Histopathology - Liver

Question 1

Portal triad

Answer 1

branches of the bile ducts, hepatic artery, portal vein

zone 1 closest to the portal triad

Question 2

which zone has the most liver enzymes?

Answer 2

Zone 3

zone that gets less oxygen (further away from portal triad)
has the most metabolically active cells of the liver
that is also where the drug metabolising hepatocytes are

Question 3

Flow of blood in the liver

Answer 3

reaches liver via hepatic portal vein (blood from gut) + hepatic artery (blood from heart)

blood travels in sinusoids –> drains in central vein –> goes to hepatic vein –> hepatic vein joins vena cava

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https: //www.google.com/search?q=hepatic+vein+vena+cava&tbm=isch&ved=2ahUKEwirzJW3p4f3AhVO3RoKHcVPAqsQ2-cCegQIABAA&oq=hepatic+vein+vena+cava&gs_lcp=CgNpbWcQAzIGCAAQCBAeMgYIABAIEB4yBAgAEBg6BwgjEO8DECc6BAgAEEM6BwgAELEDEEM6CAgAEIAEELEDOgsIABCABBCxAxCDAToFCAAQgARQkhBYiUBg70BoAHAAeACAAYwCiAHaFpIBBjAuMjEuMZgBAKABAaoBC2d3cy13aXotaW1nwAEB&sclient=img&ei=0KdRYqukH866a8WfidgK&bih=640&biw=711#imgrc=ACCrpSkAxRVGkM

Question 4

Liver marker that increases most in obstructive jaundice/ obstruction of bile duct/ damage to biliary epithelial cells

Answer 4

ALP

obstruction of the bile ducts also causes
also absence of urobilinogen in urine and presence of bile salts/acids in the blood

Question 5

• Most representative of liver function 

Answer 5

prothrombin time

 PT affected by warfarin (extrinsic pathway)
 APTT/PTTK affected by heparin (intrinsic pathway)

Question 6

What is the van den Bergh reaction

Answer 6

van den Bergh reaction measures serum bilirubin via fractionation

A direct reaction measures conjugated bilirubin

Addition of methanol causes a complete reaction, which measures total bilirubin (conjugated plus unconjugated);

the difference measures unconjugated bilirubin (an indirect reaction).

Question 7

What is the function of phototherapy?

Answer 7

Converts bilirubin to

lumirubin
photobilirubin

these compounds dont need conjugation for excretion

Question 8

How is Gilberts disease inherited + pathophysiology + mx

Answer 8

Recessive

reduced activity of UDP (uridine 5 diphospho) glucuronyl transferase to 30%–> higher unconjugated bilirubin levels –> Unconjugated bilirubin tightly albumin bound and does not enter urine –> not excretes

Worsened by fasting

Phenobarbitone reduces levels

Question 9

o if pt Anti-HBs + no Anti-HBe

o If pt Anti-HBs + Anti-HBe

Answer 9

• We only vaccinate people with HBsAg and no HBeAg
o if pt Anti-HBs + no Anti-HBe vaccinated
o If pt Anti-HBs + Anti-HBe  infected

Question 10

What are mallory denk bodies?

Answer 10

 Mallory denk bodies (clumped cytoskeleton of hepatocytes)  characteristic change in hepatocytes of alcoholic hepatitis

(2 step process: alcohol  acetaldehyde, acetaldehyde  acetic acid
acetaldehyde  toxic to hepatocytes  cross-links lysine residues  causes cytoskeleton to clump  Mallory denk bodies)

Question 11

What kind of inflammation is present in alcoholic hepatitis?

Answer 11

Neutrophilic inflammation (acute)

Question 12

ballooning of cells found in

Answer 12

steatohepatitis

Question 13

commonest cause of fatty liver disease in the west

Answer 13

• NAFLD – associated with high BMI, diabetes etc

Question 14

Vitamin deficiencies
•	D – 
•	C – 
•	B12 – 
•	B1 – 
•	B3 - 
•	Folate –

Answer 14

Vitamin deficiencies
•	D – rickets
•	C – scurvy
•	B12 – pernicious anaemia (missing the intrinsic factor, need injections of B12)
•	B1 – beri-beri
•	B3 - pellagra
•	Folate – neural tube defects

Question 15

Portal HTN triad

Answer 15

Caput medusae
Splenomegaly
Ascites

Question 16

What is the intrahepatic shunting of blood?

Answer 16

Fibrous scar joins the portal tracts + the central vein  blood flows through the fibrous scar, missing the hepatocytes and goes straight to the central vein  intrahepatic shunting of blood  this is the point at which the disease starts becoming non-reversible

Ischaemia of hepatocytes
Toxins + poisons in blood not cleared out  encephalopathy

Question 17

Micronodular cirrhosis

Macronodular cirrhosis

Answer 17

 Macronodular (nodules >3mm) – variable nodule size – viral hepatitis, Wilson’s disease, A1AT

 Micronodular (nodules <3mm)– alcoholic/non-alcoholic, biliary tract disease

Question 18

Portosystemic anastomoses

Answer 18

Oesophageal varices
Rectal varices
Umbilical vein recanalising
Spleno-renal shunt

Question 19

gall bladder is palpable in a jaundiced patient…

The cause is gallstones
The cause is pancreatic Ca

Answer 19

The cause is pancreatic Ca

o If obstruction caused by stone in CBD  gallbladder is likely to be thickened + fibrotic => not distended or palpable but rather shrivelled up
o If obstruction caused by tumour in CBD  gallbladder is likely to be normal => will dilate due to back-pressure

Question 20

Describe what happens during liver injury

Answer 20

Normally, endothelial cells are discontinuous + hepatocytes have microvilli

Liver injury
Hepatocytes lose microvilli
Stellate cells become activated to myofibroblasts – produce collagen

Changes in endothelial cells  become continuous

Blood in the sinusoid doesn’t interact with hepatocytes because of 3 reasons

1) endothelial cells are joined together
2) collagen is produced by the myofibroblasts in the space of Disse
3) hepatocytes lose their microvilli

Question 21

Acute vs chronic hepatitis + causes

Answer 21

Acute <6m
Drugs
Viruses - hep A+E

Chronic >6m
Drugs
VIruses - B, C ,D
Autoimmune

Question 22

Stage vs grade of chronic hepatitis

Answer 22

stage = severity of fibrosis
grade = severity of inflammation

stage more important than grade

Question 23

Histology - portal inflammation vs interface hepatitis (piecemeal necrosis)

Answer 23

Portal inflammation
o All the lymphocytes are in the portal tract – Inflammation hasn’t crossed the limiting plate

Interface hepatitis
o Inflammation has crossed the limiting plate – hepatitis interfaces between portal tract + parenchyma

Question 24

Features of alcoholic hepatitis

Answer 24

• Apoptosis
• Fat
• Pericellular fibrosis
• Mainly seen in zone 3
• (chronic hepatitis due to viruses – mostly seen around zone 1 – portal and periportal)
• Ballooned cells = hepatitis

Question 25

Which scoring system is being used to assess the severity of liver cirrhosis

Answer 25

o Modified Child’s Pugh Score (ABCDE) ``` Albumin Bilirubin Clotting PT Ascites (Distension) Encephalopathy ```

Question 26

PBC buzzwords ``` Epidemiology What is it Ix Association Mx ```

Answer 26

* Female * Autoimmune • Chronic inflammation with granulomas of the INTRAHEPATIC bile ducts --> Granulomatous inflammatory destruction + loss of INTRAHEPATIC bile ducts * Anti-mitochondrial antibodies = diagnostic test (anti-M2 antibodies) * US = NO bile duct dilation * Hx = bile duct loss with granulomas * Raised cholesterol, xanthelasma, steatorrhea * Chronic bile duct damage leading to fibrosis can eventually lead to cirrhosis if its treatment doesn’t stop its development Mx - ursodeoxycholic acid

Question 27

PSC buzzwords Epidemiology What is it Ix Association

Answer 27

* Males * Inflammation + fibrosis of EXTRAHEPATIC and INTRAHEPATIC bile ducts * Multifocal stricture formation with dilation of preserved segments * ERCP = beading of the bile ducts (diagnostic) * US = bile duct dilation * Hx = onion skin fibrosis • Associated with UC + cholangiocarcinoma

Question 28

Haemochromatosis/ Bronzed diabetes ``` Inheritance Chromosome Pathophysiology Cirrhosis Histology ``` Fe, Ferritin, Transferrin saturation, TIBC/transferrin

Answer 28

AR Chr 6 Increased iron absorption form the gut Hepatomegaly with micronodular cirrhosis Histology Iron deposit in hepatocytes Prussian blue stain High Fe, ferritin, transferrin saturation Low TIBC/transferrin

Question 29

Haemosiderosis cause + complication

Answer 29

caused by blood transfusion - iron accumulation in macrophages (e.g. Kupffer cells of liver) does NOT lead to cirrhosis

Question 30

Wilson's disease ``` Chromosome inheritance Protein affected Buzzwords Biochemistry Mx ```

Answer 30

Chr 13 AR copper transporting ATPase Kayser Fleischer rings Mallory bodies Rhodanine stain low serum Cu, low serum ceruloplasmin high urinary copper Lifelong penicillamne

Question 31

Autoimmune hepatitis HLA association Antibodies Dx

Answer 31

HLA-DR3 ``` Type 1 Anti-smooth muscle antibodies Anti nuclear antibodies Antti actin antibodies Anti soluble liver antigen ``` Type 2 Anti liver kidney microsomal Ig Dx Anti-smooth muscle antibodies in serum

Question 32

Liver histology of A1AT alpha 1 antitrypsin deficiency

Answer 32

intracytoplasmic inclusions of antitrypsin 1 stain with periodic acid schiff

Question 33

Benign liver tumours

Answer 33

Liver cell adenoma F>M, related to oestrogen levels, increased risk with COCP Bile duct adenoma Haemangioma Most common benign lesion

Question 34

Commonest liver tumours

Answer 34

Benign - haemangioma Malignant - secondary metastases

Question 35

Haemochromatosis symptoms

Answer 35

``` o Skin bronzing (melanin deposition) o DM o Hepatomegaly with micronodular cirrhosis o Cardiomyopathy o Hypogonadism o Pseudogout ```