Chapter 18: Gall Bladder

Question 1

What is the most common congenital anomaly of the gallbladder?

Answer 1

Inward folded fundus –> Phrygian cap

Question 2

Why is estrogen exposure a risk factor for the development of gallstones?

Because of this who is at the most risk?

Answer 2

• Increases expression of: hepatic lipoprotein receptors and hepatic HMG-CoA reductase activity —> enhanced cholesterol uptake and biosynthesis
• Females taking OCs and during pregnancy

Question 3

Rates of cholesteorl gallstones approach 75% in persons of which cultural group?

Answer 3

Native Americans of the Pima, Hopi, and Navajo groups

Question 4

Which specific gene and transporter have been implicated in the development of cholesterol gallstones?

Answer 4

• ABCG8 gene
• ATP-binding casette (ABC) transporters

Question 5

Pigment stones are more commonly seen in the setting of which 3 GI disorders?

Answer 5

• Ileal disease (i.e., Chron disease)
• Ileal resection or bypass
• CF w/ pancreatic insufficiency

Question 6

Which 4 conditions contribute to the formation of cholesterol gallstones?

Answer 6

1) Supersaturation of bile w/ cholesterol
2) Hypomobility of gallbladder
3) Accelerated cholesterol crystal nucleation
4) Hypersecretion of mucus in the GB –> traps nucleated crystals –> addition of more cholesterol –> stones

Question 7

The development of pigment stones is associated with disorders that cause an increase in what?

List some of these disorders

Answer 7

• Unconjugated bilirubin
• Chronic hemolytic anemias
• Severe ileal dysfunction or bypass
• Bacterial contamination of the biliary tree

Question 8

Infection of the biliary tree leads to the release of which enzyme that hydrolyzes bilirubin glucuronides?

Answer 8

microbial β-glucuronidases

Question 9

Infection of the biliary tree by which 3 organisms increase the risk of developing pigment stones?

Answer 9

1. E. coli
2. Ascaris lumbricides = roundworm (intestinal nematode)
3. Liver fluke -> C. sinensis

Question 10

In general, where are black pigmented stones vs. brown pigmented stones found?

Answer 10

• Black are found in STERILE gallbladder bile
• Brown are found in INFECTED large bile ducts

Question 11

Can black and brown pigmented stones be seen on X-ray?

Answer 11

• Majority of black stones are radiopaque = can see on XR (due to calcium salts)
• Brown stones are radiolucent (can’t be seen) due to calcium soaps

Question 12

When symptomatic, gallstones typically produce what type of pain, which radiates where?

Commonly presents after the patient does what?

Answer 12

• Biliary colic that may be excruciating and is typically constant
• Pain is localized to RUQ or epigastrium that may radiate to the right shoulder or the back
• Pain typically follows a fatty meal

Question 13

How does the size of the gallstone relate to the likelihood of it causing problems?

Answer 13

• Larger the calculi, the less likely they are to enter the cystic or common ducts to produce obstruction
• Very small stones, or “gravel,” are far more dangerous

Question 14

What are complications that may arise sometimes with large gallstones?

Answer 14

• May erode directly into an adjacent loop of small bowel, generating an intestinal obstruction
• “Gallstone ileus” or “Bouveret syndrome”

Question 15

Acute calculous cholecystitis is typically caused by an obstruction of which 2 areas by a stone?

Answer 15

Neck or cystic duct

Question 16

What is the primary complication of gallstones and the most common reason for emergency cholecystectomy?

Answer 16

Acute Cholecystitis

Question 17

How do bacterial infections contribute to the initiating events of Acute Calculous Cholecystitis?

Answer 17

These events occur in the absence of bacterial infections; only later in the course may a bacterial infection occur

Question 18

Patients with which metabolic disorder + symptomatic gallstones frequently develop acute calculous cholecystitis?

Answer 18

Diabetes mellitus

Question 19

Acute acalculous cholecystitis, without stone involvement, is thought to result from what?

Answer 19

Ischemia

Question 20

Which artery is implicated in Acute Acalculous Cholecystitis?

Answer 20

Cystic artery = end artery w/ no collateral circulation

Question 21

Acute Acalculous Cholecystitis most frequently occurs in patients who are hospitalized for unrelated conditions, such as (list 5 common settings)?

Answer 21

• Sepsis w/ hypotension and multisystem organ failure
• Immunosuppression
• Major trauma and burns
• Diabetes mellitus
• Infections

Question 22

When the exudate inside the gallbladder lumen is virtually pure pus, the condition is referred to as?

Answer 22

Gallbladder empyema

Question 23

In the acute cholecystitis, the GB is typicall enlarged and the serosal covering is frequently covered by what type of exudate?

Answer 23

Fibrinopurulent exudate

Question 24

In severe cases of acute cholecystitis the GB may be transformed into a green-black necrotic organ w/ small-to-large perforations and this condition is known as?

Answer 24

Gangrenous cholecystitis

Question 25

Invasion of the GB w/ gas-forming organisms, such as **clostridia and coliforms**, may cause a condition known as?

Answer 25

Acute "**emphysematous**" cholecystitis

Question 26

How does acute calculous cholecystitis typically present clinically? Associated sx's?

Answer 26

- **Progressive** RUQ or epigastric pain lasting for **\>6 hours** - Associated w/: **mild fever**, anorexia, **tachycardia**, **sweating**, **N/V**

Question 27

Presence of **hyperbilirubinemia/jaundice** in a patient presenting w/ suspected acute calculous cholecystitis suggests what kind of obstruction?

Answer 27

Obstruction of **common bile duct**

Question 28

Acute calculous cholecystitis may present with mild to moderate leukocytosis and be accompanied with what serum finding?

Answer 28

Mild elevations in **alkaline phosphatase**

Question 29

In some cases acute calculous cholecystitis may appear with remarkable suddenness and this must be dealt with how in the clinic?

Answer 29

Acute surgical emergency

Question 30

The incidence of **gangrene** and **perforation** are much higher in which type of acute cholecystitis?

Answer 30

Acute **acalculous** cholecystitis

Question 31

Which 2 organisms can give rise to acute acalculous cholecystitis?

Answer 31

- ***Salmonella typhi*** - ***Staphylococci***

Question 32

In 90% of cases Chronic Cholecystitis is associated with? In 33% of cases which 2 organisms may be culutred from the bile?

Answer 32

- **90%** of cases = associated w/ **cholelithiasis (gallstones)** - **33%** contain ***E. coli*** *and **enterococci***

Question 33

In Chronic Cholecystitis the serosa is typically smooth and glistening, but may be dulled by?

Answer 33

Subserosal **fibrosis**

Question 34

Outpuchings of the mucosal epithelium through the wall of the GB may be quite prominent in Chronic Cholecystitis and is known as?

Answer 34

**Rokitansky-Aschoff sinuses**

Question 35

In some cases of Chronic Cholecystitis, extensive dystophic calcification may yield what?

Answer 35

Porcelain gallbladder

Question 36

Porcelain gallbladder caused by extensive dystrophic calcification is associated with an increased risk for?

Answer 36

Cancer

Question 37

What is seen in Xanthogranulomatous cholecystitis, describe the morphology. Characteristic cell type?

Answer 37

- GB has **massively thickened wall** and is **shrunken, nodular,** and **chronically inflammed** w/ **foci** of **necrosis** + **hemorrhage** - **Macrophages** w/ ingested biliary phospholipids = foamy cytoplasm = **xanthoma cells**

Question 38

What triggers xanthogranulomatous cholecystitis?

Answer 38

**Rupture** of **Rokitansky-Aschoff sinuses** into the **wall of the GB** --\> accumulation of macrophages that have ingested bilirary phospholipids

Question 39

Chronic cholecystitis does not have the striking clinical manifestations of acute forms and is usually characterized by what symptoms?

Answer 39

- **Recurrent** attacks of either steady epigastric or RUQ pain - N/V and **intolerance for fatty foods** are common findings

Question 40

The diagnosis of both acute and chronic cholecystitis is important to avoid which complications?

Answer 40

- Bacterial **superinfections** w/ cholangitis or sepsis - GB **perforation** and local abscess formation - GB **rupture** w/ **diffuse peritonitis** - **Biliary enteric fistula** w/ drainage of bile into adjacent organs --\> air and bacteria into biliary tree or gallstone induced intestinal obstruction - Aggravation of preexisting med condition - **Porcelain GB** w/ increased risk of cancer

Question 41

What is the most common malignancy of the extrahepatic biliary tree?

Answer 41

Carcinoma of the GB

Question 42

Which areas of the world have the highest incidence of GB carcinoma? Where in the US?

Answer 42

- Chile, Bolivia, and Northern India - In the US, the areas w/ **highest #'s of Native Americans** or **Hispanics**, such as the SW

Question 43

What is the prognosis of GB carcinoma?

Answer 43

5-year survival is 10% = **poor**

Question 44

What is the major risk factor for carcinoma of the GB; due to?

Answer 44

Gallstones ---\> **chronic inflammation**

Question 45

Which oncoprotein is often seen overexpressed in carcinoma of the GB? Also, which chromatin remodeling genes?

Answer 45

**- ERBB2** (Her-2/neu) - Chromatin remodeling genes ***PBRM1*** and ***MLL3***

Question 46

What are the 2 patterns of growth seen in carcinomas of the GB? Which is **most common**?

Answer 46

1. Infiltrating = **most common** 2. Exophytic

Question 47

What are the morphological characteristics of the more common infiltrating growth pattern seen in carcinoma of the GB?

Answer 47

- Poorly defined area of diffuse **mural thickening** and **induration** - Deep ulceration --\> direct penetration of liver or fistula formation to adjacent viscera - **Scirrhous** w/ **firm consistency**

Question 48

What are the morphological characteristics of the exophytic growth pattern displayed by some carcinomas of the GB?

Answer 48

- **Irregular**, **CAULIFLOWER mass** - Invades the underlying wall

Question 49

Most carcinomas of the GB are what type of carcinoma?

Answer 49

Adenocarcinomas

Question 50

Carcinomas of the GB of which type generally have a better prognosis?

Answer 50

Papillary tumors

Question 51

Where are the most common sites for seeding by carcinomas of the GB?

Answer 51

- Liver --\> extension into cytic duct and adjacent bile ducts - **Peritoneum** - **GI tract** - **Lungs**

Question 52

Why are carcinomas of the GB typically of poor prognosis?

Answer 52

- Typically are **detected late** - Presenting sx's are **indistinguishable** from those associated with **cholelithiasis**

Question 53

What are 3 major risk factors/underlying diseases that cause pigment stones?

Answer 53

1) Chronic **hemolytic syndromes** 2) **Biliary infection** 3) **GI disorders** --\> ileal disease (Chron), ileal resection or pass; CF w/ pancreatic insufficiency