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Pathology of the Billiary
tract
Dr Janaki Hewavisenthi
Department of Pathology
Faculty of Medicine
Ragama.
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Pathology of the Billiary
tract
Anatomy & Physiology
Congenital abnormalities
Cholelithiasis Acute cholecystitis.
Chronic cholecystitis.
Miscellaneous Tumours of the billiary tree.
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Physiology
Function - concentration and storage of
bile. (liver secretes 0.5 - 1 litre of bile / d
cf: the capacity of the Gall bladder is 50ml)
Cholesterol is not soluble in bile but
maintained in solution by micelle
formation with bile acids.
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Histology
Compared with the GIT
Single mucosal lining of
tall columnar cells.
A fibromuscular
subserosal layer.
A layer of subserosal fat.
Peritoneal coverings
except where embeddedin the liver.
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Congenital anomalies -
Developmental
Absence.
Bilobed gall bladder.
Duplication. Folded fundus - Phyrigian cap anomaly
(Clinical significance of above )
Agenesis / atretic narrowing of the
billiary system which leads to obstructive
Jaundice.
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Cholelithiasis - Gall stones.
INCIDENCE AND RISK FACTORS.
- Ethnic / Genetic factors.
- Age- Sex
- Diet and Obesity
- Drugs Eg: Clofibrate
- Gastrointestinal disorders -Crohns disease.
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Pathogenesis
Stages involved in the formation of Gall
stones1. Supersaturation of bile
2. Nucleation or initiation of stone
formation.
3. Growth by accretion.
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Supersaturation of bile.
Deficient secretion of bile acid (salts) or
lecithin is lithogenic.
Supersaturation / increased secretion of
cholesterol.
Increased reabsorption of water.
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Stage 1 - Supersaturation of
bile
Cholesterol is maintained in solution by
micell formation with bile salts.
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Stage 2 - Nucleation /
initiation of stone formation
Nucleating factors- (increased)
Mucin - in bile supersaturated
with cholesterol forms a sludge.
Prostaglandins - promote mucin
secretion.
Antinucleating factors - (Decreased)Apoproteins / Serum lippoproteins.
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Morphology
3 types of stones -
Pure cholesterol stones.
Mixed stones
Pigment stones.
Pure cholesterol stones -
Multiple rarely single.
1 - several cms in size.C/S glistening radiating crystalline
pallisade. NOT RADIOLUCENT.
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Morphology
Mixed stones -
varying proportion of calcium
carbonates, phosphates and bilirubin.
1 - 3 cms in size.
Rounded / faceted exterior.
C/S lamellated and variable in colour
Because of the varying proportions ofcalcium substances. Depending on the
amount of calcium RADIOPAQUE.
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Pigment stones.
More common in Orientals.
Pathogenesis - Chronic haemolysis,?? Opisthorchis sinesisAlcoholic cirrhosisBilliary infectionAdvancing age.
Composed of pure Calcium bilirubinate.
Rarely >1.5cm in size.
Jet black in colour.
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Clinical picture
50% patients with gall stones are
asymptomatic.
Symptoms - indigestionIntolerance of fat
Nausea and vomiting.
?? Are these symptoms non specific.
Most of the definitive symptoms are duethe complications of Gall stones.
(See next slide)
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Clinical implications
Obstruction of the bile ducts.Biliary colicCholecystitis and Ascending
cholangitis.Obstructive jaundice.
Formation of empyema or hydrops(Mucocoele)
Gall stone ileus.
Carcinoma.
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CHOLECYSTITIS
ACUTE CHOLECYSTITIS CHRONIC CHOLECYSTITIS
ACALCULOUS
surgery, Trauma
Prolonged labour
DM & PAN
Infections -
Cholera
Salmonella
CALCULOUS
C
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Acalculous vs Calculous
Acute cholecystitis
Less common.
Predisposition - See
The common denominator being -transient invasion of the blood stream by
infective organisms and seeding in the GB
/ Ischaemic compromise.
Signs and symptoms and morphology ofthe GB are the same in both conditions.
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Clinical picture
RHC pain.
Pain radiates to right shoulder and
scapular and interscapular regions. Palpably enlarged exceedingly tender GB -
Murphy sign.
Leukocytosis
Fever and Jaundice - uncommon.
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Macroscopy
- Gall bladder is enlarged.
Red - violaceous - green black
discolouration due to subserosalhaemorrhage.
Serosa - fibrin layered.
Cloudy turbid bile in the lumen or purulent
material .
Wall is thickened.
Mucosa - hyperaemic, patchily destroyed
or denuded.
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Acute Cholecystitis
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Microscopy
All the features of acute inflammation.
The inflammatory reaction is replaced by
chronic inflammation. Calcification in the resolving phase may
lead to Porcelain Gall bladder.
In some cases (incidence unknown) Acute
cholecystitis leads to Chronic
cholecystitis.
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Chronic cholecystitis
Virtually always associated with Calculi.
? Predisposing factor
? Same factors predisposing to
calculous disease.
May be the sequel to repeated attacks of
acute cholecystitis.
Sometimes develops without antecedentacute attacks.
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Morphology
Macroscopy
Normal, small or enlarged. (This
depends on the balance between fibrosis
and obstruction in the genesis of
inflammation.)
Serosa is dulled by subserosal
fibrosis.Wall thickened. - Opaque gray white.
Stones are present in almost all cases.
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Chronic Cholecystitis
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Morpholgy
Presence of calculi even in the absence of
significant inflammation taken to indicate
Chronic cholecystitis.
MICROSCOPY
Varying degrees of chronic
inflammation.
Fibrosis.Rokitansky Aschoff sinuses in the wall.
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Miscellaneous conditions.
Porcelain Gall bladder.
Inflammatory polyps.
Cholesterosis of the Gall bladder
(Strawberry gall bladder)
Hydrops or mucocoele of the Gall bladder.
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Tumours of the Gall bladder
Benign - Adenomas and Papillomas.
Branching pedunculated masses
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Papillary adenocarcinoma
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