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General Surgery > Gallbladder Pathology > Flashcards

Gallbladder Pathology Flashcards

1
Q

what is the common age group gallstones affects?

A

middle aged women

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2
Q

what are the different types of gallstones?

A

cholesterol, bile pigment, mixed

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3
Q

how are cholesterol gallstones form?

A

Form when supersaturated bile is further concentrated – excess of mucus production – or from clumps of bacteria/desquamated mucosa
High concentration of cholesterol in gallbladder, gallbladder stasis, products that promote crystallisation of cholesterol

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4
Q

what do cholesterol gallstones look like?

A

surface is yellow and greasy

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5
Q

how can cholesterol gallstones appear?

A

 solitary oval stone – cholesterol solitaire

 Or as 2 stones -one indenting the other or as multiple mulberry stones

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6
Q

what are the risk factors to developing cholesterol gallstones?

A

contraceptive pill, pregnancy, age, FH, obesity, low dietary fibre

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7
Q

what are bile pigment gallstones made of?

A

calcium bilirubinate with some calcium carbonate

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8
Q

what do bile pigment gallstones look like?

A

Small, black, irregular, multiple, gritty and fragile

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9
Q

what are the risk factors to developing bile pigment gallstones?

A

haemolytic anaemias (spherocytosis, sickle cell disease), glucuronidases (bacteria), cirrhosis

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10
Q

what are mixed gallstones?

A

Multiple, faceted one against the other

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11
Q

how to mixed gallstones appear?

A

Grouped into two or more series, each of the same size – generation of stones

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12
Q

what do mixed gallstones look like?

A

Cut surface is laminated with alternate dark and light zones of pigment and cholesterol

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13
Q

what is the disease progression of gallstones?

A

Gallstone gets stuck in cystic duct, pain in epigastric region as gallbladder contracts to remove stone, stasis of bile, bacteria growth

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14
Q

how does a gallstone become stuck in the cystic duct?

A

o Occurs when small intestine secretes CCK where it signals gall bladder to secrete bile
o As gall bladder contracts gall stone gets lodged

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15
Q

what does stasis of bile in gallstones result in?

A

o Chemical irritant
o Mucosa in walls secrete mucus and inflammatory enzymes
o Inflammation, distension and increased pressure

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16
Q

which bacteria commonly grow in gallstones?

A

o Ecoli, enterococci, Bacteroides fragilis and Clostridium.

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17
Q

what are the complications of bacterial growth in gallstones?

A

Peritonitis

neutrophilic leucocytosis

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18
Q

what causes the shoulder tip pain in gallstones?

A

gallbladder swells causing RUQ and irritation of diaphragm

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19
Q

acute cholecystitis is caused by

A

blockage in the gallbladder

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20
Q

cholangitis is caused by

A

blockage of the common bile duct

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21
Q

what are the pathological affects of gallstones?

A 
silent
impaction
choledocholithiasis
increased pressure in bile duct
mirizzi syndrome
gallstone ileus
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22
Q

what is silent gallstones?

A

no symptoms present

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23
Q

what is gallstone impaction?

A

stuck in Hartmann’s pouch or cystic duct, causing imflammation

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24
Q

what is choledocholithiasis

A

gallstones may migrate into the common bile duct. These may be silent or produce an intermittent or complete obstruction of the common bile duct with pain and jaundice or ascending cholangitis or acute pancreatitis

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25
Q

what is the result of increased pressure in the bile duct?

A

bile seeps out and into bloodstream = increased serum conjugated bilirubin, and increased ALP (from cell damage)

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26
Q

what is Mirizzi Syndrome?

A

a gallstone may impact in the cystic duct of Hartmann’s pouch and cause extrinsic compression of the common hepatic duct, also resulting in obstructive jaundice

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27
Q

what is gallstone ileus?

A

impaction of the stone in the narrowest part of the small bowel (the distal ileum) with resulting intestinal obstruction

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28
Q

what causes a gallstone ileus?

A

a large gallstone ulcerates through the wall of the gallbladder into the adjacent duodenum

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29
Q

what is the key feature of gallstone ileus?

A

presence of air in the biliary tree that has entered the bile ducts via the fistula - seen on CT

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30
Q

what are the common clinical manifestations of gallstones?

A
  • Acute Cholecystitis
  • Chronic Cholecystitis
  • Biliary Colic
  • Cholangitis
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31
Q

what are the other clinical manifestations of gallstones?

A 
o	Obstructive jaundice with CBD stones
o	Gallstone ileus 
o	Pancreatitis
o	Mucocele-empyema
o	Mirizzi’s Syndrome
o	Gallbladder perforation
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32
Q

what are the summary features of biliary colic?

A

Colicky abdominal pain, worse postprandially, worse after fatty foods

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33
Q

what are the summary features of acute cholecystitis?

A

Right upper quadrant pain, fever, murphy’s sign on examination. Occasionally mildly deranged LFTs (especially if Mirizzi syndrome)

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34
Q

what are the summary features of gallbladder abscess?

A

Usually prodromal illness and RUQ pain. Swinging pyrexia. Patient may be systemically unwell. Generalised peritonism not present

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35
Q

what are the summary features of cholangitis?

A

Patient severely septic and unwell. Jaundice. RUQ pain.

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36
Q

what are the summary features of gallstone ileus?

A

Patients may have a history f previois cholecystitis and known gallstones. Small bowel obstruction (may be intermittent)

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37
Q

what are the summary features of Acalulous Cholecystitis?

A

Patients with intercurrent illness (.e.g. diabetes, organ failure). Patient of systemically unwell Gallbladder inflammation in abdence of stones, high fever

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38
Q

what is the summary management of biliary colic?

A

If imaging shows gallstones and history compatible then laparoscopic cholecystectomy

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39
Q

what is the summary management of acute cholecystitis?

A

Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation)

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40
Q

what is the summary management of gallbladder abscess?

A

Imaging with USS +/- CT scanning. Ideally, surgery although subtotal cholecystectomy may be needed if Calots triangle is hostile. In unfit patients, percutaneous drainage may be considered

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41
Q

what is the summary management of cholangitis?

A

Fluid resuscitation. Broad-spectrum IV antibiotics. Correct any coagulopathy. Early ERCP.

42
Q

what is the summary management of acalulous cholecysitis?

A

If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy.

43
Q

what is the summary management of gallstone ileus?

A

Laparotomy and removal of the gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and the duodenum should not be interfered with

44
Q

what are the complications of gallstones in the gallbladder and cystic duct?

A 
o	Biliary colic 
o	Acute and chronic cholecystitis
o	Mucocele
o	Empyema
o	Carcinoma 
o	Mirizzi’s Syndrome
45
Q

what are the complications of gallstones in the bile ducts?

A

o Obstructive jaundice
o Cholangitis
o Pancreatitis

46
Q

what are the complications of gallstones in the gut?

A

o Gallstone ileus

47
Q

what is the cause of acute cholecystitis?

A

Sustained impaction in gallbladder: either in Hartmann’s pouch or in the cystic duct.

48
Q

what are the clinical features of acute cholecytsitis?

A 
•	Continuous epigastric or RUQ pain 
o	May radiate to shoulder 
•	Vomiting
•	Fever
•	Local peritonism 
•	Gallbladder mass 
•	Differs from biliary colic with inflammatory component (local peritonism, fever, raised WCC)
•	Rebound tenderness
•	Positive Murphys
49
Q

what is the pathophysiology of acute cholecysitis?

A

trapped bile becomes concentrated causing chemical cholecystitis. This is first sterile but may become secondarily infected.

50
Q

what is a mucocele?

A

if stone impacts hartmans pouch when empty, gallbladder continues to secrete mucus

51
Q

what causes empyema of the gallbladder?

A

mucocele becoming secondarily infected

52
Q

what are the LFTS in acute cholecystitis?

A

• LFTs typically normal – (or serum bilirubin, Alk Phos, AMT may be slightly raised)

53
Q

what will a FBC in acute cholecystitis show?

A

Raised WCC, ESR, CRP

Raised serum amylase (if acute pancreatitis as complication)

54
Q

what imaging modalities are used for acute cholecystitis

A

US
AXR
Cholescintigraphy - HAD Scan

55
Q

what is the first line investigation for acute cholecystitis?

A

US

56
Q

what will US show in acute choelcystitis?

A

stones, mucus buildup and wall thickness

57
Q

what is the treatment of acute cholecystitis?

A
  • Pain relief
  • IVI
  • Cefuroxime
  • Laparoscopic cholecystectomy – acute or delayed
  • Open surgery if perforation
58
Q

what are the differentials of acute cholecystitis?

A
  • Acute appendicitis
  • Perforated duodenal ulcer
  • Acute pancreatitis
  • Right sided basal pneumonia
  • Coronary thrombosis
59
Q

what are the causes of chronic cholecystitis?

A
  • Gallstones

* Sometimes associated with GI malignancy

60
Q

what is the pathophysiology of chronic cholecystitis?

A

• Repeated episodes of infection result in chronic fibrosis and thickening of the entire gallbladder wall, which may contain thick, sometimes infected bile

61
Q

what are the clinical feature so chronic cholecystitis?

A

• Vague abdominal symptoms – nausea, pain, distension, flatulence, fat intolerance, IBS

62
Q

what is the imaging modalities used to diagnose chronic cholecystitis?

A
  • US

* MRCP

63
Q

what is the management of chronic cholecysitis?

A
  • Cholecystectomy

* If dilated CBD with stones – ERCP + sphincterotomy before surgery

64
Q

what are the differentials of chronic cholecystitis?

A
  • Peptic ulceration

* Hiatus hernia

65
Q

what are the clinical features of biliary colic?

A
  • Intermittent RUQ/epigastric
  • Radiates to back and right scapula
  • Particularly after large/fatty meal – 2/3 hours
  • Continuous pain, rising to plateaus
  • +/- jaundice
  • Nausea/vomiting in severe attacks
  • Begins evening, lasts until middle of night
66
Q

what is the cause of biliary colic

A

• Occurs when gallbladder contracts following cholecystokinin release by duodenum

67
Q

what determines if gallstones cause lab changes?

A

• Dependent on location – gallbladder/cystic duct won’t cause lab changes, common bile duct will

68
Q

what is the gold standard image modality for biliary colic?

A

US

69
Q

what imaging modalities can be used in the diagnosis of biliary colic?

A
  • US – gold standard
  • Plain AXR
  • Oral cholescystogrpahy
  • ERCP
70
Q

what is the management of asymptomatic gallstones?

A

None

71
Q

what is the treatment of active biliary colic

A
  • Morphine IV
  • Antiemetics
  • Elective Cholecystectomy
  • Open Cholecystectomy
  • Oral and extracorporeal shockwave lithotripsy therapies
72
Q

what is the cause of ascending cholangitis?

A
  • Gallstones
  • Primary sclerosing cholangitis
  • Carolis syndrome
73
Q

what is the pathophysiology of ascending cholangitis?

A
  • Infection of the biliary tree/bile duct by bacteria – e.coli
  • Prediposed by gallstone in common bile duct
  • Duct system severely inflamed and filled with pus - liver may be affected
74
Q

what is charcots triad?

A

RUQ, jaundice, rigors

75
Q

when is charcots triad present?

A

ascending cholangitis

76
Q

what are the clinical features of ascending cholangitis?

A
  • Charcots Triad – RUQ, jaundice, rigors

* Also fever

77
Q

what will bloods show in ascending cholangitis?

A

raised inflammatory markers

78
Q

what is the treatment of ascending cholangitis?

A
  • Antibiotics
  • Urgent biliary drainage
  • ERCP
79
Q

what is choledocholithiasis?

A

presence of gallstones in the common bile duct

80
Q

what are the causes of choledocholithiasis?

A
  • Gallstones

* Risk factor – duodenal diverticulum

81
Q

what are the clinical features of choledocholithiasis?

A
  • Murphys sign negative – distinguish from cholecystitis
  • Jaundice
  • If fever = ascending cholangitis
82
Q

what will the LFTS of choledocholithiasis show?

A

raised bilirubin and serum transaminase

83
Q

what may happen to the INR in choledocholithiasis?

A

alter

84
Q

what imaging should be done for choledocholithiasis?

A

MRCP or ERCP

85
Q

what is the first line treatment for choledocholithiasis?

A

Choledocholithotomy either ERCP or laparoscopy

86
Q

what is the second line treatment for choledocholithiasis?

A

cholecystectomy

87
Q

what are the symptoms of gallbladder polyps?

A

o Asymptomatic

o If close to Hartmann’s pouch – may produce symptoms similar to gallstones

88
Q

what is the management of a single gallbladder polyp?

A

Monitor and Cholecystectomy

89
Q

what is the management of multiple gallbladder polyps?

A

nothing

90
Q

what is the pathology of multiple gallstone polyps?

A

appearance of cholesterosis of gallbladder wall, no other significance

91
Q

what is the pathology of a single gallstone polyp?

A

premalignant – increased risk when size >1cm/1.5cm

92
Q

what is the cause of gallbladder carcinomas?

A

Chronic irritation or carcinogenic effect of cholic acid derivatives

93
Q

what are the different types of gallbladder carcinomas?

A

90% are adenocarcinomas, 10% squamous carcinomas

94
Q

what are clinical features of gallbladder carcinomas?

A

o Chronic cholecystitis – RUQ pain, N&V
o Weight loss and obstructive jaundice
o Palpable mass

95
Q

what is the management of low stage gallbladder carcinomas?

A

radical cholescysetcomy with associated liver resection and hilar lymphadectomy

96
Q

what is the management of late staged gallbladder carcinomas?

A

few surgical options and poor prognosis

97
Q

what is a cholangiocarcinoma?

A

carcinoma of the bile ducts

98
Q

what are the causes associated with cholangiocarcinoma?

A

IBD, sclerosing cholangitis, congenital hepatic fibrosis, choledochal cysts and polycystic liver

99
Q

what are the common sites of cholangiocarcinoma development?

A

left and right hepatic duct, common hepatic duct with cystic duct

100
Q

what are the clinical features of cholangiocarcinoma?

A

o Painless jaundice, dark urine and pale stools
o Epigastric pain, steatorrhea and weight loss
o Hepatomegaly

101
Q

what are the investigations for cholangiocarcinoma?

A

o MRCP
o Percutaneous transhepatic cholangiography and brush cytology
o Endoscopic ultrasound/CT guided needle biopsy

102
Q

what is the management of cholangiocarcinoma?

A

endoluminal stenting at ERCP or by percutaneous transhepatic cholangiography or surgical bypass

General Surgery (14 decks)

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