Gi-Ost522-Pathology Of The Biliary Tract-Dr.senagore(Scribe13)

Front 1

Are minor congential anomalies of the biliary tract common or rare?

Back 1

common

Front 2

Are major congenital anomalies of the biliary tract common or rare?

Back 2

rare

Front 3

What is the clinical significance of minor congenital anomalies of the biliary tract?

Back 3

These have no clinical significance unless surgery is needed-we do not want to injure the gall bladder or ducts inadvertently.

Front 4

Abberant location of the gall bladder and irregular but functional biliary tract branches-->are these examples of minor or major anomalies?

Back 4

Minor anomalies

Front 5

5-10% of gall bladders are embedded in the liver. What type of anomaly (major or minor) is this an example of?

Back 5

Abberant location-->Minor anomaly

Front 6

What is a folded fundus called?

Back 6

Phrygian cap

Front 7

A golding over of the fundus of the gall bladder is called what?

Back 7

Folded fundus or phrygian cap.

Front 8

Gall bladder: agenesis, duplicated, bilobed-->these are all examples of a major or minor gall bladder anomaly?

Back 8

Major anomaly

Front 9

Are congenital anomalies involving location major or minor?

Back 9

Minor

Front 10

Are congenital anomalies involving structure major or minor?

Back 10

Major

Front 11

Bile duct structural anomalies are often associated with what?

Back 11

Other anomalies, involving the heart, spleen, or GI tract (all the one-sided structures)

Front 12

Bile Duct: Agenesis of all or part, Atresia-fetal, perinatal, Polysplneia (multiple spleens) are all examples of a minor or major anomaly?

Back 12

Major anomaly

Front 13

What is cholelithiasis also known as?

Back 13

Gallstones

Front 14

What are the 2 major types of cholelithiasis?

Back 14

1.Cholesterol Stones
2.Pigment (bilirubin) stones

Front 15

-Common in western, industrialized nations.
-Common in Mexican and Hispanic & Native Americans
-When the stones form individually, they are usually round, whereas when they form in large numbers simulataneously, will have a faceted surface
WHAT TYPE OF CHOLELITHIASIS?

Back 15

Cholesterol Stones

Front 16

Cholesterol Stones

Back 16

What type of cholelithiasis?

Front 17

What causes cholesterol gallstones?

Back 17

1.High cholesterol or low bile salts-->crystallization of cholesterol, forming gallstones
2.Bile Stasis

Front 18

What are the 2 most important factors for increased risk of high cholesterol?

Back 18

Increased age, female gender (estrogen)

Front 19

Changes in hormone or nervous control of BG, and starvation, can lead to what?

Back 19

Bile Stasis-->Cholesterol Stones

Front 20

Increased cholesterol, decreased lecithin, and decreased Na taurocholate all cause what?

Back 20

Increase risk of cholesterol stone formation

Front 21

What is the pathogenesis of cholesterol stone formation?

Back 21

1.Increase chol
2.Decrease Lecithin
3.Decrease Na taurocholate

Front 22

1.Supersaturated bile
2.Hypomotile GB (stasis)
3.Accelerated nucleation
4.Mucus hypersecretion
All of these simulatneous defects are needed for what?

Back 22

Cholesterol Gallstone formation

Front 23

What are the 4 simultaneous defects needed for cholesterol gallstone formation?

Back 23

1.Supersaturated bile-liver hypersecretion
2.Hypomotile GB (stasis)
3.Accelerated nucleation-proteins that aid in stone formation
4.Mucus hypersecretion-acts as "scaffolding" for stone formation

Front 24

What do pure cholesterol gallstones look like?

Back 24

Rare, yellow, radiolucent

Front 25

What do cholesterol gallstones mixed with other components looke like?

Back 25

Radio-opaque (white, grey, black) but usually sill remain difficult to see on x-ray.

Front 26

Chol Gallstones

Back 26

What is this?

Front 27

Chol Gallstones

Back 27

What is this?

Front 28

-Often involved with infections not seen in the US, and hence are more prevalent in non-western, developing countries.
-Most common in Asian countries
WHAT TYPE OF CHOLELITHIASIS?

Back 28

Pigment (bilirubin) stones

Front 29

pigment (bilirubin) stones

Back 29

What type of cholesthiasis?

Front 30

Why are pigment (bilirubin) stones produced?

Back 30

Any disorder that favors production of unconjugated bilirubin will favor pigment stone formation.

Front 31

What are the 2 main types of pigment (bilirubin)stones?

Back 31

1.Brown
2.Black

Front 32

Which type of pigment stone is radioluscent, which is opaque?

Back 32

1.Brown: Radioluscent
2.Black: Radio-opaque

Front 33

Where do brown pigment (bilirubin) stones form from?

Back 33

Form in infected bile ducts

Front 34

Where do black pigment (bilirubin) stones form from?

Back 34

Form in sterile bile in GB

Front 35

What type of pigment (bilirubin) stones are responsible for chronic intravascular hemolysis?

Back 35

Black pigment (bilirubin) stones

Front 36

How does the epidemiology of cholesterol stones differ from the epidemiology of pigment stones?

Back 36

1.Cholesterol Stones: Increase in Wester Industrialized countries, Mexican and Native Americans
2.Pigment Stones: Increase in Non-Western/Developing countries; Asia

Front 37

What is cholesterolosis?

Back 37

-An incidental finding (no clinical significance) in which there is hypersecretion of cholesterol from liver into the GB

Front 38

Normally what does the GB do will excess cholesterol?

Back 38

-Normally, the mucosa of the GB will take up the excess cholesterol and convert it to esters, and then eliminate it

Front 39

In cholesterolosis, where do excess esters from the liver accumulate?

Back 39

Esters accumulate in the lamina propria of the mucosa.

Front 40

Cholesterolosis-->With xs. cholesterol, esters accumulate in the lamina propria of the mucosa.

Back 40

What does this show?

Front 41

Cholesterolosis-->Mucosa with yellow flecks; "strawberry GB"

Back 41

What is shown?

Front 42

In cholesterolosis, what does the GB look like on dissection?

Back 42

-Mucosa with "yellow flecks" flecks; "strawberry GB"
-(Microscopically forms a club-like swelling of the mucosal surface which corresponds grossly as a yellow flecked surface of the mucosa.

Front 43

Cholelithiasis

Back 43

Shown is a gross illustration of what?

Front 44

Are patients with cholelithiasis symptomatic?

Back 44

Usually not, only 1/3 of patients present with symptoms, usually PAIN

Front 45

In cholelithiasis, what is pain usually associated with?

Back 45

Pain is associated with the stone obstruction?

Front 46

What is the consequent inflammation associated with GB obstruction in cholelithiasis called?

Back 46

Cholecystitis

Front 47

What is intermittent GB pain due to obstruction called in Cholelithiasis?

Back 47

Colicky

Front 48

In cholelithiasis, are small stones or large stones at a greater risk for obstructions?

Back 48

Small stones

Front 49

In cholelithiasis, what do large stones often do? What is this called?

Back 49

Large stones do not often obstruct, but can erode their way out of the GB, and into the small intestine and obstruct it-->called gallstone ileus

Front 50

Empyema, perforation, fistulae, inflammation of biliary tree (cholangitis) are all complications of what?

Back 50

Cholelithiasis

Front 51

What sized stones increase the risk of GB carcinoma?

Back 51

All sized stones

Front 52

What is GB inflammation called?

Back 52

Cholecystitis

Front 53

What is cholecystitis often associated with?

Back 53

Gallstones

Front 54

What is one of the most common indications for abdominal surgery?

Back 54

Cholecystitis

Front 55

What are the risk factor for cholecystitis similar to?

Back 55

Same as those for gallstones.

Front 56

What is an acute chemical irritation, inflammation of an obstructed gallbladder called?

Back 56

Acute calculus cholecystitis

Front 57

Blockage of neck or cystic duct-->bile cannot flow out-->bile becomes toxic lysolecithin (detergent)-->this disrupts the mucosa leading to prostaglandin release, inflammation, dysmotility, distention, and eventually decreased blood flow-->ischemia of GB tissues-->possible necrosis and serious side effects
This sequence describes the pathogenesis of what?

Back 57

Acute calculus cholecystitis

Front 58

RUQ pain, fever, anorexia, N/V...these are all clinical features of what?

Back 58

Acute calculus cholecystitis

Front 59

What does hyperbilirubinemia without jaundice indicate? And in what illness is this found?

Back 59

Acute calculus cholecystitis

Front 60

-Hyperbilirubinemia without jaundice
-Increased WBC's
-Increase serum alkaline phosphatase
-Previous episode(s) likely
-Surgical emergencies may happen if necrosis occurs
These are clinical symptoms of what illness?

Back 60

Acute calculus cholecystitis

Front 61

What is the difference b/w Acute calculus cholecystitis and Acute Acalculus cholecystitis?

Back 61

1.Acute calculus cholecystitis-->with gallstones
1.Acute Acalculus cholecystitis-->withOUT gallstones

Front 62

In what illness are patients severly ill with additional circumstances such as severe trauma, burns, multi-system organ failure, sepsis, postoperative state, postpartum state?

Back 62

Acute Acalculus Cholecystitis

Front 63

What is Acute Acalculus Cholecystitis due to?

Back 63

Due to ischemia and poor perfusion of the GB
-cystic artery is an end artery, no collaterals
-essentially patients start at end point of acute calculus cholecystitis, they begin with decreased mucosal profusion
-At a much greater risk for complications

Front 64

What illness can rarely be due to a bacterial infection?

Back 64

Salmonella typhi, stapylococci, clostridia

Front 65

Often clincial features of this illness are insidious. They are obscured by serious conditions not related to the gallbladder. We must maintain a high level of suspicion to avoid the risk of gangrene and perfusion. What illness?

Back 65

Acute Acalculus Cholecystitis

Front 66

Acute Cholecystitis GB-->GB is ENLARGED with thickened walls, RED-purple in color, may be BLOTCHY due to neutrophil migration to the serosa, showing a suppurative, fibrin-filled exudates

Back 66

What is shown?

Front 67

Wall of GB in Acute Cholecystitis. Edema, hyperemia (red). If gangrenous: green-black (necrotic) with perforation

Back 67

What is shown?

Front 68

-Acute Cholecystitis: Microscopioc Morpholgy
-Acute inflammatory reaction with neutrophils, edema, BV congestion

Back 68

What is shown?

Front 69

What is the differential diagnosis of acalculous v calculous cholecystitis?

Back 69

No specific differences except for absence or presence of stones

Front 70

1.Usually associated with gallstones
2.Thought to be due to recurrent attacks of cholecystitis
3.In 1/3 of cases (E.coli, enterococci) are found in GB, but not thought to be the cause
WHAT IS THE ILLNESS?

Back 70

Chronic Cholecystitis

Front 71

What does the GB serosa look like in chronic cholecystitis?

Back 71

Smooth serosa

Front 72

What does the GB wall look like in chronic cholecystitis?

Back 72

Thick, opaque, gray-white wall, NOT red

Front 73

What does the GB lumen look like in chronic cholecystitis?

Back 73

Clear green-yellow mucoid bile

Front 74

What does the GB mucosa look like in chronic cholecystitis?

Back 74

Preserved mucosa

Front 75

What is a "porecelain" GB wall? And what illness is it associated with?

Back 75

1.Wall is calcified (associated with cancer)
2.Chronic cholecystitis

Front 76

What are hyrdops? And what illness is it associated with?

Back 76

Hydrops=clear secretions into GB
Associated with chronic cholecystitis

Front 77

Chronic Cholecystitis-->hydrops, clear secretions into GB

Back 77

What is shown in this GB?

Front 78

Chronic Cholecystitis: "Porcelain" GB-->wall is calcified (associated with cancer)

Back 78

What is shown?

Front 79

-Smooth serosa
-Thick, opaque grey-white wall, NOT red
-Clear, yellow mucoid bile in lumen
-preserved mucosa
-"Porcelain" GB: wall is calcified (associated with cancer)
-"Hydrops" clear secretions into GB
What illness?

Back 79

Chronic Cholecystitis-Gross Morphology

Front 80

-Lymphocytes, plasma cells, macrophages
-Whiteness and thickness of wall comes from fibrosis
-Rokitansky-Ashoff sinuses
WHAT ILLNESS?

Back 80

Chronic-Cholecystitis-Microscopic Pathology

Front 81

What are Rokitansky-Ashoff sinuses? In what illness are they found?

Back 81

1.Invagintion of mucosal epithelium deep into wall of GB. Benigh reactive change that mimics invasive carcinoma.
2.Chronic cholecystitis

Front 82

Chronic Cholecystitis: Microscopic Morphology
1.Lymphocytes, plasma cells, macrophages
2.Whiteness and thickness of wall comes from fibrosis
3.Rokitansky-Ashoff sinuses

Back 82

What is shown?

Front 83

1.Epigastric, RUQ pain, N/V
2.Recurrent attacks
3.Fatty food intolerance
CLINICAL FEATURES OF WHAT ILLNESS?

Back 83

Chronic Cholecystitis

Front 84

1.Bacterial superinfection-->cholangitis, sepsis
2.Perforation-->abscess
3.Rupture-->peritonitis
4.Aggravate a pre-existing illness
WHAT ARE THESE COMPLICATIONS OF?

Back 84

Complications of Acute and Chronic cholecystitis

Front 85

A stone in any biliary duct, although many consider it to properly refer to a stone in the common bile duct. WHAT IS THIS CALLED?

Back 85

Choledocholithiasis

Front 86

In choledocholithiasis, where do stones form in the:
1.west
2.asia

Back 86

1.West-stones form in GB
2.Asia-stones form in ducts due to infection

Front 87

In choledocholithiasis, what do symptoms depend on?

Back 87

Symptoms depend on where obstruction occurs:
1.obstruction (pancreatitis)
2.Infection (acute cholangitis)
3.Concurrent cholecystitis

Front 88

Bacterial infection of the bile ducts due to obstruction is called what?

Back 88

Acute cholangitis.

Front 89

How does bacterial infection of the bile ducts occur in acute cholangitis?

Back 89

Enteric bacteria enter ducts via sphincter of oddi due to obstruction.

Front 90

What bacteria is most commonly involved in acute cholangitis?

Back 90

E.coli or Klebsiella (gram-bacilli)

Front 91

What is ascending cholangitis?

Back 91

Cholangitis that ascends into intra-hepatic duct system.

Front 92

What is the classic triad of symptoms in acute cholangitis?

Back 92

Fever/chills, abdominal pain, jaundice

Front 93

What is the microscopic morphology of acute cholangitis?

Back 93

Mural neutrophils move toward lumen

Front 94

Acute cholangitis-->mural neutrophils move toward lumen

Back 94

What is shown in this GB?

Front 95

What is the most severe form of acute cholangitis?

Back 95

Suppurative cholangitis is most severe form-->purulent bile and spesis

Front 96

This congenital anomaly involves complete obstruction of the extra-hepatic biliary tree for first 3 months of life...WHAT IS IT?

Back 96

Biliary atresia

Front 97

What causes congential biliary atresia?

Back 97

Inflammation-->obstruction-->secondary changes in extra-hepatic ducts and hepatocytes-->secondary biliary cirrhosis

Front 98

-Most frequent cause of death from liver disease in childhood
-50-60% referred for liver transplants
WHAT CONGENITAL ILLNESS?

Back 98

Congenital Biliary Atresia

Front 99

What are the 2 main forms of congenital biliary atresia?

Back 99

2 main forms are based on timing of duct obstruction
1.Perinatal form
2.Fetal form

Front 100

Thought to occur after birth, the biliary tree is destroyed. There may be a genetic inheritance, with a viral (reovirus or rotavirus), or toxic insult. WHAT FORM OF CONGENITAL BILIARY ATRESIA?

Back 100

Perinatal form

Front 101

Occurs intrauterine, often along with other anomalies of organs. WHAT FORM OF CONGENITAL BILIARY ATRESIA?

Back 101

Fetal form

Front 102

-F>M, Asian/African Americans>Caucasian Americans
-Stools initially normal, then pale/acholic (no bile)
-Bilirubin increases
-Increae in aminotransferase and alkaline phosphatase
WHAT ILLNESS ARE THESE THE CLINCIAL FEATURES OF?

Back 102

Congenital Biliary Atresia

Front 103

In biliary atresia, what does an intrahepatic duct liver biopsy show?

Back 103

1.Porta edema/fibrosis
2.Ductile proliferation
3.Parenchymal cholestatsis in ALL ducts

Front 104

What are the features of extrahepatic bile ducts in congenital biliary atresia?

Back 104

Inflammation-->fibrosis & stricture-->obstruction

Front 105

What type of congential biliary atresia involves the common bile duct only and correctable surgicallY?

Back 105

Type 1 congenital biliary atresia

Front 106

What type of congenital biliary atresia involves the hepatic duct only and is correctable surgically?

Back 106

Type 2 congenital biliary atresia

Front 107

What type of congenital biliary atresia is at or above the porta hepatic? Is this correctable by surgery?

Back 107

1.Type III
2.NOT correctable surgically b/c there is not patent ductal system for anastomosis

Front 108

-Complications:
-->cirrhosis by 3-6 mo. age
-->death by 2 yrs age
-Treatment:
-->cure: liver transplantation with donor bile ducts
WHAT ILLNESS?

Back 108

Congenital biliary atresia.

Front 109

Congenital dilations of the common bile duct are called what?

Back 109

Cholendocal Cysts

Front 110

What are choledochoceles?

Back 110

Cystic lesions protruding into duodenal lumen-->assoc. with choledocal cysts

Front 111

-Most present before 10 years of age, includes:
1.duct dilations
2.diverticuli
3.choledochoceles
WHAT ILLNESS?

Back 111

Choledocal Cysts

Front 112

-Symptoms:
-->Jaundice, biliary pain, RUP mass
-->More common in females (3-4 times)
-Complications:
-->Most imp. is increased risk for bile duct carcinoma (for older patients)
-->Also have stone formation, stenosis, pancreatitis, and liver changes
WHAT ILLNESS?

Back 112

Choledocal Cysts

Front 113

a.Biliary tract tumors
b.Inflammatory polyps
c.Adenomyosis
THESE ALL HAVE WHAT IN COMMON?

Back 113

These are all benign biliary tract tumors

Front 114

What is adenomyosis?

Back 114

-Benign Biliary Tract Tumor
-Increased number of intramural glands in hyperplastic muscularis (smooth muscle)

Front 115

What are characteristics of carcinomas of GB and extra-hepatic bile ducts?

Back 115

1.Both uncommon
2.Both more in older populations F>M
3.Both diagnosed at stage too late to resect surgically b/c they grow insidiously
4.Both related to chronic inflammation
-->West:associated with gallstones
-->East:associated with infections, parasitic disease

Front 116

What is the most common site to have carcinoma of the GB?

Back 116

Fundus, neck

Front 117

Is carcinoma of the GB more common in females or males?

Back 117

Females

Front 118

Does carcinoma of the GB usually have an infiltrating growth pattern or an exophytic growth pattern?

Back 118

Infiltrating growth pattern

Front 119

What are most carcinomas of the GB?

Back 119

Adenocarcinomas: may be poor or well differentiated

Front 120

What are 5% of carcinoma's of the gallbladder?

Back 120

Squamous Cell or Adenosquamous

Front 121

-Preoperative diagnosis is uncommon-->incidental diagnosis
-In the best case scenario diagnosis should be made before tumor extends due to WHAT 2 THINGS?

Back 121

1.Palpable gallbladder
2.Acute cholecystitis

Front 122

What is a cholangiocarcinoma?

Back 122

Carcinoma of extra-hepatic biliary tree

Front 123

-Painless, progressively increasing obstructive jaundice
-Increase in serum alkaline phosphatase, aminotransferases, direct bilirubin
-Males more common than females; 1/3 have gallstones
-Increase risk with chronic inflammation: Primary sclerosing cholangitis, ulcerative colitis, choledochal cysts
WHAT CARCINOMA?

Back 123

Cholangiocarcinoma-Carcinoma of extrahepatic biliary tree

Front 124

-Infiltrative, malignant glands, that leads to fibrous stromal reaction causing mass to be hard
-What type of cancer?

Back 124

Cholangiocarcinoma-->Adenocarcinoma

Front 125

At junction of R/L hepatic ducts; slow growing, rarely metastasize
WHAT TUMOR?

Back 125

Klatskin tumor