GI - Pathology (Liver Part I: Cirrhosis & other conditions)

Question 1

What are 8 signs/symptoms of cirrhosis that result from effects of portal hypertension?

Answer 1

(1) Esophageal varices => (2) Hematemesis => (3) Peptic ulcer disease, (4) Melena (from esophageal varices and/or peptic ulcer disease), (5) Splenomegaly, (6) Caput medusae/Ascites, (7) Portal hypertensive gastropathy (8) Anorectal ascites

Question 2

What are 11 signs/symptoms of cirrhosis that result from effects of liver cell failure?

Answer 2

(1) Hepatic encephalopathy (2) Scleral icterus (3) Fetor hepaticus (breath smells musty) (4) Spider nevi (5) Gynecomastia (6) Jaundice (7) Testicular atrophy (8) Liver “flap” = asterixis (coarse hand tremor) (9) Bleeding tendency (decreased clotting factors, increased prothrombin time) (10) Anemia (11) Ankle edema

Question 3

Of the 11 signs/symptoms of cirrhosis that result from effects of liver cell failure, which 3 are due to increased estrogen?

Answer 3

(1) Spider nevi (2) Gynecomastia (3) Testicular atrophy

Question 4

What gross/histological features define cirrhosis?

Answer 4

Diffuse fibrosis and nodular regeneration destroys normal architecture of liver

Question 5

What risk does cirrhosis increase?

Answer 5

Increased risk for hepatocellular carcinoma (HCC)

Question 6

What are 4 etiologies of cirrhosis?

Answer 6

(1) Alcohol (60-70%) (2) Viral hepatitis (3) Biliary disease (4) Hemochromatosis

Question 7

What is a vascular consequence of cirrhosis, and why? Give 2 examples of this.

Answer 7

Portosystemic shunts partially alleviate portal hypertension: (1) Esophageal varices (2) Caput medusae

Question 8

Name 6 serum markers of liver and pancreas pathology.

Answer 8

(1) Alkaline phosphatase (ALP) (2) Aminotransferases (AST and ALT) (often called “liver enzymes”) (3) Amylase (4) Ceruloplasmin (5) gamma-glutamyl transpeptidase (GGT) (6) Lipase

Question 9

What are 3 major diagnostic uses for alkaline phosphatase (ALP)?

Answer 9

(1) Obstructive hepatobiliary disease (2) HCC (3) Bone disease

Question 10

What are 2 major diagnostic uses for Aminotransferases (AST and ALT) (often called “liver enzymes”)?

Answer 10

(1) Viral hepatitis (ALT > AST) (2) Alcoholic hepatitis (AST > ALT)

Question 11

What are 2 major diagnostic uses for Amylase?

Answer 11

(1) Acute pancreatitis (2) Mumps

Question 12

What is the major diagnostic use for Ceruloplasmin?

Answer 12

Decreased in Wilson disease

Question 13

What is the major diagnostic use of gamma-glutamyl transpeptidase (GGT)? With what condition is it associated?

Answer 13

Increase in various liver and biliary diseases (just as ALP can), but NOT in bone disease; Associated with alcohol use

Question 14

What is the major diagnostic use for Lipase?

Answer 14

Acute pancreatitis (most specific)

Question 15

What is Reye syndrome, and in what patient population does it occur?

Answer 15

Rare, often fatal childhood hepatoencephalopathy

Question 16

What are 6 clinical findings associated with Reye syndrome?

Answer 16

Findings: (1) mitrochondrial abnormalities, (2) fatty liver (microvesicular fatty change), (3) hypoglycemia, (4) vomiting, (5) hepatomegaly, (6) coma.

Question 17

What preceding exposures are associated with Reye syndrome?

Answer 17

Associated with viral infection (especially VZV and influenza B) that has been treated with aspirin.

Question 18

What is the mechanism of damage in Reye syndrome?

Answer 18

Mechanism: aspirin metabolites decreased Beta-oxidation by reversible inhibition of mitochondrial enzyme

Question 19

What is the general rule for Aspirin use in children? What is the exception?

Answer 19

Avoid aspirin in children, except in those with Kawasaki disease

Question 20

What are 3 types of alcoholic liver disease?

Answer 20

(1) Hepatic steatosis (2) Alcoholic hepatitis (3) Alcoholic cirrhosis

Question 21

What kind of change does hepatic steatosis lead to, and what causes it?

Answer 21

Reversible change with moderate alcoholic intake

Question 22

What is the key histologic finding in hepatic steatosis? How may it be reversed?

Answer 22

Macrovesicular fatty change (see hepatocytes filled with clear fat droplets) that may be reversible with alcohol cessation

Question 23

What causes alcoholic hepatitis?

Answer 23

Requires sustained, long-term consumption

Question 24

What are 2 major histologic findings in alcoholic hepatitis?

Answer 24

(1) Swollen and necrotic hepatocytes with neutrophilic infiltration. (2) Mallory bodies (intracytoplasmic eosinophilic inclusions) are present.

Question 25

Of ALT and AST, which is greater in alcoholic hepatitis? What is their ratio?

Answer 25

AST > ALT (ratio usually > 1.5); Think: “make toAST with alcohol”

Question 26

What is the final and irreversible form of alcoholic liver disease?

Answer 26

Alcoholic cirrhosis

Question 27

What is the major histologic description of alcoholic cirrhosis?

Answer 27

Micronodular, irregularly shrunken liver with “hobnail” appearance. Sclerosis around central vein (zone III).

Question 28

What vascular structure is sclerosed in liver cirrhosis, and in what zone of the liver is this?

Answer 28

Sclerosis around central vein (zone III).

Question 29

What defines the manifestations of alcoholic cirrhosis?

Answer 29

Has manifestations of chronic liver disease (e.g., jaundice, hypoalbuminemia)

Question 30

What is the pathophysiology and resultant histologic finding of non-alcoholic fatty liver disease? How does it relate to alcohol use?

Answer 30

Metabolic syndrome (insulin resistance) => fatty infiltration of hepatocytes => cellular “ballooning” and eventual necrosis. Independent of alcohol use.

Question 31

What are 2 conditions that may result from non-alcoholic fatty disease?

Answer 31

May cause cirrhosis and HCC

Question 32

Of ALT and AST, which is greater in non-alcoholic fatty liver disease?

Answer 32

ALT > AST; Think: “L = aLt & Lipids”

Question 33

Briefly give the pathogenesis of hepatic encephalopathy.

Answer 33

Cirrhosis => portosystemic shunts => decreased NH3 metabolism => neuropsychiatric dysfunction

Question 34

What is the spectrum of symptoms/signs defining hepatic encephalopathy?

Answer 34

Spectrum from disorientation/asterixis (mild) to difficult arousal or coma (severe)

Question 35

What are 2 triggers of hepatic encephalopathy? Give at least 3 examples in which each occur.

Answer 35

Triggers: (1) Increased NH3 production (due to dietary protein, GI bleed, constipation, infection) (2) Decreased NH3 removal (due to renal failure, diuretics, post-TIPS)

Question 36

What are the treatments for hepatic encephalopathy?

Answer 36

Treatment: Lactulose (increased NH4+ generation), Low-protein diet, and Rifaximin (kills intestinal bacteria)