irritation and inflammation
Occur in the absence of bacterial infection
acute calculous cholecystitis
Most common major complication of gallstone and most common reason for emergency OR
Biliary pain >6 hours severe and steady
acute calculous cholecystitis
Cholecystitis develps bec of hydrolysis of lecithin to lysolecithin which is toxic to mucosa
Protective glycoprotein mucous layer is disrupted exposing epithelium to detergent action of
bile salt and prostaglandin
distention and inc intraluminal pressure compromise blood flow to mucosa
Occur in absence of bacteria
Predisposing injury to acute acalculus chole
Major nonbiliary Severe trauma Severe burns Sepsis Dehydration Gallbladder stasis Sludging Vasc compromise Bacterial contamination
Predisposes px to chronic inflamm and stone formation
Supersaturation of bile
stones within biliary tree
sx develop because of
choledocholithiasis
biliary obstruction cholangitis hepatic abscess chronic liver disease with secondary biliary cirrhosis acute calculous chole
acute inflamm of wall of bile duct by bacterial infection of sterile lumen
cholangitis
Propensity of bacteria in biliary tree to infect intrahepatic biliary duct
Caused by E coli, Klebs, enteroccoci, clostridium, fasciola, schistosomiasis, clonorchis, opisthorchis or cryptosporidiosis
Ascending cholangitis
Complete obstruction of bile flow caused by destruction or absence of all or part of extrahepatic duct
Major cause of neonatal cholestasis
Most freq cause of death from liver disease in early childhood
Biliary atresia
Inflammation and fibrosing stricture of hepatic or common bile duct
Inflamm of major intrahepatic bile duct with progressive destruction of intrahepatic biliary tree
Florid features of biliary obstruction on liver biopsy ductular reaction, portal tract edema and fibrosis and parenchymal cholestasis
Periportal fibrosis and cirrhosis within 3-6 mos of birth
Biliary atresia
Dx biopsy
Tx liver transplant
Most freq malignant tumor of biliary tract
2-6x W in 7th decade
Gallbladder carcinoma
Most of the gallbladder cancers are
adenocarcinoma
Exhibit exophytic or infiltrating growth pattern
Infiltrating pattern is more common poorly defined area of diffuse thickening and induration of gallbladder
Scirrhous very firm irregular cauliflower-like masa invading underlying wall
Gallbladder cancer
Adenocarcinoma that arise from cholangiocyte lining intrahepatic and extrahepatic biliary duct
2/3 are extrahepatic at the hilum aka
Cholangiocarcinoma
Klatskin tumor
Risk factors of cholangiocarcinoma
Primary sclerosing cholangitis
Fibropolycystic disease of biliary tree
Clonorchis sinensis
Opisthorchis viverrini
Cause chronic cholestasis and inflamm promoting somatic mutations
Cholangiocarcinoma is associates with mutations in the ff genes
KRAS
BRAF
TP53
Adenocarcinoma with well formed glands accom by abundant fibrous stroma desmoplasia with firm gritty consistency
Absent bile pigment and hyaline inclusion from tumor with prominent intracellular mucin
Cholangiocarcinoma
Intra- nonspecific like HCC
Extra- jaundice, acholic, nausea, vomiting
Inc ALP and aminotrans
Transplantation is contraindicated
Cholangiocarcinoma spreads to the abdomen by
Invasion of peribiliary nerves
Greater propensity for spread than HCC
Most common malignancy of liver
More common than primary hepatic neoplasia
Most common primary sources:
-colon, breast, lung and pancreas
Liver metastases
90% are cholesterol stones
Contain more than 50% of crystalline cholesterol monohydrate
10% are pigment stones
Composed of bilirubin calcium salts
Cholelithiasis
Supersaturation causes nucleation into solid cholesterol monohydrate crystals
Cholesterol stones
Elevated levels of unconjugated bilirubin in bile such as hemolytic syndromes, severe ileal dysfunction and bacterial contamination
Pigment stones
sterile gallbladder bile
Composition: oxidized calcium salts of unconjugated bilirubin
Radiopaquev
Black stones
Infected intrahepatic or extrahepatic ducts
Composition: pure calcium salts of unconjugated bilirubin
Radiolucent
Brown stones
Due to ischemia
Risk factors: sepsis, immunosupression, major trauma and burns, diabetes mellitus, infections
Acute Acalculous Cholecystitis
GB exudate is virtually pure pus
Acute cholecystitis
Gallbladder empyema
GB transformed into a green-black necrotic organ
Gangrenous cholecystitis
Invasion of gas-forming organisms, notably clostridia and coliforms
Emphysematous cholecystitis
Outpouchings or the mucosal epithelium through the GB wall
Rokitansky-Aschoff sinuses
Extensive dystrophic calcification in GB wall
Increased incidence of associated cancer
Porcelain gallbladder
Massively thickened GB wall
Chronic inflammatory with necrosis and hemorrhage
Xanthogranulomatous cholecystitis
Atrophic, chronically obstructed gallbladder containing only clear secretions
Hydrops of the gallbladder
Chronic cholecystitis
Most common malignancy of the extrahepatic biliary tract
Most important risk factor: gallstones
Most common sites of involvement: fundus and neck
Gallbladder adenocarcinoma
Excessive accumulation of body iron, most of which is deposited in parenchymal organs such as the liver and pancreas
Hemochromatosis
Homozygous recessive inherited disorder
Primary hemochromatosis
Due to parenteral iron overload, transfusion, RBC anomalies, chronic liver disease
Acquired hemochromatosis (hemosiderosis)
Hepatomegaly: HP micronodular cirrhosis
Diabetes mellitus
Bronze skin pigmentation
Hemochromatosis
Liver, pancreas, myocardium, pituitary, adrenal, thyroid and parathyroid, joints, skin
Detected using Prussian blue stain
Deposition of hemosiderin
Autosomal recessive disorder
Impaired copper excretion into bile
Failure to incorporate copper into ceruloplasmin
Accumulation of toxic levels of copper in many tissues and organs (liver, brain, eye)
Wilson disease
Hepatic changes fatty change (steatosis) acute hepatitis chronic hepatitis massive liver necrosis
Atrophy and cavitation of putamen and basal ganglia
Wilson’s disease
Eye lesion of Wilson
Green to brown deposits of copper in Descemet’s membrane in the limbus of the cornea
Kayser-Fleischer rings
Obstruction of two or more hepatic veins
Characterized by liver enlargement, pain and ascites
Associations include:
Polycythemia vera
Inherited disorders of coagulation
Paroxysmal nocturnal hemoglobinura
Budd-Chiari Syndrome
Acute thrombosis of hepatic veins or hepatic portion of IVC
Liver is swollen and red-purple
Tense liver capsule
Severe centrilobular congestion and necrosis
Budd-Chiari Syndrome
Inflammatory autoimmune disease mainly affecting the intrahepatic bile ducts
Laboratory studies:
elevated alkaline phosphatase and cholesterol
(+) for antimitochondrial antibodies
Primary biliary cirrhosis
Portal tracts are infiltrated by lymphocytes, macrophages, plasma cells, and eosinophils
Florid duct lesions
Non caseating granulomatous reaction to a bile duct undergoing destruction
Pre-Cirrhotic Phase
Primary Biliary Cirrhosis
