L16- GIT Pathology VIII (gallbladder)

Question 1

describe the types of cholelithiasis and their frequency distribution

Answer 1

Cholesterol stones: cholesterol monohydrate (80%)

Pigment stones: bilirubin calcium salts (20%)

Question 2

list the risks for cholethiasis (by type)

Answer 2

Cholesterol stones: inc age, females, oral contraceptives, obesity, rapid weight loss

Pigment stones: chronic hemolysis, biliary infection

Question 3

describe cholelithiasis mechanism for cholesterol stones

Answer 3

1) supersaturation of bile with cholesterol
2) hypomotility of gallbladder
3) accelerated cholesterol crystal nucleation
4) hypersecretion of mucus in the gall bladder

Question 4

Cholelithiasis clinical presentation:

• (1) predominant symptom, then (2) is most common after (1)
• (3) is present in certain complications

Answer 4

1- asymptomatic (70-80%)

2- coliky-like pain, especially after a fatty meal

3- Murphy’s sign if cholecystitis is present

Question 5

list the complications of cholelithiasis

Answer 5

• empyema (pus in pleural cavity)
• perforation
• fistulas
• cholangitis
• pancreatitis
• gallstone ileus
• inc risk of gallbladder carcinoma

Question 6

define and list the types of cholecystitis

Answer 6

• inflammation of the gallbladder

- acute, chronic, acute superimposed on chronic

Question 7

briefly describe the types of acute cholecystitis

Answer 7

Acute Calculous cholecystitis:

• 90% cases
• primary complication of *gallbladder

Acute Acalculous cholecystitis:
-result of ischemia (maybe)

Question 8

describe acute cholecystitis pathogenesis (hint- very long)

Answer 8

1) chemical irritation / inflammation resulting from obstruction
2) mucosal phospholipase converts lecithin –> lysolecithin
3) damage to glycoprotein layer of mucosa
4) further release of PGs from mucosa
5) all (1-4) => mucosal / mural inflammation
6) gall bladder dysmotility, inc intraluminal pressure
7) superimposed bacterial contamination

Question 9

Acute Cholecystitis clinical features:

• (1) is the main symptom with (2) as associated symptoms
• (3) is present upon examination
• (4) may be indicated / a possible complication

Answer 9

1- R hypocondrium or epigastrium pain
2- fever, n/v
3- Murphy’s sign
4- surgical emergency

Question 10

Chronic Cholecystitis:

• results from (1)
• usually associated with (2), although role is unclear
• (3) is a common finding in 1/3 of patients
• (4) is a rare complication

Answer 10

1- sequel of repeated acute cholecystitis

2- cholelithiasis

3- positive microorganism culture from bile

4- extensive dystrophic calcification (porcelain gall bladder: bluish discoloration, brittle consistency, associated with cancer)

Question 11

describe histology of chronic cholecystitis

Answer 11

• mucosa infiltrated by inflammatory cells
• abnormal multiple folds
• fibrosis surrounding cirrhosis

-out-pouching of mucosa thru wall containing bile = Rokitansky-Ashcoff sinuses (herniation of mucosa outside of gallbladder)

Question 12

Gall Bladder carcinoma:

• (1) common age, gender
• (2) is present in most patients, and (3) are other risk factors
• (4) is the most common form
• (5) is common at time of diagnosis

Answer 12

1- 60s y/o, females (slightly)

2- gallstones (60-90%)
3- pyogenic / parasitic infections of biliary tract //// carcinogenic derivatives of bile may have a role

4- adenocarcinoma (exophytic)
5- invasion/spread to liver

Question 13

describe histology of gall bladder carcinoma

Answer 13

(usually exophytic carcinoma)

• disorganized malignant glands
• interspersed dense fibrosis

Question 14

list the diseases of the Hepato-biliary tree

Answer 14

(either Intra- or Extra- hepatic)

• **bile duct stones (choledocholithiasis)
• **cholangitis
• biliary tract cysts
• biliary atresia
• bile duct carcinomas (cholangiocarcinoma)

Question 15

Biliary Tree diseases, general pathophysiology:

• (1) is the most important cause, usually due to (2) and or (3)
• altered anatomy causes (4) which can lead to (5)
• (6) may result from inflammatory damage after biliary tree disease

Answer 15

1- obstruction / impaired bile flow
2- gall stones
3- neoplastic masses

4- impaired bile flow
5- cysts (choledochal cyst)
6- scarring (recurrent cholangitis)

Question 16

Choledocholithiasis:

• occurs in some patients with (1)
• defined as (2), mostly occurring at (3)
• (4) describe Mirizzi syndrome

Answer 16

1- gallstones (15%)
2- stone blocking any part of bile duct
3- common bile duct

4- gallstone in cystic duct compresses common hepatic duct => obstructive jaundice

Question 17

Cholangitis:

• (1) definition
• (2) are the most common causes
• recurrent form is common in (3) population

Answer 17

1- infection of biliary tree following biliary obstruction

2- E. coli, S. faecalis, Enterbacter

3- (recurrent pyogenic cholangitis / oriental cholangiohepatitis) Asia / Pacific rim countries due to Chinese liver fluke parasite