Quiz 5

Question 1

what is the most common tumor of the liver?

Answer 1

hepatic hemangioma

Question 2

what is the most frequent form of primary liver cancer?

Answer 2

hepatocellular carcinoma

sometimes referred to as hepatoma

Question 3

the majority of cases of cancer found in the liver occurs as a consequence of what? how?

Answer 3

occurs as a consequence of metastasis from another tissue
primary site is the GI tract (colon cancer)
occurs also in cases of BC, ovarian cancer, lung cancer, renal cancer and prostate cancer

Question 4

what term is used to describe a benign glandular tumor of the liver? what population do these occur in and what is the greatest risk? what is seen histologically?

Answer 4

hepatic adenoma

• tend to occur in women taking oral contraceptives
• though benign, have potential to rupture and cause intraperitoneal hemorrhage
• cells closely resemble normal hepatocytes, but neoplastic liver tissue is disorganized and does not contain normal lobular architecture LESS abundant cytoplasm, LESS eosinophilic

Question 5

there are two main types of primary carcinoma of the liver, they are? which is most common and what are their locations?

Answer 5

hepatocellular carcinoma

• MOST COMMON
• arises from hepatocytes
• globally - most common hepatic tumor, Hep B is a common etiology or alcohol abuse leading to cirrhosis

cholangiocarcinoma
- arises from bile duct epithelium

Question 6

what are the major risk factors for Hepatocellular carcinoma?

Answer 6

Alcoholism
Hep B - MOST COMMON WORLDWIDE
Hep C

• all of these lead to cirrhosis of the liver which increases risk for HCC

Question 7

what would be elevated in hepatocellular carcinoma?

Answer 7

serum alpha-fetoprotein

may also obstruct biliary tract and lead to elevated serum alkaline phosphatase

Question 8

what is seen microscopically in HepatoCellular Carcinoma?

Answer 8

can be either normal liver cell cords or pseudo-glandular formation
as tumor grows, presence of snake-like masses invading portal vein or IVC

Question 9

What tumor markers are present in Cholangiocarcinoma, but not HCC? what form of cholangiocarcinoma is most common?

Answer 9

CA 19-9, CA-50

peripheral cholangiocarcinoma develops intralobular ducts in the liver - most common form of this tumor
(other form is hilar, less common)

Question 10

what is of notable interest in hepatic angiosarcomas?

Answer 10

angiosarcomas of the liver are rare, but notable because of the association of occurrence after EXPOSURE TO ARSENIC (pesticides) and exposure to high levels of POLYVINYL CHLORIDE in plastics industry.

Question 11

acquired biliary atresia occurs concomitantly with? one of the prinicipal forms of?

Answer 11

autoimmune disease

one of the principal forms of chronic rejection of a transplanted liver allograft

Question 12

biliary atresia is also known as?

Answer 12

extrahepatic ductopenia

progressive obliterative cholangiopathy

Question 13

biliary atresia has two forms, what are they and what is so important about each

Answer 13

congenital - babies are born with this with an occurrence rate of 1/10,000-1/15,000

acquired - generally occurs in the setting of autoimmune disorders, one of the principal forms of chronic rejection of a transplanted liver allograft

Question 14

what type of cyst is most common with choledochal cysts?

Answer 14

Type I

represent 80-90%, consisting of saccular dilations of the common bile duct

Question 15

if gallstone migrate into the ducts of the biliary tract - what is this called? what can this condition lead to?

Answer 15

choledocholithiasis
- can obstruct the biliary tree leading to acute infection - ascending cholangitis

If the gallstones exist in the ampulla of Vater - can obstruct exocrine glands of the pancreas causing pancreatitis

Question 16

acute cholecystitis is more often caused by?

Answer 16

cholelithiasis (especially when the cystic duct is blocked)

Question 17

what is it called when the gallbladder becomes inflamed in the absence of cholelithiasis and what increases a patient’s risk of acquiring this infection?

Answer 17

acute acalculous cholecystitis

• can result from obstructing tumors or an inadequate blood supply, but more frequently seen in patients with
  CAD, Trauma, Immunosuppression

Question 18

infectious agents that cause cholecystitis are? what will be observed in laboratory work for these infections?

Answer 18

gram negatives (mostly)

• e. coli
• klebsiella
• pseduomonas
• b. fragilis
• enterococcus

lab tests frequently show increased AST, ALT and a high WBC count

Question 19

what is seen histologically for acute cholecystitis?

Answer 19

extensive ulceration of the mucosa, hemorrhage, edema and dense transmural infiltrate of neutrophils and mononuclear inflammatory cells

Question 20

Compare and contrast the 3 different types of cholelithiasis stones.

Answer 20

Choelsterol Stones (MOST COMMON), must be 80% cholesterol by weight, not visible radiographically

Pigment Stones
- small, dark stones made of bilirubin and calcium salts found in bile - contain less than 20% cholesterol, radiographically visible (depending on calcium content)

Mixed Stones
-contain 20-80% cholesterol, radiographically visible (depending on calcium content)

Question 21

what is unique about cholesterol gallstones?

Answer 21

cholesterol gallstones may present as a single stone or as dozens of stones.

the have too much cholesterol and not enough bile to move.

REMEMBER - SINGLE STONE PRESENTATION!

Question 22

what can contribute to gallstone formation in females?

Answer 22

increased levels of Estrogen (baby on board, hormone therapy, OCs)
- may increase cholesterol levels in the bile, while decreasing the movements of the gallbladder.

Question 23

for cholesterolosis - where do the cholesterol and triglyceride filled macrophages deposit? what condition is this often associated with? what is this condition often referred to as?

Answer 23

lamina propria of the gallbladder

• often associated with chronic cholecystitis
• cholesterolosis with diffuse mucosal involvement is often referred to as a “strawberry gallbladder” where the mucosa tends to be red, flecked with numerous yellowish spots

Question 24

In approximately 1/4-1/3 of chronic cholecystitis cases, what is found within the gallbladder?

Answer 24

bacteria can be cultured from fluids within the gallbladder

Question 25

what is seen histologically for chronic cholecystitis?

Answer 25

lose of normal delicate papillary appearance increase in fibrous tissue mild chronic inflammation in the lamina propria Rokitansky-Aschoff sinuses (pockets in the wall of the gallbladder) in the muscularis - seen occasionally in cholesterolosis

Question 26

what is porcelain gallbladder?

Answer 26

inflammatory scarring of the gallbladder wall combined with calcification whiten the wall that transforms the gallbladder into a porcelain-like vessel (thought to be brought on by persistent inflammation)

Question 27

acute cholangitis carries a significant risk of death, what is the leading cause? what precedes this condition in general? what causes acute cholangitis?

Answer 27

irreversible shock with multiple organ failure (a possible complication of severe infection) gallstones are noted in 70-90% of cases usually caused by bacteria ascending from the bile duct's junction with the duodenum

Question 28

what is the difference between - pyema, empyema, abscess?

Answer 28

pyemia - type of septicemia that leads to widespread abscesses of a metastatic nature, usually caused by Staphyloccocus. Expect to see pus. empyema - collection or gathering of pus within a naturally existing anatomical cavity abscess - collection of pus that has built up within the tissue of a body, creating it's own cavity.

Question 29

ascending cholangitis histologically can have..

Answer 29

onion skin-like concentric peri-ductal necrosis.. this is indistinguishable from the onion skin-like staining of PSC

Question 30

cancer of the gallbladder is strongly associated with?

Answer 30

gallstone disease, however, even this population is at low risk for adenocarcinoma of the gallbladder

Question 31

the majority of all carcinomas in the gallbladder are found to be

Answer 31

well differentiated adenocarcinomas other forms include - papillary adenocarcinoma - poorly differentiated adenocarcinoma - well differentiated adenocarcinoma with squamous metaplasia

Question 32

carcinomas of the gallbladder can either..

Answer 32

infiltrate into the wall OR | be exophytic, growing as a fungating mass into the cavity of the GB

Question 33

adenocarcinoma of the gallbladder is generally expressed as what type, what is seen histologically?

Answer 33

intestine type - tubular glands are similar to those seen in colonic adenocarcinoma can be of goblet cell variation. goblet cells should only be seen in the intestine.

Question 34

pancreatitis commonalities for men and women are different - which are most likely in each population?

Answer 34

women are more likely to have GALLSTONE related pancreatitis more commonly than men men have alcohol-induced pancreatitis more commonly than women rates seem to be the same for both sexes

Question 35

what is a possible complication of pancreatitis?

Answer 35

abscess formation

Question 36

what is the etiology for acute pancreatitis?

Answer 36

etiology may be due to: - infection - ischemia - drug toxicity 80% of pancreatitis is caused by either alcohol use/abuse or gallstone disease

Question 37

what is the pathogenesis of pancreatitis?

Answer 37

acinar cells release enzymes resulting in proteolysis, lipolysis and hemorrhage of the pancreas proposed mechanisms of action include: - duct obstruction leading to secondary acing cell injury - direct acinar cell toxicity - deranged intracellular transport

Question 38

what is the general microscopic description of acute pancreatitis?

Answer 38

necrotic debris (fatty infiltration with ghost-like cell outlines), notable hemorrhage and dense neutrophilic infiltrate

Question 39

what is the single most etiology of acute pancreatitis?

Answer 39

gallstones

Question 40

what is the single most common etiology of chronic pancreatitis?

Answer 40

alcohol

Question 41

What is a common complication of pancreatitis, what is it and what can it progress to?

Answer 41

a common complication is a pseudocyst - a peri-pancreatic fluid collection containing high concentrations of pancreatic enzymes within a defined fibrous wall that LACKS AN EPITHELIAL LINING pancreatic abscesses usually develop in patients with pancreatic pseudocysts that become infected. Potential squelae of an abscess is it may rupture** others: - infected necrosis due to bacterial contamination

Question 42

what is a pancreatic abscess? what organisms are usually isolated in these?

Answer 42

a collection of pus resulting from tissue necrosis, liquefaction and infection enteric bacteria and candida

Question 43

what is a pancreatic pseudocyst? | what does it look like histologically?

Answer 43

it's an encapsulation of fluid collections within a fibrous capsule that has NO EPITHELIAL LINING histo - no epithelial lining, contains cholesterol clefts, blood (fresh and clotted) and hemosiderin laden macrophages

Question 44

what are pancreatic abscesses most commonly associated with?

Answer 44

pseudocysts that have become infected

Question 45

pancreatic abscesses are most likely to contain which organisms?

Answer 45

``` e. coli klebsiella pneumoniae enterococcus faecalis staphylococcus aureus pseudomonas aeruginosa proteus mirabilis streptococci ``` - enteric organisms as well as pathogenic

Question 46

what are the benign tumors of the exocrine pancreas?

Answer 46

solid pseudopapillary tumor serous cystadenoma mucinous cystadenoma

Question 47

malignant tumors of the exocrine pancreas consist of?

Answer 47

pancreatic adenoarcinoma | mucinous cystadenocarcinoma

Question 48

histologically - what do mucinous cystic neoplasms of the pancreas look like?

Answer 48

columnar, mucin-producing epithelium, supported by ovarian-type stoma.

Question 49

what is seen histologically for a solid pseudopapillary tumor?

Answer 49

sheets of cells which usually have uniform nuclei and eosinophilic or clear cytoplasm with PAS positive eosinophilic cytoplasmic inclusions nuclei ovoid w.indistinct nucleoli and few mitotic figures -the cystic areas between the tumor cells have been termed pseudo-papillae

Question 50

what are the most frequent cystic tumors of the pancreas, comprising 50% of them? what is hallmark of this tumor?

Answer 50

mucinous cystadenoma thick goblet cells are hallmark of mucinous cystadenoma

Question 51

what is the second most common cystic tumor of the pancreas? what is seen pathologically?

Answer 51

serous cystadenoma - honeycombed appearance on pathology histologically - small cysts lined by ciliated cuboidal epithelium (characteristic of serous cystadenoma)

Question 52

what condition is associated with serous cystadenoma?

Answer 52

Von Hippel-Lindau - genetic condition in which cysts often develop in the pancreas, liver and kidney - hemangioblastomas are found in different organs including the cerebellum, spinal cord, kindly and retina. Skin conditions also arise such as cafe au lait spots and port-wine stains

Question 53

what is the most common pancreatic cancer? | where does it arise from?

Answer 53

pancreatic adenocarcinoma or "ductal" - arises from within the exocrine component of the pancreas - either the ducts (99%) or acinar cells (1%) - a small minority come from islet cells and are classified as neuroendocrine tumors

Question 54

what is the fourth most common cause of death worldwide?

Answer 54

pancreatic cancer