Gallbladder and Biliary Tract Pathology

A. Gallstones (Cholelithiasis) 1. Cholesterol stones a. Composition: mostly cholesterol monohydrate b. Risk factors i. Female gender precipitation of cholesterol from supersaturated bile.

Formation of cholesterol stones involves the

Note ii. Obesity iii. Pregnancy iv. Oral contraceptives and hormone replacement therapy (HRT)

v. Incidence increases with age vi. Genetics (Native American Pima and Navajo Indians)

2. Pigmented bilirubinate stones a. Composition: calcium salts and unconjugated bilirubin b. Risk factors i. Chronic hemolytic anemias ii. Cirrhosis iii. Bacteria iv. Parasites (Ascaris or Clonorchis [Opisthorchis] sinensis)

3. Clinical features of gallstones a. Presentation i. Frequendy asymptomatic ii. Biliary colic: right upper quadrant pain due to impacted stones b. Diagnosis: ultrasound c. Complications i. Cholecystitis ii. Choledocholithiasis: calculi within the biliary tract iii. Biliary tract obstruction iv. Pancreatitis v. Cholangitis

B. Inflammatory Conditions

1. Acute cholecystitis a. Definition: acute inflammation of the gallbladder, usually caused by cystic duct obstruction by gallstones medical 167

b. Presentation i. Biliary colic ii. Right upper quadrant (RUQ) tenderness on palpation iii. Nausea and vomiting iv. Low-grade fever and leukocytosis c. Complications i. Gangrene of the gallbladder ii. Perforation and peritonitis iii. Fistula formation and gallstone ileits (small bowel obstruction by a large gallstone)

2. Chronic cholecystitis a. Definition: ongoing chronic inflammation of the gallbladder usually caused by gallstones b. Micro: chronic inflammation and Rokitansky-Aschoff sinuses c. Late complication: calcification of the gallbladder ("porcelain gallbladder")

3. Ascending cholangitis a. Definition: bacterial infection of the bile ducts ascending up to the liver, usually associated with obstruction of bile flow b. Presentation: biliary colic, jaundice, high fever and chills c. Organisms: gram-negative enteric bacteria Miscellaneous Conditions

1. Cholesterolosis a. Gross: yellow speckling of the red-tan mucosa ("strawberry gallbladder")

b. Micro: collections of lipid-laden macrophages within the lamina propria

2. Hydrops of the gallbladder (mucocele): chronic obstruction of the cystic duct leads to the resorption of the normal gallbladder contents and enlargement of the gallbladder by the production of large amounts of clear fluid (hydrops) or mucous secretions (mucocele)

Biliary Tract Cancer

1. Gallbladder cancer a. Clinical presentation i. Frequently asymptomatic until late in the course ii. Cholecystitis iii. Enlarged palpable gallbladder iv. Biliary tract obstruction (uncommon)

b. X-ray: may have a calcified "porcelain gallbladder"

c. Micro: adenocarcinoma d. Prognosis: poor; 5-year survival -1%

2. Bile duct cancer a. Bile duct carcinoma: carcinoma of the extrahepatic bile ducts b. Cholangiocarcinoma: carcinoma of the intrahepatic bile ducts c. Klatskin tumor: carcinoma of the bifurcation of the right and left hepatic bile ducts

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