L12- GIT Pathology VI (liver) Flashcards by Connor Patrick

describe structure of liver lobule and acinus

(acinus is half a lobule)

central vein
surrounded by 6 portal triads
triads: hepatic artery, portal vein, bile duct
Zone 1 near periphery, Zone 3 surrounds central vein
Zone 3 most susceptible to hypoxia

Note- blood flow is outside in; bile flow is inside out

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list the cells of the liver

-Hepatocytes: thin plates/cords 1-2 cells thick

endothelial cells (blood)
Kupffer cells (liver macrophages)
stellate cells (perisinusoidal / ito cells): stores fat / vitE

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track the movement of bile (from production until it reaches intrahepatic ductules)

1) excreted by hepatocytes
2) into bile canaliculi
3) canals of Hering
4) bile ducts

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list the general clinical features of liver disease

RUQ pain
jaundice
anorexia
pruritus
fever
mental confusion
easy bruising

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list the lab investigations for the liver

Serum Bilirubin: conjugated, unconjugated
Transaminases: ALT, AST, ALP/ALK, GGT
Serum Albumin
AFP
serum ammonia
ceruloplasmin

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LFT result indicating alcoholic liver disease….

AST:ALT >2

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LFT result indicating viral hepatitis….

AST:ALT <1

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LFT result indicating cholelithiasis (biliary obstruction)….

elevated ALP, GGT

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LFT result indicating HCC….

(hepatocellular cancer)

α-fetoprotein (AFP)

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LFT result indicating hepatic failure….

elevated ammonia

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LFT result indicating Wilson’s disease….

dec Ceruloplasmin (Cu carrier)

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Indicate the *liver disease with the following LFT results:

(1) elevated GGT, ALP
(2) elevated ALP alone
(3) elevated GGT alone
(4) AST:ALT > 2
(5) AST:ALT < 1

1- cholestasis / biliary obstruction
2- infiltrative diseases / metastasis, congestive diseases via RHF
3- alcohol use
4- alcoholic liver disese
5- viral hepatitis

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Indicate the *liver disease with the following LFT results:

(1) inc AFP
(2) dec serum albumin
(3) dec ceruloplasmin
(4) inc PT
(5) inc NH3+

1- HCC
2- chronic liver disease
3- Wilson's disease
4- acute or chronic liver disease
5- hepatic failure

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list the radiographic techniques used to investigate liver disease

Visualization of biliary tree:

ERCP (endoscopic retrograde cholangiopancreatogram): diagnostic, therapeutic
MRCP (magnetic resonance cholangiopancreatogram): diagnostic

Other:

MRI, CT, US
liver biopsy

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chronic liver disease is defined as lasting longer than…..

6 mos

= chronic hepatitis

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describe how severity of liver disease is determined

*Morphological pattern of hepatocyte

reversible / self-limiting injury: normal function returns after removing offending agent
e. g. fatty degen. via EtOH, cholestasis

-irreversible damage / fibrosis + progressive = cirrhosis

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describe the 2 types of hepatocellular injury

Ballooning: large hepatocytes w/ regularly clumped cytoplasm
Feathery: fine, foamy cytoplasm due to detergent action of bile salts

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describe the morphological features of hepatic injury

Hepatocellular injury (ballooning, feathery)
Necrosis: focal, bridging, massive
Apoptosis: councilman bodies / acidophil bodies
Regeneration: hepatocyte cord thickening, mitosis, acinar change (rosettes)
Fibrosis

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list the types of steatosis and their causes

Macrovesciular steatosis: alcohol, NASH, malnutrition

Microvesicular steatosis: acute fatty liver of pregnancy, Reye syndrome, drugs, obesity, DM

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describe Macrovesicular Steatosis (+ causes)

Large Droplet: single fat vacuole, displaces nucleus to periphery

Small droplet: multiple fat vacuoles (not as fine as microvesicular)

Causes: alcohol, NASH / NAFLD (non-alcoholic steatohepatitis / non-alcoholic fatty liver disease), malnutrition

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describe Microvesicular Steatosis (+ causes)

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-multiple fine vacuoles, nucleus is central

Causes: acute fatty liver in pregnancy, Reye syndrome, drugs, obesity, DM

Signs of Liver Disease seen in acute and chronic conditions

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icterus / jaundice
hepatomegaly
RUQ pain / tenderness
peripheral edema

Signs of Liver Disease seen in only chronic conditions

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splenomegaly (portal HTN)
palmar erythema
spider angiomas
gynecomastia + testicular atrophy (men)
Dupuytren contracture (hand fibrosis contracts ulnar nerve digits)
parotic enlargement
clubbing
white nails (leukonychia)
muscle wasting

Jaundice:

defined as (1)
presence in the eye is (2), and will be seen clinically with (3) lab values
accumulation of (3) also leads to (4) in newborns
(5) / (6) describe the results of retaining two other substances

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1- skin yellowing
2- scleral icterus
3- bilirubin >2.0 mg/dL
4- kernicterus (neonatal jaundice => brain damage) 
5- cholesterol --> skin xanthomas
6- bile salts --> pruritus

list the classifications of jaundice

- pre-hepatic - hepatic - post-hepatic

list the causes of pre-hepatic jaundice

excess production of bilirubin: - hemolytic anemia - inc blood resorption from hemorrhage - ineffective erythropoiesis

list the causes of post-hepatic jaundice

impaired bile flow: - gallstones, head of pancreas cancer, extra hepatic bile ducts - biliary atresia (neonates)

list the causes of hepatic jaundice

- reduced uptake: drugs, diffuse liver disease - impaired conjugation (neonates) - dec excretions: drugs, transporter deficiency (related to impaired conjugation) - impaired bile flow --> bile duct obstruction

Cirrhosis defining characteristics

- bridging fibrous septa - parenchymal nodules created by regeneration - diffuse liver involvement NOTE- end stage result of many liver diseases are irrespective of primary etiology

define Cirrhosis classification

based on nodule size: - Micronodular, <3mm nodules - Macronodular, >3mm nodules

list the disease types that can cause Cirrohosis

Hepatic diseases: viral / autoimmune hepatitis, steatohepatitis (alcoholic/NASH) Biliary diseases: primary biliary cholangitis, primary sclerosing cholangitis (UC) Metabolic diseases: hereditary hemochromatosis, Wilson's disease, AAT deficiency Cyptogenic / Idiopathic

describe the clinical features of cirrhosis

(possibly silent / asymptomatic) - portal HTN --> ascites, splenomegaly, varices - liver failure -inc risk of HCC

what are the consequences of portal HTN (often seen in liver disease, e.g. cirrhosis)

- ascites - hepatic encephalopathy - congestive splenomegaly --> thrombocytopenia - portosystemic shunts: esophageal / gastric varices, hemorrhoids in rectum, retroperitoneum affected, caput medusae of abdominal wall

(1) is the most common infectious disease of the liver, caused mostly by (2), although (3) infections can involve the liver

1- viral hepatitis 2- Hepatitis A, B, C, D, E 3- EBV (infectious mononucleosis), CMV, yellow fever

HepA: - (1) genome - causes (acute/chronic) hepatitis - commonly affects (3), spreading via (4) route - (5) incubation period

``` 1- non-enveloped (+)ssRNA (picornavirus family) 2- acute (no chronic disease) 3- children (unvaccinated) 4- fecal-oral 5- 2-6 wks ```

HepA: - diagnosis either requires (1) or (2) - (3) does not occur with hepA virus

1- IgM anti-HepA at onset 2- IgG after few months 3- carriers

HepB: - (1) genome - aka (2), explain - (3) transmission - (4) incubation period

1- enveloped dsDNA 2- serum hepatitis b/c present in all body fluids 3- blood transfusion, sex, IV drug use, needle stick injuries 4- 4-26 wks

discuss the distribution of HepB complications post-acute infections

healty carriers, 5-10% subclinical disease, 60-65% (--> recovery) acute hepatitis, 20-25% (--> recovery, rarely fulminant/death) perisistent infection, 4% (--> most recover, some advance to chronic HepB --> cirrosis / ---> HCC / death)

HepB Histology: - (1) general hepatocyte appearance - (2) intracellular characteristic - immunostaining for (3) is necessary to confirm its abundant presence in cells, include color - (4) is a key trait of chronic hepatitis

1- ground-glass 2- large pale, finely granular pink cytoplasmic inclusions (H&E) 3- HepB surface Ag, brown 4- portal tract expansion via lymphoid follicle

HepC: - (1) genome - causes mostly (acute/chronic) hepatitis

1- enveloped (+)ssDNA (flavivirius) | 2- both, high propensity for chronic infections

discuss the distribution of HepC complications post-acute infections

- resolution, 15% - chronic hepatitis, 85% (--> either stable disease or cirrohosis with its complications) - fulminant, rare

explain HepD infection | -what needs to occur for infection, which method is more dangerous

-its a defective RNA virus -becomes infective when encapsulated by HBsAg (hepatitis B surface Ag) OR -*co-infection with HepB (*more dangerous = superinfection)

HepE: - (1) genome - causes mostly (acute/chronic) - (3) transmission, mostly affecting (4) people - possibly fatal in (5) population - (6) is a popular complication

``` 1- non-envelope 2- mostly acute 3- enteric (endemics) 4- immunosuppressed (post-liver transplant Pts) 5- pregnant 6- cholestasis ```

what are the clinical results of viral hepatitis

1- asymptomatic infection 2- carrier state 3- acute hepatitis 4- chronic hepatitis 5- fulminant hepatitis

Autoimmune hepatitis: - more in (males/females) - involves Ig(2) against (3) in adults or (4) in children - responds to (5)

1- females 2- IgG 3- anti-nuclear / anti-smooth muscle Abs (type I) 4- anti-LKM (liver kidney microsomal) Abs (type II) 5- immuno-suppressive therapy

Autoimmune hepatitis histological description (hepatitis type and defining cells)

focal lobular hepatitis w/ prominent plasma cells

list the patterns of alcoholic liver disease

- hepatic stenosis - alcoholic hepatitis (steatohepatitis) - variable amounts of fibrosis --> can progress to cirrhosis (micronodular cirrhosis --> progresses to macronodular)

NAFLD = (1): - (2) Sxs - (3) risk factors

1- nonalcoholic fatty liver disease 2- asymptomatic OR mild elevation of serum transferases, may lead to cirrhosis 3- obesity, insulin resistance, DM, hyperlipidemia

NAFLD = (1): | -similar presentation to (2- include features)

1- nonalcoholic fatty liver disease 2- alcoholic liver disease: - steatosis - steatohepatitis = ballooning, Mallory hyaline - fibrosis around central vein - may progress to cirrhosis

fulminant hepatitis definition

- acute liver disease, rapid progression - encephalopathy develops w/in 8 wks -pathology: massive necrosis, submassive necrosis

liver necrosis: - (1) general appearance - confluent necrosis in (2) region

1- small, bile-stained, soft, congested 2- periventricular region

L12- GIT Pathology VI (liver) Flashcards

(51 cards)