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Pathology > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

what do levels of billirubin, ALT, AST, ALP, GGT, albumin and PT mean in a LFT

A
  • Bilirubin
    • Unconjugatedhyperbilirubinaemiacould suggest:
      • Haemolysis (e.g. haemolytic anaemia)
      • Impaired conjugation (e.g. Gilbert’s syndrome)
    • Conjugatedhyperbilirubinaemiacould suggest:
      • Hepatocellular injury
      • Cholestasis
  • ALT
    • useful marker ofhepatocellular injury (includes hepatitis, AFLD, NAFLD)
  • AST
    • grouped together with ALT
    • AST > ALT is associated with cirrhosis and acute alcoholic hepatitis
    • ALT > AST is associated with chronic liver disease
  • ALP
    • useful indirect marker of cholestasis
  • ALT vs ALP rise
    • Agreater than 10-fold increase in ALTand aless than 3-fold increase in ALPsuggests apredominantlyhepatocellular injury
    • Aless than 10-fold increase in ALTand amore than 3-fold increase in ALPsuggestscholestasis
  • GGT
    • If ALP is increased, need to review GGT
    • Raised GGT can suggest bile flow obstruction
    • A markedly raised ALP with a raised GGT is highly suggestive of cholestasis
  • Albumin
    • Albuminlevels candecreasedue to:
      • Liver disease resulting in a decreased production of albumin (e.g. cirrhosis).
      • Inflammation triggering an acute phase response which temporarily decreases the liver’s production of albumin
  • Prothrombin time (PT)
    • liver is responsible for synthesis of clotting factors, therefore hepatic pathology can impair this process
    • increased PT can indicate liver disease
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2
Q

consequences of liver failure

A
  • Coagulopathy: liver is main producer of a number of coagulation factors
  • Hepatic Encephalopathy
    • impaired hepatic metabolism → elevated serum levels of ammonia → impaired neuronal function
    • Neurological signs: rigidity, hyperreflexia, asterixis

Cholestasis: impaired bile excretion

Portal hypertension (more for chronic LF)

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3
Q

leading causes of acute liver failure

A

Caused by drugs / toxins, Acute Hepatitis Virus (A,B and E), autoimmune hepatitis

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4
Q

histology of acute liver failure

A

Massive hepatic necrosis without obvious cell death

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5
Q

leading causes of chronic liver disease

A

Chronic Hepatitis B and C, Non-alcoholic fatty liver disease (NAFLD), Alcoholic liver disease

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6
Q

histological correlation of chronic liver failure

A
  • Histological correlation: cirrhosis (usually)

DIFFERENCE BETWEEN CHRONIC LIVER DISEASE AND CIRRHOSIS
- Chronic liver failure is a clinical diagnosis that implies the liver has long term damage
- Cirrhosis is a pathologic diagnosis that requires investigations and radiology to show that the liver is nodular
- Hence, “cirrhosis” implies the presence of severe chronic liver disease, but is not a specific diagnosis and lacks clear prognostic implications

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7
Q

clinical features of chronic liver disease

A
  • Cholestasis:
    • jaundice → pruritus
    • sclera icterus
  • Hyperestrogenemia:
    • palmar erythema
    • spider angioma
    • hypogonadism
    • gynaecomastia (could associate with testicular atrophy)
  • Coagulopathy
  • Portal hypertension:
    • Ascites
    • Caput medusae
    • Hepatic encephalopathy → asterixis (hepatic flap)
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8
Q

causes of acute on chronic liver failure

A
  • Patients with chronic hepatitis B who become superinfected with hepatitis D
  • Ascending cholangitis in patients with primary sclerosing cholangitis
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9
Q

morphology of liver cirrhosis

A

Parenchymal nodules

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10
Q

causes of liver cirrhosis

A
  • Alcoholic liver disease
  • Chronic hepatitis B virus infection
  • Chronic hepatitis C virus infection
  • Non-alcoholic fatty liver disease (NAFLD)
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11
Q

complications of liver cirrhosis

A
  • Hepatic encephalopathy
  • oesophageal varices
  • increased risk of Hepatocellular carcinoma (HCC)
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12
Q

symptoms of acute hepatitis

A
  • Jaundice
  • Dark-coloured urine
  • Poor appetite
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13
Q

which types of hepatitis are acute and which are chronic

A
  • Acute
    • usually only caused by Hep A, B, D, E
  • Chronic hepatitis
    • especially Hep C, with a small number of Hep B
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14
Q

hep A mode of transmission

A

faecal oral or water borne

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15
Q

hep A clinical features, incubation period, complications

A

Clinical features:
- benign self-limited disease: usually mild or asymptomatic, does not cause chronic hepatitis or carrier state

Incubation period
- incubation period: 2 - 6 weeks

Complications: uncommon to cause acute liver failure

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16
Q

hep A diagnosis and prevention

A

Diagnosis:
IgG anti-HAV (persists for years, giving lifelong immunity)

Prevention:
- Education on hygienic practices
- Traveller’s vaccine

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17
Q

hep B clinical features, incubation period, complications

A

Clinical features:
- Characteristic GROUND GLASS APPEARANCE
- Symptoms are initially non-specific (fever, jaundice, nausea)

Incubation period: 2 - 26 weeks

Complications:
- can cause acute hepatitis, acute hepatic failure, chronic hepatitis
- can lead to cirrhosis or carrier state
- only 5-10% of acute hepatitis patients progress to
chronic hepatitis
- Risk factor for HCC (hepatocellular carcinoma) even in the absence of cirrhosis

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18
Q

hep B mode of transmission

A
  • mode of transmission: blood-borne
    • high prevalence areas: vertical transmission
    • low prevalence areas: sexual, infected blood & blood products (transfusions, needle stick contaminations, barbers, acupuncture, IVDA)
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19
Q

hep B diagnosis and prevention

A

diagnosis:
IgM anti-HBc & HbsAg in blood
HBeAg & HBV DNA are markers for infectivity
Carriers: usually HBsAg + but HBeAg - , low or undetectable HBV DNA

Prevention:
HBV vaccine

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20
Q

hep C mode of transmission, clinical features, incubation period, complications

A
  • mode of transmission: blood borne
    • drug abusers, blood products
    • sexual, vertical transmission
      • vertical and sexual transmission rare due to low circulating virus
  • Symptoms
    • usually asymptomatic, subclinical is common
    • symptoms are milder than Hep B

Incubation period: 4-26 weeks incubation period

Complications similar to Hep B: chronic hepatitis, cirrhosis, chronic liver failure

21
Q

hep C diagnosis and prevention

A

Diagnosis: HCV-RNA by PCR, anti-HCV

Prevention: no effective vaccine

22
Q

hep D mode of transmission

A
  • mode of transmission: blood borne
    • IVDA, blood transfusions
    • individuals can only be affected by HDV if they have been infected by HBV before
  • highest prevalence in Middle East, Mediterranean, central Africa
23
Q

hep D diagnosis and prevention

A

Diagnosis: IgM anti-HDV antibody is most reliable indicator of recent HDV exposure

Prevention:
Vaccination for HBV prevents HDV infection

24
Q

hep E mode of transmission, clinical features, incubation period, complications

A
  • Faecal-oral transmission (water-borne, zoonotic)
    • zoonotic disease with animal reservoirs (monkey, cats, pigs)

Clinical features:
- Causes acute hepatitis
- usually self-limiting
- high mortality rate in pregnant women (~20%)

Incubation period
- 4-5 weeks incubation period

Complications:
Characteristically high rates of fatality amongst HEV-infected pregnant women

25
Q

hep E diagnosis and prevention

A

Diagnosis: HEV RNA and virions can be detected by PCR in stools and serum

Prevention: No vaccine

26
Q

autoimmune hepatitis epiD and diagnosis

A

Female predominance (78%)

  • Diagnosis
    • Presence of Autoantibodies
    • Elevated IgG
    • Liver histology
    • Serology still needed to properly diagnose
27
Q

important diagnostic features of drug induced liver injury (DILI)

A

Need to take thorough drug history

28
Q

possible complications of alcoholic liver disease

A

steatosis, alcoholic hepatitis, progressive steatofibrosis that eventually leads to fibrosis

29
Q

histology of alcoholic liver disease

A
  • Centrilobular steatosis
  • Mallory-Denk bodies
  • Chicken wire fence fibrosis
30
Q

blood test results of alcoholic liver disease

A
  • Blood test
    • AST > ALT (2:1 ratio)
    • Neutrophils increased
31
Q

what is NAFLD, its manisfestation and complications

A

Definition: Spectrum of disorders that have in common the presence of hepatic steatosis (fatty liver) which occur in individuals who do not consume alcohol, or do so in very small quantities (<20g/week)

  • Manifestations
    • Steatosis
    • Steatohepatitis (NASH)

Complications:
- Contributes to progression of other liver diseases such as viral hepatitis
- Increases the risk of HCC even without presence of scarring

32
Q

diagnostic criteria for MAFLD (metabolic associated fatty liver disease)

A
  • Diagnostic criteria
    • Detection of liver steatosis with at least 1 out of 3 of
      • obesity/overweight
      • T2DM
      • clinical evidence of metabolic dysfunction e.g. increased waist circumference, abnormal lipid or glycaemic profile
33
Q

what is cholestasis and its symptoms

A

impaired bile formation and bile flow

Symptoms
- Jaundice: yellow discolouration of skin
- Icterus: yellow discolouration of sclera
- Pruritus (itching of skin), skin xanthomas
- intestinal malabsorption
- Vitamin ADEK deficiency

34
Q

prehepatic jaundice: causes, clinical features, liver test results

A
  • Causes
    • Excessive production of bilirubin
      • e.g. haemolysis (haemolytic anaemia), ineffective erythropoiesis
  • Clinical features
    • Unconjugated hyperbilirubinemia
    • Stools: dark in colour (increased stercobilin)
    • Urine: normal colour (unconjugated bilirubin cannot be filtered into urine)
    • No pruritis (no bile accumulation)
  • Liver test:
    • ALT & AST: normal
    • Alkaline phosphatase & GGT: normal
    • Liver proteins: normal
35
Q

hepatic jaundice: causes, clinical features, liver test results

A
  • Causes
    • Reduced hepatic uptake
      • e.g. drugs
    • impaired bilirubin conjugation
      • e.g. physiologic/neonatal jaundice, genetic deficiency, diffuse hepatocellular disease (viral hepatitis)
    • impaired bile flow
      • e.g. autoimmune cholangiopathies
  • Clinical features
    • Unconjugated and Conjugated hyperbilirubinemia
    • Stools: normal colour
    • Urine: May be tea colour
  • Liver test:
    • ALT & AST: raised
      • AST>ALT → toxins (AST in mitochondria)
      • ALT>AST → viral (ALT in cytoplasm)
    • ALP & GGT: raised (in cholestatic phase)
    • Liver proteins: reduced (in chronic liver failure)
      • Albumin, coagulation factors decreased
36
Q

post hepatic jaundice: causes, clinical features, liver test results

A
  • Causes
    • Impaired bile flow/bile duct obstruction (gallstones or cholelithiasis, malignancies in head of biliary tree or head of pancreas)
      • Results in decreased bilirubin clearance
  • Clinical features
    • Conjugated hyperbilirubinemia
    • Stools: pale (no bile pigments)
    • Urine: Tea-coloured or dark coloured
    • Pruritis & scratch marks (bile accumulation)
  • Liver function test:
    • ALT & AST: mildly elevated
    • ALP & GGT: marked raise
    • Liver proteins: normal
37
Q

associations and causes of Hepatocellular carcinoma (HCC)

A
  • NASH (non-alcoholic steatohepatitis)
  • Hepatotropic viruses chronic infection (HBV, HCV)
38
Q

morphology and histology of HCC

A

Gross:
1. May appear as unifocal mass
2. May appear as multifocal, widely distributed nodules of variable sizes
3. May appear as diffuse infiltrative cancer where the tumour cannot exactly be seen

Histology:
- Hepatocytes have eosinophilic cytoplasm
- Pleomorphism
- Bile production (HCC is the only tumour that elaborates bile)
- Pseudoacinar formation

39
Q

clinical features of HCC

A
  • Clinical Presentation
    • Asymptomatic (majority)
    • Hepatomegaly, Ascites
    • Upper abdominal pain, malaise, fatigue, weight loss
40
Q

diagnosis of HCC

A
  • Imaging Studies (most important way to detect HCC)
    - With contrast
  • Serum alpha-fetoprotein (AFP) — rising or elevated levels present in 50% of cases
41
Q

prognostic factors for HCC

A

Poor 5 year survival: death within 2 years is common

Prognostic factors
- Stage
- Presence of cirrhosis (worse prognosis)

42
Q

complications of HCC

A
  • Budd-Chiari syndrome
  • Portal hypertension
  • Obstructive jaundice
  • Liver failure
43
Q

cholangiocarcinoma definition, risk factors and clinical presentation

A

Definition: Carcinoma of bile duct origin
Risk factors:
- HBV, HCV
- NAFLD

  • Clinical Presentation
    • Location affects presentation
    • Extrahepatic tumours present earlier and smaller with biliary obstruction, cholangitis and RUQ pain
    • Intrahepatic tumours not detected till late
44
Q

clinical features of acute cholecystitis

A
  • Episode of progressive pain that lasts more than 6 hours
  • Previous history of RUQ / perigastric pain ‘biliary colic’
  • Murphy’s sign: Pain upon inspiration at right subcostal area (inflamed gallbladder comes into contact with examiner’s hand)
  • No jaundice** — if present, suggests CBD obstruction
45
Q

complications of acute cholecystitis

A
  • Gangrene
  • Ascending cholangitis
  • Liver abscess
  • Septicemia
46
Q

morphology of acute cholecystitis

A

Gross:
- Enlarged, tense & congested gallbladder
- Gallbladder mucosa ulcerated

47
Q

cholecystitis vs cholelithiasis vs cholangitis vs choledocholithiasis

A

Cholelithiasis: stones in gall bladder
Cholecystitis: inflammation of gall bladder
Choledocholithiasis: stones in common bile duct
Cholangitis: inflammation of common bile duct

48
Q

percentage of types of primary tumours

A

HCC - 90%
Cholangiocarcinoma - 10%

Pathology (11 decks)

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