3. Viral and Non-viral Liver Disease

Question 1

LO1: Acute Hepatitis (1-length of dz, and labs, 2-causes)

Answer 1

1) < 6mo of systemic dz and lab evidence of hepatocyte injury
2) causes- acute viral hepatitis and drug injury

Question 2

LO1: Chronic Hepatitis(1-duration, 2c-causes)

Answer 2

1) Long, ongoing hepatocyte injury and inflamm >6mo
2) Causes
a) Chronic viral hepatitis
b) autoimmune hepatitis
c) drug injury

Question 3

LO2: Histo Patterns of Liver Injury (4)

Answer 3

1) Cytoplasmice accumulations
2) Degeneration, necrosis, and apoptosis
3) Inflamm
4) Regeneration, fibrosis, and cirrhosis

Question 4

LO3: Hep A - Type, mode, risk of chronicity, path, and serology (5)

Answer 4

1) ssRNA
2) Fecal-oral
3) Never ->chronic
4) Serum IgM Ab
5) Acute hepatitis only

Question 5

LO3: Hep B - Type, mode, risk of chronicity, path, serology, relationship to genome, histo (7)

Answer 5

1) partially dsDNA
2) parenteral, sexual contact, perinatal
3) 10% -> chronic liver dz
4) HBsAG or HBcAb
5) Major cause of chronic liver dz worldwide
6) Can integrate into genome
Histo
7) Ground glass hepatocytes
8) Sanded nucleus

Question 6

LO3: Hep C - Type, mode, risk of chronicity, path, serology, genetics (6)

Answer 6

1) ssRNA
2) Parenteral; intranasal cocaine-risk factor
3) 80% -> chronic liver dz
4) PCR for HCV RNA, 3rd generation ELISA for Ab
5) Major cause of chronic liver dz in US
6) Genetically unstable

Question 7

LO3: Hep D - Type, mode, risk of chronicity, path, serology, HBV relationship (9)

Answer 7

1) ssRNA
2) parenteral
3) 5% alone; <70% w/ Hep B superinfxn
4) IgM and IgG Ab
5) HDV RNA serum
6) HDAg in liver
7) Potentiate and dependent HBV
8) Increased risk of fulminant hepatitis
9) Faster progression to end stage liver dz

Question 8

LO4: Grade of dz in chronic hepatitis

Answer 8

Based on amount of inflamm and injury

Question 9

LO4: Stage of dz in chronic hepatitis

Answer 9

Amount of fibrous tissue deposition

Question 10

LO5: HCC in chronic liver dz. Prognosis?

Answer 10

Dismal long term survival

Question 11

LO6: Primary Biliary Cirrhosis (1)

Answer 11

1) Immune mediated attack of intrahepatic small caliber bile ducts

Question 12

LO6: Primary Sclerosing cholangitis (1)

Answer 12

1) Immune mediated? obliterative fibrosis of intrahepatic and extrahepatic bile ducts

Question 13

LO7: Autoimmune Hepatitis, presentation (2-4) (4)

Answer 13

1) Immune-mediated attack directed at hepatocytes
  Presentation
2) F>M
3) Other autoimmune association
4) variable course

Question 14

LO8: Drug induced Liver Injury, how common, pattern of injury, intrinsic or extrinsic (4)

Answer 14

1) Relatively common
2) Patterns of injury-cholestasis, bile ducts, auto-immune, steatosis, acute or chronic hepatitis
3) Intrinsic -dose related
4) Idiosyncratic

Question 15

LO8: Acetaminophen Toxicity, stats, intrinsic or extrinsic, necrosis where? (3)

Answer 15

1) Major cause of acute liver failure -> liver transplant
2) Intrinsic hepatotoxin
3) Centrilobular necrosis -Zone 3

Question 16

LO9: Steatosis, causes (4)

Answer 16

1) Accumulation of fat in hepatocytes
2) metabolic derangement of hepatocytes
3) causes- metabolic syndrome, ETOH, drug effect, Wilson, viral
4) Lipid influx> lipid clearance

Question 17

LO10: Benign Liver Tumors (3)

Answer 17

1) Hemangioma
2) Focal Nodular Hyperplasia
3) Hepatocellular adenoma

Question 18

LO10: Malignant Liver Tumors (2)

Answer 18

1) Hepatocellular carcinoma

2) Cholangiocarcinoma

Question 19

Hepatitis Inflammation Associations, lymphs, neutrophils, eosinophils, plasma cells (4)

Answer 19

1) Lymphs - viral hepatitides
2) Neutrophils - steatohepatitis
3) Eosinophils - common in drug injury
4) Plasma Cells - Autoimmune hepatitis

Question 20

Cytoplasmic Accumulation Associations, fat, bile, iron, copper, viral particles (5)

Answer 20

1) Fat - steatosis
2) Bile - cholestasis
3) Iron - Hemosiderosis/ genetic hemochromatosis
4) Copper -Wilson Dz/chronic cholestasis
5) Viral particles -viral hepatitis

Question 21

LO1: Acute Hepatitis Micro, inflammation where? (4)

Answer 21

1) lobular disarray
2) marked inflamm throughout
3) widespread hepatocyte injury
4) No fibrosis

Question 22

LO1: Chronic Hepatitis Micro, Inflammation where? (3)

Answer 22

1) Less prominent inflamm and injury
2) Portal-tract based inflamm
3) fibrosis

Question 23

HCV Outcomes (4)

Answer 23

1) Resolution
2) Stable dz
3) Stable cirrhosis
4) Death

Question 24

HBV Outcomes (3)

Answer 24

1) Recovery
2) 0.5% fulminant hepatitis
3) 5% Chronic hepatitis -> Cirrhosis ->HCC

Question 25

LO3: Hep E, acute or chronic, mode, who’s at risk (3)

Answer 25

1) Acute hepatitis only
2) Fecal-oral
3) Higher mortality in pregnant women

Question 26

LO6: PSC Presentation (3)

Answer 26

1) M>F
2) Asymptomatic w/ persistent Alk phos elevation
3) Progressive fatigue, pruritis, and jaundice

Question 27

LO6: PSC Dx (1)

Answer 27

1) cholangiography -alternating biliary strictures and dilations (beads on a string)
2) No specific serology

Question 28

LO6: PSC Prognosis + Histo (4)

Answer 28

1) Variable
2) Increased risk for cholangiocarcinoma
Histo:
3) Periductal “onion-skin” fibrosis
4) Fibrous obliteration of bile ducts

Question 29

LO6: PBC Presentation (3)

Answer 29

1) Insidious onset w/ pruritis before jaundice
2) Middle aged women
3) Cholestatic LFT (elevated ALP, GGT, bilirubin)

Question 30

LO6: PBC Serology, prognosis, and histo (4)

Answer 30

1) Anti-mitochondrial Ab (90%)
2) Elevated IgM

Prognosis

3) 25% w/ liver failure @ 10 yrs
4) Ductopenia

Question 31

LO7: Autoimmune Hepatitis (1)

Answer 31

1) Anti-ANA, Anti-ASMA, Anti-LKMB, elevated IgG

Question 32

LO9: Steatohepatitis (3)

Answer 32

1) Hepatocellular injury w/ steatosis +/- overt inflamm
2) Causes-ETOH, metabolic syndrome, drug injury
3) Often chronic and can lead to fibrosis and cirrhosis

Question 33

LO9: Steatohepatitis Histo (4)

Answer 33

1) Ballooning degeneration
2) Inflamm
3) Steatosis
4) Pericentral, pericellular fibrosis

Question 34

LO9: Alcoholic Steatosis/steatohepatitis (2)

Answer 34

1) Neutrophil infiltrate

2) Mallory bodies - hyaline

Question 35

LO9: Non-alcoholic steatosis/steatohepatitis (1)

Answer 35

1) Fatty liver dz w/ obesity, DM2, Hypertriglyceridemia

Question 36

LO9: Hereditary Hemochromatosis (5)

Answer 36

1) Genetic iron overload throughout body
2) Manifests as liver dz, DM2, HF
3) AR inheritance
4) HFE gene mutation
5) Iron Deposits

Question 37

Wilson Dz (3)

Answer 37

1) Genetic Cu overload throughout body
2) Liver dz and neuropsych problems
3) ATP7B mutation - transporter involved in bile excretion of Cu

Question 38

LO9: Alpha-1-Antitrypsin Deficiency (5)

Answer 38

1) Genetic decreased production of alpha-1-antitrypsin
2) Alpha-1-antitrypsin -protease inhibitor
3) AR
4) PiZZ genotype- most have emphysema
5) PASD stain - pink globules

Question 39

HCC (2)

Answer 39

1) Most common malignant liver tumor

2) Mostly in chronic liver dz (HCV, HBV, ETOH) and cirrhosis

Question 40

Cholangiocarcinoma (2)

Answer 40

1) Malignant-effects the bile ducts - intra or extrahepatic

2) Major risk - PSC

Question 41

Hemangioma (4)

Answer 41

1) Benign - dilated vascular spaces
2) Most common primary hepatic tumor
3) small and asymptomatic
4) Vague RUQ pn, early satiety, n/v

Question 42

Focal Nodular Hyperplasia (3)

Answer 42

1) Benign mass-like proliferation of hepatocytes
2) Due to local vascular flow anomaly
3) 2nd most common benign

Question 43

Hepatocellular adenoma (4)

Answer 43

1) Benign -hepatocytes
2) Women of child bearing age-OC use
3) Asymptomatic or RUQ pn
4) Extremely low risk of malignant transformation