Liver

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• MC congenital anomalies abnormal variants of
  the gallbladder
• MC folded fundus (Phrygian cap)
• Others congenitally absent, bilobed or
  aberrantly located gall bladder

Most common congenital anomaly
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• Cholelithiasis (Gall Stones)
• 10 to 20 of adults in developed countries
• Two kinds of stones
• 1. Cholesterol Stones crystalline cholesterol
  monohydrate,
• Risk factors
• Native American
• adult in industrialized country
• increased age (gt40 yrs, Forty)
• Females 21
• estrogenic influences (Fertile)
• Clofibrate
• Obesity (Fatty) or rapid weight loss
• Gallbladder stasis,
• in spinal cord injury
• pregnancy
• Hypercholesterolemic syndromes

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• 1. Cholesterol Stones contd
• Four conditions -necessary for cholesterol stone
  formation
• supersaturated bile with cholesterol
• gallbladder hypomotility ? promotes crystal
  nucleation
• microprecipitates of calcium salts (inorganic or
  bilirubin salts)
• Mucus hypersecretion in the gallbladder
• Morphology Pale yellow and hard, ovoid, usually
  single, Often radiolucent
• Cholesterol stones arise exclusively in the gall
  bladder
• 2. Pigmented Stones bilirubin calcium salts
• Risk factors
• Asian, Rural
• Chronic hemolytic syndromes
• Biliary tract infection (E. coli, Ascaris
  lumbricoides, liver fluke -Opisthorchis)
• Ileal disease (resection or bypass)
• Cystic fibrosis with pancreatic insufficiency
• Mechanisms? Unconjugated bilirubin in the
  biliary tree and precipitation of calcium
  bilirubin salts
• Morphology more often radiopaque, black color
• Clinical( both types) 70 to 80 of gallstone
  patients -asymptomatic

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• Clinical( both types)
• Symptoms
• spasmodic, colicky pain, owing to obstruction of
  bile ducts by passing stones,
• gallbladder obstruction per se generates right
  upper abdominal pain,
• Complications cholecystitis, Empyema,
  perforation, fistulas, cholangitis, Obstructive
  cholestasis or pancreatitis and , gallstone
  ileus, Mucocele
• other sites of Mucocele?

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Cholelithiasis (Gall Stones)
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• Acute Cholecystitis acute Inflammation of the
  gallbladder
• Cause MCC gallstone obstruction of the neck or
  the cystic duct(90 )
• Rarely without gallstone obstruction (10)-
  severely ill patients (ex. in the postoperative
  state, severe trauma, severe burns, multisystem
  organ failure, sepsis, prolonged
  hyperalimentation or postpartum state)
• Symptoms of CBD obstruction acute right upper
  quadrant or Epigastric pain, mild fever,
  anorexia, tachycardia, diaphoresis, nausea and
  vomiting, jaundice
• Patho Mechanisms bile acids (in
  cholelithiasis pts.) ? chemical irritation of
  gallbladder? inflammatory mediators
  (lysolecithin, prostaglandins)
• in the severely ill patient direct result of
  ischemia
• Gross enlarged, tense gallbladder , fibrin on
  serosal covering
• Course mild and intermittent or may be a
  surgical emergency,
• self-limited and mortality is less than 1, or
  severely ill patient with mortality is higher,
• complications
• cholangitis and sepsis
• gallbladder perforation or rupture
• enteric fistula formation

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• Chronic Cholecystitis
• Causes MCC from repeated bouts of symptomatic
  acute cholecystitis or
• Morphology fibrosed, contracted gallbladder, GB
  wall - thickened and gray-white
• Microscopy mucosa is preserved
• Cholesterolosis cholesterol-laden macrophages in
  the lamina propria
• Gallstones
• Rokitansky -Aschoff sinuses Mucosal out pouching
  
• porcelain gallbladder rarely - dystrophic
  calcification
• xanthogranulomatous cholecystitis Fibrosed,
  nodular histiocytic inflammation of gallbladder
• Clinically steady or colicky Recurrent attacks
  of Epigastric or right upper quadrant pain
• Complications same as acute

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Cholecystitis
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• Choledocholithiasis Stones within the biliary
  tree
• in about 10 of patients with cholelithiasis
• Western nations - almost all stones are derived
  from the gallbladder (cholesterol stones)
• Asia- stones are usually primary and pigmented
• Symptoms arise from
• obstruction
• pancreatitis
• cholangitis
• hepatic abscess
• secondary biliary cirrhosis
• acute calculous cholecystitis
• Ascending Cholangitis Bacterial infection of
  the bile ducts,
• Common in the setting of Choledocholithiasis,
• Ascending bacteria (E. coli, Klebsiella and other
  enterobacteria) enter the biliary tract through
  the sphincter of Oddi

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• Extrahepatic Biliary Atresia Complete
  obstruction of bile flow
• unknown cause
• Mechanism destruction or absence of all or part
  of the extrahepatic bile ducts
• Normal at birth , later progressive inflammatory
  destruction
• Liver changes (same as cholestasis)
• marked bile duct proliferation
• portal tract edema and fibrosis
• Cirrhosis within 3 to 6 months
• Clinical features neonatal cholestasis with
  normal birth weight postnatal weight gain
• Treatment liver transplantation is curative
• if untreated, death occurs within 2 years of
  birth
• Choledochal Cysts
• congenital dilations of the CBD in Children lt ten
  yr. age
• Clinically Jaundice, recurrent abdominal pain
• Complications
• Predispose to stone formation, stenosis and
  stricture, pancreatitis,
• in the adult life Obstructive biliary
  complications and bile duct carcinoma

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Extrahepatic Biliary Atresia
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• Carcinoma of Gall Bladder (GB) FgtM, in their
  60's
• Gallstones coexist in patients in Western nations
• critical risk factorChronic inflammation of GB
• MC- adenocarcinomas
• unresectable when discovered
• prognosis really is BAD
• Extahepatic Bile Duct Carcinoma uncommon
  malignancies of the extrahepatic biliary tree
  down to the ampulla of Vater
• Risk factors
• choledochal cysts Calori disease
• ulcerative colitis,
• Biliary infection with C. sinensis
• MC- adenocarcinomas,
• Klatskin's tumors
• tumors arising at the confluence of the right and
  left hepatic bile ducts
• notable for slow growth,
• sclerosing behavior and
• infrequency of distant metastasis
• Good Prognosis

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Gallbladder- Carcinoma