Liver Path 6: Gallbladder Flashcards
Gallbladder
Gallbladder is not essential
Blood supply is from the cystic artery
Stores and concentrates bile (~50 ml)
Bile flow is a consequence of the activity of smooth muscle in the gallbladder and the sphincter of Oddi
Gallbladder Congenital Anomalies
Shape
- Angulations (Phrygian cap) (incidence 4%, most common)
- Septation
Number
- Agenesis
- Duplication
Position (5-10% of population)
- Intrahepatic (most common aberrent location)
- Falciform ligament location
Cholelithiasis
10-20% of adult population in developed world
Risk factors
- obesity
- female sex [F:M 2:1]
- estrogens, oral - contraceptives, pregnancy
- age (middle age and older)
Two general classes of gallstones
- cholesterol stones (~75%)
- pigment stones (calcium salts of unconjugated bilirubin)
Only 15-20% of gallstones are radiopaque
Natural History and Complications of Gallstones
Complications
Asymptomatic (75%)
Biliary pain (obstruction)
Cholecystitis
Pancreatitis
Ascending Cholangitis
Fistula
Gall Bladder Carcinoma
Treatment of Asymptomatic Gallstones
Surgical treatment of asymptomatic gallstones is discouraged.
The risk of complications arising from interventions is higher than the risk of symptomatic disease
Approximately 25% of patients with asymptomatic gallstones develop symptoms within 10 years.
Cholecystectomy for asymptomatic gallstones may be indicated in the following patients:
With large gallstones greater than 2 cm in diameter
With nonfunctional or calcified (porcelain) gallbladder 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
Cirrhosis
Portal hypertension
Children
Transplant candidates
Diabetes with minor symptom
Acute Cholecystitis
precipitated in 90% of cases by obstruction of the neck or the cystic duct by a stone.
can present as an acute surgical emergency or present with mild symptoms that spontaneously resolve
incidence of gangrene and perforation is much higher in acalculous (than in calculous cholecystitis (more insidious presentation)
acute cholecystitis symptoms
Epigastric or right upper quadrant pain (usually onset >50 years) 1-2 hours after ingestion of a fatty meal
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.
Pathology of Acute Cholecystitis
Gallbladder is enlarged, edematous, and congested
Histologic hallmark of acute cholecystitis is the presence of neutrophils in the gallbladder mucosa and wall
Mucosa is often but not invariably ulcerated
Changes of chronic cholecystitis are noted in many cases
who’s at risk for emphysematous acute cholecystitis?
children with type I diabetes
Acute Cholecystitis histology
The hallmark of acute cholecystitis is a neutrophilic infiltrate in the mucosa. Inflammation may also be seen in the deeper layers of the gallbladder wall.
Chronic Cholecystitis
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
Pathology of Chronic Cholecystitis
Subserosal fibrosis to dense fibrous adhesions
Chronic inflammation
Fibrosis
Metaplasia of gall bladder mucosa
Dystrophic calcification (porcelain gallbladder) Associated with increased risk of carcinoma
Outpouchings of the mucosal epithelium into the wall (Rokitanansky-Ashoff sinuses) *
Chronic Cholecystitis
histology
Diffuse lymphoid hyperplasia with germinal center formation
Choledocholithiasis- general
- Common bile duct stones challenging diagnosis
Like stones in the gallbladder, stones in the bile ducts may remain asymptomatic for years
Complications of choledocholithiasis are obstructive jaundice, gallstone pancreatitis and acute cholangitis
- Classic presentation: fever, jaundice, and abdominal pain (Charcot’s triad)
Jean-Martin Charcot
Father of French neurology
Charcot disease
(better known as amyotrophic lateral sclerosis or Lou Gehrig disease)
Charcot’s triad
Choledocholithiasis- what’s happening
Stones usually brown and due to biliary tract infections.
Stones in the bile duct usually come to rest at the lower end of the ampulla of Vater
Bacterial infection from GI tract via ampulla of Vater usually gram-negative rods
Key Concepts (Robbins)- diseases of the gallbladder
Gallbladder diseases include cholelithiasis and acute and chronic cholecystitis and gall bladder cancer.
Gallstones are common in Western countries. The great majority are cholesterol stones. Pigmented stones containing bilirubin and calcium are most common in Asian countries.
Risk factors for the development of cholesterol stones are advancing age, female gender, estrogen use, obesity, and heredity.
Cholecystitis almost always occurs in association with cholelithiasis, although in about 10% of cases it occurs in the absence of gallstones. Gall stones are also a risk factor for gall bladder cancer.
Acute calculous cholecystitis is the most common reason for emergency cholecystectomy.
Gall bladder cancers are associated with gall stones in the vast majority of cases. Typically they are detected late because of non specific symptoms and hence carry a poor prognosis
Carcinoma of the Gallbladder
Rare, but most common gallbladder neoplasm
F > M, peaks in 7th-8th decade
Usually associated with gallstones
Infrequently diagnosed pre-op or when resectable
Pathology: adenocarcinoma
Terrible prognosis; 5-10% 5 year survival
Carcinoma of the Gallbladder signs and symptoms
Most common malignancy of the extra hepatic biliary tract, usually adenocarcinoma
95% are associated with gallstones
Most common symptoms/signs are a for abdominal pain and elevated serum alkaline phosphatase
Infrequently diagnosed pre-op or when resectable
Carcinoma of Gallbladder Pathology
Most patients present with high pathologic stage adenocarcinoma (liver spread is usually evident at time of diagnosis)
Papillary variant has best overall prognosis
Less common carcinoma variants include squamous cell carcinoma (5%) and rarely carcinoid or carcinosarcoma
