The Liver and Bililary Tract

Question 1

the average weight of a normal adult liver is between

Answer 1

1400-1600 grams

Question 2

capsule covers the surface of the liver

Answer 2

Glissons

Question 3

The liver has ______ lobes designated as______,_______,_______, and _______.

Answer 3

Right, left, quadrate, caudate

Question 4

two microscopic structural units of the liver are the _____and the_____.

Answer 4

Lobule and acinus

Question 5

Define and differentiate the sinusoids from the canaliculi.

https://histology.siu.edu/erg/liver.htm

Answer 5

Between the plates of hepatocytes are vascular sinusoids. Arterial and portal venous blood traverses the sinusoids and exits into the terminal hepatic vein through orifices in the vein wall. Between abutting hepatocytes are bile canaliculi, which are channels 1-2 micrometers in diameter, formed by grooves in the plasma membranes of the facing hepatocytes and delineated from the vascular space by tight junctions.

Question 6

The monocytic-phagocytic cells lining the sinusoids are known as

Answer 6

Kupffer cells

Question 7

The liver has a dual vascular supply coming from the _______ and the ______.

Answer 7

Portal vein and hepatic artery

Question 8

Disturbances of bilirubin metabolism cause ______and _______.

Answer 8

Jaundice and cholestasis

Question 9

Disturbances of bilirubin metabolism cause ______and _______.

Answer 9

Jaundice and cholestasis

Question 10

Define jaundice and cholestasis.

Answer 10

Jaundice – yellow discoloration of the skin and sclerae due to bile formation, disruption, and retention of pigmented bilirubin.
Cholestasis – systemic retention of not only bilirubin but also other solutes eliminated in bile.

Question 11

Describe the five pathophysiological mechanisms that produce jaundice and give examples of each.

Answer 11

acronym REDII
1. Reduced hepatic uptake – drug interference with membrane carrier system
2. Excessive production of bilirubin – hemolytic anemia
3. Deficiency of canalicular membrane transporters – Dubin-Johnson syndrome
4. Impaired conjugation – physiologic jaundice of the newborn
5. impaired bile flow – obstruction (intrahepatic or extrahepatic); manifestations relate to intestinal malabsorption including nutritional deficiencies of the fat soluble vitamins A, D, and K

Question 12

The alterations that cause liver failure fall into what three categories

Answer 12

ACH

1) Acute liver failure - massive hepatic necrosis
2) Chronic liver disease – cirrhosis
3) Hepatic dysfunction without overt necrosis – tetracycline toxicity

Question 13

Describe the pathophysiology of hepatic encephalopathy.

Answer 13

Hepatic encephalopathy is caused by abnormal neurotransmission in the central nervous and neuromuscular systems and appears to be associated with elevated blood ammonia levels, which impair neuronal function and promote generalized brain edema.

google:
Hepatic encephalopathy is deterioration of brain function that occurs in people with severe liver disease because toxic substances normally removed by the liver build up in the blood and reach the brain.

Question 14

discuss hepatorenal syndrome

Answer 14

Hepatorenal syndrome refers to the appearance of renal failure in patients with severe chronic liver disease, in which there are no intrinsic morphologic or functional causes for the renal failure.

google
portal hypertension=> splanchnic vasodilation (responsible for the hypoperfusion of the renal system which leads to the activation of the renin-angiotensin-aldosterone system ) => decreased effective circulatory volume => activation of renin-angiotensin-aldosterstone system=> renal sodium avididity (acsites) and renal vasoconstriction (hepatorenal syndrome)

Question 15

Discuss the similarities and differences between passive congestion and centrilobular hemorraggic necrosis of liver

Answer 15

Right sided cardiac decompensation leads to passive congestion of the liver. The liver is slightly enlarged, tense, and cyanotic with rounded edges. On microscopic examination, there is congestion of the centrilobular sinusoids. With time, centrilobular hepatocytes become atrophic, resulting in markedly attenuated liver cell plates. Left sided cardiac failure or shock may lead to hepatic hypoperfusion and hypoxia. In this instance, hepatocytes in the central region of the lobule undergo ischemic necrosis (centrilobular necrosis). The combination of hypoperfusion and retrograde congestion acts synergistically to generate centrilobular hemorrhagic necrosis.

note on picture that bottom is congestion/right sides heart failure and top is left sided heart failure/centrilobular necrosis

Question 16

Define and discuss Budd-Chiari syndrome and differentiate this from portal vein obstruction.

Answer 16

Budd-Chiari syndrome (hepatic vein thrombosis) - The obstruction of two or more major hepatic veins, characterized by hepatomegaly, weight gain, ascites, and abdominal pain.

Hepatic vein thrombosis is associated with polycythemia vera, inherited disorders of coagulation, Paroxysmal nocturnal hemoglobinuria, and intra-abdominal cancers.

google: think backflow vs occulsion
portal vein obstruction- Obstruction of this vein can be caused by a tumor or growth pressing on the vessel, or by a clot in the vessel

Question 17

most common cause of liver disease in the US is

Answer 17

nonalcoholic fatty liver disease

Question 18

which stains for fat and glycogen

Answer 18

FAT-sudan IV or Oil red O
glycogen-PAS
it also says “done on frozen”? dont know what that means

Question 19

Prolonged severe chronic passive congestion or centrilobular hemorrhagic necrosis of the liver associated with heart failure leads to ___________ also known as ________.

Answer 19

liver fibrosis
cardiac sclerosis

google:
Cardiac sclerosis or cardiac cirrhosis is the end-point of passive hepatic congestion from heart failure.

Question 20

What disease is characterized by inflammation and obliterative fibrosis of intrahepatic and extrahepatic bile ducts with dilation of preserved segments – “onion skin” fibrosis?

Answer 20

google:
Primary sclerosing cholangitis (answer) (PSC) is a chronic liver disease in which the bile ducts inside and outside the liver become inflamed and scarred, and eventually narrowed or blocked

Primary sclerosing (skluh-ROHS-ing) cholangitis (koh-lan-JIE-tis) is a disease of the bile ducts. Bile ducts carry the digestive liquid bile from your liver to your small intestine. In primary sclerosing cholangitis, inflammation causes scars within the bile ducts. These scars make the ducts hard and narrow and gradually cause serious liver damage. A majority of people with primary sclerosing cholangitis also have inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease.

Question 21

Define and differentiate predictable and unpredictable drug reactions and give examples of each.

Answer 21

Predictable drug reactions may occur in anyone who receives a sufficient dose of an agent - acetaminophen, tetracycline, antineoplastic agents.

Unpredictable reactions depend on idiosyncrasies ( a way of behaving or thinking that is characteristic of a person) of the host, particularly the host’s propensity to mount an immune response to the antigenic stimulus and the rate at which the host metabolizes the agent – chlorpromazine, halothane, methyldopa

Question 22

Define and differentiate neonatal hepatitis from extrahepatic biliary atresia.

Answer 22

Neonatal hepatitis – prolonged neonatal cholestasis with variable degrees of hepatic synthetic dysfunction such as hypoprothrombinemia.

Biliary atresia is defined as a complete obstruction or partial obstruction of the lumen of the extrahepatic biliary tree within the first three months of life. (Not in Robbins, p. 857)

Question 23

Define cholangitis and give some etiologies.

Answer 23

Cholangitis is the term used for bacterial infection of the bile ducts. Cholangitis can result from any lesion creating obstruction of bile flow, most commonly choledocholithiasis. Other causes- tumors, acute pancreatitis, fungi, viruses, or parasites.

Question 24

what are the 4 phases of acute symptomatic viral hepatitis with recovery

Answer 24

1) Incubation period
2) Symptomatic preicteric phase
3) Symptomatic icteric phase (the patient develop yellow discoloration of the eyes and urine (icteric phase).)
4) Convalescence (p. 836)

acronym ISS covalescence

google:
Acute viral hepatitis is diffuse liver inflammation caused by specific hepatotropic viruses that have diverse modes of transmission

Question 25

define chronic hepatits

Answer 25

Chronic hepatitis is defined as symptomatic, biochemical, or serologic evidence of continuing or relapsing hepatic disease for more than 6 months.

Question 26

Define cirrhosis and give the three characteristics features.

Answer 26

Cirrhosis – the liver is subdivided into nodules of regenerating hepatocytes surrounded by scar tissue.

Three characteristics:
Bridging fibrous septa
Parenchymal nodules
Disruption of the architecture of the entire liver (

Question 27

Discuss the pathophysiology of portal hypertension, including the three main causes, and the four main clinical consequences.

Answer 27

Increased resistance to portal blood flow may develop in a variety of circumstances, which can be divided into prehepatic, intrahepatic, and posthepatic causes.

Prehepatic – obstructive thrombosis and narrowing of the portal vein or massive splenomegaly

Intrahepatic – cirrhosis

Posthepatic – severe right sided heart failure, constrictive pericarditis, and hepatic vein outflow obstruction
Four major clinical consequences -
1) Ascites ( fluid collects in spaces within your abdomen. As fluid collects in the abdomen, it can affect your lungs, kidneys, and other organs.)

2) Formation of portosystemic venous shunts (google : rare vascular anomalies that occur secondary to abnormal development or involution of fetal vasculature)
3) Congestive splenomegaly
4) Hepatic encephalopathy (er doesn’t work properly, toxins build up in the blood. These toxins can travel to the brain and affect brain function)

Question 27

Discuss the pathophysiology of portal hypertension, including the three main causes, and the four main clinical consequences.

Answer 27

Increased resistance to portal blood flow may develop in a variety of circumstances, which can be divided into prehepatic, intrahepatic, and posthepatic causes.

Prehepatic – obstructive thrombosis and narrowing of the portal vein or massive splenomegaly

Intrahepatic – cirrhosis

Posthepatic – severe right sided heart failure, constrictive pericarditis, and hepatic vein outflow obstruction
Four major clinical consequences -
1) Ascites ( fluid collects in spaces within your abdomen. As fluid collects in the abdomen, it can affect your lungs, kidneys, and other organs.)

2) Formation of portosystemic venous shunts (google : rare vascular anomalies that occur secondary to abnormal development or involution of fetal vasculature)
3) Congestive splenomegaly
4) Hepatic encephalopathy (er doesn’t work properly, toxins build up in the blood. These toxins can travel to the brain and affect brain function)

Question 28

what are 3 distinctive forms of liver disease associated with chronic alcohol consumption?

Answer 28

1. hepatic steatosis
2. alcoholic hepatitis
3. cirrhosis

Question 29

Eosinophilic cytoplasmic inclusions dispersed about the nucleus in alcoholic cirrhosis are known as_

Answer 29

mallory bodies

google:
Mallory bodies (MB), also known as Mallory-Denk bodies (MDB), are cytoplasmic hyaline inclusions of hepatocytes, once thought to be specific for alcoholic hepatitis now occur in other liver diseases which include nonalcoholic steatohepatitis (NASH), cholestatic liver diseases, primary biliary cirrhosis (PBC

Question 30

What are the five proximate causes of death in the end-stage alcoholic?

Answer 30

1) hepatic coma
2) massive gastrointestinal hemorrhage
3) an intercurrent infection
4) hepatorenal syndrome
5) hepatocellular carcinoma

Question 31

Define Wilson disease

Answer 31

Wilson disease is an autosomal recessive disorder caused by the ATP TB gene resulting in impaired copper excretion in the bile and a failure to incorporate copper into ceruloplasmin. It is marked by the accumulation of toxic levels of copper in many tissue and organs, principally the liver, brain, and eye.

Question 32

hat is the name of the eye lesions found in patients with Wilson disease?

Answer 32

Kayser-Fleischer Rings

Question 33

Define and differentiate the two forms of biliary cirrhosis.

Answer 33

Primary biliary cirrhosis is an inflammatory autoimmune disease affecting the intrahepatic bile ducts.
Secondary biliary cirrhosis results from uncorrected obstruction of the extrahepatic biliary tree.

google:
Secondary biliary cirrhosis. This results from prolonged bile duct obstruction or narrowing or closure of the bile duct for other reasons, such as a tumor.

Question 34

discuss the pathophysiology of focal nodular hyperplasia

Answer 34

Focal nodular hyperplasia presents as a spontaneous mass lesion in a noncirrhotic liver, most frequently in young to middle-aged adults. The lesion appears to be due to heterogeneity in hepatic blood supply arising from focal obliteration of portal vein radicals and compensatory augmentation of arterial blood supply.

the f is this saying i dunno but eh cant get every concept

Question 35

What major protease inhibitor is frequently elevated in primary cancers of the liver?

Answer 35

Alpha-fetoprotein

google: protease prevents the virus from making copies of itself

Question 36

Most metastatic tumors of the liver generally arise from what primary organs?

Answer 36

breast, lung, colon, pancreas

Question 37

four histological layers of the GB

Answer 37

1) Mucosal lining with a single layer of columnar cells
2) Fibromuscular layer
3) Layer of serosal fat with arteries, veins, lymphatics, nerves, and paraganglia 4) Peritoneal covering (Not in Robbins)

Question 38

The spiral valves in the neck of the gallbladder are known as the

Answer 38

spiral valves of heister

google: mucosal folds located on the endoluminal surface of the cystic duct

Question 39

outpuchings of the mucosal epithelium with a diagnosis of chronic cholecystitis

Answer 39

Rokitansky-Aschoff sinuses

google:
The term Rokitansky-Aschoff sinuses, or Luschka’s crypts of the gall bladder, is applied to deep outpouchings of mucosa extending into or through the muscular coat and into the perimuscular layers, leading to separation of the interstices and delicate walls of the muscle bundles.

Question 40

folding of the fundus of the gallbladder

Answer 40

answer: Phrygian cap
google: Phrygian cap is a congenital anomaly of the gallbladder

Question 41

two main types of gallstones are __ and __ with __ being the most common

Answer 41

Cholesterol stones and pigment stones
Cholesterol stones

google: pigment stone are made of bilirubin

Question 42

The four major factors associated with the formation of gallstones are__

Answer 42

Age and sex, environmental factors, acquired disorders, hereditary factors

Question 43

Cholesterol gallstone formation involves a tetralogy of simultaneous defects which are

Answer 43

1. Bile must be supersaturated with cholesterol
2. Gallbladder hypomotility promotes nucleation
3. Cholesterol nucleation in bile is accelerated
4. Mucus hypersecretion in the gallbladder traps the crystals, permitting their aggregation into stones. (p. 876)

Question 44

Briefly describe the morphologic types of carcinomas of the gallbladder.

Answer 44

The infiltrating pattern is more common and usually appears as a poorly defined area of diffuse thickening and induration of the gallbladder wall that may cover several square centimeters or may involve the entire gallbladder.

Deep ulceration may cause direct penetration of the gallbladder wall or fistula formation to adjacent viscera into which the neoplasm has grown. These tumors are scirrhous (scirrhous reaction resulting in a small fibrosed and contracted gallbladder) and have a firm consistency. The exophytic pattern grows into the lumen as an irregular, cauliflower mass but at the same time invades the underlying wall. The luminal portion may be necrotic, hemorrhagic and ulcerated. Most common sites are the fundus and the neck.

google:
Incidental gallbladder cancer in routine cholecystectomy specimens can be grossly subtle, with areas of mucosal granularity / irregularity, minimally raised / polypoid mucosal lesions or focally thickened fundus / body (Am J Surg Pathol 2019;43:1668)
Frank tumors may have one or more of the following features:
Thickened and indurated gallbladder wall
Exophytic or polypoid friable mucosal lesions (especially those arising from intracholecystic papillary neoplasm)
Firm, gritty, tan-white to yellow-gray cut surface

Question 45

hydrops of the gallbladder

Answer 45

Progressive mucosal removal of luminal lipids in obstructed, inflamed gallbladders may have clear mucinous secretions.

google:Gallbladder hydrops or mucocele 5 refers to marked dilatation of the gallbladder due to chronic obstruction of the cystic duct resulting in accumulation of sterile non-pigmented mucin.

Question 46

Describe the appearance of a gallbladder with cholesterolosis.

Answer 46

The mucosal surface is studded by yellow flecks; also known as strawberry gallbladder.

Question 47

Describe the pathophysiology of cholesterolosis.

Answer 47

Cholesterol normally entering the gallbladder mucosa by free exchange with the lumen may be esterified by acyl CoA, cholesterol acyltransferase. Cholesterol hypersecretion by the liver promotes excessive accumulation of cholesterol esters within the lamina propria of the gallbladder.

Question 48

Define Courvoisier’s Law.

Answer 48

Courvoisier’s law states that, in the presence of jaundice, an enlarged gallbladder is unlikely to be due to gallstones; rather carcinoma of the pancreas or the lower biliary tree is more likely

Question 49

cholelithiasis vs choledocholithiasis

Answer 49

Cholelithiasis involves the presence of gallstones (see the image below), which are concretions that form in the biliary tract, usually in the gallbladder. Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct