Liver Pathology and CPC

Question 1

Which area gets the most oxygen, the periportal or the centrilobular areas?

Answer 1

periportal (portal tract includes the hepatic artery)

centrilobular/ zone 3 is more susceptible to injury as it receives less oxygenated blood and is exposed to higher levels of toxic electrophilic metabolites generated by CYP450

Question 2

Describe what ballooning degeneration looks like and when you might observe it.

Answer 2

cellular swelling due to accumulation of water and protein which cannot be exported, cell becomes round with a foamy cytoplasm

seen in alcoholic steatohepatitis or acute hepatitis of any cause, drugs/toxins

(grossly liver is swollen, pale due to compression of capillaries and turgid with hepatomegaly)

Question 3

Describe how steatosis appear and in what conditions it appears.

Answer 3

hepatocytes accumulate fat droplets inside their cytoplasm, becoming round with the nucleus pushed to the side

seen in alcoholic liver, drug toxicity (Reye’s syndrome), viral hepatitis c (+/-), Wilson’s disease +/-

grossly the liver is soft, yellow, swollen and greasy on cut surface

Question 4

Contrast the brown accumulations that can occur in hepatocytes.

Answer 4

with cholestasis, bile will be visible in the hepatocytes and canalicular spaces

iron overload in HH is seen within hepatocytes and can be differentiated from bile or lipofucsin with Prussian blue stain

accumulation of Cu in Wilson’s disease can be distinguished with a Copper stain

Question 5

Contrast coagulative necrosis with spotty necrosis, the two main morphological patterns of necrosis in the liver.

Answer 5

coagulative: outlines of cells persist, nuclei drop out- occurs in ischemia and infarction
spotty: individual cells undergo lytic necrosis usually following severe ballooning degeneration, hepatocytes drop out and are quickly filled with inflammatory cells, appearing as ‘spots’ of inflammatory cells as in viral hepatitis or alcohol

Question 6

Describe the appearance of apoptotic bodies/councilman bodies.

Answer 6

single hepatocyte having a dense shrunken cytoplasm with or without a pyknotic nucleus, unaccompanied by inflammation; is usually due to viral hepatitis and drugs

Question 7

Contrast focal or diffuse necrosis.

Answer 7

focal involves a particular area (zone 3 necrosis or bridging necrosis)

diffuse: extensive, pan lobar or multi lobar necrosis

Question 8

What situations might you expect Zone 3 necrosis?

Answer 8

acetaminophen toxicity, venous outflow obstruction or with ischemic injury

confluent necrosis around the central vein can extend to involve all the hepatocytes at the periphery of the acinus (which can lead to bridging fibrosis)

Question 9

Mushroom toxicity may lead to what pattern of liver injury?

Answer 9

massive necrosis

often with wrinkled shrunken gross-appearance

Question 10

How might you differentiate the inflammation in chronic hepatitis from acute hepatitis.

Answer 10

acute is more diffuse, in chronic, inflammatory cells are more concentrated around the portal tracts

pericellular occurs in alcoholic

Question 11

What pathologic changes would you expect in alcoholic steatosis?

Answer 11

steatosis- fat accumulations
ballooning
mallory bodies (pink-clumpy rope like inclusions of degenerating cytokeratin intermediate filaments)
inflammation (neutrophils)
fibrosis

Question 12

Non-alcoholic steatosis would be expected to be lacking which features of steatohepatits?

Answer 12

no ballooning or inflammation

with steatohepatitis you would expect ballooning, inflammation but mallory bodies would be less likely in fatty liver disease

Question 13

What are cellular features of chronic viral hepatitis?

Answer 13

portal nodular lymphoid aggregates, interface inflammation and ground glass hepatocytes (HBV)

Question 14

Autoimmune hepatitis has varied presentation and can resemble ____ _____ or _______ hepatitis; with severe pan lobular necrosis, fulminant failure is likely.

Answer 14

autoimmune hepatits can present like acute viral hepatitis, chronic hepatitis

**distinguished really by plasma cells in the portal tracks and parenchyma

Question 15

What extra hepatic systems are effected in HH?

Answer 15

pancreases- DM1
heart failure
arthritic joints
skin (tan due to increased melanin)

Question 16

What does the histological slide of alpha-1 antitrypsin deficiency appear?

Answer 16

accumulations of pink globules that stain magenta on a glycoprotein stain

pink globules are present on H&E stain

Question 17

Chronic venous congestion will lead to what pattern of liver damage?

Answer 17

congested liver that is swollen with alternating dark and pale areas, dark areas around zone 3 due to back pressure– nutmeg liver

sinusoids around zone 3 atrophy and necroses leaving pink area around the central vein and are replaced by fibrosis

Question 18

A bile duct surrounded by inflammation and granuloma is characteristic of what disease?

Answer 18

primary biliary cirrhosis

antimitochondrial antibodes in the serum and varied levels of inflammation will follow

Question 19

Background of liver with hepatic adenoma is ‘always’ _______, and associated with which risk factors?

Answer 19

hepatic adenoma is always on non-cirrhotic liver, etiologically associated with oral contraceptive use and anabolic steroids in males (*** bland histology- hepatic cells look normal)

Question 20

Hepatoblastoma is associated with which risk factors?

Answer 20

usually a tumor of childhood with a very high AFP

Question 21

HCC is associated with which risk factors?

Answer 21

chronic viral infections
chronic alcoholism
nonalcoholic statohepatitis
aflatoxins
HH

HH tends to resemble normal hepatocytes (just hypertrophied sinusoids)

Question 22

What is a Klatskin tumor?

Answer 22

cholangiocarcinoma arising in the hilum of the liver

Question 23

Describe the normal appearance of a cholangiocarcinoma.

Answer 23

white and firm, well circumscribed mass generally not in a cirrhoitic liver

histologically small glands or duct like structures with a dense desmopalstic response and often show perineurial invasion

Question 24

What is the liver fluke that is associated with cancer of the biliary tree

Answer 24

Opisthorchis sinesis

Question 25

Hepatic angiosarcoma are associated with which risk factors?

Answer 25

arsenic, vinyl chloride, thorotrast

Question 26

Contrast the WBC usually present with alcoholic v. viral hepatitis.

Answer 26

alcoholic- PMNs

viral- lymphocytes

Question 27

Describe the pathology of Alpha 1-Antitrypsin deficiency and how it relates to the histopathologic findings

Answer 27

pink globular proteins (visible on H&E) accumulate in the RER because they cannot be transported to the goggle apparatus due to abnormal glycosylation of the protein

you might also expect panacean emphysema due to reduced elastase inactivation (normally inhibited by A1AT)