Inflammations and tumors of the biliary system and gallbladder

1. Cholecystitis (Inflammation of Gallbladder)

A) Acute calculous cholecystitis

• Acute inflammation of a stone-containing gallbladder.
• Caused by obstruction of the cystic duct / gallbladder neck by a gallstone.

Pathogenesis

• Obstruction → bile stasis → phospholipases hydrolyze biliary lecithin → lysolecithin (toxic to mucosa) + prostaglandins → chemical inflammation.

Morphology

• Enlarged gallbladder; wall thickening.
• Empyema (pus-filled lumen), hemorrhage, fibrinosuppurative exudate.

Clinical

• Severe RUQ pain, fever, nausea, leukocytosis.
• Conjugated hyperbilirubinemia → suggests CBD obstruction (choledocholithiasis).

B) Acute acalculous cholecystitis

• ~5–10 % of cases — no stones.
• Settings: sepsis (Salmonella), postoperative, severe trauma / burns, critical illness.

C) Chronic cholecystitis

• May follow repeated acute attacks, but often develops insidiously without prior episodes.
• Almost always associated with gallstones, though stones are not the direct cause — bile supersaturation predisposes to both inflammation + stones.
• Morphology: mucosal atrophy, fibrous wall thickening, hypertrophy / hyperplasia of Rokitansky-Aschoff sinuses.
• Clinical: recurrent RUQ pain, often post-prandial.

2. Cholangitis

• Inflammation of bile duct walls, almost always bacterial.
• Caused by any lesion obstructing bile flow — esp. choledocholithiasis (stones in biliary tree); also tumors, stents, pancreatitis, strictures.
• Ascending cholangitis: infection ascends to intrahepatic ducts.
• Classic Charcot triad: fever + RUQ pain + jaundice (chills also typical).
• Most severe form: suppurative cholangitis — pus distends ducts → risk of liver abscess.

3. Carcinoma of the Gallbladder

• Most frequent malignant tumor of the biliary tract.
• Slightly more common in women; 7th decade.
• RF: gallstones (longstanding), bacterial / parasitic infections, porcelain gallbladder.
• Types:
  • Flat, scirrhous, infiltrating — poorly differentiated
  • Polypoid-fungating — well differentiated
• Usually metastatic at diagnosis (regional LN + adjacent GI organs).
• Sx insidious, indistinguishable from cholelithiasis (abdominal pain, jaundice, N/V).

4. Cholangiocarcinoma

• Adenocarcinoma with biliary differentiation arising from cholangiocytes (intra- or extrahepatic ducts).
• Klatskin tumor = cholangiocarcinoma at the hilum (extrahepatic junction).
• Age 60–70 yr.
• RF: PSC (key association), liver flukes (Clonorchis sinensis), chronic biliary infection, choledochal cysts.
• Common feature: chronic cholestasis + inflammation.
• Asymptomatic until advanced → frequently unresectable → poor prognosis.

💡 High-yield: Acute cholecystitis = stone in cystic duct → lysolecithin chemical injury (calculous, 90 %); acalculous = ICU/sepsis. Ascending cholangitis: Charcot triad (fever + RUQ pain + jaundice); suppurative → liver abscess. Gallbladder carcinoma: ♀, 7th decade, gallstones, porcelain GB; metastatic at Dx. Cholangiocarcinoma: PSC, liver flukes; Klatskin = hilar; poor prognosis.