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Gallbladder

Miscellaneous non-tumor

Cholelithiasis


Reviewer: Hanni Gulwani, M.D. (see Reviewers page)
Revised: 13 February 2013, last major update September 2012
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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● Also called gallstones
● Accounts for 1% of national heath care budget
● Affects 10% of adults in developed countries (80% are silent) vs. <1% of children
● 80% of gallstones in West are cholesterol stones with 50% or more crystalline cholesterol monohydrate
● 20% of gallstones in West are pigment stones composed of bilirubin calcium salts
● Gallstones impact at neck just proximal to cystic duct
● Typically within lumen but may be intramural

Risk factors:
● Pima, Hopi or Navajo (75% of stones are pure cholesterol vs. 25% in industrialized vs. minimal in developing countries), also Scandinavians, Chileans, Mexican-Americans, increasing age (>50% risk by age 80)
● “Fat, fertile [multiple pregnancies], forty, female”, obesity (Korean J Gastroenterol 2012;59:27), rapid weight loss, gallbladder stasis, genetic disorders that impair bile salt synthesis/secretion or increase cholesterol levels (serum or biliary), low HDL levels
● May be influenced by Apolipoprotein E genotype (Ann Epidemiol 2006;16:763)
● Biliary sludge typically occurs before gallstones
● Estrogens from birth control pills or pregnancy increase expression of hepatic LDL receptors, which increase cholesterol uptake, which stimulate HMG CoA reductase, which synthesizes cholesterol
● Pigment stone risk factors are increased unconjugated bilirubin (from hemolytic syndromes, ileal dysfunction/bypass, bacterial contamination of biliary tree)

Clofibrate:
● Anti-cholesterol drug that increases HMG CoA reductase activity and decreases conversion of cholesterol to bile acids by reducing cholesterol 7 alpha hydroxylase activity, causes excess biliary secretion of cholesterol

Symptoms:
● Usually none, but may have biliary colic (severe, right upper quadrant pain)

Complications:
● 1-2% have acute or chronic cholecystitis, choledocholithiasis, cholangitis, empyema, gallstone ileus, acute pancreatitis

Mirizzi’s syndrome:
● Rare
● Stone impacting in cystic duct or gallbladder neck causes extrinsic compression or obstruction of common bile duct, causing jaundice

Report:
● Presence of biliary sludge, number, size and type of gallstones

Diagnosis
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● Ultrasound (95% sensitive and specific for gallstones 2 mm or larger or gallbladder sludge), Xrays detect 10-25% of gallstones that are radiopaque due to calcium

Treatment
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● Laparoscopic cholecystectomy if symptomatic or in children, Native Americans, patients with sickle cell disease or porcelain gallbladder, stones 3 cm or larger

Gross description
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● 85% are 2 cm or less

Micro description
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● Minimal/mild lymphocytic mucosal inflammation, Rokitansky-Aschoff sinuses, fibrosis, thickening of muscularis propria (Am J Surg Pathol 2003;27:1313), cholesterolosis, focal epithelial metaplasia (pyloric/gastric mucin cell metaplasia or intestinal metaplasia)

End of Gallbladder > Miscellaneous non-tumor > Cholelithiasis


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