Pathology of Biliary Diseases Flashcards
Outline the clinical presentation of someone with cholelithiasis.
Steady pain - character varies based on position
- Patient moves - seeks position of relief
Describe pathogenesis of cholelithiasis
Intermittent pain (based on muscle contraction)
List 5 risk factors for cholelithiasis.
- Fat
- Fertile
- Forty
- Female
- Familial
Describe cholesterol stones.
- Usually stones are of mixed composition - rarely pure cholesterol
- Stones contain CH, calcium carbonate, some bilirubin pigment.
- Can be radiopaque if they contain calcium carbonate
- CH stones are radiolucent.
Describe pigment gallstones
- Develop when increased unconjugated bilirubin
- Composed of calcium bilirubinate (calcium salts of unconjugated bilirubin) + calcium carbonate + less than 20% of cholesterol
Describe black pigment stones.
- Sign of chronic extravascular hemolytic anemia e.g sickle cell anemia, hereditary spherocytosis
- Excess CB in bile is converted into UCB, which combines with calcium to produce calcium bilirubinate stones (black pigment stones).
Describe brown pigment stones.
- Sign of infection in the CBD
- Commonly seen in Asians
- Infection deconjugates CB, which increases UCB in bile and causes the brown pigment stones.
List some risk factors for cholelithiasis.
- Advanced age
- Increased female hormone production
- Genetics
- Metabolic abnormalities
Describe cholelithiasis pathogenesis.
- Increased biliary cholesterol secretion/cholesterol synthesis
- Cholesterol precipitation
- Nucleation
- Cholesterol and pigment accumulation
- Stone enlargement
List some sites of cholelithiasis
Gallbladder
Common hepatic or bile ducts (latter leads to obstructive jaundice)
Cystic duct
What do cholesterol stones look like?
- Large, smooth, yellowish, and radiolucent.
- Cross-section has a radial pattern.
- Cholesterol pigment gallstones are metabolic calculi.
- Cross section shows a pattern of layered rings of yellow, brownish black, and white material.
What do black pigment stones look like?
- Stones are radiolucent.
- Hemolytic calculi.
- Small, mulberry-shaped, multiple, black, and radiolucent.
- Brown pigment gallstones are cholangitis calculi. They are ellipsoid-to-cylindrical, crumbly, and earthy.
Describe the complications of gallstones.
- Obstructive jaundice - from common bile duct obstruction. Raised blood cholesterol and bilirubin
- Ascending cholangitis - secondary bacterial infection from obstructed bile flow
- Pancreatitis
- Gallstone ileus
- Mucocele
- Malignancy
What is meant by mucocele?
- Hydrops of gallbladder
- Chronic obstruction of cystic duct leads to resorption of normal gallbladder contents and production of large amounts of clear fluid
Describe clinical presentation of acute cholecystitis
- Oedema and inflammation
- Patient lies motionless - minor movements exacerbate pain
- Nausea
What is acute cholecystitis?
- Acute inflammation of the gallbladder
- Usually caused by cystic duct obstruction by gallstones.
- Biliary colic, right upper quadrant tenderness on palpation, nausea and vomiting, low-grade fever, and leukocytosis
- Inflammation - fibrinous due to ulceration
Describe the outcome and complications of acute cholecystitis
- Mild cases - Resolution
- Recurrent attack - becomes chronic
- Severe - empyema (fills with pus) and perforation (can lead to peritonitis)
Describe chronic cholecystitis
Chronic inflammation of the gallbladder, usually caused by gallstones
Describe gross and microscopic findings in chronic cholecystitis.
- Thickened and fibrosed walls
- Presence of inflammatory cells
- Hypertrophy of muscle fibres
- Packed with gallstones
- Ulceration and haemorrhage
- Mucosal diverticula herniation through muscular layer (R-A sinuses)
What is the most common type of gallbladder cancer?
ADENOCARCINOMA
Describe adenocarcinoma of the gallbladder.
- Arises in fundus and diffuse infiltration without symptoms until at advanced stage
- 75% of cases have gallstones
- Most common when age in 60s-70s, elderly women
- Prognosis usually poor
Describe microscopic appearance of adenocarcinoma.
- Varying degrees of differentiation.
- Well-differentiated carcinomas consist of well-formed glands lined by a layer of cuboidal cells and often embedded in a desmoplastic stroma.
What sort of lining does the gallbladder have?
GLANDULAR
