HistoPath - Liver CPC

Question 1

What may cause high bilirubin

Answer 1

Pre-hepatic: Haemolysis, Gilbert’s
Hepatic: Hepatitis, cirrhosis, Liver failure
Post-hepatic: Obstruction, Cholecystitis, pancreatic Ca

Question 2

What makes the endothelial cells of the liver unique

Answer 2

The endothelial cells are discontinuous - there are spaces between cells and between the endothelium and hepatocytes (Space of Disse)

Question 3

What investigations should be done for an isolated raised bilirubin

Answer 3

Is it pre-hepatic, hepatic or post hepatic?
a. Pre-hepatic: haemolysis → FBC + blood film
b. Hepatic → repeat LFTs
c. Post-hepatic: Obstructed

Question 4

What is the Van den Bergh reaction

Answer 4

Measures serum bilirubin via fractionating
Direct reaction: conjugated
Indirect reaction: Unconjugated

Question 5

What are the considerations for jaundice in children

Answer 5

Need to know whether unconjugated or conjugated.
Jaundice is normal >24h, but bilirubin should be unconjugated (liver immaturity + fall in the Hb in early life)
If it does not settle, other rare causes should be looked for including hypothyroidism, other causes of haemolysis (including Coomb’s test or DAT) and the unconjugated bilirubin will be useful

Question 6

What is Gilbert’s syndrome and what is its inheritance

Answer 6

A common condition that causes an isolated raised bilirubin in the absence of any deranged liver values
Causes jaundice that is worsened by fasting
Recessive inheritance (50% carry the gene)

Question 7

What is the prevalence of Gilbert’s syndrome

Answer 7

1 in 20

Question 8

What is the pathophysiology of Gilbert’s syndrome

Answer 8

UDP glucoronyl transferase activity is reduced to 30%
Unconjugated bilirubin tightly albumin bound → does NOT enter urine

Question 9

Which measurements assess liver function

Answer 9

Prothrombin time (most representative)
Bilirubin
Albumin (production is slow)

Question 10

How is hep A transmitted and what is the timeline for infection

Answer 10

Faeco-oral transmission

1. Virus excreted in the 4 weeks before becoming ill (incubation)
2. IgM response
3. Jaundice develops
4. IgG response → immunity

Question 11

What is the timeline for hepatitis B infection

Answer 11

1. Infection
2. Hbe antigen production - acutely infectious, exposed to the LIVE virus
3. Anti-Hbe production to neutralise Hbe Ag
4. Anti-Hbc and anti-Hbc IgM production

Question 12

What is seen on histology of the liver for alcoholic hepatitis

Answer 12

“clear spaces” - fatty change (due to reversible fatty change in the liver)
Mallory hyaline bodies - pink, dense material
Neutrophils and lymphocytes present
Damaged hepatocytes
Brown/green pigment (bile) due to accumulation

Collagen stains blue to show collagen surrounding hepatocytes (scarring)

Question 13

What are the defining histological features of liver damage

Answer 13

Liver cell damage (Balloon cells with Mallory hyaline, mixed neutrophilic and lymphocytic)
Inflammation
Fibrosis
Fatty change
Mega/giant mitochondria seen

Question 14

What is the management for alcoholic hepatitis

Answer 14

Vitamin B1
Thiamine
Stop drinking
Supportive
Nutrition

Question 15

What does vitamin B1 deficiency cause

Answer 15

Beri-Beri

Question 16

What are the clinical signs of chronic liver disease

Answer 16

Multiple spider naevi
Palmar erythema
Gynaecomastia (liver is unable to break down oestradiol)
Dupuytren’s contracture (fourth finger most commonly affected)

Question 17

What are the features of portal hypertension

Answer 17

Splenomegaly
Visible veins
Ascites

Question 18

What is a flap on examination indicative of

Answer 18

Liver failure

Question 19

What are the functional deficits in liver failure and what can it lead to

Answer 19

Synthetic function
Clotting factor and albumin -> bleeding tendencies
Clearance of bilirubin -> jaundice
Clearance of ammonia

Can lead to encephalopathy

Question 20

What is the histology of liver failure

Answer 20

Gross: pale liver, made up of fat, uniform nodules with a cuff of fibrous tissue around each, whole liver involved

Micro: nodule of regenerating hepatocytes with a fibrous cuff around the nodule

Question 21

Why may liver failure lead to encephalopathy and varices

Answer 21

Scarring between the portal tracts and portal veins which allows the blood to bypass the hepatocytes (intra-hepatic shunting of blood), while formation of varices/haemorrhoids are extra-hepatic shunts

Question 22

What are the causes of liver cirrhosis

Answer 22

Fatty liver disease (alcoholic and non-alcoholic) -> micronodular
Viral hepatitis (Hep B, C and D) -> macronodular
Haemochromatosis (iron)
Wilson’s disease (copper)
Primary biliary cholangitis
Primary sclerosing cholangitis

Question 23

Give examples of portal-systemic anastomoses

Answer 23

Oesophageal varices
Rectal varices
Umbilical vein recanalising
Spleno-renal shunt

Question 24

What do scratch marks suggest in liver disease

Answer 24

Obstruction of the bile ducts → bile salts/acids enter the skin

Question 25

What is Courvoisier’s law

Answer 25

Gall bladder is palpable in a jaundiced patient - likely to be pancreatic cancer (and NOT gallstones)

Gallstones = Gall bladder becomes thickened and fibrosed → cannot enlarge