Hepatobilliary pathology

Question 1

What are the main pathologies of the liver?

Answer 1

• Liver failure
• Jaundice
• Cirrhosis
• Intrahepatic bile duct obstruction
• Tumours

Question 2

What is the main pathology that can affect the gallbladder?

Answer 2

Inflammation

Question 3

What is the main pathology that affects the extrahepatic bile ducts?

Answer 3

Obstruction

Question 4

What types of injury to the liver can cause liver failure?

Answer 4

Both acute and chronic injuries (cirrhosis etc) can cause it

Question 5

What acute liver injuries can cause liver failure?

Answer 5

Hepatitis:

• Viruses, alchohol & drugs

Bile duct obstruction

Question 6

What viruses can cause damage to the liver?

Answer 6

Hepatitis A, B, C, E

+ other viruses

Question 7

Describe the pathology of viral hepatitis

Answer 7

Inflammation of the liver

Damage/death of hepatocytes in the liver

Question 8

Acute infections by which types of hepatitis are able to resolve without causing liver failure?

Answer 8

Hepatitis A & E

Question 9

Acute infections by what types of hepatitis will cause liver failure if there is severe damage?

Answer 9

Hepatitis A, B, E

Question 10

Acute infections by which type of hepatitis are able to progress to chronic hepatitis / cirrhosis?

Answer 10

Hepatitis B & C

Question 11

In summary, which Hepatitis viruses are most damaging to the liver?

Answer 11

Hepatitis C

(B isn’t great either)

Question 12

How does the liver change in alcoholic liver disease?

Answer 12

Initial fatty change (followed by high risk of)

Alcoholic hepatitis

This leads to liver failure

This leads to cirrhosis

Question 13

What are the pathological features of alcoholic hepatitis?

Answer 13

Acute inflammation

Cell death

Liver failure

Question 14

What are the 3 sections of the metabolic pathway for bilirubin?

Answer 14

Pre-hepatic

Hepatic

Post-hepatic

Question 15

What happens in the Pre-hepatic pathway for bilirubin’s metabolism?

Answer 15

1. Breakdown of haemoglobin in spleen to form Haem & globin
2. Haem converted to bilirubin
3. Bilirubin released into circulation

Question 16

What happens in the Hepatic phase of bilirubin metabolism?

Answer 16

1. Hepatocytes suck up bilirubin from the blood
2. They then conjugate it
3. Conjugated bilirubin is then excreted into the biliary system

Question 17

What happens in the post-hepatic phase of bilirubin metabolism?

Answer 17

1. Conjugated bilirubin is transported in biliary system
2. Bilirubin conjugate is then broken down in the intestine
3. Bilirubin is then re-absorbed and enters the enterohepatic circulation

Question 18

What causes pr-hepatic jaundice?

Answer 18

Increased release of haemoglobin from RBC’s (haemolysis)

Question 19

What are the hepatic causes of jaundice?

Answer 19

Cholestasis - _{decrease in bile flow due to impaired secretion by hepatocytes or to obstruction of bile flow}

Intra-hepatic bile duct obstruction

Question 20

What is cholestasis?

Answer 20

Accumulation of bile within hepatocytes or bile canaliculi

Question 21

What are the causes of cholestasis? (and thus potential causes of hepatic jaundice)

Answer 21

• Viral hepatitis
• Alcoholic hepatitis
• Liver failure
• Drugs

Question 22

What is the difference between predictable and unpredictable drug induced cholestasis?

Answer 22

Predictable = dose related

Unpredictable = not dose related

Question 23

What are the causes of Intra-hepatic bile duct obstruction?

Answer 23

Primary biliary cholangitis (PBC)

Primary sclerosing cholangitis (PSC)

Tumours

Question 24

What types of tumours can cause intra-hepatic bile duct obstruction?

Answer 24

Hepatocellular carcinoma (HCC)

Tumours of the intrahepatic bile duct

Metastatic tumours from elsewhere

Question 25

What is primary biliary cholangitis?

Answer 25

Autoimmune disease in which there is granulomatous inflammation and progressive destruction of intrahepatic bile ducts Inflammation progresses to cirrhosis

Question 26

Who is most at risk of developing primary biliary cholangitis?

Answer 26

Females (9:1)

Question 27

What biomarkers are present in those who have primary biliary cholnagitis?

Answer 27

Anti-mitochondrial auto-antibodies in serum Raised serum alkaline phosphotase (ALP)

Question 28

What is primary Sclerosing cholnagitis?

Answer 28

Chronic inflammation and fibrous obliteration of bile ducts - causing loss of intrahepatic bile ducts Like primary biliary cholangitis - it also progresses to cirrhosis Linked to inflammatory bowel disease (Crohn's & UC)

Question 29

Primary sclerosis cholangitis causes an increased risk of what?

Answer 29

Increased risk of development of cholangiocarcinoma

Question 30

What condition is referred to as the 'end stage of chronic liver disease'?

Answer 30

Hepatic cirrhosis

Question 31

What are the main causes of Hepatic cirrhosis?

Answer 31

Alcohol Hep B, C (the bad ones) Immune mediated disease (PBC, Autoimmune Hepatitis) Metabolic disorders Obesity (DM)

Question 32

What metabolic disorders can cause hepatic cirrhosis?

Answer 32

Primary haemochromatosis (excess iron) Wilson's disease (excess copper)

Question 33

What is the histological appearance of cirrhotic liver?

Answer 33

Nodules of hepatocytes and fibrous tissue

Question 34

What are the complications of hepatic cirrhosis?

Answer 34

Liver doesn't function (liver failure) Abnormal blood flow (portal hypertension) Increased risk of Hepatocellular carcinoma (HCC)

Question 35

What is hepatocellular carcinoma?

Answer 35

Malignant tumour of hepatocytes

Question 36

What is cholangiocarcinoma?

Answer 36

Malignant tumour of bile duct epithelium

Question 37

What are the causes of post-hepatic jaundice?

Answer 37

Cholelithiasis (gallstones) Gallbladder disease Extra-hepatic bile duct obstruction

Question 38

What are the main risk factors for gallstones?

Answer 38

Obesity Diabetes

Question 39

Describe the pathology of gallstones in the gall bladder

Answer 39

Can cause inflammation called 'cholecystitis' This can be acute or chronic (acute cholecystitis etc)

Question 40

What is the main risk with acute cholecystitis?

Answer 40

Acute inflammation of the gallbladder can lead to an Empyema (abscess) This can perforate and may lead to biliary peritonitis (which isnt good)

Question 41

What are the causes of common (extrahepatic) bile duct obstruction?

Answer 41

Gallstones Tumours Benign structures External compression (from other tumours)

Question 42

What are the effects of common bile duct obstruction?

Answer 42

Jaundice (post hepatic) Impact on digestion (no bile into duodenum) Ascending cholangitis (infection of bile proximal to obstruction) Secondary biliary cirrhosis

Question 43

What would cause secondary biliary cirrhosis?

Answer 43

If the bile duct obstruction remains for a prolonged period of time