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Flashcards in Liver Histopath Deck (46):
1

Major causes of cirrhosis (3) & less common causes (3)

  1. Alcoholic fatty liver disease
  2. Non alcoholic fatty liver disease
  3. Chronic hepatitis infection

Autoimmune hepatitis

Drugs e.g. Methotrexate

Biliary causes: PBC & PSC

2

Genetic causes of cirrhosis (5)

1) haemochromatosis - HFE gene chr 6

2) Wilson's disease - ATP7B gene chr 13

3) alpha 1 anti-trypsin deficiency (pulmonary & hepatic dysfunction)

4) galactosaemia

5) Glycogen storage disease

3

Difference between micronodular & macronodular cirrhosis & 2 examples of each

Micronodular indicates regenerating nodules (of regenerating hepatocytes) < 3mm e.g. alcoholic &amp; biliary tract disease

Macro > 3mm e.g. Viral, Wilson's

4

Briefly describe pathophysiology of cirrhosis (Refer to picture)

1) chronic inflammation activates the normally quiescent stellate cells

2) convert to myofibroblasts and deposit collagen in space of disse

3) when myofibroblasts contract they cause constriction of the sinusoids - increasing vascular resistance

4) undamaged hepatocytes regen in nodules between fibrous septa

A image thumb
5

5 criteria of the child's Pugh score - indicates prognosis of cirrhosis

Ascites (none, mild, severe)

Encephalopathy (none, mild, severe)

Bilirubin (<34, 34-50, >50)

Albumin (>35, 28-35, 6)

PTT (seconds more than normal) (<4, 4-6, >6)

Score 1,2 &amp; 3 respectively

6

Score boundaries for Child Pugh A, B &amp; C (Indicates cirrhosis prognosis)

  • < 7 (A) = 45% 5 yr survival
  • 7-9 (B) = 20% 5 yr survival
  • 10+ (C) = <20% 5 yr survival 

7

Portal htn (>10-12mmHg) venous system dilates, where do collateral vessels form? (6)

1) gastro-oesophageal

2) Rectal

3) Umbilical

4) retroperotneal

5) diaphragm

6) left renal vein

8

Causes of portal HTN (pre hepatic, hepatic &amp; post hepatic)

Pre-hepatic: portal vein thrombosis (e.g, Factor V Leiden)

Hepatic:

  • Pre sinusoidal: schistomasis, PBC, Sarcoidosis
  • Sinusoidal: Cirrhosis
  • Post-sinusoidal: veno-occlusive disease Post-hepatic: Budd-Chiari syndrome

9

Give some causes of Budd-Chiari &amp; treatment

Occlusion of hepatic vein!

Causes: 30% idiopathic, thrombophilia, OCP, leukaemias, compression by renal tumours etc.

Treatment: Thrombolytic, treat underlying cause, TIPS (transjugular intrahepatic portosystemic shunt)

10

Triad of Budd Chiari

Pain + ascites + hepatomegaly

11

3-4 features of cirrhosis

1) hepatocyte necrosis

2) nodules of regenerating hepatocytes

3) fibrosis

4) disrupted liver architecture> increased resistance to blood flow through liver > portal hypertension

12

Microscopic characteristics of hepatic steatosis (fatty liver)

Steatosis - fatty droplets in hepatocytes. Fibrosis in late stage if chronic exposure reversible if alcohol avoided

13

microscopic characteristics of alcoholic cirrhosis

MICRONODULAR cirrhosis - small nodules + bands of fibrous tissue

14

Microscopic characteristics of alcoholic hepatitis (2)

Hepatocyte BALLOONING &amp; necrosis due to accumulation of fat, water &amp; proteins

MALLORY BODIES (damaged intermidiate filaments within hepatocytes)

fibrosis

seen acutely after night of heavy drinking

15

What antibodies are present in Type 1 autoimmune hepatitis? (4)

ANA (anti nuclear ab), anti-SMA (anti smooth muscle ab), anti-actin ab, anti-soluble liver antigen ab

16

What antibody is present in Type 2 autoimmune hep?

Anti-LKM Ig (anti-liver-kidney-microsomal Ig)

17

How is autoimmune hepatitis managed?

Immune suppression until transplant, (but disease returns in up to 40%)

18

Associations of autoimmune hepatitis: Who gets it? M or F? HLA association?

People with autoimmune conditions females (78%) HLA-DR3

19

What is main tissue destroyed by autoimmune inflammation in PBC?

medium sized INTRAHEPATIC bile ducts (this leads to cholestasis which very SLOWLY leads to development of cirrhosis over many years)

A image thumb
20

Ratio of F:M in PBC

10:1

21

What will the investigations/ histology show in PBC? (4)

High ALP, high cholesterol, high IgM, ANTI-MITOCHONDRIAL Abs in 90%

US - NO bile duct dilatation

histology - bile duct loss with GRANULOMA formation

22

Presentation of PBC?

Fatigue, pruritis, abdo discomfort

23

Secondary symptoms of PBC (give 3)

xanathelasma, skin pigmentation, steatorrhoea, inflammatory arthropathy

24

Treatment of PBC

Ursodeoxychilic acid (slows down absorption of cholesterol from intestine) in early phase (25% remission)

25

Briefly describe the pathophysiology of PSC

inflammation &amp; obliterative fibrosis of EXTRA &amp; INTRAHEPATIC bile ducts > leads to multi focal STRICTURE FORMATION &amp; dilatation

A image thumb
26

What autoimmune condition is PSC particularly associated with?

IBD - esp UC

27

what will the investigations// histology show in PSC?

increased serum ALP, several auto abs- esp p-ANCA

US - bile duct DILATATION

ERCP - BEADING OF BILE DUCTS (due to multifocal strictures) increased incidence of CHOLANGIOCARCINOMA

28

Main differences between PBC &amp; PSC:

PSC more common in males, PBC in females

PSC associated with UC, PBC not as much

PSC both intra &amp; extra hepatic bile ducts affected, in PBC only intra Therefore in PSC you get bile duct dilatation, in PBC you dont

29

Pathophysiology of Haemochromatosis

Inheritance - autosomal recessive Mutate HFE gene at chr 6(p21.3) > increased Fe absorption from gut > deposition everywhere > eventually leads to fibrosis

30

Histology of Haemochromatosis (which stain used)

Fe deposits in liver, stains with PRUSSIAN blue

31

Signs/symptoms of haemochromatosis (at least 3)

Skin pigmentation

Diabetes

Hepatomegaly

pseudogout

32

Investigations

Fe high,

Transferrin saturation high (>45%),

Ferritin high,

TIBC low (transferrin transports iron, it has binding sites normally only a third are occupied - more iron = more transferritin saturation. TIBC is total iron binding capactiy )

33

Pathophysiology of Wilson's disease

autosomal recessive Mutation in ATPB7 gene - encodes Cu transporter protein on cannilicular membrane > so reduced biliary Cu excretion > deposition in liver, CNS, iris

34

Histology of Wilson's (2)

Cu stains on Rhodanine stain

Mallory bodies (damaged IFs) &amp; fibrosis on microscopy

35

Signs/ symptoms of Wilson's (neuro, hepatic, eyes)

Neuro: parkinson's, dementia (if basal ganglia involved), psychosis

Hepatic: acute hep, cirrhosis, liver failure

Eyes: Kayser Fleischer rings: copper deposits in Descemet's membrane in cornea

36

Investigations Wilsons (3)

reduced serum caeruloplasmin,

reduced serum copper,

increased urinary copper

37

Alpha 1 antitrypsin deficiency pathophysiology

A1AT is produced in liver and normally 1 of its functions is protection of lungs from neutrophil esterase.

In A1AT deficiency the mutation results in defective A1AT > accumulates in liver &amp; causes cirrhosis (cannot be secreted properly) and because it cannot protect lungs > emphysema

38

Histology of Alpha 1 antitrypsin deficiency (2)

INTRACYTOPLASMIC INCLUSIONS OF A1AT which stain with PERIODIC ACID SCHIFF

39

Signs and symptoms of A1AT def (kids and adults)

Kids - neonatal jaundice

Adults - emphysema &amp; chronic liver disease

40

Investigations of Alpha 1 antitrypsin deficiency (2)

low A1AT

Absent alpha globulin bands on electrophoresis

41

Treatment of Haemochromatosis

VENESECTION

DESFERRIOXAMINE (siderophore - chelates Fe)

42

Treatment of Wilson's disease

Life long PENICILLAMINE - chelates coppper (good prog with early treatment, but any neuro damage is permanent)

43

Clinical features of Hepatic adenoma &amp; how to treat

Benign hepatic tumour, associated with OCP presents with

Abdo pain + intraperitoneal bleeding

Resect if symptomatic or > 5 cm or if doesnt shrink after stopping OCP

44

Clin features of Haemangioma

most common benign lesion - doesnt require treatment

45

Hepatocellular carcinoma causes (4) &amp; investigations (2)

Causes: chronic hep B + C, alc cirrhosis, NAFLD, Steroids

Ix: AFP, USS

46

Cholangiocarcinoma: what is it? prognosis? causes (3)

Adenocarcinoma arising from bile ducts poor prognosis

Causes: PSC Chronic liver disease Lynch syndrome type 2