Liver Pathology

Question 1

How heavy is the liver?

Answer 1

1.5 kg

Question 2

What is the blood supply to the liver?

Answer 2

Dual: hepatic artery (20%) and portal vein (80%)

Question 3

What are the cells of the liver?

Answer 3

Hepatocytes
Bile ducts
Blood vessels
Endothelial cells
Kupffer cells
Stellate cells

Question 4

What is the key parts of the definition of cirrhosis?

Answer 4

Whole liver involved
Fibrosis
Nodules of regenerating hepatocytes
Distortion of liver vasculature- intra and extra hepatic shunting of blood

Question 5

Why are intrahepatic shunts bad?

Answer 5

There is unfiltered toxic blood

Question 6

How do you classify cirrhosis?

Answer 6

Nodule size: micronodular vs macronodular

Aetiology: alcoholic/ insulin resistance (more likely to be micronodular)/ viral hepatitis (more likely to be macronodular)

Question 7

What are the complications of cirrhosis?

Answer 7

Portal hypertension (may present with palpable spleen)

Hepatic encephalopathy

Liver cell cancer

Question 8

What causes acute hepatitis?

Answer 8

Viruses

Drugs

Question 9

What causes chronic hepatitis?

Answer 9

Viruses
Drugs
Autoimmune

Question 10

How do you evaluate chronic hepatitis histology?

Answer 10

Severity of inflammation = grade

Severity of fibrosis = stage

Question 11

What are the stages of ALD?

Answer 11

Fatty liver
Alcoholic hepatitis
Cirrhosis

Question 12

What are the features of alcoholic hepatitis?

Answer 12

Ballooning ( +/- Mallory Denk Bodies)
Apoptosis
Pericellular fibrosis
Mainly seen in Zone 3

Question 13

What is NAFLD?

Answer 13

Histologically looks like alcoholic liver disease

Due to insulin resistance associated with raised BMI and diabetes

Becoming recognised as one of the commonest causes of liver disease, world-wide

Question 14

What is PBC?

Answer 14

Previously primary biliary cirrhosis.

F> M

Bile duct loss associated with chronic inflammation (with granulomas)

Diagnostic test is detection of anti-mitochondrial antibodies

Question 15

What is PSC?

Answer 15

M > F
Periductal bile duct fibrosis leading to loss
Associated with ulcerative colitis
Increased risk of cholangiocarcinoma
Diagnostic test is bile duct imaging

Question 16

What is haemochromatosis?

Answer 16

Genetically determined increased gut iron absorption
Gene on chromosome 6 (HFe)
Parenchymal damage to organs secondary to iron deposition (bronzed diabetes)
Prussian blue stain is used to pick out iron

Question 17

What is haemosiderosis?

Answer 17

Accumulation of iron in macrophages NOT hepatocytes

No inflammation

Blood transfusion for treatment

Question 18

What is Wilsons disease?

Answer 18

Recessive disease (Chromosome 13, heteroallelic): Accumulation of copper due to failure of excretion by hepatocytes into the bile

Assessed by biopsy (Rhodanine stain for copper) or biochemistry

Accumulates in the liver and CNS (hepato-lenticular degeneration) including Kayser-Fleishcer rings

Causes cell damage

Question 19

What is AIH?

Answer 19

F>M

Active chronic hepatitis with plasma cells

Anti-smooth muscle actin antibodies in the serum

Responds to steroids

Question 20

What is Alpha 1 Antitrypsin deficiency?

Answer 20

Failure to secrete alpha-one antitrypsin

Intra-cytoplasmic inclusions due to misfolded protein

Hepatitis and cirrhosis

Presents in neonatal period with giant cell hepatitis

Question 21

What is DILI?

Answer 21

“any kind of liver disease can be caused by a drug” ie. hepatocellular and / or cholestatic

10% of drug reactions involve the liver

Liver is the site for xenometabolism

May be dose-related or idiosyncratic

Question 22

What are hepatic granulomas caused by?

Answer 22

Specific causes:
PBC
drugs

General causes:
TB
Sarcoid
Other infective aetiologies etc.

Question 23

What are the benign liver tumours?

Answer 23

1) liver cell adenoma
2) bile duct adenoma
3) haemangioma

Question 24

What are the malignant liver tumour classed as?

Answer 24

1. secondary tumours (more common)

2. primary tumours

Question 25

What is the anatomy of the portal venous system?

Answer 25

The superior mesenteric vein drains from the gut into the portal vein The inferior mesenteric vein joins the splenic vein into the portal vein The short gastric veins, left gastric vein, and umbilical vein drain into the portal vein The portal veins splits off into the right and left branches then into segmental veins and venules

Question 26

What are the primary liver tumours?

Answer 26

1. hepatocellular carcinoma 2. hepatoblastoma (primitive hepatocytes-children) 3. cholangiocarcinoma 4. haemangiosarcoma (blood vessels)

Question 27

What is liver cell cancer (HCC) associated with?

Answer 27

Usually associated with cirrhosis especially in the West.

Question 28

What are the associations of cholangiocarcinomas?

Answer 28

Associated with: PSC Worm infections Cirrhosis ``` Can arise from: intrahepatic ducts extrahepatic ducts (including gall bladder) ```

Question 29

Why are extrahepatic shunts bad?

Answer 29

Blood cannot get through liver- porto-systemic anastomoses have increased pressure

Question 30

What is acute hepatitis classes as?

Answer 30

<6 months | Chronic > 6 months

Question 31

Are Hepatitis B and C acute or chronic?

Answer 31

Both

Question 32

Is alcoholic related fatty change reversible?

Answer 32

Yes

Question 33

Where is fibrosis in viral and alcoholic hepatitis?

Answer 33

``` Viral = zone 1 Alcoholic = zone 3 ```

Question 34

How does paracetamol toxicity cause damage?

Answer 34

Paracetamol converted to toxic metabolite in the liver and can cause damage Zone 3 damage (most drug metabolism here)

Question 35

What is a granuloma?

Answer 35

Organised collection of activated macrophages