Gallbladder pathology

Question 1

A patient has RUQ abdominal pain and a stone obstructing the common bile duct (CBD). Which two biliary ducts drain directly into the CBD?


Answer 1

The cystic duct and common hepatic duct


Question 2

Bile passes through this sphincter to enter the duodenum.


Answer 2

The sphincter of Oddi


Question 3

A patient has a colicky abdominal pain with elevated amylase, lipase, and alkaline phosphatase. What structure has become involved?


Answer 3

Ampulla of Vater (this is a gallstone that is now obstructing both biliary and pancreatic ducts)


Question 4

An elderly man presents with jaundice, weight loss, and RUQ pain. His transaminases are elevated. Where might a pancreatic tumor be located?


Answer 4

The head of the pancreas (a tumor in the head of the pancreas can present with jaundice, as it obstructs the common bile duct)

Question 5

Is primary sclerosing cholangitis intrahepatic, extrahepatic, or both?


Answer 5

Both (the entire biliary tree is affected)


Question 6

What is the underlying change in primary sclerosing cholangitis?


Answer 6

Concentric “onion skin” fibrosis of unknown cause (leading to alternating strictures and dilation of intra-/extrahepatic ducts)


Question 7

A 39-year-old woman has a liver biopsy. What findings would suggest a diagnosis of primary biliary cirrhosis?


Answer 7

Lymphocytic infiltrate, granulomas, destruction of intralobular bile ducts


Question 8

A man with jaundice and dark urine undergoes both ERCP and MRCP. What finding(s) suggest(s) primary sclerosing cholangitis?


Answer 8

Alternating strictures, dilation of the bile ducts (also called beading)


Question 9

A patient has jaundice, light stools, pruritus, dark urine, and hepatosplenomegaly. What organ is most likely affected?


Answer 9

The biliary tracts (this is a common presentation for both primary and secondary biliary cirrhosis)


Question 10

What autoimmune disease is classically associated with primary sclerosing cholangitis?


Answer 10

IBD (especially in young men) (more specifically, ulcerative colitis)


Question 11

Which antibody abnormalities are classically seen in patients with primary biliary cirrhosis?


Answer 11

Positive anti-mitochondrial antibodies, elevated IgM antibodies


Question 12

How can secondary biliary cirrhosis result from primary sclerosing cholangitis?


Answer 12

PSC can cause biliary strictures, which cause extrahepatic biliary obstruction, leading to secondary biliary cirrhosis


Question 13

A patient has secondary biliary cirrhosis. What do you expect his conjugated bilirubin, cholesterol, and alkaline phosphatase levels to be?


Answer 13

All increased (a cholestatic pattern)


Question 14

A woman is positive for antimitochondrial antibodies. What will his conjugated bilirubin, cholesterol, and alkaline phosphatase levels be?


Answer 14

All will be increased (the patient has primary biliary cirrhosis, and a cholestatic pattern is seen)


Question 15

A man has a biliary disease associated with ulcerative colitis. What are conjugated bilirubin, cholesterol, and alkaline phosphatase levels?


Answer 15

All will be increased (the patient has primary sclerosing cholangitis, and a cholestatic pattern is seen)


Question 16

A patient with CREST syndrome and celiac disease presents with jaundice. What biliary tract disease does she most likely have?


Answer 16

Primary biliary cirrhosis (classically associated with other autoimmune conditions)


Question 17

What class of immunoglobulin is elevated in primary sclerosing cholangitis?


Answer 17

Immunoglobulin M


Question 18

What causes secondary biliary cirrhosis?


Answer 18

Extrahepatic biliary obstruction leading to increased pressure in the intrahepatic ducts, with fibrosis and stasis of bile


Question 19

A patient with secondary biliary cirrhosis presents with fever and abdominal pain. What complication must now be considered?


Answer 19

Ascending cholangitis, which is a bacterial infection facilitated by biliary stasis


Question 20

Name some disease states associated with primary biliary cirrhosis.


Answer 20

Autoimmune conditions such as CREST, Sjögren syndrome, rheumatoid arthritis, celiac disease


Question 21

A man with primary sclerosing cholangitis presents with a right upper quadrant mass. After HCC, what is the next most concerning etiology?


Answer 21

Cholangiocarcinoma, a potential complication of primary sclerosing cholangitis

Question 22

List the two types of gallstones.


Answer 22

Cholesterol stones and pigment stones


Question 23

A woman with a history of obesity, OCP use, and multiple pregnancies will likely have radiolucent or radiopaque kind of stones?


Answer 23

Radiolucent (the patient likely has cholesterol gallstones)


Question 24

Approximately what percentage of cholesterol stones are radiopaque?


Answer 24

10–20% (due to calcification)


Question 25

Why does Crohn disease predispose patients to gallstones?


Answer 25

Because of the inability of the diseased terminal ileum to absorb bile salts


Question 26

List at least four common risk factors for the formation of cholesterol stones.


Answer 26

Obesity, Crohn disease, cystic fibrosis, advanced age, clofibrate, estrogens, multiparity, rapid weight loss, Native American origin


Question 27

What percentage of gallstones are cholesterol stones?


Answer 27

80%

Question 28

An alcoholic with a history of cirrhosis and biliary infections will most likely have what kind of gallstones (radiolucent or radiopaque)?


Answer 28

Radiopaque (the patient likely has pigment gallstones)


Question 29

A patient has RUQ pain, jaundice, and fever. Ultrasound shows gallstones, and labs show elevated white blood cells. What is the diagnosis?


Answer 29

Acute cholangitis (Charcot triad = RUQ pain, jaundice, and fever)


Question 30

List at least three common risk factors for pigment stones.


Answer 30

Chronic hemolysis, alcoholic cirrhosis, advanced age, biliary infection, total parenteral nutrition


Question 31

A 39-year-old overweight woman presents with jaundice and RUQ pain. How would you diagnosis her condition, and what is the treatment?


Answer 31

Ultrasound to identify a distended gallbladder with stones; cholecystectomy


Question 32

Name at least two major complications of gallstones.


Answer 32

Ascending cholangitis, acute pancreatitis, bile stasis, cholecystitis


Question 33

Define biliary colic.


Answer 33

Biliary contraction pain after eating due to neurohormones (e.g., CCK) forcing a gallstone into the cystic duct, causing visceral irritation


Question 34

Ultrasound shows an 8-mm stone in the cystic duct of a long-time diabetic man. Despite this, he had no complaint of significant pain. Why?


Answer 34

Diabetic patients might have neuropathy, which can reduce the sensation of pain from gallstones


Question 35

What radiographic finding is associated with obstruction of the ileocecal valve by a gallstone?


Answer 35

Air in the biliary tract (also known as pneumobilia or gallstone ileus)


Question 36

Name the 4 Fs associated with an increased risk of developing gallstones.


Answer 36

Female, Fat, Fertile (prgenancy), Forty (age)


Question 37

A patient has jaundice, fever, and right upper quadrant pain. Likely diagnosis?


Answer 37

These symptoms are classic for the Charcot triad, which indicates cholangitis

Question 38

A patient presents with abdominal pain. On deep palpation of the right upper quadrant, she appears to hold her breath. Name this finding.


Answer 38

Positive Murphy sign (inspiratory arrest on deep palpation) indicative of cholecystitis


Question 39

Name three possible causes of cholecystitis.


Answer 39

Gallstones (most common), infection (either 2° to spread or 1° cytomegalovirus [uncommon]), and ischemia


Question 40

If the bile duct becomes involved in a patient with cholecystitis, what lab value would you observe to be increased?


Answer 40

Alkaline phosphatase (ALP)


Question 41

____ is inflammation of the gallbladder, whereas ____ is inflammation of the bile duct.


Answer 41

Cholecystitis, cholangitis


Question 42

A patient who you think has chronic inflammation of the gallbladder should be diagnosed using what method?


Answer 42

Ultrasound or HIDA scan