Pathology-Liver and Gallbladder Path Flashcards
(100 cards)
A mother brings her 2 month old baby in because his skin is yellow. A CT scan showed biliary atresia. What are causes of this in such a young baby and what complications is he at risk for?
This can be due to congenital failure to form OR early destruction of the extra-hepatic biliary tree from infection. This can progress to liver cirrhosis.
A mother brings her 2 month old baby in because his skin is yellow. A CT scan showed biliary atresia. What type of bilirubin is causing the jaundice?
Conjugated, it has already passed through the liver.
A patient presents with RUQ pain. Ultrasound of his gallbladder is shown below. Name 3 ways gallstones can form.
Stasis can promote bacterial infection which deconjugate the bilirubin and cause bilirubin stones. A high concentration of cholesterol or bilirubin could cause stone precipitation in the bile. Decreased phospholipids (lecithin) or bile acids could also cause stone formation because they function to solubilize the cholesterol.
A 55 year old man presents to the clinic with colicky RUQ pain. He has a history of high cholesterol and is on cholestyramine to manage it. How could the medication be causing his symptoms?
Cholestyramine forms insoluble complexes with bile acids, preventing reabsorption and they are secreted in the feces. This lowers the concentration of bile acids and can thus promote formation of cholesterol gallstones due to lower solubility.
Why do we typically use ultrasound to look for these in the West?
The most common type of gallstones in the West are cholesterol stones, which are radiolucent.
Why are women at higher risks for gallstones than men?
Estrogen increases the activity of HMG-CoA reductase, increasing cholesterol synthesis. Estrogen also increases expression of LDL-R, increasing the amount of cholesterol available to put into the bile.
Risk factors for development of gallstones.
Fat, fertile, female in her forties with a family history and flatulence. Native American & hyperlipidemia too.
How does Clofibrate increase your risk for gallstones?
1) Increases HMG-CoA reductase activity, increasing cholesterol synthesis 2) Decreases bile acid synthesis, decreasing solubility of bile cholesterol.
Why are you at increased risk for gallstones if you have Crohn’s disease or liver cirrhosis?
Crohn’s: damage to terminal ileum -> decreased uptake of bile salts -> decreased bile cholesterol solubility. Cirrhosis: decreased synthesis of bile salts -> decreased bile cholesterol solubility
What are the major risk factors for the condition shown below?
Risk factors for bilirubin stones are: 1) Extravascular hemolysis: large production of unconjugated bilirubin is produced by the splenic macrophages (reticuloendothelial system), this increases the concentration of conjugated bilirubin in the bile. 2) Biliary tract infection: bacteria deconjugate the bilirubin and decreases bilirubin solubility
How do RBCs contribute to bilirubin concentration in the bile?
Hemoglobin -> haem + globin -> Haem goes to Fe2+ and protoporphyrin, globin goes to A.A. -> Fe is recycled, protoporphyrin is converted to unconjugated bilirubin -> unconjugated bilirubin binds albumin and heads to liver -> liver conjugates bilirubin -> Sent out in bile canaliculi -> Bile duct -> Gallbladder
What organisms can deconjugated bilirubin and increase risk for precipitation and bilirubin gallstone formation?
E. coli, ascaris lumbricoides and clonorchis sinesis
What is the most common symptom of people with gallstones?
They are typically asymptomatic.
A patient presents with waxing and waning colicky RUQ pain. Suddenly the pain goes away. If he had a gallstone, what was causing the pain? What may he be at risk for now?
He has biliary colic due to contraction and relaxation of the gallbladder while the stone is blocking the cystic duct. The pain went away once the stone passed. If the stone is now blocking the ampulla of Vater, he is at risk for obstructive jaundice and pancreatitis.
An overweight 40 year old Native American woman presents with RUQ pain radiating to her right scapula, nausea and vomiting. She has a fever of 102 and an elevated WBC. What is likely causing her condition?
He has acute cholecystitis. This is due to stone impaction -> gallbladder dilation -> pressure ischemia on vessels in gallbladder wall -> bacterial overgrowth -> inflammation of the gallbladder wall.
An overweight 40 year old Native American woman presents with RUQ pain radiating to her right scapula, nausea and vomiting. She has a fever of 102 and an elevated WBC. What other lab value may be elevated if she has acute cholecystitis?
Serum alkaline phosphatase. The epithelium in the gallbladder have this enzyme and would be releasing it as they die off.
An overweight 40 year old Native American woman presents with RUQ pain radiating to her right scapula, nausea and vomiting. She has a fever of 102, an elevated WBC and serum alkaline phosphatase. What is the major complication this patient is at risk for?
Rupture of the gallbladder wall.
An overweight 40 year old Native American woman presents with vague RUQ pain after meals. She has a history of gallstones and works in a textile factory. Gallbladder biopsy is shown below. What is causing her pain?
This patient has chronic cholecystitis due to chronic inflammation of the gallbladder. The inflammation was likely caused by chemical irritation or longstanding cholelithiasis. Note the Rokitansky-Aschoff sinus formation (outpouching of gallbladder sinuses in the smooth muscle).
An overweight 40 year old Native American woman presents with vague RUQ pain after meals. She has a history of gallstones and works in a textile factory. What is a late complication of the condition she currently has?
Porcelain gallbladder is a late complication of chronic cholecystitis. This is because chronic inflammation causes dystrophic calcification of the gallbladder, as shown in the radiograph below.
An overweight 40 year old Native American woman presents with vague RUQ pain after meals. She has a history of gallstones and works in a textile factory. How do you treat her?
Cholecystectomy, especially if porcelain gallbladder is present because it is a risk factor for gallbladder cancer.
An overweight 40 year old Native American woman presents with jaundice and abdominal pain. She is also septic. She has a history of choledocolithiasis. What is causing her condition?
This patient has ascending cholangitis. This is due to bacterial infection of the bile ducts, typically by enteric gram-negative bacteria. Choledocolithiasis can cause this because it blocks bile flow out of the duct, decreasing the “washing out” of bacteria from the duct by normal flow. Bacteria walk up the duct and cause an ascending infection.
An overweight 40 year old Native American woman presents with a long history of recurrent RUQ pain. She presents today because she had an acute onset of colicky abdominal pain and abdominal distention. What could be causing her condition?
This patient has gallstone ileus. This happens when inflammation of the gallbladder wall causes rupture and fistula formation with the small bowel. Now the large stones can enter the small bowel and obstruct it.
An 80 year old woman presents with vague RUQ pain after meals that sometimes radiates to her right scapula. She has a history of gallstones, but has not felt like this in 20 years. What is likely causing her condition?
An elderly woman with a history of gallstones, especially porcelain gallbladder, presenting with cholecystitis, a condition of middle-aged women, could likely have gallbladder carcinoma.
What cells does the tumor shown below arise from?
Gallbladder adenocarcinoma arises from glandular epithelium in the gallbladder wall.
