17 cholecystitis

7/30/2019 17 cholecystitis

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Biliary Tract

Kimiko Suzue MD, Ph.D.

Department of Pathology


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Biliary Tract

Extrahepatic biliary tract

Gallbladder

Cystic duct

Common hepatic duct

Common bile duct

Intrahepatic biliary tract


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Biliary Disease

Gallbladder Disorders

-Cholelithiasis

-Cholesterolosis

-Cholecystitis

Extrahepatic Bile Duct Disorders

-Choledocholithiasis

-Cholangitis-Biliary Atresia

-Choledochal cysts

Tumors


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GALLBLADDER

Storage and

concentration of

bile

Contraction of the

muscle induced by

cholecystokinin


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Gallbladder

Gallstones (cholelithiasis) Afflict 10% of adult population

in Western countries

Costs of management: $6 billion

a year 20 million patients are estimated

to have gallstones totalling

several tons

Made of cholesterol, bilirubinand calcium salts with different

concentrations


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CholelithiasisIn West, >90% are cholesterol stones

Usually radiolucent (10% radiopaque due to calcium)

Risk factors:

-Native Americans-Women > Men

-Advancing Age (25-30% of people over 80)

-Estrogenic influence

Pregnancy, Oral contraceptives-Clofibrate

-Obesity

-Gallbladder stasis (neurogenic or hormonal)

-Hereditary (bile acid metabolism)


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Cholelithiasis

Pigmented bilirubin stonesUsually radiopaque (calcium bilirubinate)

Risk factors:

-Chronic hemolytic states (increased bilirubin in bile)Sickle cell, hereditary spherocytosis, cardiac valve

replacement, malaria)

-Ileal disease (bile salt malabsorption)

Crohns disease, bowel resection

-Biliary tract infection/infestation

Ascaris lumbricoides, Clonorchis sinensis

-Liver disease (alcoholic cirrhosis)


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Hepatolithiasis

Choledocholithiasis

Cholelithiasis


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Cholelithiasis

Asymptomatic: 70%

Obstruction: Biliary Colic

Spasmodic right upper quadrant pain

Symptoms are relieved if stone passesInfection: Cholecystitis, cholangitis

Acute Pancreatitis

Gallbladder cancer

Principal therapeutic modality:

Laporascopic cholecystectomy (late 1980s)


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Cholesterolosis

Aggregates of lipid-containingmacrophages in lamina propria of

gallbladder

Debated clinical relevance Strawberry gallbladder


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Cholesterolosis


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Polypoid cholesterolosis

Abundant foamy macrophages forming polypoid

excrescences


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Cholecystitis

General Features

Present in autopsy series in half of the population

Female, obese, multiparous, 5th

and 6th

decades Acute (Chemical irritation and inflammation)

Suppurative (Empyema, purulent contents)

Emphysematous (clostridia and coliforms)

Gangrenous (Necrotic) Chronic


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CholecystitisClinical Picture

Acute: RUQ pain referred to right shoulder

Rigidity of abdominal wall (RUQ)

Fever, nausea, vomiting, leukocytosis Jaundice (25% of cases)

Increased WBC count

Increased serum alkaline phosphatase (duct damage)

Chronic: Fatty food intolerance

Epigastric distress, nausea

Vague RUQ pain

Complications: Ca or obstructive jaundice


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Acute Cholecystitis

Gross Pathology The gallbladder is enlarged (x2 or x3)

The gallbladder wall is thickened (x10)

The serosa is covered by fibrin with subserosalhemorrhages

The lumen is filled with turbid bile, fibrin or pus

The mucosa is hyperemic, ulcerated or franklynecrotic

Gallstones are present in 80% of cases


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Acute Cholecystitis

Histology

Edema and neutrophilic inflammation

Vascular congestion

Abscess formation & gangrenous necrosis

Later neutrophils eosinophils (subacute)

Ca++

deposition:porcelain gallbladder


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Porcelain

Gallbladder


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PorcelainGallbladder withStones


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Chronic Cholecystitis

Histology Mucosa is preserved or atrophic

Mononuclear cell infiltration

Subepithelial and subserosal fibrosis

Severe fibrosis with replacement of smooth

muscle

Outpouchings of mucosal epithelium

through wall Rokitansky-Aschoff sinuses


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Choledocholithiasis

Passage of gallstones into common bile duct occurs in10-15% of patients with cholelithiasis

Majority are cholesterol stones formed in gallbladder

Primary calculi arising de novo in ducts are typicallypigmented stones in pts with:

-Chronic recurrent cholangitis

-Congenital anomalies of bile ducts (Carolis disease)

-Dilated, sclerosed or strictured ducts-MDR3 gene defect leading to impaired biliary phospholipid

secretion


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Choledocholithiasis

May remain asymptomatic May pass spontaneously into duodenum

May present as biliary colic or complications

-Cholangitis

-Obstructive jaundice

-Pancreatitis

-Secondary biliary cirrhosis


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Cholangitis

Acute or chronic

Bacteria present in 75% of pts with acute

cholangitis Charcots triad

Intermittent abdominal pain

Spiking fevers with chills Jaundice


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Biliary Atresia

Complete or partial obstruction of lumen of

extrahepatic biliary tree within first 3 months of life Perinatal type (80% to >90%)

-Presumed normal biliary tree is destroyed at birth

-Jaundice develops within 2 weeks

-No associated congenital anomalies

-Etiology unknown(?viral, ?autoimmunity)

Fetal type (less common)

-Jaundice at birth or within a day or 2

-Assoc cardiac and vascular malformations, sinus inversus,polysplenia, midgut malrotation

-Presumed aberrant intrauterine development of extrahepaticbiliary tree


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Biliary Aresia

Histologic features:

Bile ductular proliferation

Portal fibrosis

Bile plugs in bile ducts/ductules

Parenchymal cholestasis


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Biliary Atresia

Type I Disease limited to common bile duct

Type II Disease limited to hepatic bile ducts

Type III Obstruction of ducts above porta hepatis


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Biliary Atresia

Normal birth weight and postnatal weight gain

Initially normal stools but become acholic stools

Present with neonatal cholestasis

Timing of biopsy Liver biopsy shows nonspecific changes at less than 4 weeks

Fairly good sensitivity/specificity at 6-8 weeks

Diagnostic at >8 weeks

Cirrhosis develops within 3 to 6 months if not recognized

Kasai procedure for types I and II Liver transplantation for rest

Without surgery, death within 2 years


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Choledochal Cysts

Congenital dilatations of bile duct


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Choledochal Cysts

Present most often before 10 yrs of age

Jaundice, abdominal pain, abdominal mass

Delayed diagnosis can lead to complications:

- Pancreatitis

- Spontaneous perforation

- Cholelithiasis

- Cholangitis- Secondary biliary cirrhosis

- Portal hypertension

- Carcinoma


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Carcinoma of the Gallbladder

Clinical Symptoms Pain 70-80%

Weight loss 60%

Jaundice 50%

Gallstones 50-80%

Palpable mass 60%

Ascites 20%


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Carcinoma of the Gallbladder

Histologic Types Adenocarcinoma

Adenosquamous carcinoma

Squamous cell carcinoma Intracystic or intraductal papillary neoplasm with

an associated invasive carcinoma

Mucinous cystic neoplasm with an associated

invasive carcinoma Undifferentiated carcinoma

Neuroendocrine neoplasms

Mesenchymal tumors


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Dysplasia


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Adenoca. of Gallbladder


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Adenoca of Gallbladder


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Biliary Disease

Gallbladder Disorders

-Cholelithiasis

-Cholesterolosis

-Cholecystitis

Extrahepatic Bile Duct Disorders

-Choledocholithiasis

-Cholangitis

-Biliary Atresia

-Choledochal cysts

Tumors

17 cholecystitis

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