medical conditions of the liver

Question 1

three main histological patterns

Answer 1

• hepatitis - inflammation
• steatosis - fatty liver
• cholestasis - retention of bile

there can be overlap

Question 2

acute liver inflammation

Answer 2

<6 months is acute hepatitis
symptoms not always present
- fatigue, anorexia, nausea, jaundice, tenderness

typically lasts 2-4 weeks
minority progress to acute liver failure
- multiple disparate causes

Question 3

chronic liver inflammation

Answer 3

• greater than 6 months
• symptoms not always present
• weakness, tiredness and malaise
• often identified on screening blood tests
• aetiology dictates progression rate of damage and development of cirrhosis and carcinoma

Question 4

causes of acute hepatitis

Answer 4

hep A, E, B, C, D
immunosuppressed/transplant - CMV, EBV, HSV
other infections - toxoplasma, Q fever, leptospirosis, brucellosis
alcohol
drugs - parecetomol
toxins - mushrooms, carbon tetrachloride
ischaemia
pregnancy
autoimmune conditions
metabolic

Question 5

causes of chronic hepatitis

Answer 5

- hep B, C 
alcohol 
drugs 
autoimmune hepatitis 
biliary 
metabolic 
NAFLD - non-alcohol fatty liver disease

Question 6

biliary causes of chronic hepatitis

Answer 6

• primary biliary cholangitis

primary sclerosis cholangitis

Question 7

metabolic cause of chronic hepatitis

Answer 7

alpha -1 - antitrypsin deficiency
hereditary haemochromatosis
Wilson’s disease

Question 8

aetiologies of steatosis

Answer 8

alcohol
NAFLD/NASH - non alcoholic stet-hepatitis
drugs - methotrexate, amiodarone
hep C

Question 9

causes of cholestasis

Answer 9

primary biliary cholangitis
primary sclerosisg cholangitis
extra hepatic biliary obstruction
drugs

Question 10

hepatitis and liver inflammation

Answer 10

a necro-infalmmatory process comparing inflammation, hepatocyte necoris and repair, involving the portal and lobular regions

Question 11

histological features of liver inflammation

Answer 11

portal tract inflammation
limiting plate - interface hepatitis
lobular inflammation and hepaocyte necrosis - apoptosis of coagulative necrosis
repair - macrophages, hepatocyte regeneration and fibrosis which may progress to cirrhosis

Question 12

macro vesicular steatosis

Answer 12

one vacuole is filling the cytoplasm, variable in size but often large

Question 13

microvesicular steatosis

Answer 13

multiple small vacuoles filling the cytoplasm of a hepatocyte
uncommon

Question 14

causes of microvessicular steatosis

Answer 14

Reye’s syndrome
acute faty liver of pregnancy
drugs - tetracycline, valproic acid
congenital metabolic disorders - urea cycle disorders, Jamaican vomtiting disease

Question 15

causes of macrovessicular steatosis

Answer 15

alcohol
- acute hepatitis - hepatocyte necrosis with a neutrophil infiltrate. Mallory’s hyaline steatosis
- chronic stages - portal tract chronic inflammation and fibrosis, central vein sclerosis, often mild increase in iron
NASH - non alcohol steatohepatitis
- associated with obesity diabetes, GI surgery, TPN, metabolise syndrome features - fat, mallory’s hyaline, inflammation, fibrosis
- drugs - methotrexate, amiodarone
- hep C virus

Question 16

NASH

Answer 16

non alcohol steatohepattitis

Question 17

NASH causes of macrovessicular hepatitis

Answer 17

• obesity
• drugs
• hep C

Question 18

cholestasis

Answer 18

incomplete excretion of bile

Question 19

histology of cholestasis

Answer 19

- feathery degeneration of hepatocytes 
bile plugs 
cell death with inflmaammtion 
bile ductile proliferation at the edge of portal tracts 
fibrosis - cirrhosis

Question 20

pre haptic cholestasis

Answer 20

excess production of bilirubin (RBC breakdown)

Question 21

intrahepatic causes of cholestisis

Answer 21

inform errors
drugs - flucloxicillin - destroys bile ducts
primary biliary cholangitis
primary sclerosing cholangitis

Question 22

primary biliary cholangitis

Answer 22

4 stages

• duct lesion - duct damage, portal inflammation, granulomata
• ductular proliferation - expanded portal tracts, interface hepatitis
• scarring - fibrosis, loss of bile ducts
• cirrhosis

Question 23

primary sclerosis cholangitis

Answer 23

large duct vs small duct

inflammation and concentric fibrosis around ducts resulting in epithelial necrosis and duct loss

Question 24

post hepatic cause of cholestasis

Answer 24

extra-hepatic biliary obstruction (gall stones, tumours in the head of the pancreas
- bile plug in ducts - may rupture to form bile likes +/- ascending cholangitis (neutrophils in bile ducts), abscesses

Question 25

biopsy diagnosis

Answer 25

asses whether hepatitis, steaotic, cholestatic, fibrotic, overlap or other rarely make a diagnosis in isolation always a combination of serological, clinical and/or radiological not frequently a non-specific pattern - however, some etiologists can produce characteristic patterns that may be highly suggestive of a particular cause

Question 26

ground glass hepatocytes

Answer 26

hepatocytes with ground glass inclusions | hep B surface antigen

Question 27

auto-immune hepatitis

Answer 27

florid lobular and portal inflammation, interface hepatitis, hepatocyte rosettes, plasma cells

Question 28

mallory bodies

Answer 28

occur in alcoholic hepatitis

Question 29

biliary diseases

Answer 29

- primary biliary cholangitis - cirrhosis - primary sclerosis cholangitiss - extra hepatic biliary obstruction

Question 30

histopathology of biliary diseases

Answer 30

``` inflammation/dmaaaage around the bile ducts cholestasis bile ductile proliferation hepatocyte damage fibrosis ```

Question 31

PBC histology

Answer 31

jigsaw pattern of fibrosis

Question 32

PSC histology

Answer 32

inflammation and fibrposis | sclerosing fibrosis

Question 33

inborn errors

Answer 33

``` congenital - hereditary haemochromatosis - iron overload - alpha -1 anti-trypsin Wilson's copper storage disease cystic fibrosis ```

Question 34

hereditary haemochromatosis

Answer 34

iron granules present in liver cells

Question 35

investigations

Answer 35

- LFTs - infective agents - serology - autoimmune Ab, iron studies - tumour markers, alpha-feto protein - imaging for mass lesions - liver biopsy

Question 36

cirrhosis

Answer 36

diffuse alteration of the normal architecture by fibrous septa separating nodules of regenerating hepatocytes the end point of many disease processes where there are cycles of necrosis/infalmmation and repair/fibrosis

Question 37

aetiologies of cirrhosis

Answer 37

``` alcohol/drugs viral hepatitis auto immune hepatitis metabolic diseases genetic haemochomatosis alpha-1-antitrypsin deficiency Wilson's disease biliary tract disease non-alcoholic steatohepatitis idiopathic ```

Question 38

clinical symptoms and signs of cirrhosis

Answer 38

- no symptoms, abnormal liver function tests - non specific symptoms and signs - malaise, abdominal pain, hepatomegaly - liver failure signs and symptoms - multi organ failure/death

Question 39

treatment of liver cirrhosis

Answer 39

remove/treat aetiology - anti virals - stop drinking - Immunosuppressor - cease medication - remove iron -venesection support and await repair transplant

Question 40

acute liver failure

Answer 40

rapid deterioration of liver function in a previously healthy individual 1. coagulopathy - impaired protein synthesis - as measured by the prothrombin time in the blood 2. hepatic encephalopathy - alteration of mental status hyper acute is within 1 week - acute is 1-4 weeks and subacute is 4-12 weeks

Question 41

aetiologies of acute liver failure

Answer 41

``` drugs/alcohol hep, EBV, CMV auto immune hepatitis metabolic diseases - Wilson's disease (copper overload) idiopathic ```

Question 42

paracetamol overdose

Answer 42

characteristic appearance nutmeg liver zones of necrosis

Question 43

liver transplantation

Answer 43

the replacement of a disease liver with some or all of a healthy liver from another person usually the native liver is removes and replaced by the donor organ in some anatomic location needs a blood group matched donor multiple anastomoses

Question 44

indications of transplantation

Answer 44

- end stage chronic liver disease - acute liver failure - hepatic neoplasms