Chapter 18- The Liver Flashcards by Taylor Horlock

What are the functions of the liver?

Glycogen storage

Toxin removal

Nutrient processing

Nutrient storage (Vit A and iron)

Cholesterol, albumin and clotting factor production

Alcohol and drug metabolism

Bile production

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What is the function of bile?

Major excretory route for exogenous lipophilic substances and endogenous substrates not readily excreted by the kidney

Cholesterol elimination

Excretion of IgA, cytokines, stimulates innate immune system

Hormone and pheromone excretion

Bile salts emulsify dietary fats

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What reversible changes can occur in the liver?

Steatosis (fat accumulation)

2. Cholestasis (bilirubin build up)

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How do liver scars form and regress?

Stellate cells are activated and converted to fibrogenic myofibroblasts (cytokines)

Conversion reversed if insult stops

Metalloproteinases from hepatocytes break down scar

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What is associated with acute liver failure?

Encephalopathy

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What is fulminant hepatic failure?

Encephalopathy within two weeks of jaundice

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What are the characteristics of acute liver failure?

Massive hepatic necrosis

Small and shrunken liver

Nausea, vomiting and jaundice

Reduced clotting factors

Portal hypertension

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What is responsible for about 50% of acute liver failure?

Acetaminophen

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What is hepatorenal failure?

Form of renal failure in patients with liver failure

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What are causes of chronic liver failure?

Alcohol abuse

Viral hepatitis

Nonalcoholic steatohepatitis

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What is the morphology of cirrhosis?

Regenerative nodules surrounded by fibrous bands and degrees of vascular shunting

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What are the characteristics of chronic liver failure?

Jaundice

Encephalopathy

Coagulopathy

Intense pruritis

Spider angiomas

Hyperestrogenemia

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What causes death in chronic liver failure?

Hepatic encephalopathy

Bleeding from esophageal varices

Bacterial infections

Hepatocellular carcinoma

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What is portal hypertension?

Increased flow and/or resistance to portal blood flow

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What are the three types of portal hypertension and what can cause them?

Prehepatic- obstructive thrombosis, portal vein narrowing and massive splenomegaly with increased splenic vein flow
Intrahepatic- cirrhosis, schistomiasis, massive fatty change, granulomatous disease, nodular regenerative hyperplasia
Posthepatic- RSHF, constrictive pericarditis or hepatic vein obstruction

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What is acute on chronic liver failure?

Acute liver failure that has developed in patients with stable but advanced chronic liver disease

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What are the different kinds of hepatitis and their characteristics?

Hep A- damage due to CD8 cells, fecal-oral

Hep B- acute and nonprogressive chronic hepatitis, acute hepatic failure, damage due to CD8 cells, vertical and horizontal transmission

Hep C- often progresses to chronic disease, horizontal transmission

Hep D- dependent on HBV infection (superinfection), progression to cirrhosis

Hep E- enterically transmitted, self limiting, fatal in pregnant women

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What forms of hepatitis can increase hepatocellular carcinoma?

Hep B

Sometimes Hep D

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What types of hepatitis have vaccines available?

Hep A and B

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How can extrahepatic infections affect the liver?

Can induce hepatic inflammation

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What is the morphology of parasitic infections in the liver?

Hepatic abscesses

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What type of autoimmune hepatitis is autoimmune hepatitis?

Chronic and progressive

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What is the most common hepatotoxic causing chronic liver disease?

Alcohol

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What are the forms of alcohol induced liver injury and their characteristics?

Hepatocellular steatosis or fatty change- accumulation of lipid droplets, greasy liver
Alcoholic (steato-) hepatitis- foci of cells that undergo swelling and necrosis, clusters of inflammatory cells, Mallory-Denk bodies, neutrophilic reactions
Steatofibrosis- activation of stellate cells and portal fibroblasts, perisinusoidal scar accumulated and spreads outwards, cirrhosis in late stages

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What are Mallory-Denk bodies?

Clumped eosinophilic material in the liver

What is Laennec/micronodular cirrhosis?

End stage alcoholic liver disease

Where does fibrosis begin in steatofibrosis?

Central vein sclerosis

What are the different types of metabolic liver disease?

Nonalcoholic fatty liver disease (NAFLD) Hemochromatosis Wilson disease Alpha-1-antitrypsin deficiency

What is NAFLD?

Hepatic steatosis in the absence of heavy alcohol consumption

What is NAFLD associated with?

Metabolic syndrome

NAFLD increases the risk of what?

HCC

What do the hepatocytes in NAFLD look like?

Filled with fat vacuoles

What is the major cause of mortality?

CVD

What is hemochromatosis?

Excessive iron accumulation in the parenchymal cells of various organs

What are the forms of hemochromatosis?

1. Hereditary | 2. Hemosiderosis

What can cause hemosiderosis?

Repetitive transfusions Ineffective erythropoiesis Increased iron intake Chronic liver disease

How is hemochromatosis treated?

Regular phlebotomy

How is hemochromatosis visualized?

Prussian blue stain

What is Wilson disease?

Impaired copper excretion

How does Wilson disease affect the liver?

Minor to severe damage Fatty change, acute and chronic hepatitis

What are Kayser-Fleischer rings?

Green/brown/copper deposits in Descemeh membrane of the cornea

What are the effects of alpha-1-antitrypsin deficiency?

Emphysema- no inhibition of proteases at inflammatory sites Hepatic disease- accumulation of misfolded proteins (necrosis/apoptosis)

What stain is used to demonstrate alpha-1-antitrypsin deficiency?

PAS (positive)

What is caused by excess bilirubin?

Jaundice Icterus Kernicterus

What is cholestasis?

Impaired bile formation/flow leading to intrahepatic bile pigment in the parenchyma

What are the effects of cholestasis?

Jaundice Pruritis Skin xanthomas Intestinal malabsorption Bile canaliculi and hepatocyte degeneration Feathery degeneration

What is large bile duct obstruction commonly due to?

Extrahepatic cholelothiasis

What can prolonged obstruction of the large bile duct cause?

Biliary cirrhosis

What can large bile duct obstruction promote?

Ascending cholangitis

How can large bile duct obstruction be corrected?

Surgically

Cholestasis of sepsis is due to what kind of infection?

Intrahepatic bacterial infection

What is the morphology of cholestasis of sepsis?

Large, dark, bile concentrations with dilated canals

What is primary hepatolithiasis?

Intrahepatic gallstone formation Calcium bilirubinate stones in distended intrahepatic bile ducts

Ducts in primary hepatolithiasis show what?

Chronic inflammation Mural fibrosis Peri-biliary gland hyperplasia without obstruction

What is the liver parenchyma like in primary hepatolithiasis?

Destroyed by inflammation

What is neonatal cholestasis?

Prolonged conjugated hyperbilirubinemia

What is biliary atresia?

Obstruction of the extrahepatic biliary tree in the first three months of life

What are the two forms of biliary atresia and their characteristics?

1. Fetal- associated with other abnormalities | 2. Perinatal- biliary tree is destroyed after birth

What are the two forms of autoimmune cholangiopathies and their characteristics?

1. Primary biliary cirrhosis- inflammatory destruction of intrahepatic bile ducts 2. Primary sclerosing cholangitis- fibrosis of the extra and intrahepatic biliary tree

What can primary biliary cirrhosis progress to?

Cirrhosis

What characteristic radiologic feature is seen in primary sclerosing cholangitis?

Beading of contrast material

What are two types of structural anomalies of the biliary tree?

1. Choledochal cysts | 2. Fibropolycystic disease

Choledochal cysts can predispose the biliary tree to what pathology?

Stone formation

What effects can choledochal cysts cause?

Stenosis Stricture Pancreatitis Obstructive biliary complications

What is fibropolycystic disease?

Group of lesions that cause congenital malformations of the biliary tree

What lesions are associated with fibropolycystic disease and what are their characteristics?

Von Meyenburg complexes- small bile duct hamartomas Biliary cysts- intra or extrahepatic Congenital hepatic fibrosis- collagenous tissue forms septae that divide the liver

What is Caroline syndrome?

Cystic dilation of biliary ducts with congenital hepatic fibrosis

Circulatory disorders affect what aspect of the liver?

Morphology

How are liver circulatory disorders grouped?

Inflow Intrahepatic Outflow

What are liver infarcts rare?

Dual blood supply

What can cause localized infarcts of the liver?

Thrombosis or compression of an intrahepatic artery branch

How does hepatic artery thrombosis differ in a transplanted liver?

Leads to infarction of major ducts (arterial supply only)

What is Budd-Chiari syndrome?

Thrombosis of major hepatic veins

How does shock affect the liver?

Hepatocyte necrosis around the central vein (centrilobular necrosis)

What is the morphology of passive liver congestion?

Nutmeg liver- centrilobular necrosis with hemorrhage

What are the symptoms of preeclampsia?

Hypertension Proteinuria Peripheral edema Coagulation abnormalities

Why is eclampsia more severe than preeclampsia?

Neural manifestations are present (convulsions)

What is HELLP syndrome?

Fibrin deposits cause hemorrhage- coagulative necrosis, hepatic hematoma Hemolysis Increased liver enzymes Decreased platelets

How can HELLP lead to eclampsia?

Hepatic rupture

What is nodular hyperplasia?

Benign nodule(s) in the absence of cirrhosis

What are the two forms of nodular hyperplasia and their characteristics?

1. Focal- we’ll demarcated, poorly encapsulated with central grey-white stellate scar 2. Regenerative- entire liver is transformed, looks cirrhotic

What are two forms of benign liver neoplasms?

1. Cavernous hemangiomas | 2. Hepatocellular adenomas

What are hepatocellular adenomas associated with?

Oral contraceptive use in young women

Most malignant tumours in the liver are primary or metastatic?

Metastatic

What is the most common original site of hepatic metastatic cancer?

Colon

What are the types of liver cancer and what are their characteristics?

1. Hepatoblastoma- children 2. Hepatocellular carcinoma (HCC)- emerges from chronic liver disease (HBV, toxic injury) 3. Fibrolamellar carcinoma- HCC variant, single, scirrhotic mass 4. Cholangiocarcinoma- arise from biliary tree

What are Klatskin tumours?

Prehilar cholangiocarcinomas

What is the most common cholangiocarcinoma?

Klatskin tumours

What is the morphology of intra and extrahepatic cholangiocarcinomas?

Intra- branching or solid masses Extra- small lesions with wall thickening

What congenital anomalies are associated with the gallbladder?

Absent/ectopic Bilobed Phrygian cap (folded fundus) Cysts Biliary atresia Adenomyomatosis- hyperplastic cholecystosis of the gallbladder wall

What is cholelothiasis and what causes it?

Gallstones Supersaturation of cholesterol in bile

What can increase the risk of forming gallstones?

Mucous hypersecretion Biliary colic Gallbladder hypomotility Empyema Perforation Fistulas Cholangitis Obstruction Pancreatitis

What are the differences between pure and impure cholesterol stones?

Pure- pale yellow, round, granular, hard Impure- grey-white/black, may be lamellated, more opaque

What are the differences between black and brown pigment stones?

Black- sterile, small, many, friable, radiopaque Brown- infected, laminated, greasy, soft

What are the characteristics of acute cholecystitis?

Enlarged, tensed, bright red/blotchy or green-black gallbladder Fibrinous exudate on serosa Bile can be turbid with pus and fibrin and blood

Where is a stone often found in acute cholecystitis?

Neck of the gallbladder

What are the different forms of acute cholecystitis?

Calculous Acalculous (ischemia) Empyema (pus filled) Gangrenous Emphysematous (gas forming bugs, bubbles in wall)

What are the characteristics of chronic cholecystitis?

Most have stones (bile supersaturation) Variable size Thickened wall, preserves mucosa Cholesterolosis Rokitansky-Aschoff sinuses- mucosa outpouchings Porcelain gallbladder- wall calcification Xanthogranulomatous cholescystitis- massive wall thickening with nodular gallbladder

What is the most common extrahepatic biliary tract malignancy?

Gallbladder cancer

What are the two patterns of gallbladder cancer?

1. Infiltrating | 2. Exophytic

What is a risk factor for developing gallbladder cancer?

Chronic inflammation

Most gallbladder cancers have what?

Gallstones

Chapter 18- The Liver Flashcards

(102 cards)