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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
what is the result of increased pressure in the bile duct?
bile seeps out and into bloodstream = increased serum conjugated bilirubin, and increased ALP (from cell damage)
26
what is Mirizzi Syndrome?
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
27
what is gallstone ileus?
impaction of the stone in the narrowest part of the small bowel (the distal ileum) with resulting intestinal obstruction
28
what causes a gallstone ileus?
a large gallstone ulcerates through the wall of the gallbladder into the adjacent duodenum
29
what is the key feature of gallstone ileus?
presence of air in the biliary tree that has entered the bile ducts via the fistula - seen on CT
30
what are the common clinical manifestations of gallstones?
* Acute Cholecystitis * Chronic Cholecystitis * Biliary Colic * Cholangitis
31
what are the other clinical manifestations of gallstones?
``` o Obstructive jaundice with CBD stones o Gallstone ileus o Pancreatitis o Mucocele-empyema o Mirizzi’s Syndrome o Gallbladder perforation ```
32
what are the summary features of biliary colic?
Colicky abdominal pain, worse postprandially, worse after fatty foods
33
what are the summary features of acute cholecystitis?
Right upper quadrant pain, fever, murphy’s sign on examination. Occasionally mildly deranged LFTs (especially if Mirizzi syndrome)
34
what are the summary features of gallbladder abscess?
Usually prodromal illness and RUQ pain. Swinging pyrexia. Patient may be systemically unwell. Generalised peritonism not present
35
what are the summary features of cholangitis?
Patient severely septic and unwell. Jaundice. RUQ pain.
36
what are the summary features of gallstone ileus?
Patients may have a history f previois cholecystitis and known gallstones. Small bowel obstruction (may be intermittent)
37
what are the summary features of Acalulous Cholecystitis?
Patients with intercurrent illness (.e.g. diabetes, organ failure). Patient of systemically unwell Gallbladder inflammation in abdence of stones, high fever
38
what is the summary management of biliary colic?
If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
39
what is the summary management of acute cholecystitis?
Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation)
40
what is the summary management of gallbladder abscess?
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
41
what is the summary management of cholangitis?
Fluid resuscitation. Broad-spectrum IV antibiotics. Correct any coagulopathy. Early ERCP.
42
what is the summary management of acalulous cholecysitis?
If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy.
43
what is the summary management of gallstone ileus?
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
what are the complications of gallstones in the gallbladder and cystic duct?
``` o Biliary colic o Acute and chronic cholecystitis o Mucocele o Empyema o Carcinoma o Mirizzi’s Syndrome ```
45
what are the complications of gallstones in the bile ducts?
o Obstructive jaundice o Cholangitis o Pancreatitis
46
what are the complications of gallstones in the gut?
o Gallstone ileus
47
what is the cause of acute cholecystitis?
Sustained impaction in gallbladder: either in Hartmann’s pouch or in the cystic duct.
48
what are the clinical features of acute cholecytsitis?
``` • 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
what is the pathophysiology of acute cholecysitis?
trapped bile becomes concentrated causing chemical cholecystitis. This is first sterile but may become secondarily infected.
50
what is a mucocele?
if stone impacts hartmans pouch when empty, gallbladder continues to secrete mucus
51
what causes empyema of the gallbladder?
mucocele becoming secondarily infected
52
what are the LFTS in acute cholecystitis?
• LFTs typically normal – (or serum bilirubin, Alk Phos, AMT may be slightly raised)
53
what will a FBC in acute cholecystitis show?
Raised WCC, ESR, CRP | Raised serum amylase (if acute pancreatitis as complication)
54
what imaging modalities are used for acute cholecystitis
US AXR Cholescintigraphy - HAD Scan
55
what is the first line investigation for acute cholecystitis?
US
56
what will US show in acute choelcystitis?
stones, mucus buildup and wall thickness
57
what is the treatment of acute cholecystitis?
* Pain relief * IVI * Cefuroxime * Laparoscopic cholecystectomy – acute or delayed * Open surgery if perforation
58
what are the differentials of acute cholecystitis?
* Acute appendicitis * Perforated duodenal ulcer * Acute pancreatitis * Right sided basal pneumonia * Coronary thrombosis
59
what are the causes of chronic cholecystitis?
* Gallstones | * Sometimes associated with GI malignancy
60
what is the pathophysiology of chronic cholecystitis?
• Repeated episodes of infection result in chronic fibrosis and thickening of the entire gallbladder wall, which may contain thick, sometimes infected bile
61
what are the clinical feature so chronic cholecystitis?
• Vague abdominal symptoms – nausea, pain, distension, flatulence, fat intolerance, IBS
62
what is the imaging modalities used to diagnose chronic cholecystitis?
* US | * MRCP
63
what is the management of chronic cholecysitis?
* Cholecystectomy | * If dilated CBD with stones – ERCP + sphincterotomy before surgery
64
what are the differentials of chronic cholecystitis?
* Peptic ulceration | * Hiatus hernia
65
what are the clinical features of biliary colic?
* 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
what is the cause of biliary colic
• Occurs when gallbladder contracts following cholecystokinin release by duodenum
67
what determines if gallstones cause lab changes?
• Dependent on location – gallbladder/cystic duct won’t cause lab changes, common bile duct will
68
what is the gold standard image modality for biliary colic?
US
69
what imaging modalities can be used in the diagnosis of biliary colic?
* US – gold standard * Plain AXR * Oral cholescystogrpahy * ERCP
70
what is the management of asymptomatic gallstones?
None
71
what is the treatment of active biliary colic
* Morphine IV * Antiemetics * Elective Cholecystectomy * Open Cholecystectomy * Oral and extracorporeal shockwave lithotripsy therapies
72
what is the cause of ascending cholangitis?
* Gallstones * Primary sclerosing cholangitis * Carolis syndrome
73
what is the pathophysiology of ascending cholangitis?
* 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
what is charcots triad?
RUQ, jaundice, rigors
75
when is charcots triad present?
ascending cholangitis
76
what are the clinical features of ascending cholangitis?
* Charcots Triad – RUQ, jaundice, rigors | * Also fever
77
what will bloods show in ascending cholangitis?
raised inflammatory markers
78
what is the treatment of ascending cholangitis?
* Antibiotics * Urgent biliary drainage * ERCP
79
what is choledocholithiasis?
presence of gallstones in the common bile duct
80
what are the causes of choledocholithiasis?
* Gallstones | * Risk factor – duodenal diverticulum
81
what are the clinical features of choledocholithiasis?
* Murphys sign negative – distinguish from cholecystitis * Jaundice * If fever = ascending cholangitis
82
what will the LFTS of choledocholithiasis show?
raised bilirubin and serum transaminase
83
what may happen to the INR in choledocholithiasis?
alter
84
what imaging should be done for choledocholithiasis?
MRCP or ERCP
85
what is the first line treatment for choledocholithiasis?
Choledocholithotomy either ERCP or laparoscopy
86
what is the second line treatment for choledocholithiasis?
cholecystectomy
87
what are the symptoms of gallbladder polyps?
o Asymptomatic | o If close to Hartmann’s pouch – may produce symptoms similar to gallstones
88
what is the management of a single gallbladder polyp?
Monitor and Cholecystectomy
89
what is the management of multiple gallbladder polyps?
nothing
90
what is the pathology of multiple gallstone polyps?
appearance of cholesterosis of gallbladder wall, no other significance
91
what is the pathology of a single gallstone polyp?
premalignant – increased risk when size >1cm/1.5cm
92
what is the cause of gallbladder carcinomas?
Chronic irritation or carcinogenic effect of cholic acid derivatives
93
what are the different types of gallbladder carcinomas?
90% are adenocarcinomas, 10% squamous carcinomas
94
what are clinical features of gallbladder carcinomas?
o Chronic cholecystitis – RUQ pain, N&V o Weight loss and obstructive jaundice o Palpable mass
95
what is the management of low stage gallbladder carcinomas?
radical cholescysetcomy with associated liver resection and hilar lymphadectomy
96
what is the management of late staged gallbladder carcinomas?
few surgical options and poor prognosis
97
what is a cholangiocarcinoma?
carcinoma of the bile ducts
98
what are the causes associated with cholangiocarcinoma?
IBD, sclerosing cholangitis, congenital hepatic fibrosis, choledochal cysts and polycystic liver
99
what are the common sites of cholangiocarcinoma development?
left and right hepatic duct, common hepatic duct with cystic duct
100
what are the clinical features of cholangiocarcinoma?
o Painless jaundice, dark urine and pale stools o Epigastric pain, steatorrhea and weight loss o Hepatomegaly
101
what are the investigations for cholangiocarcinoma?
o MRCP o Percutaneous transhepatic cholangiography and brush cytology o Endoscopic ultrasound/CT guided needle biopsy
102
what is the management of cholangiocarcinoma?
endoluminal stenting at ERCP or by percutaneous transhepatic cholangiography or surgical bypass

General Surgery (14 decks)

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