Liver Path 6 - Gallbladder Flashcards
The gallbladder stores and concentrates bile (~50 ml), but is not an essential orgen.
What supplies blood to the gallbladder?
What controls bile flow?
- Blood supply is from the cystic artery
- Bile flow is a consequence of the activity of smooth muscle in the gallbladder and the sphincter of Oddi
What percentage of biliary tract disease is attributable to gallstones?
over 95%
What is the primary site of gallstone impaction?
The rapid tapering of the gallbladder neck just proximal to the cystic duct.
On histological exam you will notice that the gallbladder differs from the remainder of the GI tract in that it lacks a discrete muscularis mucosae and submucosa.
Identify the indicated structures.
Upper arrow = single smooth muscle layer and subserosal soft tissue.
Lower arrow = Absorptive columnar epithelium of the mucosa
Gallbladder congenital anomalies can arise in the form of:
Shape
Number
Position
Give some examples of each.
Shape
- angulations (phrygian cap)
- septation
Number
- Agenesis
- duplication
Position
- Intrahepatic (most common aberrent location)
- Falciform ligament location
This asymptomatic 2nd year med student was practicing ultrasound on himself when he found the attached image. Concerned he asks you what you think is going on.
You, being a jerk answer… “ooh that looks like gallstones for sure.” Before telling him that you’re kidding and that it actually is?
A phyrigian cap denotes folding of the fundus back upon the gallbladder body.
•Although clinically unimportant, it may be mistaken on ultrasound examination for septation or possibly stone
What are the major components of bile?
Bile salts - chenodeoxycholates
Cholates - yeah I read it as chocolates first too.
deoxycholates
phospholipids
Cholelithiasis impacts 10-20% of the adult population in the developed world.
What are four major risk factors?
- obesity
- female sex [F:M 2:1]
- estrogens, oral contraceptives, pregnancy
- age (middle age and older)
What are the two general classes of gallstones?
Do they show up on xray?
- cholesterol stones (~75%) radiographically opaque
- pigment stones usually radiographically opaque (calcium salts of unconjugated bilirubin)
15-20% per radiopaedia
“Who ya gonna trust?”
What symptoms do most gallstones present with?
Vast majority (75-80%) are silent.
Although the most frequent outcome is for the patient with a gallstone to remain asymptomatic throughout life, some do develop symptoms.
What are 4 of the most common complications?
- Biliary pain
- Acute cholecystitis
- Cholangitis
- Pancreatitis
Surgical tx of asymptomatic gallstones is discouraged. In what patients is surgery recommended?
3
- Patients with large gallstones greater than 2 cm in diameter
- Patients with nonfunctional or calcified (porcelain) gallbladder observed on imaging studies and who are at high risk of gallbladder carcinoma
- Patients with sickle cell anemia in whom the distinction between painful crisis and cholecystitis may be difficult
Patients with risk factors for complications of gallstones may be offered elective cholecystectomy. What are some examples of these risk factors?
- •Cirrhosis
- •Portal hypertension
- •Children
- •Transplant candidates
- •Diabetes with minor symptom
In what populations are the prevalence rates of gallstones highest?
What american population has the lowest?
Highest
- Native americans - females in particular
- Chileans
- Hispanic americans
Lowest
- Lowest in black Americans
What is shown on this imaging study?
Cholelithiasis
What is shown in this image?
Cholesterolosis - sometimes referred to as “strawberry gallbladder”
What precipitates acute cholecystitis in 90% of cases?
Obstruction of the neck or the cystic duct by a stone.
What are two possible presentations of acute calculous cholecystitis?
- Acute surgical emergency
- Mild symptoms that spontaneously resolve
Is the incidence of gangrene and perforation of the gallbladder higher in acalculous or calculous acute cholecystitis?
Acalculous - more insidious presentation
This gallbladder was taken from an 11 y/o patient with DM I. Radiographic studies showed increased air:fluid ratio in the gallbladder. What does this kid have?
The gross specimen suggests what would have been an consequence soon seen?
Histopathology shows emphysematous cholecystitis with impending perforation in 11-year-old child with insulin-dependent diabetes mellitus
What do the radiographic findings taken from this patient with RUQ pain indicate?
Acute emphysematous cholecystitis - note the Increased air:fluid levels, and presence of “signal void bubbles” in the lumen of the distended gallbladder and the common bile duct.
What does the histology indicate was happening in this patient who had RUQ pain?
This image shows the hallmark of acute cholecystitis: a neutrophilic infiltrate in the mucosa. Inflammation may also be seen in the deeper layers of the gallbladder wall.
What does this tissue sample from a patient with chronic cholecystitis reveal?
Rokitansky–Aschoff sinus
This tissue sample was taken from a patient with chronic cholecystitis, what characteristics shown here are indicative of chronic cholecystitis?
Diffuse lymphoid hyperplasia with germinal center formation
This slide also reveals a classic characteristic of chronic cholecystitis. What does it show?
Gastric metaplasia of gallbladder mucosa
The gallbladder lesion shown here occurs in the 7th or 8th decade typically and impacts females more frequently.
While rare, this is the most common gallbladder neoplasm.
What is it?
What is the prognosis?
Adenocarcinoma of the gallbladder
•Infrequently diagnosed pre-op or when resectable, so terrible prognosis, 5-10% 5 year survival.
What is shown in this image?
Small primary gallbladder adenocarcinoma with massive direct liver invasion.
What do you see in these histo images that indicates this patient has an adenocarcinoma of the gallbladder?
Upper two arrows: malignant cells forming glands
Lower two arrows: presence of dense fibrosis
