Gallbladder and Biliary Tree: Tombazzi

Question 1

Your pt has BROWN pigment gallstones. What does this signify?

Answer 1

Infection

Question 2

Your pt has BLACK pigment gallstones. What does this signify?

Answer 2

Hemolysis

Question 3

The most common type of gallstone is the:

Answer 3

Cholesterol stone

Question 4

What is the most significant way in which your body gets rid of cholesterol?

Answer 4

Through bile excretion

Question 5

What are the risk factors for cholesterol gallstones?

Answer 5

the 4 F's
Female
Fat- excess free cholesterol
Forty- older age = less bile salt prod. = excess free chol.
Fertile- estrogen

Question 6

List the 3 major pathophysiological contributors to gallstone formation.

Answer 6

Cholesterol supersaturation
Accelerated nucleation (crystalization)
Gallbladder hypomotility

Question 7

A loss of balance between these two factors contributes to cholesterol supersaturation:
Explain the relationship, the consequences of their relative change.

Answer 7

Free cholesterol and Bile acids
FC^, BA stays same = problem
FC stays same, BA v = problem

Question 8

Describe the histology of abetalipoproteinemia and why this occurs.

Answer 8

Histo: foamy enterocytes bc of build-up of triglycerides and inability to release them to the lacteals.
Usually present as infant w/ failure to thrive.

Question 9

Pt comes into your ED with RUQ abdominal pain. They have sickle cell dz. What do you need to rule out as the cause of the RUQ pain?

Answer 9

Black pigment (hemolysis) gallstones causing obstruction of bile ducts/cholecystitis. 
Hemolysis --> high levels of unconjugated bilirubin--> black stones

Question 10

What type of stone is called a “primary biliary” stone, meaning it was formed in the bile ducts and not the gallbladder?

Answer 10

Brown pigment stone

Question 11

For this clinical manifestation of gallstones, describe the sign/symptom/lab finding that will differentiate it from other clinical manifestations:
Biliary colic

Answer 11

Abdominal pain

Question 12

For this clinical manifestation of gallstones, describe the sign/symptom/lab finding that will differentiate it from other clinical manifestations:
Acute cholecystitis

Answer 12

Fever and abd. pain- this is a medical emergency. Need to admit pt, get them on IV abx and get surgical consult. Possible complication- ruptured GB–> sepsis–> death

Question 13

For this clinical manifestation of gallstones, describe the sign/symptom/lab finding that will differentiate it from other clinical manifestations:
Choledocholithiasis (stone in CBD) w/ cholangitis (abd. pain, fever, jaundice)

Answer 13

Jaundice, abd pain, fever - due to blocked COMMON bile duct–> hyperbilirubinemia, lighter stools bc bilirubin not making it to intestines to be oxidized to urobilinogen.

Question 14

For this clinical manifestation of gallstones, describe the sign/symptom/lab finding that will differentiate it from other clinical manifestations:
Biliary pancreatitis

Answer 14

Increased Amylase, abd. pain- due to pancreatic injury

Question 15

30yo WF, 2 weeks post-partum. Light stools. RUQ pain. Jaundice. What is going on?

Answer 15

Choledocholithiasis (stone in CBD) w/ cholangitis

Question 16

What is cholangitis?

Answer 16

Abd. pain
Fever
Jaundice

Question 17

You find neutrophils infiltrating glands of the GB. On gross examination, you find the GB serosal surface to be green and red. What do you have here?

Answer 17

Acute cholecystitis- red/green serosa = subserosal hemorrhage.

Question 18

Describe the histologic findings in gangrenous cholecystitis.

Answer 18

The wall of the GB is thickened, edematous, and hyperemic. Neutrophilic inflammation. Invasion by gram neg. anaerobes (clostridia/coliforms) can result in gas gangrene = acute “emphysematous” cholecystitis

Question 19

What is the hallmark histological sign of chronic cholecystitis?

Answer 19

Rokitansky-Aschoff sinuses- GB mucosal infoldings into the wall of the GB, forming deep sinuses/buried crypts of epithelium.
Will also see lymphocytic infiltrates, subSEROSAL fibrosis.

Question 20

What is xanthogranulomatous cholecystitis?

Answer 20

When the Rokitansky-Aschoff sinuses rupture into the wall of the GB, macrophages migrate to the site for cleanup and get foamy and pigmented from ingested biliary phospholipids. These are called xanthoma cells.

Question 21

Intrahepatic cholestasis is usually _______ in etiology.

Answer 21

metabolic etiology: primary biliary cirrhosis, meds, malignant infiltration, primary sclerosing cholangitis (PSC)

Question 22

Extrahepatic cholestasis is usually ________ in etiology.

How to dx?

Answer 22

Obstructive
Will see biliary ductal dilation proximal to obst. on ultrasound.
MRI
Endoscopic retrograde cholangiopancreatography
Endoscopic US

Question 23

Describe the histological manifestation of cholestasis on hepatocytes.

Answer 23

Hepatocytes accumulate bile pigments. Can be extracellular bile plugs (brown-green in color) or intracellular (yellow-brown vesicles)

Question 24

What is going on in primary sclerosing cholangitis and what is the terminal pathology?

Answer 24

Inflammatory infiltration of larger ducts and circumferential “onion skin” fibrosis of ductules–> ductal obliteration–> biliary cirrhosis –> may lead to cholangiocarcinoma

Question 25

How does cirrhosis secondary to hepatitis and cirrhosis secondary to biliary obstruction differ on histology?

Answer 25

Hepatic regenerative nodules are more circular in hepatitis cirrhosis.
The nodules are more irregularly shaped in obstructive biliary cirrhosis.

Question 26

Describe the clinical course of cholangiocarcinoma.

Answer 26

Rapid, often ending in mortality. They don’t show symptoms until really late in the course, by that time, it is too late to treat.

Question 27

Due to their adenomatous nature, how do you differentiate cholangiocarcinomas from Rokitansky-Aschoff sinuses?

Answer 27

R-A sinuses do not grow horizontally, whereas the adenocarcinoma will.

Question 28

What is porcelain gallbladder and what is its clinical significance?

Answer 28

Rare, caused by extensive dystrophic calcification within the gallbladder wall.
Notable for markedly incr. incidence of cholangiocarcinoma.

Question 29

Hemobilia- blood in bile duct for any reason, presents as:

Answer 29

Abd. pain
Melena
Jaundice from clot–> obstruction