Liver Path 6 - Gallbladder Flashcards
The gallbladder stores and concentrates bile (~50 ml), but is not an essential orgen.
What supplies blood to the gallbladder?
What controls bile flow?
- Blood supply is from the cystic artery
- Bile flow is a consequence of the activity of smooth muscle in the gallbladder and the sphincter of Oddi
What percentage of biliary tract disease is attributable to gallstones?
over 95%
What is the primary site of gallstone impaction?
The rapid tapering of the gallbladder neck just proximal to the cystic duct.
On histological exam you will notice that the gallbladder differs from the remainder of the GI tract in that it lacks a discrete muscularis mucosae and submucosa.
Identify the indicated structures.
Upper arrow = single smooth muscle layer and subserosal soft tissue.
Lower arrow = Absorptive columnar epithelium of the mucosa
Gallbladder congenital anomalies can arise in the form of:
Shape
Number
Position
Give some examples of each.
Shape
- angulations (phrygian cap)
- septation
Number
- Agenesis
- duplication
Position
- Intrahepatic (most common aberrent location)
- Falciform ligament location
This asymptomatic 2nd year med student was practicing ultrasound on himself when he found the attached image. Concerned he asks you what you think is going on.
You, being a jerk answer… “ooh that looks like gallstones for sure.” Before telling him that you’re kidding and that it actually is?
A phyrigian cap denotes folding of the fundus back upon the gallbladder body.
•Although clinically unimportant, it may be mistaken on ultrasound examination for septation or possibly stone
What are the major components of bile?
Bile salts - chenodeoxycholates
Cholates - yeah I read it as chocolates first too.
deoxycholates
phospholipids
Cholelithiasis impacts 10-20% of the adult population in the developed world.
What are four major risk factors?
- obesity
- female sex [F:M 2:1]
- estrogens, oral contraceptives, pregnancy
- age (middle age and older)
What are the two general classes of gallstones?
Do they show up on xray?
- cholesterol stones (~75%) radiographically opaque
- pigment stones usually radiographically opaque (calcium salts of unconjugated bilirubin)
15-20% per radiopaedia
“Who ya gonna trust?”
What symptoms do most gallstones present with?
Vast majority (75-80%) are silent.
Although the most frequent outcome is for the patient with a gallstone to remain asymptomatic throughout life, some do develop symptoms.
What are 4 of the most common complications?
- Biliary pain
- Acute cholecystitis
- Cholangitis
- Pancreatitis
Surgical tx of asymptomatic gallstones is discouraged. In what patients is surgery recommended?
3
- Patients with large gallstones greater than 2 cm in diameter
- Patients with nonfunctional or calcified (porcelain) gallbladder observed on imaging studies and who are at high risk of gallbladder carcinoma
- Patients with sickle cell anemia in whom the distinction between painful crisis and cholecystitis may be difficult
Patients with risk factors for complications of gallstones may be offered elective cholecystectomy. What are some examples of these risk factors?
- •Cirrhosis
- •Portal hypertension
- •Children
- •Transplant candidates
- •Diabetes with minor symptom
In what populations are the prevalence rates of gallstones highest?
What american population has the lowest?
Highest
- Native americans - females in particular
- Chileans
- Hispanic americans
Lowest
- Lowest in black Americans
What is shown on this imaging study?
Cholelithiasis
What is shown in this image?
Cholesterolosis - sometimes referred to as “strawberry gallbladder”
What precipitates acute cholecystitis in 90% of cases?
Obstruction of the neck or the cystic duct by a stone.
What are two possible presentations of acute calculous cholecystitis?
- Acute surgical emergency
- Mild symptoms that spontaneously resolve
Is the incidence of gangrene and perforation of the gallbladder higher in acalculous or calculous acute cholecystitis?
Acalculous - more insidious presentation
What is acute acalculous cholecystitis thought to result from?
Ischemia - cystic artery is an end artery with no collateral circulation
What are five risk factors associated with acalculous cholecystitis?
- sepsis with hypotension and multisystem organ failure
- immunosuppression
- major trauma and burns
- diabetes mellitus
- infections
Acute cholecystitis may present with epigastric or right upper quadrant pain 1-2 hours after ingestion of a fatty meal.
What is a major complication in 10-15% of cases?
What do most authorities agree is the role of infection in the onset of acute cholecystitis?
- Major complication in ~10-15% cases is acute gangrenous cholecystitis (may perforate)
- Most authorities agree that infection is secondary and does not contribute to the onset of acute cholecystitis.
In acute cholecystitis, the gallbladder is enlarged, edematous and congested. What is the histologic hallmark of acute cholecystitis?
Presence of neutrophils in the gallbladder mucosa and wall
In acute cholecystitis, the mucosa is often, but not invariably ulcerated. If obstruction of the cystic duct results in frank pus in the lumen of the gallbladder, what do we call this?
What is usually present in the bile in this situation?
Empyema of the gallbladder
Enteric organisms
If there is extensive necrosis of the gallbladder wall, usually accompanied by a marked acute inflammatory infiltrate, we term this?
Gangrenous cholecystitis
What does emphysematous cholecystitis result from?
How do we identify this?
- Infection of the gallbladder by gas-forming bacterial species such as Clostridium.
- Air-fluid levels in the gallbladder may be visualized with radiographic studies.
This gallbladder was taken from an 11 y/o patient with DM I. Radiographic studies showed increased air:fluid ratio in the gallbladder. What does this kid have?
The gross specimen suggests what would have been an consequence soon seen?
Histopathology shows emphysematous cholecystitis with impending perforation in 11-year-old child with insulin-dependent diabetes mellitus
Commonly isolated organisms in cases of emphysematous cholecystitis include Clostridium welchii/perfingrens, Escherichia coli and Bacteroides fragilis.
How is this type of cholecystitis different in terms of progression and outcomes?
Much higher rates of gangrene and perforation of the gallbladder and significantly increased rates of mortality (15-25%).
What do the radiographic findings taken from this patient with RUQ pain indicate?
Acute emphysematous cholecystitis - note the Increased air:fluid levels, and presence of “signal void bubbles” in the lumen of the distended gallbladder and the common bile duct.
What does the histology indicate was happening in this patient who had RUQ pain?
This image shows the hallmark of acute cholecystitis: a neutrophilic infiltrate in the mucosa. Inflammation may also be seen in the deeper layers of the gallbladder wall.
Chronic cholecystitis presents with recurrent attacks of either steady epigastric or right upper quadrant pain (usually onset in 50s). Nausea, vomiting, and intolerance for fatty foods are frequent accompaniments. Chronic cholecystitis can be a sequel to acute cholecystitis, but often presents without a history of earlier attacks
What are histologic findings in chronic cholecystitis associated with the following?
- Subserosa
- Wall
- Mucosa
- Other general findings
- subserosal fibrosis
- wall is variably thickened
- mucosa itself is generally preserved
- fibrous adhesions
The pathological findings in chronic cholecystitis include, subserosal fibrosis to dense fibrous adhesions, chronic inflammation, fibrosis, metaplasia of gallbladder mucosa.
What are two other findings that can be found in these cases?
- Dystrophic calcification (porcelain gallbladder)
- Associated with increased risk of carcinoma
- Rokitanansky-Ashoff sinuses
What the hell are Rokitanansky-Ashoff sinuses?
•Outpouchings of the mucosal epithelium into the wall (Rokitanansky-Ashoff sinuses)
What does this tissue sample from a patient with chronic cholecystitis reveal?
Rokitansky–Aschoff sinus
This tissue sample was taken from a patient with chronic cholecystitis, what characteristics shown here are indicative of chronic cholecystitis?
Diffuse lymphoid hyperplasia with germinal center formation
This slide also reveals a classic characteristic of chronic cholecystitis. What does it show?
Gastric metaplasia of gallbladder mucosa
Choledocholithiasis involves common bile duct stones and is a challenging diagnosis. Like stones in the gallbladder, stones in the bile ducts may remain asymptomatic for years.
What is the classic presentation?
Charcot’s triad
- Abdominal pain (RUQ presumably)
- Fever
- Jaundice
Choledocholitiases are usually brown and d/t biliary tract infections. Where do they typically come to rest/get stuck at?
Lower end of the ampula of vater
Bacterial infection by what types of organisms is typically the cause of choledocholithiasis?
Gram-negative rods
The gallbladder lesion shown here occurs in the 7th or 8th decade typically and impacts females more frequently.
While rare, this is the most common gallbladder neoplasm.
What is it?
What is the prognosis?
Adenocarcinoma of the gallbladder
•Infrequently diagnosed pre-op or when resectable, so terrible prognosis, 5-10% 5 year survival.
What is an association we should know regarding carcinoma of the gallbladder?
Usually associated with gallstones
Adenocarcinoma of the gallbladder is the most common malignancy of the extra hepatic biliary tract, and over 95% of the time is associated with gallstones.
The most common symptoms/signs are abdominal pain and elevated serum alkaline phosphatase.
How does this often present clinically?
Many gallbladder adenocarcinomas present as cholecystitis and are clinically silent.
Most patients with carcinoma of the gallbladder present with high pathologic stage adenocarcinoma and spread to the liver at time of diagnosis. What variant has the best overall prognosis?
Papillary variant
Carcinoma of the gallbladder are usually scirrhous. What does that mean?!!
Associated with dense fibrosis
What are some less common types of gallbladder cancer?
SCC
Carcinoid
Carcinosarcoma
What is shown in this image?
Small primary gallbladder adenocarcinoma with massive direct liver invasion.
What do you see in these histo images that indicates this patient has an adenocarcinoma of the gallbladder?
Upper two arrows: malignant cells forming glands
Lower two arrows: presence of dense fibrosis
