SM_153: Pathology of the Gallbladder and Biliary Tract Flashcards
Describe intrahepatic flow of bile
Intrahepatic flow of bile
- Bile canaliculi
- Bile ductules
- Septal ducts
- Left and right hepatic ducts
Descibe extrahepatic flow of bile
Extrahepatic flow of bile
- Left and right hepatic ducts
- Common hepatic duct and cystic duct
- Common bile duct
Bile is synthesized in the ____, stored in the ____, and secreted into the ____
Bile is synthesized in the liver, stored in the gallbladder, and secreted into the duodenum
- Lipid digestion and absorption
- Absorption / recycling of lipid soluble materials
- Process lipid-soluble waste for excretion: bilirubin, cholesterol, xenobiotics, heavy metals
- Most water, also inorganic electrolyes and organic solutes
Describe pathway of bilirubin
Bilirubin
- Breakdown of heme into bilirubin
- Extrahepatic bilirubin bound to albumin
- Hepatocellular uptake
- Glucuronidation (water soluble) -> excreted into bile
- Gut bacteria deconjugate the bilirubin -> colorless urobilinogens -> feces (some reabsorption and excretion into urine)
Cholestasis is ____
Cholestasis is when bile cannot flow from liver to duodenum
- Intrahepatic
- Extrahepatic
Cholestasis results in ____, ____, ____, and ____
Cholestasis results in
- Retention of pruritogens (bile acids) -> pruritis
- High serum bilirubin and serum lipids -> jaundice xanthomas
- Reduced / no bile acid entry into the intestine -> malabsorption of fat and fat soluble vitamins (ADEK)
- Hepatic accumulation of copper, bile acids, other compounds -> liver damage
These are ____
These are bile plugs
Two autoimmune disorders of bile ducts are ____ and ____
Two autoimmune disorders of bile ducts are primary biliary cholangitis (primary biliary cirrhosis) and primary sclerosing cholangitis
- Primary biliary cholagnitis is intrahepatic
- Primary sclerosing cholangitis is extraheptic
Primary biliary cholangitis is ____
Primary biliary cholangitis is autoimmune destruction of small intraheptic bile ducts
- Inflammation and fibrosis
- Decreases bile flow (obstructive)
- Anti-mitochondrial autoantibody in 90-95%
- Symptoms: pruritis, jaundice, and xanthomas
Anti-mitochondrial autoantibody indicates ____
Anti-mitochondrial autoantibody indicates primary biliary cholangitis
- Elevated alkaline phosphatase, gamma glutamyltranspeptidase, bilirubin, immunoglobulins (IgM)
Pruritis, jaundice, and xanthomas is ___
Pruritis, jaundice, and xanthomas is primary biliary cholangitis
Describe stages of primary biliary cholangitis on histology
Primary biliary cholangitis stages on histology
- Florid duct lesions: lymphoplasmacytic inflammation with or without granulomas
- Ductular proliferations
- Fibrosis / scarring
- Cirrhosis
This is ___
This is primary biliary cholangitis
(bile plugs)
Primary sclerosing cholangitis involves ____ that leads to ____
Primary sclerosing cholangitis involves chronic cholestatic liver disease that leads to progressive inflammation, fibrosis, and destruction of the intra- and extrahepatic bile ducts
- Massively increased risk of cholangiocarcinoma
- Most have coexisting ulcerative cholitis
____ is chronic progressive inflammatory destruction of intrahepatic and extrahepatic biliary duct
Primary sclerosing cholangitis is a chronic progressive inflammatory destruction of intrahepatic and extrahepatic biliary duct
- Typical scenario: young men with diarrhea / bloody stools / jaundice, fatigue / itching, Alk-P > 1000, elevated bilirubin, and AST/ALT near normal
Primary sclerosis cholangitis histology involves ____ and ____
Primary sclerosis cholangitis histology involves sclerosis causing ductule destruction and concentric onion-skin like fibrosis
This is ____
This is primary sclerosing cholangitis
Middle age woman with jaundice and itching likely has ____
Middle age woman with jaundice and itching likely has primary biliary cholangitis
Young man with jaundice and diarrhea and a history of ulcerative cholitis likely has ____
Young man with jaundice and diarrhea and a history of ulcerative cholitis likely has primary sclerosing cholangitis
Hepatic duct reduction in diameter can result from ____, ____, ____, ____, and ____
Hepatic duct reduction in diameter can result from congenital biliary atresia, tumor, stricture, stone, and pancreatic disease
Extrahepatic bile ducts include ____, ____, ____, and ____
Extrahepatic bile ducts include right and left hepatic ducts, hepatic dut, cystic duct, and common bile duct
Most gallstones are ____ so ____ or ____ is required
Most gallstones are NOT radiopaque so contrast material or ultrasound is required
Cholesterol stones are ____
Cholesterol stones are predominantly cholesterol crystals
Pigmented stones are ____
Pigmented stones are predominantly calcium salts of unconjugated bilirubin
Describe pathogenesis of cholesterol stones
Cholesterol stones pathogenesis
- Free cholesterol is insoluble in water
- Free cholesterol is converted to bile acids and eliminated through bile
- Cholesterol converted to bile acids via 7-a-hydroxylase
Bile acids are ____
Bile acids are detergents
- Water-soluble sterols derived from hepatic catabolism of cholesterol
- Display both hydrophobic and hydrophilic groups (amphophilic)
- Solubilize lipids in water via micelles formation
Describe pathogenesis of cholesterol stones
Cholesterol stones pathogenesis
- Bile supersaturated with cholesterol -> formation of solid cholesterol monohydrate crystals (nucleation)
- Hypomotility of the gallbladder -> accelerated nucleation
- Hypersecretion of mucus in the gallbladder traps the nucleated crystals -> aggregation
Risk factors for cholesterol stones are ___, ___, ___, ___, and ___
Risk factors for cholesterol stones are fat, female, fair skin, fertile, and 40+ in age
- Fertile: premenopausal -> increased estrogen -> increased cholesterol and decreased gallbladder contraction
Black pigment stones are ____, ____, ____, and ____
Black pigment stones are unconjugated bilirubin + calcium, no cholesterol, hard consistency, mostly radiopaque
- Chronic hemolysis -> increase in unconjugated bilirubin -> precipitation of Ca with bilirubin (black pigmented stone)
Someone with cholangiohepatitis may also have ____ stones
Someone with cholangiohepatitis may also have brown pigmented stones
- Calcium salts of unconjugated bilirubin + cholesterol fraction + calcium salts of palmitate
- Radiolucent
- Form in bile duct
- Soft, friable consistency
These are ___
These are cholesterol gallstones
Gallstones in gallbladder can cause ____, ____, and ____
Gallstones in gallbladder can cause cholecystitis, choldeocolithiasis, and gallstone ileus
Acute cholecystitis is ____
Acute cholecystitis is acute inflammation of the gallbladder
- Calculous cholecystisis (90%): gallstone obstructing the cystic duct
- Acalculous cholecystitis (10%): assocated with critical conditions
Fever, leukocytosis, and right upper quadrant pain indicates ____
Fever, leukocytosis, and right upper quadrant pain indicates acute cholecystitis
Chronic cholecystitis is ____
Chronic cholecystitis is repeated mild to severe bouts of acute cholecystitis
- Associated with gallstones in 90%
- Many without apparent antecedent attacks
Recurrent attacks some with steady or colicky RUQ pain with nausea / vomiting or intolerance to fatty food indicates ____
Recurrent attacks some with steady or colicky RUQ pain with nausea / vomiting or intolerance to fatty food indicates chronic cholecystitis
This is ____
This is chronic cholecystitis
Gallbladder carcinoma involves the risk factor of ___
Gallbladder carcinoma involves the risk factor of gallstone
- Porcelain gallbladder is a calcified gallbladder
- 6th and 7th decades
- Female:male is 4:1
- Common in Caucasians
