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, (radio- opaque 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 obstructionCHOLECYSTITIS .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, Rokitansky-Aschoff 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
Extra-Hepatic 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 cholecystitisBILIARY 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 .AdenomyosisCARCINOMA 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