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This Concept Map, created with IHMC CmapTools, has information related to: Gallbladder Pathology, Gallbladder Pathology Congenital Anomalies Rare, but anatomic variations possible: Folded fundus most common ->phrygian cap Aberrant locations in 5-10% of pop Partial-complete embedding in liver Congenitally-absent GB GB duplication, Bilobed GB Agenesis of components rare Hypoplastic narrowing of bil tree rare, Gallbladder Pathology Tumors GB CARCINOMA -slightly higher in WOMEN-60s -mean 1% 5-yr survival, even w/ surgery -stones often present -Asia-pyogenic, parasitic dz common, not stones PATHOGENESIS-chron inflam, irritation MORPH-fundus, neck especially -mostly adenoCAs, 5% SqCCs -Infiltrating-more common-penetration -indurated wall, scirrhous -Exophytic-grows into lumen AND wall -often spread before detection -peritoneum, GI, liver CLINICAL-insidious Sx, like stones -fortunate pt w/ early ACC, Gallbladder Pathology Stones CHOLELITHIASIS-general 10-20% of adults in West- ½ need surgery 80% Cholesterol stones 20% PIGMENT stones bilirubin Ca salts CLINICAL-70-80% (-)Sx for life -convert to Sx at 1-3%/yr, dec w/ age Sx-constant bil pain or colicky, chol’it is -empyema, perf, fistulas, cholangitis, panc’it is SMALL STONES MORE DANGEROUS Get in ducts Large can erode into small bowel Can->mucocele, GB CA, Gallbladder Pathology Stones Risk Factors for CHOLESTEROL 75% Native Americans-cholesterol stones -25% pop in West, rare in developing Age, White women Estrogenic: BCP, preg->stim HMG-CoA reductase -> excess bil secretion -Clofibrate, obesity do the same Gall bladder stasis->both stones FHx, IEMs-impaired bile salt synth, Hyperlipidemias Lith genes Formation: cholesterol supersaturated bile, GB hypomotility, accel’d chol nucleation, mucus hypersecretion PRIMARY Defect-chol hypersecretion Exacerbate: fasting, cord injury, TPN, rapid wt loss, preg MORPH-pale yellow, round, hard, in GB -radiolucent if all chol -radiopaque if enough CaCO3, Gallbladder Pathology Stones CHOLESTEROLOSIS -chol hypersecretion by liver-GB esterifies ->accumulate CEs->yellow flecks ->’strawberry gallbladder’, Gallbladder Pathology Extrahepatic Bile Ducts CHOLEDOCHOLITHIASIS (CCL) -stones w/in bil tree -Orient-more often primary in duct -can->obstruction, panc’it is, cholangitis, hep abscess, 2ndary bil cirrhosis, ACC, Gallbladder Pathology CHOLECYSTITIS -inflam of GB-acute or chronic -almost always w/ gallstones ->indicates need for surgery ACUTE CALCULOUS (ACC) -90% ppt’d by stone obstruction-neck/duct Mostly in: postop from nonbil surgery, severe trauma, burns, multi-organ failure, sepsis, postpartum ‘acalculous’-no stones-from ischemia -dehydration, blood transfusions -GB stasis -biliary sludge accum -bac (S. typhi, staph) AIDS,wall inflam -DM-clostridia, coliforms->'acute emphysematous chol’itis' MORPH-cloudy bile-fibrin, pus -severe->gangrenous chol’it is->perfs -more likely if acal CLINICAL-can be sudden, need surgery -or can be mild and Tx w/out surg -mostly not jaundice -hyperbili if duct obstruction -mildly high alk phos ACAL-more insidious -often obscured by underlying dz, Gallbladder Pathology CHOLECYSTITIS -inflam of GB-acute or chronic -almost always w/ gallstones ->indicates need for surgery CHRONIC CALCULOUS -w/ or w/out antecedent attacks -1/3 w/ microorgs-enterococci -arise w/ long-term stones, lo-grade inflam MORPH-smoother serosa, mononuc cells -mildly thickened wall -acute changes may be superimposed Rokitantsky-Aschoff sinuses-outpouch of epith through wall Porcelain GB-w/ lots of dystrophic Ca’tion -inc incidence of CA Xanthogranulomatous chol’it is-shrunken, Nodular, histiocytes w/ lipids, fibrosis Hydrops of GB-w/ just clear secretions CLINICAL-usually steady or colicky pain -N/V, intolerance of fatty foods -Risk fistulas, perf, rupture, bac infx, Gallbladder Pathology Tumors Benign INFLAMMATORY POLYPS -sessile mucosal w/ fibrous stroma -chronic inflam cells, lipid-laden macs -look like neoplasms on imaging ADENOMYOSIS -hyperplasia of muscularis -intramural hyperplastic glands, Gallbladder Pathology Tumors EXTRAHEP BILE DUCT CA -uncommon, insidious -painless, deepening jaundice -risk increases w/ Clonorchis sinesis -biliary tree fluke -or primary sclerosing cholangitis, IBD, choledochal cysts -some are periampullary MORPH-small at Dx b/c jaundice -mostly adenoCA KLATSKIN tumors-at confluence of R, L hep ducts – slow, marked sclerosis CLINICAL-discolored stools, wt loos, n/v -hepatomeg in half, palpable GB in 25% -elevated liver enzs, alk phos -bile-stained urine -diff’ate from stone -most not resectable-survival 6-18 mos, Gallbladder Pathology Stones PIGMENT – Unconj bili-Ca salts -unconj usually minor in bile-inc’d w/ infx -E.coli, Ascaris, Opisthorchis Hemolytic syns, ileal dysfcn, bac contam of bil tree, parasites MORPH-mucin glycoprotein for scaffold -black in sterile bile, crumbly -most radiopaque b/c CaCO3 -brown in infx bile in intra/extra ducts -radiolucent-Ca soaps-laminated, Gallbladder Pathology Extrahepatic Bile Ducts BILIARY ATRESIA 1/3 of infants w/ NN cholestasis -rapidly-ɮndary bil cirrhosis -need liver xplant -most common cause of kid liver death PATHO-intact tree at birth ->rapid destruction by inflam wks -multiple mechs MORPH- ‘florid’-duct prolif, portal tract fib, edema, parenchymal cholestasis ->cirrhosis w/in 3-6 mos after birth CLINICAL-NN cholestasis -NL wt, etc->progress to acholic stools -mod elevated transaminase, alk phos -90% w/ type III (above porta hepatis) -noncorrectable Tx-surgery-otherwise death w/in 2yrs, Gallbladder Pathology Extrahepatic Bile Ducts ASCENDING CHOLANGITIS -bac infx of duct, esp from obstruction esp CCL or stents, catheters, tumors -enter through Oddi -‘ascending’ if infx of radicles -E.coli, Klebsiella, Clostridium, Bacteroides, Enterobacter -acute inflam w/ neutrophils, jaundice -intermittent Sx -most severe-suppurative cholangitis ->liver abscesses -sepsis dominates picture, Gallbladder Pathology Extrahepatic Bile Ducts CHOLEDOCHAL CYSTS -congenital dilations of common duct -presents before age 10 -jaundice, recurrent abd pain, colic -20% Sx in adulthood -FEMALES -can be w/ CAROLI dz-(intrahepatic) -predispose to stones, stenosis, stricture, panc’itis, obstructed bil complications -older pt->inc risk of bile duct CA