Lecture 28 Flashcards
Gall bladder pathology
Gallstones
Cholecystitis
Carcinoma of the gall bladder
Cholelithiasis
Gall stones
present in 10-20% of adults
80% of gallstones are “silent” - asymptomatic. indicental finding when scanning patient for something else, or assoc. w acute Cholecystitis
About 80% of gallstones contain crystalline cholesterol monohydrate and are called cholesterol stones
-The remainder are composed mainly of bilirubin and calcium salts and are called Pigment stones (patients with on going homolysis, chronic hemolytic conditions-inherited Hb synthesis disorders, alot of hemolysis and increased breakdown of bilirubin)
Pathogenesis: Cholesterol stones
Bile supersaturated with cholesterol
Conditions favour crystal formation
Cholesterol crystals remain in gall bladder long enough for stones to form (stasis)
-increase in size to the point of causing symptoms
Risk factors for choleslithiasis
The incidence rises with age and is greater in woman
-related to estrogen exposure, increased BMI
(fear, fat, female, 40)
Estrogenic influences (oral contraceptives, pregnancy) obesity and rapid weight loss favour stone formation
Gall bladder stasis favours stone formation
A family history of gallstones
Rare in under developed or developing societies (3rd world)
-more a condition of affluence
Gallbladder features
can be small or large
can be gravelly (small multiple stones)
Clinical consequences of Gall stones
May be asymptomatic (70-80% asymptomatic lifetime)
Symptomatic 1-3% per year
a)-Cholecystitis - acute/chronic (obstruction causing acute inflammation most common)
b)-Biliary colic - due to choledocholithiasis (obstruct bile duct, peristalsis normally occurring try to push stone forward, very painful (right upper quadrant abdominal pain to try overcome the obstruction). Blockage= extra hepatic obstruction = rise in bilirubin and liver enzyme (GGT and ALP)
-Complications of above: cholangitis (bacteria infection, gram -ve infection and inflammation in bile duct), obstructive cholestasis, pancreatitis (if stone goes right down to ampulla of vata blocking pancreatic duct)
Acute Cholecystitis
Acute inflammation features: wall swollen, odematis, pink and erothematis, vasodilation of vessels, areas of hemoarrhage onto gb wall, some bile staining - see inflammatory cells (Neutrophils) under microscope Most cases precipitated by gallstones Acalculous cholecystitis - hard diagnosis (as patients have abdominal pain and features related to cholecystitis but no stones seen on imaging, so often excluding other pathologies) Obstruction of the neck of the gall bladder or of the cystic duct Chemical irritation (of mucosal lining setting up acute inflammation) appears to be the major factor with bacterial infection later (as a complication) -not infection primarily, is inflammation of irritation of obstruction and bile salt, but can bacterial component to it
Acute abdominal pain abdo 02
“sudden onset abdominal pain. She finds the pain severe and she has been vomiting”
- 40 and female (no BMI info) -risk group from cholelithiasis
- abdominal pain and vomiting
- could also be pancreatitis?
Clinical features of Cholecystitis
RUQ abdominal pain and tenderness (localised)
-often comes on after eating/fatty meals
-sometimes history of recurrent episodes of pain (transeitn blockage)
Febrile
Laboratory:
-Neutrophil leucocytosis (seen in any other acute inflammatory process (pancreatitis))
-Raised bilirubin, ALP and GGT if stone is in the common bile duct (extra hepatic obstruction)
-(amylase is going to be normal or mildly elevated- as pancreatitis more likely to be epigastric pain and tenderness and amylase is morelikely to be severely elevated)
Imaging- US ultra sound of gall bladder (look for stones and edema in wall of gal bladder to support diagnosis in conjunction with clinical and lab studies)
Chonic Cholecystitis
Chronic cholecystitis results from low-term association of gallstones and low-grade inflammation.
(multiple recurring acute inflammation/colecystitis)
Some cases have a history of repeated attacks of mild and acute cholecystitis
Pathology variable:
-wall thickened (not swollen and odematisis and erothematis, more shrunken down with scar tissue. -more chonic inflammatory response + repair pathway with fibrosis)
-gall bladder often contracted - but may be normal size or enlarged
Management sof Cholecystitis
Initial acute event:
-Many settle with conservative therapy: IV fluids, pain relief. (settle down inflammation. pot nasogastric tubes to settle down gastric secretions.)
-If suspicion of secondary infection (cholangitis or bacterial infection) then additional antibiotics
-Up to 25% may require acute surgical intervention
Long term:
-cholecystectomy - most now laparoscopic (more definitive therapy)
-quicker recovery
-look to do later as want inflammation to settler down. removing odematis and inflamed gallbladder would result in a higher risk of complications and risk of needing to convert to open laparotomy and cholecystectomy with longer recovery times
Choledocholithiasis
Choledocholithiasis is the presence of stone within the biliary tree
-cystic duct or common bile duct
–obstruction: biliary colic, allow bacteria to result in infection (due to stasis)
-ampulla- blocks common bile duct and pancreatic duct
–trigger pancreatitis
Complications:
1. Biliary obstruction colicky abdominal pain
2. Obstructive jaundice (raised bilirubin, dark urine and pale stools as additional complication)
3. Pancreatitis
4. Cholangitis
-3 + 4 inflammation and sepsis within bile ducts
Patient with jaundice abdo 13
“gone yellow” - jaundice, biliary tree, pancreas or liver
“suffers from bouts of abdominal pain, especially after eating”
-fatty meal, gallbladder contracts, stones tried to move down by peristalsis
-recurrent and pain
“his stool is pale and urine is dark”
-could be pancreatic pathology, tumour at pancreas head
-could also be stone in biliary duct
Investigations:
-Image further and manage appropriately
Cancers of the Biliary system
Carcinoma of the Gall bladder
Carcinoma of the Extrahepatic ducts
-Rare in biliary tree, but unfavourable prognosis cancers
-significant change in structure
Carcinomas of the Gallbladder Pathology
Most are adenocarcinomas
Most have invaded the liver by the time of diagnosis
Seen on older patients
-because high risk biology + advanced and beyond surgical intervention by time of diagnosis
Poor prognosis 5 yr OS 1%
-usually by time of presentations would have already had metastatic spread to liver (often)
Rectal bleeding Abdo 20:
A 55 year old NZ european man presents to his GP complaining of passing blood when he is passing a bowel motion. You are the trainee intern attached to the clinic and are asked to see him before the doctor. He is concerned because his father was diagnosed with bowel cancer in his 50s . Your own grandfather died of bowel cancer last week
family history
- under 50 is rare for colorectal cancer (most commonly 60s), links to familial cancer
- should see patients reflecting own experiences
- “passing blood when he is passing a bowel motion”
- “his father was diagnosed with bowel cancer in his 50s”
- sigmoid or descending colon pot tumous, investigate with colonoscopy
Adult with abdominal mass Abdo5:
A 52 year old NZ european woman presents to her GP with bloating of her abdomen, worsening over the last few months, associated with intermittent diarrhoea and 5kg weight loss. Her brother and father were diagnosed with bowel cancer in their 40’s
- re how bowel cancer might present (symptoms alert to significant GI pahtology- weightliss, abdominal bloating, and change in bowel habits) -may suggest underlying colorectal malignancy
- strong family history of colorectal cancer at young age - alerts to thinking about familial cancer
- “bloating of her abdomen”
- “intermittent diarrhoea and 5kg weight loss. Her brother and father were diagnosed with bowel cancer in their 40’s” - strong malignancy suggestion
Bowel obstruction (abdo 3): A 68 year old NZ european/Maori man presents to the Accident and Medical centre with vomiting and abdominal distention. He has also noted that his bowels have not moved for 4 days and he is not passing wind
often how bowel cancer presents
- strong suggestion of bowel obstruction
- even though multiple potential causes, but frequently if tumour obstruction, may lead to small or large bowl (typically large bowel) obstruction
- “vomiting and abdominal distention. His bowels have not moved for 4 days and he is not passing wind” - require further investigations
Tumours of colon and rectum
Cancers of colon major health problem in NZ (lung is largest as often inoperable and biology of disease)
Most common cancer in NZ
Second most common cause of cancer death in NZ after lung cancer
Benign tumours- mainly polyps
Malignant tumours - mainly adenocarcinomas (ulcerating lesion with rolled edges, pot. necrotic)
-Adenoma with adenocarcinoma ( risen out of previous benign tumour.
-all adenocarcinomas all arise from benign adenoma that will then progress into a adenomacarcinoma
Most common cancers
- Colorectal 14.6% (2716 cases)
- Breast 13.3% (2479 cases)
- Prostate 13.3% (2471 cases)
- Melanoma 10.8% (2017 cases)
- Lung 8.9% (1659 cases)
Leading causes of cancer death
- Lung 18.2% (1451)
- Colorectal 15.3% (1222)
- Breast 8.2% (652)
- Prostate 7.1% (564)
- Pancreas 4.1% (353)
Polyps
A circumscribed growth or tumour which projects above the surrounding mucosa
Need (excised) biopsy to determine nature
-Non neoplastic polyps (benign overgrowths/small tumours that rise above mucosa, all clinically look similar)
-Neoplastic polyps - adenoma
Non-neoplastic Polpys
No malignant potentials. No follow ups required. Reassuring. Incidental findings
- Hyperplastic polyps
- small
- benign (no potential to progress into adenocarcinoma)
- usually asymptomatic (found in patients having screening colonoscopy, or being investigated for other reasons (biopsy report back indicating))
- normal bowel morphology, just an over growth of mucosa
- do not have malignant potential
- small 3-6mm, common - Inflammatory polyps
- seen in IBD, overgrowth
- reactive change/response of mucosa (small overgrowths/polyps)
- Benign, (pseudopolyps)
Neoplastic polyps
Adenomas:
- Benign polyps with malignant potential (e.g. HMPCC) (familial adnomas pulposus carcinomas)
- Most age >50, M=F
- Familial predisposition
- Epithelial Proliferation with variable degrees of dysplasia (abnormal growth)
