Pathology of the Gallbladder Flashcards
Cholecystitis
Cholecystitis is an inflammation of the gallbladder and has a few forms that we will be covering: Acute cholecystitis Acute acalculous cholecystitis Chronic cholecystitis Emphysematous cholecystitis Gangrenous cholecystitis
S&S depend on type …
What are the signs and symptoms of Cholecystitis
S&S:
Sharp or dull pain in RUQ and/or epigastric area (Murphy’s sign)
Referred pain in or below right shoulder (diaphragm irritation)
Nausea and vomiting
Fever or chills
Chronic diarrhea (non-acute disease)
Jaundice
Unusual stools (clay-coloured) or urine
Above symptoms after fatty meal or at night
Acute Cholecystitis
Acute cholecystitis is usually caused by calculi blocking either the gallbladder neck, cystic duct, or CBD. Can also be caused by other obstructions to the flow of bile.
Clinical Presentation: Acute RUQ pain Fever Leukocytosis Increased serum bilirubin and ALP levels
Ultrasound Presentation: Gallbladder wall > 3mm Distended gallbladder lumen > 4cm Gallstones Positive Murphy’s sign Increased colour Doppler flow in GB wall Pericholecystic fluid collection Impacted stone in GB neck, Hartmann’s pouch, or the cystic duct
Acute Acalculous Cholecystitis
Consists of about 10% of all cases of acute cholecystitis.
The main cause of acalculous cholecystitis is gallbladder dysfunction or stasis with stagnant bile. More common in ill hospital patients (ICU), AAC is a life-threatening condition with a high risk of perforation and necrosis compared to cholecystitis involving calculi.
Clinical Presentation: same as for acute cholecystitis but without the elevated serum bilirubin and ALP levels. Why?
Ultrasound Presentation: Gallbladder wall > 3mm Distended gallbladder lumen > 4cm Positive Murphy’s sign Increased colour Doppler flow in GB wall Pericholecystic fluid collection
Chronic Cholecystitis
- Gallbladder is damaged by repeated attacks of acute inflammation
- Repeated attacks of acute cholecystitis and RUQ pain as the calculi occlude the cystic duct or neck
- GB appearance may be thick-walled, scarred, and smaller in size
Note: lack of or minimal pericholecystic fluid
Emphysematous Cholecystitis
- Severe form of acute cholecystitis
- Life-threatening anaerobic infection
- Can be rapidly fatal – 15-20% mortality rate c.f. 1% for acute cholecystitis
- Associated with the presence of gas-forming bacteria
- Increased risk of gangrene of the GB wall and subsequent perforation
- Surgical emergency
Ultrasound Presentation:
- Air in the wall or lumen of the GB, in tissue adjacent to GB, or in the biliary ducts
- If air is within the gallbladder, it can appear like a WES sign. However, it does ‘rise to the top’ so you can move the patient on their side and check to see if the gas has moved position.
- If air is intraluminal, you see bright echoes with ringdown artefact
Gangrenous Cholecystitis
- Acute surgical emergency requiring cholecystectomy
- Serious complication of acute cholecystitis
- Marked distention of GB wall leads to increased tension
- Inflammation leads to progressive vascular insufficiency
- Necrosis and perforation of the gallbladder wall
- RUQ pain may not be present in 2/3 of patients due to denervation of GB wall due to necrosis
Ultrasound Presentation:
Thickened gallbladder wall with de-lamination
Decreased blood flow in walls on colour Doppler
Irregular gallbladder mucosal layer outline
Gas within the gallbladder
May have an absence of calculi
Large pericholecystic collection
Cholestasis
Cholestasis is when bile flow ceases or reduces significantly. Causes can include the following: Acute hepatitis Alcoholic liver disease Liver metastases Cirrhosis due to viral Hep B or C Blockage to bile duct (e.g. calculus, cholangiocarcinoma) Primary biliary cholangitis Pancreatic adenocarcinoma Pancreatitis Some drugs (e.g. amoxicillin/clavulanate, oral contraceptives) Cholestasis of pregnancy
S&S: Jaundice – skin and eyes Dark urine Light-coloured stools Generalised itching all over the skin
May present with the following (depending on cause of cholestasis): Abdominal pain Loss of appetite Vomiting Fever
Biliary sludge
Sludge, or thickened bile, frequently occurs from bile stasis.
May be seen in patients with prolonged fasting, pregnancy, and with obstruction of the gallbladder.
Cholelithiasis
- Single, large gallstone or multiple tiny stones
- Patients often fall under the category of the Five F’s: Fat, Female, Forty, Fertile, and Fair
- Other risk factors include pregnancy, diabetes, oral contraceptive use, cholesterol lowering medication, rapid weight loss, very low fat diets, over 60, hypothyroidism, and family history.
- Whether gallstones cause symptoms or not partially depends on their size
- Gallstones that stay within the gallbladder are relatively uncomplicated – may experience pain associated with a fatty meal as the GB contracts if taking up a big volume of space
- Larger stones can get impacted in the neck of the GB if they happen to be situated there and the GB contracts – Mirizzi syndrome (positive Murphy’s sign, severe RUQ pain)
Porcelain gallbladder
- Calcifications within the gallbladder wall
- Usually consists of diffuse intramural calcifications
- Low association with gallbladder carcinoma in recent articles (6%)
S&S:
Often non-specific symptoms
Abdo pain
May have nausea and vomiting, jaundice, and/or fever
Gallbladder adenocarcinoma
Makes up about 85% of all GB cancers
Develop within the mucous membranes in the gallbladder
Gallbladder cancer is uncommon overall but needs to be considered for DDx
People with a Hx of gallstones and inflammation of GB more likely to develop GB adenocarcinoma
FHx GB cancer increases risk 5-fold
S&S same as most other GB pathology
Wall Thickening
- May be acute and inflammatory, or chronic with minimal inflammation
- Already seen in a lot of the conditions discussed in this lecture and the last one
Causes: Ascites Gallbladder wall abscess Hepatitis and cirrhosis Right heart failure Renal failure Multiple myeloma Portal node lymphatic obstruction Hypoalbuminaemia
Gallbladder Polyps
Three types of gallbladder polyps:
- Pseudopolyps or “cholesterol polyps” – 60-90% of all GB polyps, cholesterol-filled growths, often accompanying other GB pathology (e.g. CC), benign
- Inflammatory polyps – 5-10% of all GB polyps, extensions of inflamed GB wall, usually found in ppl who have experienced cholecystitis >1x or who have acute biliary colic, benign
- True gallbladder polyps – rare, may become malignant, usually measure 5-20mm, cholecystectomy recommended when large polyps present
Adenomyomatosis
Most patients are over 40 years old
3:1 ratio female to male
Hyperplasia of the gallbladder wall
Formation of Rokitansky-Aschoff sinuses – intramural diverticula lined by mucosal epithelial cells
Crystals form in the RA sinuses – comet-tail artefact
Unknown cause
Incidental finding, no treatment required
