Gallbladder & Extrahepatic Bile Ducts

Question 1

Conditions of the gallbladder & extrahepatic bile ducts

Answer 1

1. Choledochal cyst
2. Cholelithiasis
3. Acute cholecystitis

Question 2

Features of choledochal cyst

Answer 2

• congenital dilations of the common bile duct
• most commonly presents in children <10y
• non specific symptoms - jaundice, recurrent abdominal pain

Question 3

Complications of choledochal cyst (3)

Answer 3

1. Biliary obstruction
   - stone formation, cholangitis, cholangitis abscesses, biliary cirrhosis
2. Rupture, GI bleeding
3. Biliary carcinoma - exposure to bile - carcinogenic

Question 4

Definition of cholelithiasis

Answer 4

• gallstones formed within the gallbladder

- stones found in the bile ducts are called choledocholithiasis

Question 5

Types of gallstones

Answer 5

1. Cholesterol gallstones

2. Pigment gallstones

Question 6

Cholesterol gallstones & its associations

Answer 6

• crystalline cholesterol monohydrate
• yellow, finely granular, hard, radiolucent
• forty, female, fertile, fatty
• oral contraceptives, pregnancy
• estrogenic influence - increases uptake & biosynthesis of cholesterol in the liver - increases biliary cholesterol excretion
• obesity, metabolic syndromes, hyperlipidemia

Question 7

Pigment gallstones & its associations

Answer 7

• calcium bilirubinate
• black or brown, friable
• chronic hemolytic anemia - increased biliary bilirubin excretion
• biliary tract infection
• ascaris, liver flukes

Question 8

Pathogenesis of gallstones (3)

Answer 8

1. Supersaturation of cholesterol
   - excessive biliary cholesterol or insufficient bile salt formation
2. Hypomotility of gallbladder
   - promotes cholesterol nucleation - forms insoluble cholesterol crystals
3. Accretion of nucleated cholesterol crystals to form stones
   - promoted by mucus hypersecretion, gallbladder hypomotility, calcium salts

Question 9

Effects & complications of gallstones (5)

Answer 9

1. Asymptomatic, colicky pain (spasms, trying to expel stones)
2. Cholecystitis - irritation, inflammation
   - lodged, chronic cystic duct obstruction - gallbladder secretions cannot be discharged - dilates - produces “white bile” - accumulation of clear watery fluid - Hydrops of gallbladder
   - fluid is a good milieu for infection - empyema
3. Common bile duct obstruction leading to obstructive jaundice, ascending cholangitis, biliary cirrhosis
4. Cholecystointestinal fistula
   - inflammation - adhesions - erosion of common wall by stones - possible intestinal obstruction
5. Carcinoma of the gallbladder - exposure to bile

Question 10

Definition of cholecystitis

Answer 10

inflammation of the gall bladder - acute, chronic or acute-on-chronic

Question 11

Causes & pathogenesis of acute cholecystitis

Answer 11

1. Calculous obstruction
   - stasis - more prone to infection
   - chemical irritation - mucosal phospholipases hydrolyse lecithins (to lysolecithins, toxic to mucus layer)
   - mucosal damage - exposed to direct detergent action of bile salts - inflammation
   - gallbladder dysmobility - distension & increased intraluminal pressure - blood flow compromised - ischemia- sec bact inf
2. Acalculous
   - sepsis w hypotension, immunosuppresion, major trauma & burns, DM, infection

Question 12

Effects & complications of acute cholecystitis (4)

Answer 12

1. Pericholecystic abscesses, subdiaphragmatic abscesses
2. Peritonitis
3. Ascending cholangitis, liver abscess
4. Septicemia

Question 13

Morphology of acute cholecystitis

Answer 13

• G: grossly enlarged, tense, with fibrinosuppurative serosal surface
• M: acute inflammatory infiltrate, hyperemic, edema/exudate

Question 14

Definition of chronic cholecystitis

Answer 14

• repeated inflammation (repeated bouts of acute cholecystitis)
• mostly associated with cholelithiasis

Question 15

Morphology of chronic cholecystitis

Answer 15

• G: thickened, contracted wall (fibrosis) associated w obstructive calculi

M:

• chronic inflammatory infiltrate
• muscular hypertrophy - tries to expel obstruction
• dystrophic calcification
• Rokintansky-Aschoff sinuses - mucosal outpouchings through areas of weakness in wall 2 to increased intraluminal pressure due to muscular hypertrophy - communicates w lumen of gall bladder - bile accumulates - stasis - infection