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3 - Basic Principles of Liver Pathology Flashcards

1
Q

The most common cause of abnormal LFTs in the US today!

A

Fatty liver

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2
Q

Liver Biopsy is used for

A

Grading & Staging of chronic hepatitis
Workup of possible fatty liver disease (alcoholic or non-alcoholic)
Evaluation of cholestasis & jaundice
Establish a tissue dx of tumor
Determine whether cirrhosis is present

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3
Q

Hepatocellular Diseases

A

Acute Hepatitis
Chronic Hepatitis
Fatty Liver Diseases
Metabolic Diseases (Genetic mutations: AAT def., Fe, Cu, inherited storage disorders)

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4
Q

Biliary Tract Diseases

A

Large bile duct obstruction (LBDO)
Intrahepatic bile ducts
Bile canaliculi/hepatocytes (“pure” or intrahepatic cholestasis)

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5
Q

Vascular Diseases

A

Central veins & sinusoids

Portal veins/hepatic arteries

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6
Q

Hepatitis - Most common etiologies

A

Infection by the Hepatitis Viruses

Drug Hepatitis

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7
Q

Hepatitis Viruses

A

HAV (28nm) - RNA (oral-fecal)
HBV (42nm) - dsDNA (genome incorporated into human genome, lead to cancer)
HCV (60nm) - RNA (also causes cancer in the liver)
HDV (30nm) - RNA (delta agent, parasite. Can’t exist without HBV at the same time. You’re a carrier for HBV, and then you shoot up with something contaminated with HDV)
HEV (32nm) - RNA (fecal-oral, meat)
Other viruses (CMV, HSV, etc)

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8
Q

Drug Hepatitis

A

Predictable (CCl4, acetaminophen)

Unpredictable (INH, aldomet)

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9
Q

Viral Hepatitis - Pathogenesis

A 
Virus enters cell
Is encoded
Reproduces
Viral antigens are expressed on the hepatocyte membrane
CD8 cells kill that bitch
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10
Q

Drug Hepatitis - Pathogenesis

A

Predictable
Metabolite directly damages hepatocyte (Tylenol)
No immune system necessary

OR

Unpredictable
Metabolism in the liver of the drug, producing antigen “hapten” that binds the hepatocyte, causing T-Cells or Eosinophils to KILLLLLLLL

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11
Q

Acute Hepatitis

A 
Does not mean neutrophils
Diffuse inflammation (lymphocytes)
Lymphocytes come through portal tract, infiltrate and spread towards central vein
Lobular disarray
Hepatocyte ballooning/apoptosis
"Spotty Necrosis"
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12
Q

Spotty Necrosis

A

Hepatitis, but can’t tell if it’s idiosyncratic or if it’s viral

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13
Q

Massive hepatic necrosis

A

Seen in Fulminant Hepatitis
Viral causes are HAV & HBV
HEV can do it too in the nondeveloped world
Destroys all the hepatocytes in the damn liver.
Periportal progenitor/steam cell activation leads to formation of bile ductular structures. They tryna make up the difference gurl.
Wrinkled capsule!!!!!!
Occurs within 8 weeks of onset of infection/drug
Sometimes it creeps along for months

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14
Q

Fulminant Hepatitis

A

Occurs in 1 - 3 % of cases (between all acute viral and acute drug hepatites)

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15
Q

Submassive Necrosis

A

A thing he didn’t explain

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16
Q

Chronic Hepatitis

A

Inflammation of the liver continuing without improvement for 6 months or longer

Disease process involving portal tracts/pp regions, lobules

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17
Q

Causes of Chronic Hepatitis

A 
HBV
HCV
HDV (with co-presence of HBV)
Autoimmune hepatitis
Drugs (Hx of chronic intake)
2 metabolic diseases (α-1-antitrypsin deficiency, Wilson's)
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18
Q

Presenting Time of Wilson’s

A

Not 60 years old. Younger? I missed it.

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19
Q

Grade 1

A

Sometimes modest inflammation only in the portal tracts, intermittently seeding out lymphocytes.

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20
Q

Grade 2

A

Ground glass Hepatitis B surface antigen inclusions. More inflammation getting out, “interface hepatitis.”

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21
Q

Scarring

A

Scarring occurs, usually through stellate cells, making irregular portal tracts and thickened plates

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22
Q

Interface Hepatitis

A

Interface in all the portal tracts leads to increased fibrosis, losing all the hepatocytes.

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23
Q

Chronic Hepatitis - Grade 1

A

Minimal

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24
Q

Chronic Hepatitis - Grade 2

A

Mild

Includes interface hepatitis at the edge, some lobular as well

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25
Chronic Hepatitis - Grade 3
Moderate More circumferential
26
Chronic Hepatitis - Grade 4
Marked Extensive interface and extensive lobular involvement
27
Chronic Hepatitis - Stage 1
Dots
28
Chronic Hepatitis - Stage 2
Dots with legs
29
Chronic Hepatitis - Stage 3
Stars
30
Chronic Hepatitis - Stage 4
Needlepoint
31
How can you tell on liver biopsy what caused the chronic hepatitis?
We may never know. I was taking notes on other shit
32
Hepatitis C Hallmarks
Once you have the virus chronically, the lymphoid system knows there is an antigen out there. Takes over and sets up housekeeping in the portal tracts Lymphoid aggregates form Primary lymphoid follicle in the portal tract, essentially. CLASSIC Hepatitis C
33
Autoimmune chronic hepatitis
Regenerative liver-cell rosettes Interface hepatitis Plasma cells
34
α-1-antitrypsin deficiency
Mutation in the gene for the gene product New product doesn't exit well Gets stuck in hepatocytes Visible on DPAS as purple globules!!!
35
Wilson's Disease
Copper steigns for copper oh-ver-lode
36
Liver-Cell Dysplasia (LCD)
Pre-neoplastic lesion associated with HCC Atypical nuclei Seen in individuals with years of chronic hepatitis ``` Nuclear atypia: Hyperchromatic Convoluted contour Prominent nucleoli Multiple nuclei and nucleoli Large hepatocytes ``` 3/4 have cirrhosis first before progressing to cancer
37
Potential sequelae of acute viral hepatitis
Immune system clears virus | Resolution
38
Other potential sequelae of acute viral hepatitis (1 - 3%)
Immune system clears virus | Fulminant hepatitis
39
Other other potential sequelae of acute viral hepatitis (5% with HBV, 80% with HCV)
Poor CD4 response Chronic hepatitis Cirrhosis (with liver cell dysplasia) HCC
40
Fatty Liver (Steatosis)
Will float in water | Large droplet vs. small droplet
41
Macrovesicular (large droplet) steatosis
Most common type of fatty liver Due to alcohol, obesity, diabetes, corticosteroids Droplets contain triglycerides Increased Triglyceride synthesis or decreased Triglyceride excretion Usually begins centrilobular, then moves to other regions
42
Microvesicular (small droplet) steatosis
Uncommon Severe mitochondrial injury ``` Impaired β-FA oxidation: Acute fatty liver of pregnancy Reye's syndrome Tetracycline toxicity Nucleoside analogue toxicity Valproic acid toxicity ```
43
Fatty Liver (large vacuole) and possible sequelae
Fatty liver AFLD - Alcoholic fatty liver disease NAFLD - Non-alcoholic fatty liver disease Steatohepatitis (with peroxidation, swelling, fibrosis, etc) ASH - Alcoholic steatohepatitis NASH - Non-alcoholic steatohepatitis Cirrhosis
44
Steatohepatitis
Fibrosis (activated Ito cells) Steatosis (large droplet) inflammation Intrahepatocellular Mallory bodies (or Mallory-Denk bodies) Hepatocyte swelling (ballooning); cell injury Fibrosis is "chicken-wire" centrilobular & pericellular/perisinusoidal
45
Mallory Denk Bodies
Circular inclusions that are like almost the size of a nucleus and they are just red, like a cherry red spot almost
46
Contents of Mallory Denk Body
Abnormal keratins (8 & 18) specific to hepatocytes. It is hyperphosphorylated or misfolded or crosslinked. GET IT OUT!! it's ubiquitinated, but doesn't make it out. It is evidence of steatohepatitis P62 upregulation leads to aggregation Overwhelms the proteosome/autophagy Leads to micronodular cirrhosis (ASH or NASH)
47
Hit 1 - Causes fat
Alcoholics - Acetaldehyde | Non-Alcoholics - Obesity, diabetes, metabolic syndrome, certain drugs
48
Hit 1 - Causes steatohepatitis
Cytokines | Endotoxin
49
Large bile duct obstruction (LBDO)
Portal Edema Neutrophils Proliferation of bile ductular structures
50
Causes of LBDO
Gallstone obstruction Cholelithiasis (gall stones) Cholecystitis ``` Ampullary Carcinoma (pancreas) Stricture (from scar) Lymphoma or cancer in portall hepatitits lymph nodes Cholangiocarcinoma (bile duct cancer) Gallbladder cancer Common bile duct cancer ```
51
Primary Sclerosing Cholangitis (PSC)
``` Younger patients Hx of IBD (UC>Crohns) Serum pANCA + 80% Risk of Cholangio carcinoma Periductal concentric "onion skin" fibrosis - diagnostic ``` Diagnose via ERCP
52
Primary Biliary Cirrhosis (PBC)
Targeting by antimitochondrial antibody that's an antigen on the intermitochondrial cristae 90% in females 10% in men Serum positive antimitochondrial antibody Partial destruction of interlobular bile ducts (one side but not the other!!!) Does not affect large ducts
53
PBC
Middle aged women +AntiMitochondrial Ab (M2 subtype) Alk Phos up It's like post-strep rheumatic fever! If you've had a Gram (-) UTI in the past, there are similar antigens on the inner cristae of the mitochondrial membrane (PDC-E2 - Pyruvate dehydrogenase complex - E2) IgM up Associated with other autoimmune diseases (RA, sicca, celiac, scleroderma
54
4 Stages of PBC
Stage 1 - Florid bile duct lesion Stage 2 - Bile ductular proliferation Stage 3 - Scarring Stage 4 - Cirrhosis
55
Signs of Chronic Cholestasis
Jaundice + Scleral Icterus Xanthelasma (eyelids) Pruritus Skin excoriations (from scratching)
56
Cholestasis - Retention of Pruritogen
Pruritis
57
Cholestasis - Increased serum bilirubin and serum lipids
Jaundice | Xanthomas
58
Cholestasis - Decreased bile acids entering intestine
``` Malabsorption of fat and fat-soluble vitamins Steatorrhea bone disease coagulopathy night blindness ```
59
Cholestasis - Hepatic accumulation of copper, bile acids, and other compounds
Exacerbation of liver damage
60
Vascular disease & the liver
Veins - Central/hepatic Sinusoids Arteries Left HF (shock, hypotensive, septic) - Centrilobular Necrosis Right HF - Centrilobular Congestion (nutmeg liver) Both HF - Both!!
61
Budd-Chiari Syndrome
Hepatic Venous Outflow Obstruction Thrombosis of hepatic vein/IVC Tumor invasion of hepatic vein/IVC OCPs Coagulopathy (protein S, Protein C, Factor V leiden def, anti-cardiolipin Abs) Tumor invasion (renal cell carcinoma + HCC) Small vein disease (VOD "bush tea")
62
Cirrhosis - Many causes, pathologic features vary, depending on the cause, complications often similar
1 - Liver Failure 2 - Portal HTN 3 - Hepatocellular carcinoma
63
2 gross types of cirrhosis
Micronodular (nodules 3mm) Both have diffuse fibrosis + architecturally abnormal regenerative nodules
64
Causes of cirrhosis
Chronic hepatitis - Chronic HBV, HCV, Autoimmune Fatty liver disease - AFLD, NAFLD Chronic biliary tract disease Metabolic diseases (Hemochromatosis, Wilson's disease, α-1-antitrypsin deficiency (AAT deficiency))

GI / Hepatology (28 decks)

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