Liver Path 6 - Gallbladder

Question 1

The gallbladder stores and concentrates bile (~50 ml), but is not an essential orgen.

What supplies blood to the gallbladder?

What controls bile flow?

Answer 1

• Blood supply is from the cystic artery
• Bile flow is a consequence of the activity of smooth muscle in the gallbladder and the sphincter of Oddi

Question 2

What percentage of biliary tract disease is attributable to gallstones?

Answer 2

over 95%

Question 3

What is the primary site of gallstone impaction?

Answer 3

The rapid tapering of the gallbladder neck just proximal to the cystic duct.

Question 4

On histological exam you will notice that the gallbladder differs from the remainder of the GI tract in that it lacks a discrete muscularis mucosae and submucosa.

Identify the indicated structures.

Answer 4

Upper arrow = single smooth muscle layer and subserosal soft tissue.

Lower arrow = Absorptive columnar epithelium of the mucosa

Question 5

Gallbladder congenital anomalies can arise in the form of:

Shape

Number

Position

Give some examples of each.

Answer 5

Shape

• angulations (phrygian cap)
• septation

Number

• Agenesis
• duplication

Position

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

Question 6

This asymptomatic 2nd year med student was practicing ultrasound on himself when he found the attached image. Concerned he asks you what you think is going on.

You, being a jerk answer… “ooh that looks like gallstones for sure.” Before telling him that you’re kidding and that it actually is?

Answer 6

A phyrigian cap denotes folding of the fundus back upon the gallbladder body.

•Although clinically unimportant, it may be mistaken on ultrasound examination for septation or possibly stone

Question 7

What are the major components of bile?

Answer 7

Bile salts - chenodeoxycholates

Cholates - yeah I read it as chocolates first too.

deoxycholates

phospholipids

Question 8

Cholelithiasis impacts 10-20% of the adult population in the developed world.

What are four major risk factors?

Answer 8

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

Question 9

What are the two general classes of gallstones?

Do they show up on xray?

Answer 9

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

15-20% per radiopaedia

“Who ya gonna trust?”

Question 10

What symptoms do most gallstones present with?

Answer 10

Vast majority (75-80%) are silent.

Question 11

Although the most frequent outcome is for the patient with a gallstone to remain asymptomatic throughout life, some do develop symptoms.

What are 4 of the most common complications?

Answer 11

1. Biliary pain
2. Acute cholecystitis
3. Cholangitis
4. Pancreatitis

Question 12

Surgical tx of asymptomatic gallstones is discouraged. In what patients is surgery recommended?

3

Answer 12

• Patients with large gallstones greater than 2 cm in diameter
• Patients with nonfunctional or calcified (porcelain) gallbladder observed on imaging studies and 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 13

Patients with risk factors for complications of gallstones may be offered elective cholecystectomy. What are some examples of these risk factors?

Answer 13

1. •Cirrhosis
2. •Portal hypertension
3. •Children
4. •Transplant candidates
5. •Diabetes with minor symptom

Question 14

In what populations are the prevalence rates of gallstones highest?

What american population has the lowest?

Answer 14

Highest

1. Native americans - females in particular
2. Chileans
3. Hispanic americans

Lowest

• Lowest in black Americans

Question 15

What is shown on this imaging study?

Answer 15

Cholelithiasis

Question 16

What is shown in this image?

Answer 16

Cholesterolosis - sometimes referred to as “strawberry gallbladder”

Question 17

What precipitates acute cholecystitis in 90% of cases?

Answer 17

Obstruction of the neck or the cystic duct by a stone.

Question 18

What are two possible presentations of acute calculous cholecystitis?

Answer 18

1. Acute surgical emergency
2. Mild symptoms that spontaneously resolve

Question 19

Is the incidence of gangrene and perforation of the gallbladder higher in acalculous or calculous acute cholecystitis?

Answer 19

Acalculous - more insidious presentation

Question 20

What is acute acalculous cholecystitis thought to result from?

Answer 20

Ischemia - cystic artery is an end artery with no collateral circulation

Question 21

What are five risk factors associated with acalculous cholecystitis?

Answer 21

1. sepsis with hypotension and multisystem organ failure
2. immunosuppression
3. major trauma and burns
4. diabetes mellitus
5. infections

Question 22

Acute cholecystitis may present with epigastric or right upper quadrant pain 1-2 hours after ingestion of a fatty meal.

What is a major complication in 10-15% of cases?

What do most authorities agree is the role of infection in the onset of acute cholecystitis?

Answer 22

• 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 23

In acute cholecystitis, the gallbladder is enlarged, edematous and congested. What is the histologic hallmark of acute cholecystitis?

Answer 23

Presence of neutrophils in the gallbladder mucosa and wall

Question 24

In acute cholecystitis, the mucosa is often, but not invariably ulcerated. If obstruction of the cystic duct results in frank pus in the lumen of the gallbladder, what do we call this?

What is usually present in the bile in this situation?

Answer 24

Empyema of the gallbladder

Enteric organisms

Question 25

If there is extensive necrosis of the gallbladder wall, usually accompanied by a marked acute inflammatory infiltrate, we term this?

Answer 25

Gangrenous cholecystitis

Question 26

What does emphysematous cholecystitis result from? How do we identify this?

Answer 26

1. Infection of the gallbladder by gas-forming bacterial species such as Clostridium. 2. Air-fluid levels in the gallbladder may be visualized with radiographic studies.

Question 27

This gallbladder was taken from an 11 y/o patient with DM I. Radiographic studies showed increased air:fluid ratio in the gallbladder. What does this kid have? The gross specimen suggests what would have been an consequence soon seen?

Answer 27

Histopathology shows **emphysematous cholecystitis** with impending perforation in 11-year-old child with insulin-dependent diabetes mellitus

Question 28

Commonly isolated organisms in cases of emphysematous cholecystitis include Clostridium welchii/perfingrens, Escherichia coli and Bacteroides fragilis. How is this type of cholecystitis different in terms of progression and outcomes?

Answer 28

Much higher rates of gangrene and perforation of the gallbladder and significantly increased rates of mortality (15-25%).

Question 29

What do the radiographic findings taken from this patient with RUQ pain indicate?

Answer 29

Acute emphysematous cholecystitis - note the Increased air:fluid levels, and presence of "signal void bubbles" in the lumen of the distended gallbladder and the common bile duct.

Question 30

What does the histology indicate was happening in this patient who had RUQ pain?

Answer 30

This image shows the hallmark of acute cholecystitis: a neutrophilic infiltrate in the mucosa. Inflammation may also be seen in the deeper layers of the gallbladder wall.

Question 31

Chronic cholecystitis presents with 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 What are histologic findings in chronic cholecystitis associated with the following? * Subserosa * Wall * Mucosa * Other general findings

Answer 31

* subserosal fibrosis * wall is variably thickened * mucosa itself is generally preserved * fibrous adhesions

Question 32

The pathological findings in chronic cholecystitis include, subserosal fibrosis to dense fibrous adhesions, chronic inflammation, fibrosis, metaplasia of gallbladder mucosa. What are two other findings that can be found in these cases?

Answer 32

* Dystrophic calcification (porcelain gallbladder) * Associated with increased risk of carcinoma * Rokitanansky-Ashoff sinuses

Question 33

What the hell are Rokitanansky-Ashoff sinuses?

Answer 33

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

Question 34

What does this tissue sample from a patient with chronic cholecystitis reveal?

Answer 34

Rokitansky–Aschoff sinus

Question 35

This tissue sample was taken from a patient with chronic cholecystitis, what characteristics shown here are indicative of chronic cholecystitis?

Answer 35

Diffuse lymphoid hyperplasia with germinal center formation

Question 36

This slide also reveals a classic characteristic of chronic cholecystitis. What does it show?

Answer 36

Gastric metaplasia of gallbladder mucosa

Question 37

Choledocholithiasis involves common bile duct stones and is a challenging diagnosis. Like stones in the gallbladder, stones in the bile ducts may remain asymptomatic for years. What is the classic presentation?

Answer 37

_Charcot's triad_ * Abdominal pain (RUQ presumably) * Fever * Jaundice

Question 38

Choledocholitiases are usually brown and d/t biliary tract infections. Where do they typically come to rest/get stuck at?

Answer 38

Lower end of the ampula of vater

Question 39

Bacterial infection by what types of organisms is typically the cause of choledocholithiasis?

Answer 39

Gram-negative rods

Question 40

The gallbladder lesion shown here occurs in the 7th or 8th decade typically and impacts females more frequently. While rare, this is the most common gallbladder neoplasm. What is it? What is the prognosis?

Answer 40

Adenocarcinoma of the gallbladder ## Footnote •Infrequently diagnosed pre-op or when resectable, so terrible prognosis, 5-10% 5 year survival.

Question 41

What is an association we should know regarding carcinoma of the gallbladder?

Answer 41

Usually associated with gallstones

Question 42

Adenocarcinoma of the gallbladder is the most common malignancy of the extra hepatic biliary tract, and over 95% of the time is associated with gallstones. The most common symptoms/signs are abdominal pain and elevated serum alkaline phosphatase. How does this often present clinically?

Answer 42

Many gallbladder adenocarcinomas present as cholecystitis and are clinically silent.

Question 43

Most patients with carcinoma of the gallbladder present with high pathologic stage adenocarcinoma and spread to the liver at time of diagnosis. What variant has the best overall prognosis?

Answer 43

Papillary variant

Question 44

Carcinoma of the gallbladder are usually scirrhous. What does that mean?!!

Answer 44

Associated with dense fibrosis

Question 45

What are some less common types of gallbladder cancer?

Answer 45

SCC Carcinoid Carcinosarcoma

Question 46

What is shown in this image?

Answer 46

Small primary gallbladder adenocarcinoma with massive direct liver invasion.

Question 47

What do you see in these histo images that indicates this patient has an adenocarcinoma of the gallbladder?

Answer 47

Upper two arrows: malignant cells forming glands Lower two arrows: presence of dense fibrosis