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CPC 4- GALLBLADDER ADENOCARCINOMA

Salient Features:
• 63 year old female
• 4 months history of abdominal pain
• CC: Hematemesis
• PMHx: BPUD, PTB (4 months treatment)
o and HPN
• S/P TAHBSO (1983)
• S/P Hemorrhoidectomy (1998)

External Examination
 Skin is jaundiced with minimal postmortem rigidity and posterior lividity.
 Head is normocephalic.
 Sclerae are icteric.
 Chest is symmetrical.
 Abdomen is globular with a midline infraumbilical scar measuring 5 cm in length.

Internal Examination
Thoracic Cavity
 Marked pleural adhesions were noted at the right hemithorax.
 Mediastinum is shifted to the left and markedly thickened with adherence to
the left lung.
 No fluid pleural fluid noted.
 Pericadial sac: 30 cc of clear, serous, straw-colored fluid.
Esophagus
Ruptured esophageal varices
Liver
Weighs: 2,232 grams (NV: 1,100 – 1,300 gms)
Measures: 22.5 x 13 x 3 cm.
Thickened fibrous capsule

Spleen
 Weighs: 157 gms (NV: 80 -125 grams)
 10 x 9 x 3 cm.
 Capsule is dull and thickened.
 CSS: solid and dark red parenchyma
 CONGESTION

Kidneys
 RIGHT: 242 grams
 LEFT: 267 grams
 Capsules are easily stripped off revealing fine granularities on the cortical surface.
 CSS:
indistinct corticomedullary junctions
unremarkable pelvico-calyceal stuctures
*** ACUTE TUBULAR NECROSIS

Intestines
Haemorrhages and necrosis

FINAL ANATOMIC DIAGNOSIS


I. Well-Differentiated Adenocarcinoma, gallbladder with extension to adjacent liver bed and
porta hepatis
Portal hypertension
Ruptured esophageal varices.
Severe congestion, spleen
Ascites, 50 ml
II. Hemorrhagic shock secondary to Bleeding Varices
Acute tubular necrosis, bilateral kidneys
Severe congestion, spleen
Massive atelectasis and hemorrhages, bilateral lungs.
Pericardial effusion, 30cc
III. Fibrocalcific nodule consistent with healed tuberculosis, right lung.
IV. Hypertensive Cardiomyopathy with left ventricular hypertrophy.
V. Gastic Ulcerations
VI. Status Post Total Abdominal Hysterectomy and Bilateral Salphingooophorectomy
secondray to Papillary serous cystadenocarcinoma(1983).
Status Post hemorroidectomy (1998).

DISCUSSION ( from Robbins.... )

Gallbladder Carcinoma
 Uncommon but aggressive type of malignancy
 Incidence: slightly more in females (3-4:1)
most frequent in 7th decade
 Usually diagnosed late or in advance state.
 Location:
• Fundus (60 %)
• Body (30 %)
• Neck (10 %)
 Growth patterns:
• Infiltrating – more common, appears as poorly defined area of diffuse
thickening and induration of the gallbladder wall
• Exophytic – cauliflower-like mass within the lumen; invades the underlying
wall, luminal portion may be necrotic, hemmorhagic, and ulcerated
 S/Sx: indolent, chronic abdominal pain, anorexia,weight loss; jaundice, nausea and
vomiting
 PE: palpable mass
hepatomegaly
jaundice - malignant obstruction of the biliary tree rather than hepatic
metastasis .
 Spread: directly to the liver and adjacent structures (biliary tree)

Common sites of seeding: GIT, peritoneum, lungs

Histology of Gallbladder Carcinoma


 Adenocarcinomas (90%)
 Grade:
• Well Differentiated
• Moderately Differentiated
• Poorly Differentiated
 Several histologic variants:
• Papillary
• Intestinal
• Mucinous
• Signet-ring cell
• Clear cell.

TNM staging of gallbladder carcinoma


Primary tumor (T)
TX - primary tumor cannot be assessed
T0 - no evidence of primary tumor
Tis - carcinoma in situ (high grade dysplasia)
T1 - tumor invades lamina propria or muscle layer
T1a - tumor invades lamina propria
T1b - tumor invades muscle layer
T2 - tumor invades perimuscular connective tissue; no extension beyond
serosa or into liver
T3 - tumor perforates the serosa (visceral peritoneum) or directly invades the
liver or
one other adjacent organ or structure, such as the stomach,
duodenum, colon,
pancreas, omentum or extrahepatic bile ducts
T4 - tumor invades main portal vein or hepatic artery or invades multiple
extrahepatic
organs or structures

Regional lymph nodes (N)


NX - regional lymph nodes cannot be assessed
N0 - no regional lymph node metastasis
N1 - regional lymph node metastasis

Distant metastasis (M)


MX - distant metastasis cannot be assessed
M0 - no distant metastasis
M1 - distant metastasis
 NOTE: Direct extension into liver, colon, duodenum, stomach, common bile duct,
abdominal wall or diaphragm is not considered a metastasis

Treatment and Prognosis


 Definitive: Surgery
Stages I and II - cholecystectomy
Stages III and IV - cholecystectomy + right hepatic
lobectomy and lymphadenectomy
Stage V - palliation
 Prognosis:

5-year survival rate


Stage I and II > 90 %

Stage III and IV 11 %

Stage V 0%

63 year old, female Chronic hypertension


4 months hx of abdominal
pain
CC: hematemesis and melena
LV hypertrophy

Gallbladder Adenocarcinoma

Liver / Porta Hepatis


Involvement

Portal Hypertension
( ascites, jaundice,
esophageal varices)
Gallbladder Adenocarcinoma Ruptured esophageal varices
with involvement of (hematemesis and melena)
liver parenchyma and porta
hepatis
Massive Bleeding

Predisposes to DIC

Hemorrhagic Shock

Multi-Organ
Failure

DEATH
( other pathological diseases... )

Portal hypertension
- Increased resistance to portal flow
a. Prehepatic
- Obstructive thrombosis and narrowing of portal vein, massive
splenomegaly
b. Intrahepatic
- Cirrhosis  dominant intrahepatic cause acct for most cases of portal
hpn
- Schistosomiasis
- Massive fatty change
- Diffuse fibrosing granulomatous disease ( sarcoidosis and military Tb)
c. Posthepatic
- Severe right sided heart failure , constrictive preicarditis and hepatic
vein outflow obstruction
Pathophysio:
- Increased resistance to portal flow at the level of sinusoids and compression of the
terminal hepatic veins by perivenular scarring and expansile parenchymal nodules

Hemorrhagic shock
- Hypovolemic shock
- Loss of blood or plasma volume
- Cardiovascular collapse
- Gives rise to systemic hypoperfusion caused by reduction either in cardiac output or
in effective circulating blood volume
- End results are hypotension, flowed by impaired tissue perfusion and cellular hypoxia

DIC / Disseminated Intravascular Coagulation


 Release of tissue thromboplastin and unknown substances liberated into the blood
stream and result in deposition of fibrin and fibrin precursor substances like
fibrinogen
 S/Sx of bleeding: ARF, RF, tissue hypoperfusion and infarction
Laboratory Tests:
Thrombocytopenia, hypofibrinogenemia, PT and APTT Abnormalities, Immunologic FDP
tests, D-dimer

Ayan.. haha! Tpos na. Galing to sa book, ppts, harrison’s and post notes ntin last year s
patho...  natuwa tuloy ako mgbasa ng mga greetings ntin last year...  sana helpful po ung
4 n CPC tranx.. hi hello sa mga ka OFW lunch ko knina... Starfish! Lucky! Wico! And the
cook.. Joana!  sa susunod daw smin n venue... c Peter barber.. ( Grrr.. Ahhh!), wala ka
naman sa nicasia. Ang lamig s tagaytay! WAAAHHHH! Pero okei lng, natpos ko naman ang
last tranx ng CPC ditto... Hahaha! hi wix kahit d mo to mbabasa, busy ka kasi mg aral dyn
sa harap ko! 
GO Superfriends!  <yeye, keln maglalaban si histioxytosis X at si walking zombie sign?>
Studdy Buddies! 1 week na naman tyong may bangagan session!  luto uli kyo ng food! 
Karen... 8.5 pla ah! 