THE BILIARY
TRACT
Gall
Bladder
.a storage organ for bile, with a capacity
of 50 mL in adults
.histology
-mucosa
-fibro-muscular layer
-sub-serosal layer
-peritoneal covering
.cystic duct joins common hepatic duct>
common bile duct courses head of
pancreas>duodenum through Ampulla
of Vater
CONGENITAL ANOMALIES
.Agenesis
.Duplicated
.Bi-lobed
.Aberrant location
.Folded fundus
CHOLELITHIASIS
.afflicts 10%-20% of adults
.types
-cholesterol-containing stones, (80%)
-bilirubin-containing stones, (20%)
.risk factors
-cholesterol stones
.old age
.female sex hormones
.obesity & metabolic syndrome
.rapid weight reduction
.gallbladder stasis
.inborn errors of bile acid metabolism
.hyperlipidemia syndromes
-pigment stones
.chronic hemolytic syndromes
.biliary infection
.gastro-intestinal disorders (Crohn
disease, ileal resection or bypass,
cystic fibrosis)
.pathogenesis
-cholesterol stones
.super-saturation of bile with bilirubin
& cholesterol
-pigment stones
.disorders associated with elevated
levels of unconjugated bilirubin in bile
-hemolytic syndromes
-severe ileal dysfunction or bypass
-bacterial contamination of biliary tree
.morphology
-cholesterol stones
.pure-pale yellow, round to ovoid,
(radiolucent)
.mixed (calcium carbonate, phosphates,
& bilirubin)-gray-white to black, (radioopaque in 10%-20%)
-pigment stones
.black-sterile bile (radio-opaque in 50%75%)
.brown-infected bile (all radiolucent)
Gall bladder, cholesterol stones
Gall bladder, pigment stones
.clinical features
-silent
-biliary colic
-complication in gall bladder (empyema,
perforation, fistulas, cholecystitis,
carcinoma)
-cholangitis & cholestasis
-pancreatitis
-intestinal obstruction
CHOLECYSTITIS
.almost always occurs in association
with gall stones
.types
-acute
-chronic
-active chronic
Acute Cholecystitis
.calculous cholecystitis (obstruction of
bladder neck or cystic duct)
.acalculous cholecystitis (severely ill
patients)
-post-operative state
-severe trauma
-severe burns
-multi-system organ failure
-sepsis
-prolonged intra-venous line
-post-partum state
.pathogenesis
-calculous (chemical inflammation)
-acalculous (ischemia)
.morphology
-enlarged hemorrhagic gallbladder
-lumen is filled with turbid bile that may
contain pus & fibrin
-empyema
-gangrene
.clinical features
-abdominal pain at right upper quadrant
or epigastric region
-most patients have no jaundice
-in calculous cholecystitis, the attack
may be sudden
-in acalculous cholecystitis, symptoms
are more insidious
Chronic Cholecystitis
.follows bouts of acute cholecystitis, or
occurs de novo
.gall stones are present in 90% of cases
.pathogenesis
-super-saturation of bile
.morphology
-gross, thickened wall, lumen contains
clear, mucoid bile & usually stones
-histology, inflammation
-hydrops of gallbladder
Chronic cholecystitis
Chronic cholecystitis, RokitanskyAschoff sinus
.clinical features
-recurrent attacks of abdominal pain
at epigastric or right upper quadrant
-nausea, vomiting, & intolerance for
fatty foods
.complications
-bacterial infection>cholangitis
-gallbladder perforation>local abscess
-gallbladder rupture>peritonitis
-biliary-enteric fistula
-aggravation of a pre-existing medical
illness
-porcelain gall bladder>cancer
ExtraHepatic Bile
Ducts
CHOLEDOCHOLITHIASIS
.stones either arise within gallbladder, or
formed in ducts
.clinical features
-asymptomatic
-obstruction>cholangitis
-pancreatitis
-hepatic abscess
-secondary biliary cirrhosis
-acute calculous cholecystitis
BILIARY ATRESIA
.complete or partial obstruction of lumen
of extra-hepatic biliary tree within first
3 months of life
.presents as neonatal cholestasis
.pathogenesis
-fetal form, associated with other
anomalies
-perinatal form, normal biliary tree is
destroyed after birth, due to
.viral infection, or
.genetic predisposition
Tumors Of
Gall Bladder
BENIGN TUMORS AND TUMOR-LIKE
LESIONS
.Adenoma
.Inflammatory polyp
.Adenomyosis
CARCINOMA OF THE GALLBLADDER
.slightly more common in females
.most frequently in the 7th decade of life
.only rarely is surgically resectable
.mean 5-year survival rate is about 1%
.predisposing factors
-stones
-infection
.morphology
-grossly (infiltrative, exophytic)
-microscopically (adenocarcinoma)
.clinically, rarely detected preoperatively
Gall bladder, adenocarcinoma
Gall bladder, adenocarcinoma