Gi: Pathology Of Gall Bladder

Front 1

Describe this gall bladder biopsy, is this normal or pathologic?

Back 1

Normal gall bladder
- mucosa: tall columnar epithelium (mucin secreting)
- lamina propria: lymphocytes, no lymphocytes
- fibromuscular layer: mixed fascicles of smooth muscle and fibrous tissue

Front 2

Composition of bile solutes.

Back 2

- bile salts (67%): cholates, chenodeoxycholates, deoxycholates, lithocholates, ursodeoxycholates
- phospholipids (22%)
- cholesterol (4%)
- protein (4.5%): secreted to conjugate drugs
- bilirubin (0.3%)

Front 3

Compostion of bile secreted by hepatocytes.

Back 3

- 97% water
- 3% solutes

Front 4

What are some functions of gall bladder?

Back 4

- concentrate bile by 5-10 fold: active absorption of eletrolytes, waters follows sodium
- release bile when stimulated by CCK (I cell in duodenum and jejunum) in response to lipid and protein in small intestine.

Front 5

Where are most of secreted bile (95%) salts reabsorbed?

Back 5

ileum

Front 6

What is a very sensitive screen for gall bladder calculi?

Back 6

ultrasound
- can detect stones as small as 2-3mm diameter

Front 7

What is ERCP useful for?

Back 7

- directly visualize bile ducts
- inject dye into pancreatic and extrahepatic bile ducts
- take biopsies
- place stents to relieve obstructions

Front 8

What imaging step is required after cholecystectomy?

Back 8

Intraoperative cholangiogram
- make sure there is no left over gall stone in common bile duct

Front 9

Name three general categories of congenital gall bladder anomalies.

Back 9

- cystic diseases
- extrahepatic biliary atresia
- anatomic variants

Front 10

What are some classes of cystic diseases of bile ducts (5)?

Back 10

- choledochal cyst: dilation of common bile duct
- diverticulum of bile duct
- choledochocele: cysts protrudes into duodenum
- multiple cysts (caroli disease)
- fusiform cysts: intra- and extra- hepatic

Front 11

What is this cystic disease of gall bladder?

- dilations of common bile ducts

Back 11

choledochal cyst

Front 12

What is this cystic disease of gall bladder?

- cysts attached to common bile duct

Back 12

diverticulum

Front 13

What is this cystic disease of gall bladder?

- cysts protrudes into duodenum

Back 13

choledochaocele of intraduodenal bile duct

Front 14

What is this cystic disease of gall bladder?

- multiple intrahepatic cysts

Back 14

caroli disease

Front 15

What is this cystic disease of gall bladder?

- intra- and extra-hepatic cysts

Back 15

fusiform cysts

Front 16

What are some complications of cystic disease?

Back 16

- obstruction
- perforation -> bile peritonitis
- ascending cholangitis (caroli disease)
- hepatic abscess
- secondary biliary cirrhosis
- carcinoma (rare)

Front 17

What is a common complication associated with caroli disease?

Back 17

ascending cholangitis

Front 18

What is this gall bladder disease?

- complete obstruction od bile flow due to destruction/absence of all or part of extrahepatic bile ducts

Back 18

extrahepatic biliary atresia
- neonatal jaundice (conjugated)
- 10% surgically curable. others need liver transplant

Front 19

Treatment for extrahepatic atresia.

Back 19

- 10% surgically curable
- others need liver transplant

Front 20

Describe the morphology of early sequalae of extrahepatic biliary atresia.

Back 20

- inflammation and/or necrosis of bile duct cells

Front 21

Describe the morphology of late sequalae of extrahepatic biliary atresia.

Back 21

- fibrosis/obliteration of bile duct -> biliary cirrhosis

Front 22

Name some anatomic variations of gall bladder (3).

Back 22

- hourglass gallbladder
- double and bilobed gallbladder
- aberrant locations of gall bladder: intrahepatic gallbladder, and left sided gallbladder.

Front 23

Name some anatomic variations of bile ducts (3).

Back 23

- abnorsmally long
- accessory hepatic ducts
- low fusion of hepatic ducts -> double common bile duct

Front 24

What is this anatomic variation of gallbladder?

Back 24

Hourglass gallbladder
- septation

Front 25

Definition: stones in gallbladder.

Back 25

cholelithiasis

Front 26

Definition: stones in common bile duct.

Back 26

choledocholithiasis

Front 27

Three varieties of gallstones.

Back 27

- pure cholesterol: 10%
- pure pigment (calcium bilirubinate): 10%
- mixed: 80%

Front 28

What percentage of all gallstones contain cholesterol?

Back 28

90%

Front 29

What percentage of all gallstones contain pure cholesterol?

Back 29

10%

Front 30

What makes up the pure pigment gallstone?

Back 30

Calcium bilirubinate

Front 31

Pathogenesis of gallstone.

Back 31

- deficient bile salts or excess cholesterol -> cholesterol supersaturation -> crystals
- gallbladder hypomotility and hypersecretion of mucus -> accretion of crystals
- calcium salts + cholesterol crystals => stone

Front 32

Why is flat plate abdominal xray not used anymore to diagnose gallstones?

Back 32

not very sensitive
- only 10-20% stone are opaque.

Front 33

Which gender has more risk for cholesterol containing gallstones?

Back 33

premenopausal women
- estrogen promotes uptake and synthesis of cholesterol by hepatocytes (OCP and pregnancy)

Front 34

What are some risk factors for cholesterol containing gallstones?

Back 34

- native american, inductrialized societies
- elderly
- premenopausal women
- estrogen
- obesity
- hypercholesterolemia
- family history
- GI disorder that interferes with bile salt reabsorption in ileum (Crohn's)

Front 35

What are some risk factors for pure pigment gallstones?

Back 35

disorders with elevated unconjugated bilirubin in bile
- hemolytic syndromes
- disease or removal of ileum
- bacterial infection of biliary tree (E coli): beta-glucuronidase convert conjugated yo unconjugated bilirubin
- parasitic infection: clonorchis, ascaris lumbricoides

Front 36

How does bacterial infection such as E. coli cause pure pigment stones of gallbladder?

Back 36

beta-glucuronidase convert conjugated yo unconjugated bilirubin

Front 37

People who had ileum removal is at risk for what gallbladder conditions?

Back 37

gall stones
- less bile salts in bile

Front 38

Which two parasites may cause pure pigment stones?

Back 38

- Clonorchis sinensis
- Ascaris lumbricoides

Front 39

What are some complications of gallstones?

Back 39

- common bile duct obstruction
- biliary colic
- acute cholecystitis with sepsis
- acute pancreatitis (obstriction of pancreatic duct)
- gallstone ileis: fistula from gallbladder to small bowel
- Mirizzi syndrome: stone in bile duct causing stricture

Front 40

What is this complication of gallstones?

- fistula from gallbladder to small bowel

Back 40

gallstone ileus

Front 41

What is this complication of gallstones?

- stone in bile ducts causing stricture

Back 41

Mirizzi syndrome

Front 42

Is medical treatment useful in gallstones?

Back 42

only for pure cholesterol stones

Front 43

How to treat gallstones?

Back 43

- medicine for pure cholesterol stones
- surgery: laproscopic, open cholecystectomy, ERCP

Front 44

What is this gallbladder disease?

- intermittent pain, recently worse RUQ pain
- fever, leukocytosis
- palpable dilated gallbladder
- jaundice

Back 44

acute cholecystitis

Front 45

Pathogenesis of acute cholecystitis.

Back 45

- 90% calculous

Front 46

What is this gallbladder disease?

- edema, hemorrhage, mucosal necrosis

Back 46

acute cholecystitis
- transmural infiltrate of neutrophils, hemorrhage, edema, necrosis

Front 47

What is this gallbladder disease?

- ulcerated epithelium with dense infiltrate of neutrophils extending through fibromuscular layer

Back 47

acute cholecystitis

Front 48

What are some treatments for acute cholecystitis?

Back 48

- 25% require risky surgery because of pain, stones or sepsis
- others: antibiotics followed by elective surgery

Front 49

What is this gallbladder disease?

- intermittent nausea, belching, discomfort
- epigastric or RUQ pain
- symptoms worse after meals (fatty or large meals) "flatulent dyspepsia"

Back 49

chronic cholecystitis

Front 50

What is this gallbladder disease?

gross
- stones and thickened wall
micro
- hyperplasia of fibromuscular layer

Back 50

chronic cholecystitis

Front 51

What are some variants of typical chronic cholecystitis?

Back 51

- Porcelain gallbladder: lithiasis gradually erode mucosa, leaving a leathery wall
- hydrops: stone obstructing cystic duct -> watery fluid in lumen
- mucocele: stone obstructing cystic duct -> thick mucoid fluid in lumen

Front 52

What is this gallbladder disease?

- leathery thicj all and eroded mucosa
- stone found at orifice of cystic duct

Back 52

porcelain gallbladder (variant of chronic cholecyctitis)

Front 53

What is this gallbladder disease?

- watery fluid in lumen
- stone obstructing cystic duct

Back 53

hydrops variant of chronic cholecystitis

Front 54

What is this gallbladder disease?

- thick mucoid fluid in lumen
- stone obstructing cystic duct

Back 54

mucoid variant of chronic cholecystitis

Front 55

Name some non-neoplastic disorders of the gallbladder.

Back 55

- cholesterolosis
- cholesterol polyps
- diverticular disease
- torsion
- metaplasia (gastric type) and dysplasia

Front 56

What is this gallbladder disease?

- accumulation of lipid laiden macrophages in lamina propria

Back 56

cholesterolosis
- diffuse linear streaks in mucosa

Front 57

What is this gallbladder disease?

- accumulations of cholesterolosis

Back 57

cholesterol polyps

Front 58

What is this gallbladder disease?

- diffuse mural thickening with cysts in the wall
- cysts lined by normal columnar epithelium embedded within fibromuscular layer

Back 58

diverticula: localized adenomyomatous hyperplasia type

Front 59

Name the 2 types of diverticular diseases of the gallbladder.

Back 59

- diffuse type: adenomyomatosis
- localized type: adenomyomatous hyperplasia

Front 60

Pathogenesis of diverticular disease of gallbladder.

Back 60

pulsion diverticulum

Front 61

Torsion of the gallbladder leads to _____.

Back 61

ischemia -> necrosis (urgent surgery to avoid rupture with bile peritonitis

Front 62

Neoplastic or non-neoplastic gallbladder disease?

Back 62

non-neoplastic
- metaplasia (gastric type) due to chronic inflammation

Front 63

Neoplastic or non-neoplastic gallbladder disease?

Back 63

non-neoplastic
- dysplasia due to chronic inflammation

Front 64

Are gallbladder neoplasms common?

Back 64

NO!
but if one has one, it is more likely to be malignant.

Front 65

Benign neoplasm of the gallbladder. (4)

Back 65

- papillary adenoma
- heterotopias: gastric, pancreatic
- non-epithelial neoplasms: lipoma, fibroma
- adenomyomatous hyperplasia (diverticulum)

Front 66

What is this gallbladder disease?

gross
- soft, polypoid, exophytic lesion protruding into lumen
micro
- papillary frons of epithelium supported by fibrovascular stroma
- no invasion of wall

Back 66

papillaty adenoma

Front 67

Which type of gross appearance is this gallbladder carcinoma?

Back 67

diffusely infiltrating (70%)

Front 68

What type of gross appearance is this gallbladder carcinoma?

Back 68

localized fungating (30%)

Front 69

Which is more common?

carcinoma of the gallbladder or carcinoma of the bile duct

Back 69

carcinoma of the gallbladder

Front 70

What is the observation of the correlation between gallstone and gallbladder carcinoma?

Back 70

- 80-90% gallbladder carcinoma have gallstones
- 0.5% patients with gallstones develop carcinoma

Front 71

3 microscopic features of gallbladder carcinomas. Which one is most common?

Back 71

- adenocarcinoma in situ (5%)
- invasive adenocarcinomas (90%)
- squamous cell carcinoma or mixed (5%)

Front 72

What is the clinical presentation of gallbladder carcinoma?

Back 72

- often late and invading liver with regional/distant metastases
- poor prognosis: 5-10% 5 yr survival

Front 73

What is this gallbladder disease?

Back 73

Adenocarcinoma
- well differentiated cell invading wall

Front 74

What is this gallbladder disease?

Back 74

carcinoma with glandular and squamous features

Front 75

What is this gallbladder disease?

Back 75

carcinoma (mixed)
- adenocarcinoma (top)
- squamous carcinoma (lower)

Front 76

What is the most common site of carcinoma of bile ducts?

Back 76

1. ampula
2. common bile duct
3. hepatic duct
4. junction hepatic and common duct (Klatskin tumor)

Front 77

What is this called?

- carcinoma at the junction of hepatic and common bile duct

Back 77

Klatskin tumor

Front 78

What is this biliary disease?

- obstructive jaundice
- predisposition: gallstones, parasitic infections, sclerosing cholangitis, chronic ulcerative colitis

Back 78

- carcinoma of bile ducts
- stones in common bile duct

* need to differentiate

Front 79

How to surgically treat carcinoma of bile duct?

Back 79

Whipple procedure for lesion <2cm big