GI - Hepatic Disease Flashcards
How much does the average healthy liver weigh?
1.5 Kg
70% of hepatic blood flow comes from what vessel?
(I.e. the hepatic artery or portal vein?)
The portal vein
How many liver segments are there?
8
True/False.
Each hepatic segment has its own vascular and biliary pedicle and venous drainage.
True.
For small tumors of the liver, one would do a ______________ resection.
For small tumors of the liver, one would do a subsegmental (wedge) resection.
For large tumors of the liver, one would do a ______________.
For large tumors of the liver, one would do a segmentectomy.
Zone ____ of the liver surrounds the portal tract (closest to vascular supply).
Zone ____ is the intermediate section.
Zone ____ is nearest the terminal hepatic venule.
Zone 1 of the liver surrounds the portal tract (closest to vascular supply).
Zone 2 is the intermediate section.
Zone 3 is nearest the terminal hepatic venule.
Zone 1 of the hepatic lobules is known as the ________ zone.
Zone 2 of the hepatic lobules is known as the ________ zone.
Zone 3 of the hepatic lobules is known as the ________ zone.
Zone 1 of the hepatic lobules is known as the periportal zone.
Zone 2 of the hepatic lobules is known as the mid-zonal zone.
Zone 3 of the hepatic lobules is known as the centrilobular zone.
Which zone of the hepatic lobule is most at-risk for ischemic necrosis?
Zone 3
Hepatic lymph is created where?
The space of Disse
What are the main stages of chronic liver injury?
Fibrosis –>
Cirrhosis –>
Failure
Name a few causes of central/lobular hepatic fibrosis.
Alcohol;
NASH (non-alcoholic steatohepatitis);
ischemia: venous outflow obstruction, Budd-Chiari syndrome (blocked hepatic veins), CHF, veno-occlusive disease (sinusoidal obstruction syndrome)
Name a few causes of hepatic portal fibrosis.
Biliary and chronic hepatitis
What is the size that distinguishes a micronodular vs. a macronodular cirrhotic liver?
3 mm
(> is macro; < is micro)
Alcoholic hepatitis is typically ______nodular.
Alcoholic hepatitis is typically micronodular.
What is compensated cirrhosis?
A cirrhotic liver with preserved function
What is decompensated cirrhosis?
A cirrhotic liver with complications (e.g. portal hypertension, ascites, DIC, hepatic encephalopathy, etc.)
Which is more common, acute or chronic cirrhosis?
Chronic
Most biliary tree injury leading to hepatitis arises from what etiologies?
Congenital;
obstructive;
autoimmune
What length of time is typically used to differentiate acute from chronic liver disease?
6 months
What hepatic change is here described?
Eosinophilia, cell swelling / rupture, potential blebbing
Hepatic necrosis
How do hepatocyte acidophilic bodies appear?
Councilman bodies, apoptotic hepatocytes, very eosinophilic
What hepatic change is here described?
Cells become large w/ pale cytoplasm
Ballooning degeneration
What hepatic change is here described?
Cytoplasmic inclusions of intermediate filaments (not specific for liver disease)
Mallory’s hyaline
Fatty liver disease of pregnancy, tetracycline toxicity, and Reye’s syndrome are all associated with ____________ hepatic steatosis.
Fatty liver disease of pregnancy, tetracycline toxicity, and Reye’s syndrome are all associated with microvesicular hepatic steatosis.
Alcoholic and non-alcoholic liver disease are both associated with ____________ hepatic steatosis.
Alcoholic and non-alcoholic liver disease are both associated with macrovesicular hepatic steatosis.
Which is the most common benign hepatic tumor?
(Note: it is typically an asymptomatic, incidental finding characterized by blood-filled vascular channels; it may be surgically resected if causing hemorrhage.)
Cavernous hemangioma
Which is the second most common benign hepatic tumor?
Focal nodular hyperplasia
Zone ______ – where blood flow enters the liver lobule (six portal triads at hexagonal points).
Zone ______ – where blood flow exits the liver lobule (via a single central hepatic vein).
Zone 1 – where blood flow enters the liver lobule (six portal triads at hexagonal points).
Zone 3 – where blood flow exits the liver lobule (via a single central hepatic vein).
What is cirrhosis?
Diffuse fibrosis
What is hepatic steatosis?
Fatty liver change
_______ hepatitis is characterized by no fibrosis.
Acute hepatitis is characterized by no fibrosis.
Acute hepatitis (no fibrosis) is characterized by spotty injury focused in the liver _________ (_________).
Acute hepatitis (no fibrosis) is characterized by spotty injury focused in the liver lobules (parenchyma).
Hepatitis A is associated with which type of hepatitis (acute or chronic)?
Acute
Are drug reactions, toxins, and vascular insults associated with acute or chronic hepatitis?
Either!
Name a few etiologies associated most with chronic hepatitis and not acute.
Hepatitis B and C;
metabolic or developmental defects;
autoimmune reactions
What are the primary hepatocellular markers?
AST and ALT
What are the primary bile duct and canalicular markers?
Gamma-glutamyltransferase and ALP
Mallory hyaline bodies are deposits of _____________.
Mallory hyaline bodies are deposits of intermediate filaments (e.g. keratin).
Mallory hyaline bodies are deposits of intermediate filaments (e.g. keratin) most associated with liver disease of what etiology?
Alcoholic-related
In approaching liver histology, what respective stains can be used in marking each of the following?
Iron
Copper
Fat
Prussian blue (iron)
Rhodanine (copper)
Oil red O (fat)
Describe the difference between macro- and micro-vesicular hepatosteatosis.
Acute hepatitis is more likely to be characterized by __________ inflammation.
Chronic hepatitis is more likely to be characterized by __________ inflammation.
Acute hepatitis is more likely to be characterized by central/lobular inflammation.
Chronic hepatitis is more likely to be characterized by portal inflammation.
Portal fibrosis is most associated with what etiologies?
Biliary fibrosis;
chronic hepatitis
Central/lobular fibrosis is most associated with what etiologies?
Alcohol / NASH / ischemia / venous outflow obstruction
Transplantation is not needed for cirrhotic livers unless what?
Unless severe complications are present
(e.g. ascites, variceal hemorrhage, coagulopathy, hepatic failure, etc.)
What is the gold standard for diagnosis of non-alcoholic fatty liver disease (non-alcoholic steatohepatitis)?
Liver biopsy
Non-alcoholic fatty liver disease (non-alcoholic steatohepatitis) is typically ________-related with a negative history of _________ use.
Non-alcoholic fatty liver disease (non-alcoholic steatohepatitis) is typically obesity-related with a negative history of alcohol use.
Cirrhosis results from chronic hepatitis (> ___ months).
Cirrhosis results from chronic hepatitis (> 6 months).
What is stage 0 of chronic hepatitis?
1?
2?
3?
4?
No fibrosis
Periportal fibrosis
Septal fibrosis
Bridging fibrosis
Cirrhosis
What is the ‘grade’ of cirrhosis?
Level of inflammatory activity
What is the ‘stage’ of cirrhosis?
The level of fibrosis
Cirrhotic nodules are chunks bordered by ___________ connecting central veins.
Cirrhotic nodules are chunks bordered by fibrous tissue connecting central veins
What veins join to become the portal vein?
IMV, SMV, splenic vein, coronary v.
Where does the fluid in ascites come from?
Fluid ‘sweating’ off of Gleason’s capsule
Hepatic lymph is produced in what space?
The space of Disse (as fluid leaves the sinusoids)
What is the proximal cause of hepatorenal syndrome?
Portal hypertension and resultant splanchnic vessel dilatation
(resulting in hypotension + excessive angiotensin-renin activation + renal failure)
How do portal hypertension and the resultant splanchnic vessel dilatation cause hepatorenal syndrome?
The resulting hypotension leads to:
excessive angiotensin-renin activation + renal failure
Ammonia from the gut is converted to __________ in the liver.
Ammonia from the gut is converted to glutamate in the liver.
Hepatic encephalopathy is due to a build-up of ___________.
Hepatic encephalopathy is due to a build-up of ammonia.
What two tissues are most affected by hyperammonemia?
(1) Brain (swelling / astrocyte damage);
(2) muscles most affected
Name three of the effects of hyperestronism as a result of chronic cirrhosis (one of which is unique to males).
Spider angiomata;
palmar erythema;
gynecomastia
Is alcoholic hepatitis associated with micro- or macronodular cirrhosis?
Micronodular
Is alcoholic hepatitis associated with micro- or macrovesicular steatosis?
Both/either
Alcoholic hepatitis is associated with __________ (physical finding) and __________ (painless/tender) hepatomegaly.
Alcoholic hepatitis is associated with jaundice and tender hepatomegaly.
Virtually all alcoholics have _______ ______ (hepatic condition).
Virtually all alcoholics have fatty liver.
While virtually all alcoholics have steatosis, 1/3 develop __________ and 1/6 develop __________.
While virtually all alcoholics have steatosis, 1/3 develop hepatitis and 1/6 develop cirrhosis.
Is Wilson’s disease associated with micro- or macronodular cirrhosis?
Micronodular
Is Wilson’s disease associated with micro- or macrovesicular steatosis?
Macrovesicular
Wilson’s disease is associated with a mutation in which gene?
ATP7B
Is alcoholic hepatitis associated with micro- or macrovesicular steatosis?
Both/either
The hepatic inclusions seen in alpha-1 antitrypsin deficiency stain positive for what?
Diastase + PAS
A congenital lack of __________ in the duodenal cells may lead to unchecked iron uptake and increased likelihood for developing hemochromatosis.
A congenital lack of hepcidin in the duodenal cells may lead to unchecked iron uptake and increased likelihood for developing hemochromatosis.
Hemochromatosis is associated with a mutation in what gene?
C282Y
Most iron is absorbed via ________-mediated transport in the ________.
Most iron is absorbed via hepcidin-mediated transport in the duodenum.
Name a few etiologies associated with acute renal failure.
Idiopathic;
drug-induced (e.g. acetaminophen);
Amanita phalloides mushrooms (death caps)
What is the most common benign hepatic tumor?
Cavernous hemangiomas
Although hepatic cavernous hemangiomas typically follow a benign course and are only discovered incidentally, what are two dangerous complications that may arise?
DIC;
rupture (and hemorrhage)
What is the second most common benign hepatic tumor?
Focal nodular hyperplasia
(NOT a neoplasm)
Focal nodular hyperplasia (a hepatic tumor) is most common in what demographic?
Young-ish females
What is the etiology of hepatic focal nodular hyperplasia?
Local hyper-perfusion due to presence of an anomalous artery
_________________ (hepatic tumors) are typically solitary and occur in young women.
Hepatocellular adenomas are typically solitary and occur in young women.
_________ _________ increase risk of hepatocellular adenoma development.
Steroid hormones increase risk of hepatocellular adenoma development.
Hepatocellular adenomas can be very dangerous for rupture and/or malignant transformation in cases of what?
Preeclampsia or HELLP syndrome
_____% of women with hepatocellular adenomas have some abdominal mass symptom like pain.
50% of women with hepatocellular adenomas have some abdominal mass symptom like pain.
Describe the characteristic morphology of hepatocellular adenomas.
Lacking portal triads
True/False.
Hepatocellular adenomas can be HIF-1alpha-related, inflammatory (gp130 and IL-6 overactivation), beta-catenin-associated, or unclassified.
True.
What is the most common primary malignancy of the liver?
Hepatocellular carcinoma
True/False.
Hepatocellular carcinomas are typically HCV-related; can also be HBV, alcoholism, aflatoxins, etc.
False.
Hepatocellular carcinomas are typically HBV-related; can also be HCV, alcoholism, aflatoxins, etc.
What three methods can be used in diagnosing hepatocellular carcinomas?
CT imaging;
serum AFP;
serum glypican-3
True/False.
Hepatocellular carcinomas always present as solitary tumors.
False.
They may spread intra-hepatically and present as multiple tumors.
Name the treatments for the following categories of hepatocellular carcinomas:
Small –
Large –
Metastatic –
Small – resection
Large – ablation
Metastatic – drugs (regorafenib, sorafenib)
___________ hepatocellular carcinomas are a subtype that present in young, non-cirrhotic adults and are easily treated with simple resection.
Fibrolamellar hepatocellular carcinomas are a subtype that present in young, non-cirrhotic adults and are easily treated with simple resection.
____________ development is associated with vinyl chloride exposure.
Angiosarcoma development is associated with vinyl chloride exposure.
The most common cause of hepatic tumors are from what?
Metastases
(colorectal, melanoma, breast, lung, etc.)
Cholangiocarcinomas are ________ (rare/common) and occur in the ___________ (location).
Cholangiocarcinomas are rare and occur in the biliary tree.
Are cholangiocarcinomas most commonly intra-hepatic, hilar, or extra-hepatic?
Hilar
Name a few inciting etiologies associated with cholangiocarcinoma development.
Primary sclerosing cholangitis;
inflammatory bowel disease (ulcerative colitis or Crohn’s)
choledochal cysts
Clonorchis sinensis
What two imaging techniques are used in diagnosing cholangiocarcinomas?
ERCP; EUS
True/False.
Cholangiocarcinomas are typically made of adenocarcinoma-like cells, but there are also subtypes that are mixed between hepatocellular carcinoma and cholangiocarcinoma cells.
True.
What pediatric hepatic neoplasm is seen in the first five years of life, my be epithelial/fetal or mesenchymal, and often portends a poor prognosis?
Hepatoblastoma
Name some of the S/Sy of a hepatoblastoma in a pediatric patient.
Anemia, thrombocytosis, elevated AFP
