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GI / Hepatology > 3 - Basic Principles of Liver Pathology > Flashcards

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
Q

Chronic Hepatitis - Grade 3

A

Moderate

More circumferential

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26
Q

Chronic Hepatitis - Grade 4

A

Marked

Extensive interface and extensive lobular involvement

27
Q

Chronic Hepatitis - Stage 1

A

Dots

28
Q

Chronic Hepatitis - Stage 2

A

Dots with legs

29
Q

Chronic Hepatitis - Stage 3

A

Stars

30
Q

Chronic Hepatitis - Stage 4

A

Needlepoint

31
Q

How can you tell on liver biopsy what caused the chronic hepatitis?

A

We may never know. I was taking notes on other shit

32
Q

Hepatitis C Hallmarks

A

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
Q

Autoimmune chronic hepatitis

A

Regenerative liver-cell rosettes
Interface hepatitis
Plasma cells

34
Q

α-1-antitrypsin deficiency

A

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
Q

Wilson’s Disease

A

Copper steigns for copper oh-ver-lode

36
Q

Liver-Cell Dysplasia (LCD)

A

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
Q

Potential sequelae of acute viral hepatitis

A

Immune system clears virus

Resolution

38
Q

Other potential sequelae of acute viral hepatitis (1 - 3%)

A

Immune system clears virus

Fulminant hepatitis

39
Q

Other other potential sequelae of acute viral hepatitis (5% with HBV, 80% with HCV)

A

Poor CD4 response
Chronic hepatitis
Cirrhosis (with liver cell dysplasia)
HCC

40
Q

Fatty Liver (Steatosis)

A

Will float in water

Large droplet vs. small droplet

41
Q

Macrovesicular (large droplet) steatosis

A

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
Q

Microvesicular (small droplet) steatosis

A

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
Q

Fatty Liver (large vacuole) and possible sequelae

A

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
Q

Steatohepatitis

A

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
Q

Mallory Denk Bodies

A

Circular inclusions that are like almost the size of a nucleus and they are just red, like a cherry red spot almost

46
Q

Contents of Mallory Denk Body

A

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
Q

Hit 1 - Causes fat

A

Alcoholics - Acetaldehyde

Non-Alcoholics - Obesity, diabetes, metabolic syndrome, certain drugs

48
Q

Hit 1 - Causes steatohepatitis

A

Cytokines

Endotoxin

49
Q

Large bile duct obstruction (LBDO)

A

Portal Edema
Neutrophils
Proliferation of bile ductular structures

50
Q

Causes of LBDO

A

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
Q

Primary Sclerosing Cholangitis (PSC)

A 
Younger patients
Hx of IBD (UC>Crohns)
Serum pANCA + 80%
Risk of Cholangio carcinoma
Periductal concentric "onion skin" fibrosis - diagnostic

Diagnose via ERCP

52
Q

Primary Biliary Cirrhosis (PBC)

A

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
Q

PBC

A

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
Q

4 Stages of PBC

A

Stage 1 - Florid bile duct lesion
Stage 2 - Bile ductular proliferation
Stage 3 - Scarring
Stage 4 - Cirrhosis

55
Q

Signs of Chronic Cholestasis

A

Jaundice + Scleral Icterus
Xanthelasma (eyelids)
Pruritus
Skin excoriations (from scratching)

56
Q

Cholestasis - Retention of Pruritogen

A

Pruritis

57
Q

Cholestasis - Increased serum bilirubin and serum lipids

A

Jaundice

Xanthomas

58
Q

Cholestasis - Decreased bile acids entering intestine

A 
Malabsorption of fat and fat-soluble vitamins
Steatorrhea
bone disease
coagulopathy
night blindness
59
Q

Cholestasis - Hepatic accumulation of copper, bile acids, and other compounds

A

Exacerbation of liver damage

60
Q

Vascular disease & the liver

A

Veins - Central/hepatic
Sinusoids
Arteries

Left HF (shock, hypotensive, septic) - Centrilobular Necrosis
Right HF - Centrilobular Congestion (nutmeg liver)
Both HF - Both!!

61
Q

Budd-Chiari Syndrome

A

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
Q

Cirrhosis - Many causes, pathologic features vary, depending on the cause, complications often similar

A

1 - Liver Failure
2 - Portal HTN
3 - Hepatocellular carcinoma

63
Q

2 gross types of cirrhosis

A

Micronodular (nodules 3mm)

Both have diffuse fibrosis + architecturally abnormal regenerative nodules

64
Q

Causes of cirrhosis

A

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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