Liver Path 6: Gallbladder

Question 1

Gallbladder

Answer 1

Gallbladder is not essential

Blood supply is from the cystic artery

Stores and concentrates bile (~50 ml)

Bile flow is a consequence of the activity of smooth muscle in the gallbladder and the sphincter of Oddi

Question 2

Gallbladder Congenital Anomalies

Answer 2

Shape

• Angulations (Phrygian cap) (incidence 4%, most common)
• Septation

Number

• Agenesis
• Duplication

Position (5-10% of population)

• Intrahepatic (most common aberrent location)
• Falciform ligament location

Question 3

Cholelithiasis

Answer 3

10-20% of adult population in developed world

Risk factors

• obesity
• female sex [F:M 2:1]
• estrogens, oral - contraceptives, pregnancy
• age (middle age and older)

Two general classes of gallstones

• cholesterol stones (~75%)
• pigment stones (calcium salts of unconjugated bilirubin)

Only 15-20% of gallstones are radiopaque

Question 4

Natural History and Complications of Gallstones

Answer 4

Complications
Asymptomatic (75%)

Biliary pain (obstruction)
Cholecystitis
Pancreatitis
Ascending Cholangitis

Fistula
Gall Bladder Carcinoma

Question 5

Treatment of Asymptomatic Gallstones

Answer 5

Surgical treatment of asymptomatic gallstones is discouraged.

The risk of complications arising from interventions is higher than the risk of symptomatic disease

Approximately 25% of patients with asymptomatic gallstones develop symptoms within 10 years.

Question 6

Cholecystectomy for asymptomatic gallstones may be indicated in the following patients:

Answer 6

With large gallstones greater than 2 cm in diameter

With nonfunctional or calcified (porcelain) gallbladder 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

Question 7

Patients with risk factors for complications of gallstones may be offered elective cholecystectomy

Answer 7

Cirrhosis

Portal hypertension

Children

Transplant candidates

Diabetes with minor symptom

Question 8

Acute Cholecystitis

Answer 8

precipitated in 90% of cases by obstruction of the neck or the cystic duct by a stone.

can present as an acute surgical emergency or present with mild symptoms that spontaneously resolve

incidence of gangrene and perforation is much higher in acalculous (than in calculous cholecystitis (more insidious presentation)

Question 9

acute cholecystitis symptoms

Answer 9

Epigastric or right upper quadrant pain (usually onset >50 years) 1-2 hours after ingestion of a fatty meal

Major complication in ~10-15% cases is acute gangrenous cholecystitis (may perforate)

Most authorities agree that infection is secondary and does not contribute to the onset of acute cholecystitis.

Question 10

Pathology of Acute Cholecystitis

Answer 10

Gallbladder is enlarged, edematous, and congested

Histologic hallmark of acute cholecystitis is the presence of neutrophils in the gallbladder mucosa and wall

Mucosa is often but not invariably ulcerated

Changes of chronic cholecystitis are noted in many cases

Question 11

who’s at risk for emphysematous acute cholecystitis?

Answer 11

children with type I diabetes

Question 12

Acute Cholecystitis histology

Answer 12

The hallmark of acute cholecystitis is a neutrophilic infiltrate in the mucosa. Inflammation may also be seen in the deeper layers of the gallbladder wall.

Question 13

Chronic Cholecystitis

Answer 13

Recurrent attacks of either steady epigastric or right upper quadrant pain (usually onset in 50s)

Nausea, vomiting, and intolerance for fatty foods are frequent accompaniments.

Chronic cholecystitis can be a sequel to acute cholecystitis, but often presents without a history of earlier attacks

Question 14

Pathology of Chronic Cholecystitis

Answer 14

Subserosal fibrosis to dense fibrous adhesions

Chronic inflammation

Fibrosis

Metaplasia of gall bladder mucosa

Dystrophic calcification (porcelain gallbladder)
Associated with increased risk of carcinoma

Outpouchings of the mucosal epithelium into the wall (Rokitanansky-Ashoff sinuses) *

Question 15

Chronic Cholecystitis

histology

Answer 15

Diffuse lymphoid hyperplasia with germinal center formation

Question 16

Choledocholithiasis- general

Answer 16

• Common bile duct stones challenging diagnosis

Like stones in the gallbladder, stones in the bile ducts may remain asymptomatic for years

Complications of choledocholithiasis are obstructive jaundice, gallstone pancreatitis and acute cholangitis

• Classic presentation: fever, jaundice, and abdominal pain (Charcot’s triad)

Question 17

Jean-Martin Charcot

Answer 17

Father of French neurology

Charcot disease
(better known as amyotrophic lateral sclerosis or Lou Gehrig disease)

Charcot’s triad

Question 18

Choledocholithiasis- what’s happening

Answer 18

Stones usually brown and due to biliary tract infections.

Stones in the bile duct usually come to rest at the lower end of the ampulla of Vater

Bacterial infection from GI tract via ampulla of Vater usually gram-negative rods

Question 19

Key Concepts (Robbins)- diseases of the gallbladder

Answer 19

Gallbladder diseases include cholelithiasis and acute and chronic cholecystitis and gall bladder cancer.

Gallstones are common in Western countries. The great majority are cholesterol stones. Pigmented stones con­taining bilirubin and calcium are most common in Asian countries.

Risk factors for the development of cholesterol stones are advancing age, female gender, estrogen use, obesity, and heredity.

Cholecystitis almost always occurs in association with cholelithiasis, although in about 10% of cases it occurs in the absence of gallstones. Gall stones are also a risk factor for gall bladder cancer.

Acute calculous cholecystitis is the most common reason for emergency cholecystectomy.

Gall bladder cancers are associated with gall stones in the vast majority of cases. Typically they are detected late because of non specific symptoms and hence carry a poor prognosis

Question 20

Carcinoma of the Gallbladder

Answer 20

Rare, but most common gallbladder neoplasm
F > M, peaks in 7th-8th decade
Usually associated with gallstones
Infrequently diagnosed pre-op or when resectable
Pathology: adenocarcinoma
Terrible prognosis; 5-10% 5 year survival

Question 21

Carcinoma of the Gallbladder signs and symptoms

Answer 21

Most common malignancy of the extra hepatic biliary tract, usually adenocarcinoma

95% are associated with gallstones

Most common symptoms/signs are a for abdominal pain and elevated serum alkaline phosphatase

Infrequently diagnosed pre-op or when resectable

Question 22

Carcinoma of Gallbladder Pathology

Answer 22

Most patients present with high pathologic stage adenocarcinoma (liver spread is usually evident at time of diagnosis)

Papillary variant has best overall prognosis

Less common carcinoma variants include squamous cell carcinoma (5%) and rarely carcinoid or carcinosarcoma