BILIARY

PATHOLOGY
SAINT NWAY AYE
Lecturer (Pathology)
saintnwayaye@imu.edu.my
Ext: 1907
Lesson outcomes

On completion of this plenary, the students

should be able to;
• List the congenital disorders of biliary tract.
• Describe the pathogenesis, pathology and
clinical features of Cholecystitis &
Cholelithiasis.
• List the common biliary tract tumors.
Congenital Anomalies

• Agenesis
• Duplication
• Bilobed gallbladder
• Aberrant locations
• Phrygian cap - A folded fundus is the most
common anomaly
• Biliary atresia
• Choledochal cyst- cystic dilatation of any
portion of extrahepatic bile duct
Duplication
of
gallbladder

Phrygian
cap
Cholelithiasis (Gallstones)

• Development of stones (calculi) in

gallbladder.
• Common in western countries
• 20% to 40% in Latin American
• 3% to 4% in Asian countries
• Two main types of gallstones
•

• cholesterol stones
• pigment stones
• Mixed stones
Pathogenesis of gall stones

Cholesterol stones
• excess cholesterol from the body is
eliminated as bile salts
• Cholesterol become water-soluble by
aggregation with bile salts and lecithins
• When cholesterol concentrations exceed
the solubilizing capacity of bile gall
stones forms
• Is enhanced by hypomobility of the
gallbladder (stasis)
Pigment stone
• Formed by unconjugated bilirubin and
insoluble calcium bilirubinate salt
• Occur in hemolytic anemia and infections
of the biliary tract
•

• Stones often leads to infection & infection

promotes further stone formation.
Morphology of Gall stone

Cholesterol stones
• exclusively in the gallbladder
• consist of 50% to 100% cholesterol
• Pure cholesterol stones- pale yellow
(radiolucent)
• With some proportion of calcium carbonate,
phosphates, and bilirubin gray-white to
black discoloration (radio opaque)
• ovoid and firm
• Single or multiple
Pigment stone
• Usually multiple
• small in size, fragile to the touch
• Brown to black in color (radiopaque)
•

Clinical features of Gall stones:

• 70% to 80% - asymptomatic
• right upper quadrant or epigastric pain
• often excruciating
Cholesterol
stones

Pigment stones
Complications of Gallstones

1. Acute cholecystitis
2. Chronic cholecystitis
3. Mucocele gallbladder- cystic duct is
obstructed by stones
4. Obstruction of bile flow- Jaundice
5. Gallstone ileus – when stone ulcerate the
gallbladder and into intestine & cause
intestinal obstruction
6. Carcinoma of gallbladder
1. Empyema gallbladder & biliary peritonitis
2. Biliary colic
3. Ascending cholangitis (Charcot’s triad)
4. Cholecysto-intestinal fistula
5. Acute or chronic pancreatitis
Cholecystitis

• Inflammation of the gallbladder

• may be acute or chronic
• almost always associated with gallstones
•

Acute Calculous Cholecystitis:

• Acute inflammation of a gallbladder that
contains stones
• obstruction of the gallbladder neck or cystic
duct
• most common major complication of
gallstones
Acute Acalculous Cholecystitis
• 5% - 12% of acute cholecystitis contain no
gallstones
• most common predisposing factors:
•

• Major surgery
• Severe trauma (e.g., from motor vehicle
crashes)
• Severe burns
• Sepsis
Acute Cholecystitis
Clinical Features of acute cholecystitis:
• Severe upper abdominal pain
• Radiates to the right shoulder
• Fever, nausea
• In mild case- resolution
• Recurrence chronic cholecystitis
• severe case empyema gall bladder,
perforation and peritonitis
• Murphy’s sign
Chronic Cholecystitis

• Due to repeated attack of acute

cholecystitis
• gallbladder may be contracted, of normal
size, or enlarged
• Mucosal ulcerations and fibrosis
• recurrent attacks of steady epigastric or
right upper quadrant pain
• Nausea, vomiting, and intolerance for fatty
foods
Aschoff-
Rokitansky
sinus

Chronic
cholecystitis
Carcinoma of the Gallbladder

• Benign tumor of gall bladder is very rare

• carcinoma of the gallbladder is the most
frequent malignant tumor of the biliary tract
• more common in women
• 60% to 90% of cases – gallstones (+)
• develop cancer as a result of recurrent
trauma and chronic inflammation by the
stone
Morphology of carcinoma gallbladder:
• most common – fundus & neck, 20% -
lateral wall
• Exophytic or infiltrating growth patterns
• Exophytic pattern grows into the
lumen as an irregular, cauliflower-like mass
• Infiltrative tumor diffuse thickening
and induration of the gallbladder wall
• Firm in consistency
• Histology: Most are adenocarcinomas
• Only 5% are squamous cell carcinomas
Carcinoma
Gallbladder
Cholangiocarcinomas

•
adenocarcinomas arise from cholangiocytes
lining of intrahepatic biliary ducts
•
extrahepatic bile duct- Bile duct carcinoma
•
Extrahepatic Cholangiocarcinoma- known as
Klatskin tumors (if it occurs in hilum)
•
50 to 70 years of age
•
Prognosis is poor
•
risk factors - primary sclerosing cholangitis,
infestation by Clonorchis sinensis or
Opisthorchis viverrini
•
cholestasis and inflammation somatic
mutations in cholangiocytes
Morphology:
• typical adenocarcinomas with abundant
fibrous stroma (desmoplasia)
• Spread to extrahepatic sites such as regional
lymph nodes, lungs, bones, and adrenal
glands
Clinical features:
• nonspecific signs and symptoms such as
weight loss, pain, anorexia, and ascites
• jaundice, pale stools
• elevated serum levels of alkaline
phosphatase and aminotransferase
Cholangiocarcinom
a
References:

• Robbins and Cotran Pathologic Basis of

Disease, 9th Edition, 2015 Kumar V, Abbas
AK & Aster JC, Saunders. (Chapter18-
Gallbladder: Pg. 875-879)
•

• Mohan H. Textbook of Pathology.6th

ed.Jaypee.2010. (Chapter 21-Biliary
System: Pg. 638-644)
•

• Davidson’s Principle & Practice of

Medicine, 22nd edition, 2014. (Chapter
23:Pg. 981-985)