Liver

Question 1

The five main functions of the liver are:

Answer 1

• Metabolising, storing or excreting the absorbed products of digestion
• Makes and excretes bile
• Synthesises proteins
• Metabolises hormones and drugs
• Mounts an immune response to portal pathogens

Question 2

How many segments is the liver divided into:

Answer 2

8

Question 3

Name the four lobes of the liver

Answer 3

Left, right, caudate and quadrate

Question 4

Liver blood supply

Answer 4

Arterial blood from right, middle and left hepatic arteries which are branches of the common hepatic artery arising from the coeliac axis.
Venous blood from the hepatic portal vein which drains the alimentary tract

Question 5

What are liver cells called

Answer 5

Hepatocytes

Question 6

What are Kupffer cells?

Answer 6

The liver’s resident macrophages

Question 7

What structures constitute the portal triad

Answer 7

Bile duct, hepatic artery and portal vein

Question 8

Increased breakdown of red blood cells(haemolysis) resulting in the production of bilirubin that exceeds the capacity of the liver to conjugate and excrete it

Answer 8

Pre-hepatic jaundice (unconjugated dhyperbilirubinaemia)

Question 9

Failure of hepatocytes to conjugate and excrete bilirubin. The excess bilirubin is predominantly conjugated, reabsorbed into the blood and then excreted in the urine, causing darkening

Answer 9

Intrahepatic jaundice

Question 10

Obstruction of the bile ducts so bilirubin can not be excreted in to the duodenal lumen. Excess bilirubin is conjugated and darkens the urine. Patients stools will be pale as bile pigment does not reach the intestines

Answer 10

Post-hepatic jaundice

Question 11

Examples of enzymes which leak into the blood upon hepatocyte injury are:

Answer 11

ALT, AST, GGT

Question 12

What enzyme level is raised in the blood during biliary obstruction

Answer 12

alkaline phosphatase

Question 13

Major serum protein synthesised in the liver, It has a relatively long half-life, so low levels indicate long-tem insufficient liver function

Answer 13

Albumin

Question 14

Liver cells synthesise most clotting factors, therefore a bleeding tendency results from hepatic insufficiency. This can be detected by measuring ………….

Answer 14

The prothrombin time

Question 15

First imaging test to use in most circumstances to view the liver due to relatively low cost, mobility and no ionising radiation

Answer 15

Ultrasound

Question 16

Name the three imaging techniques used to view the biliary tree

Answer 16

MRCP - only diagnostic
ERCP - should only use if therapeutic procedure planned
PTC - more invasive, only used if other methods do not work

Question 17

Hepatocyte injury with cell death, inflammation and regeneration without structural change to the liver

Answer 17

Acute hepatitis

Question 18

A result of acute severe liver cell injury with insufficient regeneration (massive necrosis). Result in vomiting, hypoglycaemia, encephalopathy, very high ALT and AST, jaundice and bruising

Answer 18

Acute liver failure

Question 19

Infiltration of liver cells by fat

Answer 19

Steatosis

Question 20

Inflammation of the liver with concurrent fat accumulation

Answer 20

Steatohepatitis

Question 21

Diffuse and irreversible process, potential end stage of chronic liver disease of any cause. Characterised by fibrosis and nodular regeneration. Complications are liver failure, portal hypertension and liver cell carcinoma

Answer 21

Cirrhosis

Question 22

The most common type of liver cancer. Most cases are as a result of either a viral hepatitis infection (hepatitis B or C), metabolic toxins such as alcohol or aflatoxin, conditions like hemochromatosis and alpha 1-antitrypsin deficiency or NASH

Answer 22

Hepatocellular carcinoma

Question 23

What are the three histological changes seen in alcoholic liver injury:

Answer 23

Fatty change(steatosis)
Alcoholic steahepatosis, combination of fatty changes and inflammation - leads to liver cell death and fibrosis
Architectural damage ranging from pericellular fibrosis to cirrhosis

Question 24

How does alcohol injure the liver

Answer 24

• Alcohol metabolism disturbs other metabolic pathways, such as fat and carbohydrate, so fat accumulates in liver cells
• Acetaldehyde, the main product of alcohol metabolism, binds to liver cell proteins, resulting in injured hepatocytes and an inflammatory reaction.
• Alcohol stimulates collagen synthesis in the liver, leading to fibrosis and eventually cirrhosis

Question 25

Associated with obesity and excess calorie intake with little exercise. Usually asymptomatic but now recognised to be the commonest cause of persistent mild elevation of liver enzymes. In a proportion of patients it progresses to cirrhosis

Answer 25

Non-alcoholic fatty liver disease

Question 26

Similar to alcoholic steatohepatitis with less inflammation

Answer 26

non-alcoholic steatohepatitis(NASH)

Question 27

Hepatitis viruses spread by oral route

Answer 27

A, E

Question 28

Hepatitis viruses spread blood-borne route

Answer 28

B, C

Question 29

Occurs more commonly in females, is often a severe form of hepatitis that can cause acute liver failure. Liver biopsy shows chronic hepatitis often with plasma cells and liver cell rosettes. Raised serum IgG snd transaminases. Anti-smooth muscle, antinuclear or anti-LKM(liver-kidney microsomal) antibodies are often present. Treatment with long-term immunosuppression can prevent progression to cirrosis

Answer 29

Autoimmune hepatitis

Question 30

Granulomatous inflammation surrounds and destroys bile ducts in early disease. Liver biopsy shows bile duct destruction, granulomas, ductular proliferation, fibrosis and eventual cirrhosis. Biopsy not now considered necessary for diagnosis in patients with anti-mitochondrial antibodies, high IgM and alkaline phosphatase. Clinical features include pruritus and xanthelasmas. Female > male

Answer 30

Primary biliary cirrhosis

Question 31

Autoimmune disease that results in damage and destruction of the bile ducts. Associated with ulcerative colitis. Liver biopsy shows periductal 'onion skin' fibrosis, bile duct loss, progresses to cirrhosis. Males > females

Answer 31

Primary sclerosing cholangitis

Question 32

A group of autosomal recessive disorders of iron metabolism. The defects result in excessive iron absorption from intestinal absorption. This excess iron accumulates in tissues causing a variety of signs and symptoms. Liver biopsy done to determine the degree of iron excess and fibrosis. Treatment is by venesection, removing units of blood until excess iron is depleted

Answer 32

haemochromatosis

Question 33

Rare but treatable inherited autosomal recessive disorder in which copper accumulates in the liver causing hepatitis and cirrhosis, and in the basal ganglia of the brain, causing severe progressive neurological disability

Answer 33

Wilson's disease

Question 34

Genetic disorder of synthesis of a serum protein in the liver. The misfolded protein accumulates as globules in liver cells. Injury to these hepatocytes results in progressive fibrosis and cirrhosis. This disorder also predisposes to pulmonary emphysema due to unopposed action of neutrophil enzymes damaging alveolar walls

Answer 34

Alpha-1 antitrypsin deficiency

Question 35

Increased blood pressure in the hepatic portal vein is due to a combination of: -increased portal blood flow -increased hepatic vascular resistance -intrahepatic arteriovenous shunting Leads to oesophageal varices, haemorrhoids, ascites, splenomegaly, caput medusae

Answer 35

Portal hypertension

Question 36

Results mostly in livers with cirrhosis as a result of progression through a series of pre-malignant lesions. Presents as decompensating cirrhosis due to replacement of liver by cancer cells. A small proportion occur in patients without cirrhosis, they tend to present late with a large intrahepatic mass. In these patients the remaining liver retains its regenerative capacity so surgical management is possible for early stage cancers

Answer 36

Hepatocellular carcinoma

Question 37

Adenocarcinoma of bile ducts particularly associated with inflammatory conditions of the bile ducts(e.g. Primary sclerosing cholangitis)

Answer 37

Cholangiocarcinoma

Question 38

Liver is common deposit site for metastases. Should assume that a tumour found in the liver is secondary until proved otherwise. Usually form multiple deposits from a few large tumours with central necrosis to numerous small metastases throughout the liver. Most often due to metastatic adenocarcinoma, especially from a primary in the pancreas, stomach, bowel, lung or breast

Answer 38

Metastatic tumours

Question 39

LOOK UP IN LETURE NOTES ABOUT LIVER TRANSPLANT

Answer 39

Liver transplantation

Question 40

Functionally decompensated cirrhosis. Characterised clinically by: - Hypoalbuminaemia causes oedema. - Clotting factor deficiencies cause bruising. - Ascites caused by low albumin, portal hypertension and a disturbance of aldosterone metabolism. - Encephalopathy, sometimes leading to coma - Fetor hepaticus, characteristic breath odour

Answer 40

Chronic liver failure