Gallbladder And Biliary Tree Flashcards by Denisse Tiangco

Cholesterol stone formation is enhanced by

Hypomobility of gallbladder promoting nucleation
Mucus hypersecretion with trapping of crystals
Cholesterol exceeding solubilizing capacity of bile and crystalization

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Precipitation of insoluble calcium in unconjugated bilirubinate salts

Pigment stone

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Exclusive in the gallbladder
Pale yellow inc proportion of calcium carbonate, phosphates and bilirubin
gray white to black discoloration
ovoid firm radiolucent but 20% with calcium carbonate making them radiopaque

Cholesterol stone

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Arise anywhere in biliary tree 
Black and brown 
Black in sterile gallbladder
Brown in infected
Calcium salt of inconjigated bilirubin 
Small fragile numerous  with greasy and soaplike consistency from FA 
Radiopaque black, brown radiolucent

Pigment stone

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red blotchy violaceous color with subserosal hemorrhage of GB
serosa covered by fibrinopurulent exudate
90% of cases stones are present often obstructing neck of bladder or cystic duct
Lumen is filled with cloudy turbid bile containing fibrin, blood and pus

Acute cholecystitis

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Pus in gallbladder

Thick edematous hyperemic

empyema

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Green black necrotic organ of gallbladder

Gangrenous cholecystitis

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Acute inflamm of gallbladder with stones by obstruction of neck or cystic duct
Due to chemical irritation and inflammation
Occur in the absence of bacterial infection

acute calculous cholecystitis

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Most common major complication of gallstone and most common reason for emergency OR

Biliary pain >6 hours severe and steady

acute calculous cholecystitis

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Cholecystitis develps bec of hydrolysis of lecithin to lysolecithin which is toxic to mucosa

Protective glycoprotein mucous layer is disrupted exposing epithelium to detergent action of

bile salt and prostaglandin

distention and inc intraluminal pressure compromise blood flow to mucosa

Occur in absence of bacteria

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Predisposing injury to acute acalculus chole

Major nonbiliary
Severe trauma
Severe burns
Sepsis 
Dehydration 
Gallbladder stasis
Sludging
Vasc compromise
Bacterial contamination

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Predisposes px to chronic inflamm and stone formation

Supersaturation of bile

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stones within biliary tree

sx develop because of

choledocholithiasis

biliary obstruction
cholangitis
hepatic abscess
chronic liver disease with secondary biliary cirrhosis
acute calculous chole

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acute inflamm of wall of bile duct by bacterial infection of sterile lumen

cholangitis

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Propensity of bacteria in biliary tree to infect intrahepatic biliary duct

Caused by E coli, Klebs, enteroccoci, clostridium, fasciola, schistosomiasis, clonorchis, opisthorchis or cryptosporidiosis

Ascending cholangitis

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Complete obstruction of bile flow caused by destruction or absence of all or part of extrahepatic duct

Major cause of neonatal cholestasis
Most freq cause of death from liver disease in early childhood

Biliary atresia

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Inflammation and fibrosing stricture of hepatic or common bile duct
Inflamm of major intrahepatic bile duct with progressive destruction of intrahepatic biliary tree
Florid features of biliary obstruction on liver biopsy ductular reaction, portal tract edema and fibrosis and parenchymal cholestasis
Periportal fibrosis and cirrhosis within 3-6 mos of birth

Biliary atresia

Dx biopsy
Tx liver transplant

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Most freq malignant tumor of biliary tract

2-6x W in 7th decade

Gallbladder carcinoma

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Most of the gallbladder cancers are

adenocarcinoma

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Exhibit exophytic or infiltrating growth pattern
Infiltrating pattern is more common poorly defined area of diffuse thickening and induration of gallbladder
Scirrhous very firm irregular cauliflower-like masa invading underlying wall

Gallbladder cancer

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Adenocarcinoma that arise from cholangiocyte lining intrahepatic and extrahepatic biliary duct

2/3 are extrahepatic at the hilum aka

Cholangiocarcinoma

Klatskin tumor

Risk factors of cholangiocarcinoma

Primary sclerosing cholangitis
Fibropolycystic disease of biliary tree
Clonorchis sinensis
Opisthorchis viverrini

Cause chronic cholestasis and inflamm promoting somatic mutations

Cholangiocarcinoma is associates with mutations in the ff genes

KRAS
BRAF
TP53

Adenocarcinoma with well formed glands accom by abundant fibrous stroma desmoplasia with firm gritty consistency
Absent bile pigment and hyaline inclusion from tumor with prominent intracellular mucin

Cholangiocarcinoma

Intra- nonspecific like HCC

Extra- jaundice, acholic, nausea, vomiting

Inc ALP and aminotrans

Transplantation is contraindicated

Cholangiocarcinoma spreads to the abdomen by

Invasion of peribiliary nerves Greater propensity for spread than HCC

Most common malignancy of liver More common than primary hepatic neoplasia Most common primary sources: -colon, breast, lung and pancreas

Liver metastases

90% are cholesterol stones Contain more than 50% of crystalline cholesterol monohydrate 10% are pigment stones Composed of bilirubin calcium salts

Cholelithiasis

Supersaturation causes nucleation into solid cholesterol monohydrate crystals

Cholesterol stones

Elevated levels of unconjugated bilirubin in bile such as hemolytic syndromes, severe ileal dysfunction and bacterial contamination

Pigment stones

sterile gallbladder bile Composition: oxidized calcium salts of unconjugated bilirubin Radiopaquev

Black stones

Infected intrahepatic or extrahepatic ducts Composition: pure calcium salts of unconjugated bilirubin Radiolucent

Brown stones

Due to ischemia Risk factors: sepsis, immunosupression, major trauma and burns, diabetes mellitus, infections

Acute Acalculous Cholecystitis

GB exudate is virtually pure pus

Acute cholecystitis | Gallbladder empyema

GB transformed into a green-black necrotic organ

Gangrenous cholecystitis

Invasion of gas-forming organisms, notably clostridia and coliforms

Emphysematous cholecystitis

Outpouchings or the mucosal epithelium through the GB wall

Rokitansky-Aschoff sinuses

Extensive dystrophic calcification in GB wall | Increased incidence of associated cancer

Porcelain gallbladder

Massively thickened GB wall | Chronic inflammatory with necrosis and hemorrhage

Xanthogranulomatous cholecystitis

Atrophic, chronically obstructed gallbladder containing only clear secretions

Hydrops of the gallbladder | Chronic cholecystitis

Most common malignancy of the extrahepatic biliary tract Most important risk factor: gallstones Most common sites of involvement: fundus and neck

Gallbladder adenocarcinoma

Excessive accumulation of body iron, most of which is deposited in parenchymal organs such as the liver and pancreas

Hemochromatosis

Homozygous recessive inherited disorder

Primary hemochromatosis

Due to parenteral iron overload, transfusion, RBC anomalies, chronic liver disease

Acquired hemochromatosis (hemosiderosis)

Hepatomegaly: HP micronodular cirrhosis Diabetes mellitus Bronze skin pigmentation

Hemochromatosis

Liver, pancreas, myocardium, pituitary, adrenal, thyroid and parathyroid, joints, skin Detected using Prussian blue stain

Deposition of hemosiderin

Autosomal recessive disorder Impaired copper excretion into bile Failure to incorporate copper into ceruloplasmin Accumulation of toxic levels of copper in many tissues and organs (liver, brain, eye)

Wilson disease

``` Hepatic changes fatty change (steatosis) acute hepatitis chronic hepatitis massive liver necrosis ``` Atrophy and cavitation of putamen and basal ganglia

Wilson’s disease

Eye lesion of Wilson Green to brown deposits of copper in Descemet’s membrane in the limbus of the cornea

Kayser-Fleischer rings

Obstruction of two or more hepatic veins Characterized by liver enlargement, pain and ascites Associations include: Polycythemia vera Inherited disorders of coagulation Paroxysmal nocturnal hemoglobinura

Budd-Chiari Syndrome

Acute thrombosis of hepatic veins or hepatic portion of IVC Liver is swollen and red-purple Tense liver capsule Severe centrilobular congestion and necrosis

Budd-Chiari Syndrome

Inflammatory autoimmune disease mainly affecting the intrahepatic bile ducts Laboratory studies: elevated alkaline phosphatase and cholesterol (+) for antimitochondrial antibodies

Primary biliary cirrhosis

Portal tracts are infiltrated by lymphocytes, macrophages, plasma cells, and eosinophils Florid duct lesions Non caseating granulomatous reaction to a bile duct undergoing destruction

Pre-Cirrhotic Phase | Primary Biliary Cirrhosis