128. Circulatory disorders and tumors of the liver & gall bladder

Question 1

Impaired blood flow into the liver

Answer 1

• hepatic artery obstruction
  - cause: embolism, neoplasia, inflammation (ex:
  polyarteritis nodosa)
• portal vein obstruction
  • extrahepatic portal vein, feature: portal HTN, cause:
    thrombosis, hypercoagulable state, inflammation,
    trauma
  • intrahepatic portal vein, feature: infract of zahn,
    cause: schistosomiasis; acute thrombosis

Question 2

Impaired blood flow through the liver

Answer 2

features: necrosis of hepatocytes
cause: cirrhosis, DIC, intrasinusoidal metastasis and eclampsia

Question 3

hepatic venous outflow obstruction

Answer 3

sinusoidal obstruction syndrome: obstruction of small intrahepatic veins due to thrombosis
- cause: 3 weeks after HSC transplantation,
chemotherapy
- patho: damage to sinusoidal cell –> inflammation –>
congestion

Budd-Chiari syndrome: obstruction of more than 1 hepatic vein –> hepatosplenomegaly, pain, ascites

• cause: thrombosis or hepatocellular carcinoma
• morph: centrilobular congestion and necrosis

Question 4

Nutmeg liver

Answer 4

centrilobular hemorrhagic necrosis

• right heart failure –> centrilobular congestion (due to retrograde congestion)
• left heart failure –> centrilobular necrosis (due to hypoperfusion and hypoxia)

Question 5

Benign tumors of liver

Answer 5

focal nodular hyperplasia
-hypoperfused parenchyma collapses to produce septa while
hyperperfused regions undergo hyperplasia

cavernous hemangioma

• benign blood vessel neoplasm
• most common benign liver tumor

hepatocellular adenomas

• benign tumor
• arise from: hepatocytes
• cause: hella sex hormones (oral contraceptives)
• malignant potential: depending on molecular classification
• complications: rupture and bleeding

Question 6

Malignant carcinomas of liver

Answer 6

Hepatocellular carcinoma
- most common primary malignant tumor in the liver
- risk group: male
- pathogenesis: synergic effect when the following factors are combined
- chronic liver disease is the most common setting for emergence of HCC
- viral infection: HBV and HCV
- toxic injury: alfatoxins and alcohol
- hereditary liver disease (hemochromatosis, alpha-1 AT deficiency, Wilson disease)
- NAFLD
- genetic mutation: HCC is induced by acquiring driver mutations
- driver mutations: Beta-catenin (gain of function due to genomic instability) and p-53 (loss of function,
associated with aflatoxin effect)
- premalignant lesions can give rise to HCC
- hepatic adenoma (carries beta-catenin activating mutations)
- dysplastic nodules ( are found in any stage of chronic liver disease)
- the high grade dysplastic nodules are found to lead to HCC
- metastasis to the lungs
- diagnosis:imaging, serology (alpha-fetoprotein
- clinical features: same as cirrhosis
- complications: cachexia, GI or esophageal varices, liver failure, tumor rupture and bleeding

Cholangiocarcinoma

• second most common
• arise: intra/extrahepatic bile duct epithel (cholangiocytes)
• pathogenesis: chronic inflammation and cholestasis
  - liver fluke:
  - primary sclerosing cholangitis (associated with ulcerative colitis)
  - HBV and HCV
  - NAFLD
• morph: mucin secreting adenocarcinoma and desmoplastic reaction is dominant

Question 7

Gall bladder carcinoma

Answer 7

most common malignant tumor of the extrahepatic biliary tract
older women are in the risk group
risk factors: chronic inflammation with gallstones (cholecystitis); primary sclerosing cholangitis