PATHOLOGY OF GALLBLADDER
1. Biliary Atresia
Most common reason for pediatric liver transplantation.
Fibro-obliterative destruction of bile ducts → cholestasis.
Often presents as a newborn with persistent jaundice after 2 weeks of life, darkening
urine, light colored/ acholic stools, hepatomegaly.
Labs: ↑ direct bilirubin and GGT.
Treatment: surgery (Kasai procedure) Create conduit for bile drainage using small
intestine.
2. Gallstones ( Cholelithiasis )
Bilirubin, Bile Salts, Cholesterol are the Components of bile in gallbladder
Delicate balance between these components keeps bile in fluid form
If balance is upset → precipitation → stones
Clinical features
Asymptomatic in 70-80% cases.
Biliary colic:
Sudden onset post prandial abdominal pain. Associated with nausea/vomiting and dull
RUQ pain.
Neurohormonal activation ( by CCK after a fatty meal) triggers contraction of
gallbladder, forcing stone into cystic duct.
Labs are normal, ultrasound shows cholelithiasis.
Complications:
• Cholecystitis ( most common).
• Common bile duct obstruction.
• Gallbladder cancer.
• Ascending cholangitis.
• Gallstone ileus.
• Acute pancreatitis.
, Cholesterol Stones Pigment Stones
Risk factors include: Associated with
• Age (40s). • Crohn disease
• Estrogen ( Increased cholesterol • Ileal bypass
synthesis ). • Chronic hemolysis
• Female gender • Alcoholic cirrhosis
• Obesity ( Increased total body • Advanced age
cholesterol ). • Total parenteral nutrition (TPN).
• Rapid weight loss ( Increased • Biliary infections ( e.g., E coli, Ascaris
cholesterol mobilization ). lumbricoides, and Clonorchis sinensis ).
• Multiple pregnancies ( Estrogen plus • Ascaris lumbricoides is a common
progesterone which slows gallbladder roundworm that infects 25% of the world's
emptying ). population, especially in areas with poor
• Oral contraceptives. sanitation (fecal-oral transmission); infects
• Clofibrate ( Inhibit bile acid synthesis ). the biliary tract, increasing the risk for
• Cystic fibrosis ( Fat malabsorption → gallstones
loss of bile acids in stool ). • Clonorchis sinensis is endemic in China,
• Crohn disease ( Inflammation of ileum Korea, and Vietnam (Chinese liver fluke);
with Abnormal resorption of bile salts ). infects the biliary tract, increasing the risk
• Cirrhosis ( Decreased synthesis of bile for gallstones, cholangitis, and
salts ). cholangiocarcinoma.
• Native American ethnicity
Features Features
Most common Less common
Arise in gallbladder.
Contain 50-100 % cholesterol. Black stones :
80-90% are radiolucent ( not visible on x ray ). Composed of oxidized inorganic calcium salts +
10-20% are radio opaque due to presence of unconjugated bilirubin.
calcium carbonate. Sign of sterile gallbladder.
Radiopaque because of calcium and
Pathogenesis phospholipids.
Supersaturation of bile with cholesterol due to
hepatocellular hypersecretion of cholesterol. Brown stones :
Gallbladder hypomobility. Composed of pure inorganic calcium salts +
Accelerated nucleation of cholesterol crystals. unconjugated bilirubin.
Sign of infected gallbladder.
Radiolucent because of calcium soaps .
1. Biliary Atresia
Most common reason for pediatric liver transplantation.
Fibro-obliterative destruction of bile ducts → cholestasis.
Often presents as a newborn with persistent jaundice after 2 weeks of life, darkening
urine, light colored/ acholic stools, hepatomegaly.
Labs: ↑ direct bilirubin and GGT.
Treatment: surgery (Kasai procedure) Create conduit for bile drainage using small
intestine.
2. Gallstones ( Cholelithiasis )
Bilirubin, Bile Salts, Cholesterol are the Components of bile in gallbladder
Delicate balance between these components keeps bile in fluid form
If balance is upset → precipitation → stones
Clinical features
Asymptomatic in 70-80% cases.
Biliary colic:
Sudden onset post prandial abdominal pain. Associated with nausea/vomiting and dull
RUQ pain.
Neurohormonal activation ( by CCK after a fatty meal) triggers contraction of
gallbladder, forcing stone into cystic duct.
Labs are normal, ultrasound shows cholelithiasis.
Complications:
• Cholecystitis ( most common).
• Common bile duct obstruction.
• Gallbladder cancer.
• Ascending cholangitis.
• Gallstone ileus.
• Acute pancreatitis.
, Cholesterol Stones Pigment Stones
Risk factors include: Associated with
• Age (40s). • Crohn disease
• Estrogen ( Increased cholesterol • Ileal bypass
synthesis ). • Chronic hemolysis
• Female gender • Alcoholic cirrhosis
• Obesity ( Increased total body • Advanced age
cholesterol ). • Total parenteral nutrition (TPN).
• Rapid weight loss ( Increased • Biliary infections ( e.g., E coli, Ascaris
cholesterol mobilization ). lumbricoides, and Clonorchis sinensis ).
• Multiple pregnancies ( Estrogen plus • Ascaris lumbricoides is a common
progesterone which slows gallbladder roundworm that infects 25% of the world's
emptying ). population, especially in areas with poor
• Oral contraceptives. sanitation (fecal-oral transmission); infects
• Clofibrate ( Inhibit bile acid synthesis ). the biliary tract, increasing the risk for
• Cystic fibrosis ( Fat malabsorption → gallstones
loss of bile acids in stool ). • Clonorchis sinensis is endemic in China,
• Crohn disease ( Inflammation of ileum Korea, and Vietnam (Chinese liver fluke);
with Abnormal resorption of bile salts ). infects the biliary tract, increasing the risk
• Cirrhosis ( Decreased synthesis of bile for gallstones, cholangitis, and
salts ). cholangiocarcinoma.
• Native American ethnicity
Features Features
Most common Less common
Arise in gallbladder.
Contain 50-100 % cholesterol. Black stones :
80-90% are radiolucent ( not visible on x ray ). Composed of oxidized inorganic calcium salts +
10-20% are radio opaque due to presence of unconjugated bilirubin.
calcium carbonate. Sign of sterile gallbladder.
Radiopaque because of calcium and
Pathogenesis phospholipids.
Supersaturation of bile with cholesterol due to
hepatocellular hypersecretion of cholesterol. Brown stones :
Gallbladder hypomobility. Composed of pure inorganic calcium salts +
Accelerated nucleation of cholesterol crystals. unconjugated bilirubin.
Sign of infected gallbladder.
Radiolucent because of calcium soaps .
