CP11-2&4 Hepatobiliary System and pancreas Flashcards
What cells make up the normal parenchyma of the liver?
Hepatocytes
what are the portal tracts?
Bile ducts
Blood vessels
Fibroblasts
Inflammatory cells
Where do primary tumours of the liver usually arise from?
Hepatocytes or bile ducts mostly but can affect other cells
What are adenomas of the liver cells?
A benign proliferation of the liver cells. May be multiple tumours.
What is the name for multiple adenomas?
Adenomatosis
What causes adenomas in liver cells?
Often exogenous steroids e.g. oral contraceptive pill and anabolic steroids
What is a complication of liver adenomas?
Can rupture causing haemoperitomeum - a surgical emergency
What are the two types of adenomas of the bile ducts?
Bile duct adenoma
Von meyenberg complex
What is the pathogenesis of adenomas in the bile ducts?
Benign proliferation of bile duct cells
How can you detect if a tumour in the bile duct is benign or malignant?
By doing a frozen section to look at microscopically
How do bile duct adenomas appear histologically?
With tiny white nodules
What are the two types of tumours of portal vessels?
Haemangioma
Focal nodular hyperplasia
What is a haemangioma?
A tumour affecting 1% of the population which is often incidentally found in liver imaging
What is a focal nodular hyperplasia?
What are hepatocellular carcinomas?
A malignant tumour of the liver arising from cirrhosis
What causes hepatocellular carcinomas?
Hep C and hep B (mainly in East)
Cirrhosis as a result of fatty liver disease or alcohol (mainly in west)
What are characteristics of a hepatocellular carcinoma?
What is a Cholangiocarcinoma?
A malignant tumour of bile duct cells which can be a result of chronic inflammation
What causes chronic inflammation leading to cholangiocarcinoma?
P.S.C
Liver fluke aka clonorchis sine sis)
What are the two subtypes of cholangiocarcinoma?
Central/hilar
Peripheral
What is the prognosis of cholangiocarcinoma?
Poor as aggressive and difficult to resect - especially if at hilum of the liver
What is an angiosarcoma?
An aggressive malignant tumour of blood vessels
What are angiosarcomas associated with?
Toxins e.g. vinyl chloride (records) and thorotrast (contrast agent)
Are a majority of liver tumours primary or secondary?
Secondary
What are the commonest sites of origin for secondary tumours in the liver?
Lung
Breast
Colon
Pancreas
What is characteristic of secondary liver tumours?
Multiple whitish nodes that can be cystic or pitted and replace large volumes of liver before compromising function.
How can metastatic carcinomas of the liver be treated?
With surgery using clips to prevent haemorrhage and intra-operative ultrasound to guide resection.
What causes gall stones?
Cholesterol, bile salts, bacterial growth + calcification which slowly form a calculus.
What are risk factors for galls stones?
Female
Middle aged
Overweight
What percentage of gall stones are asymptomatic?
80%
How do symptomatic patients present with gall stones?
Biliary colic which patients will describe as a cramps pain - usually after eating
What are complications of gallstones?
Obstruction at neck of gallbladder or in common bile duct leading to jaundice
Chronic cholecystitis
Perforation of gallbladder
Obstruction of bile duct at pancreatic level causing pancreatitis.
Adenocarcinoma
What is chronic cholecystitis?
Chronic inflammation of the gallbladder usually due to chemicals or bacteria
How does chronic cholecystitis progress?
Inflammation —> fibrosis —> ulceration of gall bladder
What are symptoms of chronic cholecystitis?
Pain in right upper quadrant
Fever
Jandice
How is chronic cholecystitis diagnosed?
Via ultrasounds as only 25% visible on x ray
How is chronic cholecystitis treated?
With cholecystectomy
What are some functions of the liver?
Produced bile
Produced routines for clotting
Cholesterol production and fat metabolism
Stores glycogen
Conversion of ammonia to urea
Drug metabolism
Drug/toxin metabolism
Clearance of bilirubin (from haemoglobin)
What is jaundice?
A sign of liver disease where the skin and sclera appears yellow due to build up of bilirubin.
At what level of bilirubin will jaundice occur?
> 40 umol/l
What causes jaundice?
Pre-hepatic causes where too much bilirubin is produced e.g. haemolytic anemia and Gilbert’s syndrome
Hepatic causes when there are too few functioning hepatocytes e.g. due to acute diffuse liver cell injury, end stage chronic liver disease and inborn errors of metabolism
Post hepatic causes where bile duct is obstructed e.g. by a stone, stricture or tumour.
Where is bilirubin produced?
In the spleen during breakdown of red blood cells
In pre-hepatic, hepatic and post hepatic jaundice, is bilirubin conjugated or unconjugated?
Pre-hepatic = unconjugated
Hepatic = mainly conjugated
Post hepatic = conjugated
What is meant by unconjugated and conjugated bilirubin?
Unconjugated bilirubin = bound to albumin thus insoluble so not excreted - presents as yellow eyes and skin only
Conjugated bilirubin = not bound to albumin so is water soluble and can be excreted - present with yellow eyes, skin and dark urine. When fully conjugated also get pale stool as bilirubin can’t enter the gut.
What is tested for in liver function tests?
Bilirubin
Albumin
Clotting factors
Liver enzymes that leak form the hepatocytes e.g. ALT and AST, and that leak from the bile ducts e.g. Alkaline phosphatase
What investigations are done if a patient has jaundice?
Blood tests - LFTs
Ultrasound to look for dilated ducts or obstruction
Liver biopsy if no dilated ducts seen on ultrasound
What is the most common cause of non-obstructive cases of jaundice?
Acute hepatitis
What are histopathological features of obstructive jaundice?
Bile in liver parenchyma
Over time, increasing…
… portal tract expansion
… oedema
…ductular reaction
… accumulation of bile salts and copper
What symptoms will patients with accumulation of bile salts present with?
Itching
What is the wide spectrum of clinical presentation with acute hepatitis?
Asymptomatic
Malaise
Jaundice
Coagulopathy
Encephalopathy
Death
What causes hepatocyte damage?
Toxic/metabolic injury e.g. alcohol, drugs (especially paracetamol)
Inflammatory injury e.g. due to hepatitis
Viruses
Autoimmunity
Idiopathic
How does the liver look histologically in acute hepatitis?
Lobular disarray
Spotty necrosis
What is it called when all hepatocytes have died?
Confluence panacinar necrosis
What causes chronic hepatitis ?
immunological injury e.g. viral, autoimmune or drug induced
toxic/metabolic injury e.g. due to fatty liver disease
genetic inborn errors
biliary disease e.g. due to duct obstruction, autoimmunity or drugs
vascular disease e.g. clotting disorders
How does chronic liver disease progress?
Fibrosis starts to form around the portal tracts —> production of bridges between areas of fibrosis —> formation of nodules known as cirrhosis
What is viral hepatitis?
How does alcohol affect the liver?
Fatty change in liver aka steatosis —> inflammation in liver aka alcoholic steatohepatitis —> cirrhosis
How does steatoheoatitis look histologically?
Hepatocytes become ballooned with Mallory bodies, there are fatty changes and presence of inflammatory cells. Fibrosis in portal tract and pericellular fibrosis around hepatocytes.
What are risk factors for non-alcoholic fatty liver disease?
How does non-alcoholic fatty liver disease appear histologically?
How is drug induced liver injury classified?
Intrinsic - will happen every time so is predictable
Idiosyncratic- rare and unpredictable and usually occurs due to a metabolic or immunological reaction to the drug
How can drugs causes acute liver failure, e.g. paracetamol?
What are symptoms of acute liver failure due to paracetamol?
nausea, vomiting, sweating within 24 hours and later jaundice due to associated liver dysfunction
What are complications of acute liver failure due to paracetamol?
What is seen histologically with acute liver injury due to paracetamol?
Intrinsic hepatotoxicity with uniform zonal necrosis. Hepatocytes furthest from portal tracts produce the toxic metabolite and are first to undergo necrosis.
What is inherited haemochromatosis?
What is Wilson’s disease?
Inborn error of copper metabolism causing accumulation in the liver (causing cirrhosis), eyes (causing Kayseri-fleishcer rings) and the brain (leading to ataxia).
It is treated with chelate copper, and penicillamine to enhance excretion.
What is inherited alpha 1 antitrypsin deficiency?
What are examples of autoimmune liver diseases?
Autoimmune hepatitis
Primary biliary cholangitis
Primary sclerosing cholangitis
What is cirrhosis?
End stage liver disease where
What causes cirrhosis?
How does cirrhosis appear microscopically?
What are complications of liver cirrhosis?
- portal hypertension due to structural changes causing oesophageal varices/hemorrhoids/caput medusa
- liver cell failure causing oedema, bruising, muscle wasting, encephalopathy, hormone fluid retention and jaundice
- increased vulnerability to infection
What is hepatic failure?
Liver failure
How do patients with chronic hepatic failure present?
Ascites
Muscle wasting
Bruising
Gynaecomastia
Spider naevi
Varies - caput medusae
What are some structural changes of the liver in chronic liver failure?
