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clinical pathology > CP11-2&4 Hepatobiliary System and pancreas > Flashcards

CP11-2&4 Hepatobiliary System and pancreas Flashcards

1
Q

What cells make up the normal parenchyma of the liver?

A

Hepatocytes

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2
Q

what are the portal tracts?

A

Bile ducts
Blood vessels
Fibroblasts
Inflammatory cells

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3
Q

Where do primary tumours of the liver usually arise from?

A

Hepatocytes or bile ducts mostly but can affect other cells

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4
Q

What are adenomas of the liver cells?

A

A benign proliferation of the liver cells. May be multiple tumours.

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5
Q

What is the name for multiple adenomas?

A

Adenomatosis

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6
Q

What causes adenomas in liver cells?

A

Often exogenous steroids e.g. oral contraceptive pill and anabolic steroids

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7
Q

What is a complication of liver adenomas?

A

Can rupture causing haemoperitomeum - a surgical emergency

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8
Q

What are the two types of adenomas of the bile ducts?

A

Bile duct adenoma
Von meyenberg complex

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9
Q

What is the pathogenesis of adenomas in the bile ducts?

A

Benign proliferation of bile duct cells

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10
Q

How can you detect if a tumour in the bile duct is benign or malignant?

A

By doing a frozen section to look at microscopically

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11
Q

How do bile duct adenomas appear histologically?

A

With tiny white nodules

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12
Q

What are the two types of tumours of portal vessels?

A

Haemangioma
Focal nodular hyperplasia

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13
Q

What is a haemangioma?

A

A tumour affecting 1% of the population which is often incidentally found in liver imaging

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14
Q

What is a focal nodular hyperplasia?

A
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15
Q

What are hepatocellular carcinomas?

A

A malignant tumour of the liver arising from cirrhosis

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16
Q

What causes hepatocellular carcinomas?

A

Hep C and hep B (mainly in East)
Cirrhosis as a result of fatty liver disease or alcohol (mainly in west)

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17
Q

What are characteristics of a hepatocellular carcinoma?

A
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18
Q

What is a Cholangiocarcinoma?

A

A malignant tumour of bile duct cells which can be a result of chronic inflammation

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19
Q

What causes chronic inflammation leading to cholangiocarcinoma?

A

P.S.C
Liver fluke aka clonorchis sine sis)

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20
Q

What are the two subtypes of cholangiocarcinoma?

A

Central/hilar
Peripheral

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21
Q

What is the prognosis of cholangiocarcinoma?

A

Poor as aggressive and difficult to resect - especially if at hilum of the liver

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22
Q

What is an angiosarcoma?

A

An aggressive malignant tumour of blood vessels

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23
Q

What are angiosarcomas associated with?

A

Toxins e.g. vinyl chloride (records) and thorotrast (contrast agent)

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24
Q

Are a majority of liver tumours primary or secondary?

A

Secondary

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25
Q

What are the commonest sites of origin for secondary tumours in the liver?

A

Lung
Breast
Colon
Pancreas

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26
Q

What is characteristic of secondary liver tumours?

A

Multiple whitish nodes that can be cystic or pitted and replace large volumes of liver before compromising function.

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27
Q

How can metastatic carcinomas of the liver be treated?

A

With surgery using clips to prevent haemorrhage and intra-operative ultrasound to guide resection.

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28
Q

What causes gall stones?

A

Cholesterol, bile salts, bacterial growth + calcification which slowly form a calculus.

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29
Q

What are risk factors for galls stones?

A

Female
Middle aged
Overweight

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30
Q

What percentage of gall stones are asymptomatic?

A

80%

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31
Q

How do symptomatic patients present with gall stones?

A

Biliary colic which patients will describe as a cramps pain - usually after eating

32
Q

What are complications of gallstones?

A

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

33
Q

What is chronic cholecystitis?

A

Chronic inflammation of the gallbladder usually due to chemicals or bacteria

34
Q

How does chronic cholecystitis progress?

A

Inflammation —> fibrosis —> ulceration of gall bladder

35
Q

What are symptoms of chronic cholecystitis?

A

Pain in right upper quadrant
Fever
Jandice

36
Q

How is chronic cholecystitis diagnosed?

A

Via ultrasounds as only 25% visible on x ray

37
Q

How is chronic cholecystitis treated?

A

With cholecystectomy

38
Q

What are some functions of the liver?

A

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)

39
Q

What is jaundice?

A

A sign of liver disease where the skin and sclera appears yellow due to build up of bilirubin.

40
Q

At what level of bilirubin will jaundice occur?

A

> 40 umol/l

41
Q

What causes jaundice?

A

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.

42
Q

Where is bilirubin produced?

A

In the spleen during breakdown of red blood cells

43
Q

In pre-hepatic, hepatic and post hepatic jaundice, is bilirubin conjugated or unconjugated?

A

Pre-hepatic = unconjugated
Hepatic = mainly conjugated
Post hepatic = conjugated

44
Q

What is meant by unconjugated and conjugated bilirubin?

A

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.

45
Q

What is tested for in liver function tests?

A

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

46
Q

What investigations are done if a patient has jaundice?

A

Blood tests - LFTs
Ultrasound to look for dilated ducts or obstruction
Liver biopsy if no dilated ducts seen on ultrasound

47
Q

What is the most common cause of non-obstructive cases of jaundice?

A

Acute hepatitis

48
Q

What are histopathological features of obstructive jaundice?

A

Bile in liver parenchyma
Over time, increasing…
… portal tract expansion
… oedema
…ductular reaction
… accumulation of bile salts and copper

49
Q

What symptoms will patients with accumulation of bile salts present with?

A

Itching

50
Q

What is the wide spectrum of clinical presentation with acute hepatitis?

A

Asymptomatic
Malaise
Jaundice
Coagulopathy
Encephalopathy
Death

51
Q

What causes hepatocyte damage?

A

Toxic/metabolic injury e.g. alcohol, drugs (especially paracetamol)
Inflammatory injury e.g. due to hepatitis
Viruses
Autoimmunity
Idiopathic

52
Q

How does the liver look histologically in acute hepatitis?

A

Lobular disarray
Spotty necrosis

53
Q

What is it called when all hepatocytes have died?

A

Confluence panacinar necrosis

54
Q

What causes chronic hepatitis ?

A

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

55
Q

How does chronic liver disease progress?

A

Fibrosis starts to form around the portal tracts —> production of bridges between areas of fibrosis —> formation of nodules known as cirrhosis

56
Q

What is viral hepatitis?

A
57
Q

How does alcohol affect the liver?

A

Fatty change in liver aka steatosis —> inflammation in liver aka alcoholic steatohepatitis —> cirrhosis

58
Q

How does steatoheoatitis look histologically?

A

Hepatocytes become ballooned with Mallory bodies, there are fatty changes and presence of inflammatory cells. Fibrosis in portal tract and pericellular fibrosis around hepatocytes.

59
Q

What are risk factors for non-alcoholic fatty liver disease?

A
60
Q

How does non-alcoholic fatty liver disease appear histologically?

A
61
Q

How is drug induced liver injury classified?

A

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

62
Q

How can drugs causes acute liver failure, e.g. paracetamol?

A
63
Q

What are symptoms of acute liver failure due to paracetamol?

A

nausea, vomiting, sweating within 24 hours and later jaundice due to associated liver dysfunction

64
Q

What are complications of acute liver failure due to paracetamol?

A
65
Q

What is seen histologically with acute liver injury due to paracetamol?

A

Intrinsic hepatotoxicity with uniform zonal necrosis. Hepatocytes furthest from portal tracts produce the toxic metabolite and are first to undergo necrosis.

66
Q

What is inherited haemochromatosis?

A
67
Q

What is Wilson’s disease?

A

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.

68
Q

What is inherited alpha 1 antitrypsin deficiency?

A
69
Q

What are examples of autoimmune liver diseases?

A

Autoimmune hepatitis
Primary biliary cholangitis
Primary sclerosing cholangitis

70
Q

What is cirrhosis?

A

End stage liver disease where

71
Q

What causes cirrhosis?

A
72
Q

How does cirrhosis appear microscopically?

A
73
Q

What are complications of liver cirrhosis?

A
  • 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
74
Q

What is hepatic failure?

A

Liver failure

75
Q

How do patients with chronic hepatic failure present?

A

Ascites
Muscle wasting
Bruising
Gynaecomastia
Spider naevi
Varies - caput medusae

76
Q

What are some structural changes of the liver in chronic liver failure?

A

clinical pathology (65 decks)

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