Hepatobiliary- Exam II Flashcards
1
Q
Describe the structure of the liver:
A
“Classic lobule”
- roughly hexagonal
2
Q
The liver consists of stacks of ____ with intervening ___
A
hepatocyte plates; sinusoidal spaces
3
Q
The center of the lobule is a ___ , into which the ___ drain
A
central vein (venule); sinusoids
4
Q
Where do the sinusoids drain?
A
into the central venules
5
Q
The liver structure is roughly hexagonal with ____ at the angles of the hexagon
A
portal triads
6
Q
Contains connective tissue with terminal branches of the hepatic artery, portal, as well as a bile duct:
A
portal triads at the angles of the hexagon
7
Q
What do the portal triads at the angles of the hexagon contain? (5)
A
- connective tissue with terminal branches of the hepatic artery
- portal vein
- bile duct
- lymphatic vessels
- nerves
8
Q
Where does blood enter the liver?
A
hepatic artery and the portal vein
9
Q
Branches of what vessels travel in the portal triads?
A
hepatic artery and portal vein
10
Q
Blood from the triads enters the ___, where it is mixed, and flows to the ____.
A
hepatic sinusoids; central veins
11
Q
Central veins drain into ____ which drain into the ____
A
sublobular veins; hepatic vein
12
Q
Label the following image:
A
A: Hepatic vein
B: Hepatic artery
C: Portal vein
D: Common bile duct
E: Gallbladder
13
Q
Hepatocyte functions include: (5)
A
- protein synthesis
- oxidation & conjugation of drugs/toxins/etc.
- lipid metabolism
- carbohydrate metabolism
- bile production (an exocrine secretion)
14
Q
What proteins are hepatocytes responsible for producing?
A
- albumin & other transport proteins
- clotting factors
- lipoproteins (especially VLDL)
15
Q
How do hepatocytes function in oxidation and conjugation of drugs, toxins, & etc.?
A
makes substances not easily excreted by the kidney more hydrophilic, to enhance excretion
16
Q
Hepatocytes function to make substances not easily excreted by the kidney more hydrophilic, to enhance excretion through what three processes?
A
- hydroxylation
- carboxylation
- conjugation
17
Q
Describe the lipid metabolism function of hepatocytes:
A
stores or breaks down fatty acids from plasma; as well as the synthesis and uptake of cholesterol
18
Q
In the hepatocytes function of carbohydrate metabolism, they either convert glucose to ___ for carb storage; or break down glycogen to ___ for energy usage
A
glycogen; glucose
19
Q
Hepatocytes produce bile (and exocrine secretion) which contains ______ which aid in ____
A
bile salts; emulsifying lipids in the GI tract
20
Q
What function of the hepatocyte is being described below?
production of albumin and other transport proteins, clotting factors, lipoproteins (especially VLDL)
A
Protein synthesis
21
Q
What function of the hepatocyte is being described below?
Makes substances not easily excreted by the kidney more hydrophilic, to enhance excretion via hydroxylation, carboxylation, & conjugation:
A
Oxidation & conjugation of drugs, toxins, etc.
22
Q
What function of the hepatocyte is being described below?
Stores or breaks down fatty acids from plasma; synthesis and uptake of cholesterol
A
Lipid metabolism
23
Q
What function of the hepatocyte is being described below?
Either converts glucose to glycogen for carbohydrate storage, or breaks down glycogen to glucose for energy usage
A
carbohydrate metabolism
24
Q
What function of the hepatocyte is being described below?
Contains bile salts which aid in emulsifying lipids in the GI tract:
A
bile production (an exocrine secretion)
25
Hepatocyte injury describes either ___ or ___ changes
reversible or non-reversible
26
What hepatocyte injury is being described?
accumulation of fat (steatosis) &/or accumulation of bilirubin
reversible changes
27
What hepatocyte injury is being described?
Necrosis and/or apoptosis
Non-reversible
28
Liver hepatocyte necrosis may follow ___ and may be single cell death or it can be zonal or regional
hypoxia/ischemia
29
Necrosis that may follow hypoxia/ischemia may be : (3)
1. single cell death
2. zonal
3. regional (confluent necrosis)
30
Regional necrosis of the liver may be termed:
confluent necrosis
31
Necrosis or apoptosis of the hepatocytes of the liver may follow: (3)
1. viral infection
2. toxin exposure
3. inflammatory conditions
32
By dividing hepatocytes near the site of injury , or in more severe injuries by dividing stem cells:
regeneration
33
Describe the process of liver regeneration:
occurs via dividing hepatocytes near the site of injury, or in more severe injuries by dividing stem cells
34
Most often a result of chronic liver injury:
scar formation
35
Scar formation of the liver may progress to:
cirrhosis
36
Situation in which the liver is made up of nodules of regenerating hepatocytes surrounded by dense bands of collagen
liver cirrhosis
37
Acetaminophen ingestion, autoimmune hepatitis, acute viral hepatitis, and other drugs/toxins may result in:
acute liver failure
38
Describe the clinical features of acute liver failure:
presents with nausea/vomiting, jaundice, fatigue, followed by encephalopathy & coagulation defects
39
If a patient presents with nausea/vomiting, jaundice, fatigue, followed by encephalopathy & coagulation defects you would most likely diagnose them with:
acute liver failure
40
Yellow coloration of the skin due to bilirubin retention and cholestasis:
jaundice
41
Discoloration of the sclera:
icterus
42
symtoms ranging from behavioral abnormalities to confusion, stupor, coma, and death:
hepatic encephalopathy
43
What is hepatic encephalopathy believed to be caused by:
elevated ammonia levels (impairs neuronal function and causes cerebral edema)
44
What can be seen in the following images?
icterus
45
What can be seen in the following image?
jaundice
46
Bruising and bleeding associated with liver failure:
coagulopathy
47
In patients without pre-existing renal disease, acute liver failure can result in decreased renal perfusion, leading to decreased urine output:
hepatorenal syndrome
48
Chronic liver failure is characterized by: (3)
1. cirrhosis
2. portal hypertension
3. ascites
49
diffuse transformation of the lier into regenerative hepatocyte nodules surrounded by bands of dense fibrous connective tissue (essentially scar)
cirrhosis
50
Most common causes of chronic liver failure worldwide include: (4)
1. chronic hep B
2. chronic hep C
3. nonalcoholic fatty liver disease (NAFLD)
4. alcohol-related liver disease
51
____ does not indicate the presence of a specific disease; it is a common final pathway of a number of chronic liver diseases
cirrhosis
52
Not all chronic liver diseases result in ____ and not all cirrhosis results in ____
cirrhosis; end-stage liver disease
53
Increased portal vascular resistance; portosystemic shunts may develop (e.g. esophageal varices)
portal hypertension
54
Esophageal varices is an examples of ____ that may be caused by ____
portosystemic shunt; portal hypertension
55
Increase in fluid in the peritoneal space, arises primarily due to portal hypertension:
ascites
56
Viral hepatitis may be caused by:
hepatotropic viruses A, B, C, D, and E
57
Hepatitis A:
1. Usually ___ & ___
2. Caused by:
3. ___ root of transmission
4. Symptoms include:
5. Infection persists for:
6. (does/does not) cause chronic hepatitis
7. diagnosis:
1. benign & self-limited
2. ingestion of contaminated food/water
3. fecal-oral
4. fever, fatigue, n/v, decreased appetite, and jaundice
5. 2-12 weeks
6. does not
7. detection of IgM antibodies
58
Hepatitis B:
1. Describe the clinical course
2. HBV-associated chronic hepatitis incurs and elevated risk for:
3. ____ people worldwide have chronic Hep B infections
4. Prevalence is greater in the regions of:
5. ___ transmission
6. describe vaccine effectiveness:
7. diagnosis:
1. clinical course varies widely
2. hepatocellular carcinoma
3. 2 billion
4. africa and asia
5. parenteral
6. approximately 95% effective
7.detection of HBsAg; anti-HBcA:, HBV DNA by PCR
59
The clinical course of Hep B varies widely, including:
1. acute hepatitis with clearance and recovery
2. non-progressive chronic hepatitis
3. progressive chronic hepatitis leading to cirrhosis
4. fulminant hepatitis with massive liver necrosis
5. asymptomatic carrier state
60
HBV-associated chronic hepatitis insures an elevated risk for:
hepatocellular carcinoma
61
Label the following image from top to bottom:
- subclinical disease
- acute hepatitis
- chronic hepatitis
62
Label the following image from top to bottom:
- recovery
- fulminant hepatitis
- recovery
- cirrhosis
- hepatocellular carcinoma
63
Label the following image from top to bottom:
- death or transplant
- death or transplant
64
How is a typical presentation of hepatocytes in hep B infection?
ground glass appearance
65
Hepatitis C:
1. Affects approximately ____ people worldwide
2. ___ route of transmision
3. Acute infection is generally asymptomatic in ___% of cases, but ___% of case develop persistent, chronic infections, leading to cirrhosis in about ___ % over 2-3 decades
4. Those that develop cirrhosis from hep C are at an increased risk of:
5. Diagnosis:
6. Treatment:
1. 170 million
2. parenteral
3. 85%; 80-90%; 20%
4. hepatocellular carcinoma
5. HCV RNA (qualitative & quantitative tests available)
6. treatable with antiviral combination therapy (can cure 95% of infections)
66
If a liver biopsy shows chronic inflammation of a portal tract, this is a typical sign that it is:
Hep C infection
67
Hepatitis D:
1. Dependent on ___ for its life cycle to progress
2. ____ route of transmission
3. Diagnosis:
4. Describe coinfection
5. Describe superinfection:
1. HBV
2. parenteral
3. detecting HDV RNA
4. clinically indistinguishable from HBV infection, usually self-limited
5. HBV carrier exploded to HDV, resulting in either severe acute hepatitis or exacerbation of chronic HBV
68
What may result from an HBV carrier being exposed to HDV?
Superinfection- resulting in either severe acute hepatitis or exacerbation of chronic HBV
69
Clinically what two types of hepatitis are indistinguishable:
HBV and HDV
70
Hepatitis E:
1. ____ transmitted (____)
2. clinically produces:
3. ____ with ____ reservoirs
4. Diagnosis:
1. enterically (fecal-oral)
2. acute, self-limited hepatitis
3. zoonotic; animal reservoirs
4. IgM, HEV, RNA
71
Aise from liver infections being caused by hepatitis viruses (A, B, C, D, E); liver infections may also be caused by:
1. bacteria
2. parasites
72
Describe a liver infection caused by bacteria:
Ascending infections involving the biliary tract (usually gut flor)
73
The seeding of bacteria in a liver in infection is via:
blood
74
What two types of liver infection-causing bacteria are responsible for seeding via blood?
1. S. aureaus
2. Salmonella typhii
75
If a liver infection is caused by bacteria, the result may be:
an abscess
76
Describe some parasitic causes of a liver infection:
1. worms (schistosomiasis, liver flukes, ehincococcus)
2. entamoeba histolytica
77
List the following features that are seen with the chronic, progressive disorder of autoimmune hepatitis:
1. presence of autoantibodies
2. responds to immunosupression
3. may have a genetic presdisposition
4. may be associated with other autoimmune diseases
78
Autoimmune hepatitis can be described as:
a chronic progressive disorder
79
Autoimmune hepatitis is associated with the presence of autoantibodies, list some examples:
antinuclear antibodies (ANA), anti-smooth muscle antibodies (ASMA)
80
Autoimmune hepatitis responds to immunosuppression resulting in:
remission in 90% of patients (even those with cirrhosis)
81
Describe the morphology associated with autoimmune hepatitis: (2)
1. necrosis and inflammation (especially plasma cells)
2. may lead to cirrhosis
82
List the patterns of liver injury associated with drugs and toxins:
1. fatty change (micro vesicular or macro vesicular)
2. fibrosis
3. cholestasis
4. necrosis
83
Fatty changes in the liver (microvesicular or macrovesicular) may be due to:
alcohol, methotrexate, or tetracycline
84
Fibrosis of the liver may be due to:
alcohol or methotrexate
85
Cholestasis of the liver may be due to:
Chlorpromazine
86
Necrosis of the liver may be due to:
acetaminophen, carbon tetrachloride, mushroom toxins (amanita phalloides- "death cap")
87
Drug reactions that cause injury to the liver may be predictable (____) or unpredictable (____)
intrinsic; idosyncratic
88
An example of a predictable (intrinsic) drug reaction in the liver=
acetaminophen
89
An example of an unpredictable (idiosyncratic) drug reaction in the liver=
chlorpromazine
90
Both feature varying degrees of steatosis, steatohepatitis and gradually increasing fibrosis which may eventually progress to cirrhosis:
fatty liver disease (alcohol and non-alcohol related)
91
Symptoms and lab abnormalities that develop in the setting of an already-fatty liver (malaise, anorexia, upper abdominal discomfort)
steatohepatitis
92
List some examples of steatohepatitis:
malaise, anorexia, upper abdominal discomfort
93
Condition of the liver that is becoming increasingly common, associated with type II DM, obesity, hyperlipidemia, and hypertension:
NAFLD
94
Alcohol-related fatty liver disease is caused by:
excessive ethanol consumption
95
Cause of more than 60% of chronic liver disease in western countries:
excessive ethanol consumption
96
In liver disease caused by excessive ethanol consumption, 40-50% of deaths are ultimately caused by:
cirrhosis
97
Metabolic liver diseases include: (3)
1. hemochromatosis
2. Wilson disease
3. Alpha-1 anti-trypsin deficiency
98
Metabolic liver disease characterized by excessive absorption of iron, deposited in the liver, pancreas, heart, and other organs
Hemochromatosis
99
Hemochromatosis may be ___ , especially in ____
acquired; transfusion-dependent patients
100
Although hemochromatosis may be acquired, it is usually ____ characterized by:
hereditary; loss or impairment of regulatory control of intestinal iron absoprtion
101
Mutation of the ___ gene is the most common mutation causing hereditary hemochromatosis
HFE gene
102
In hemochromatosis, we see tissue deposition of ___ leading to gradually increasing ____.
hemosiderin; fibrosis
103
In hemochromatosis, iron deposition in other organs can lead to ___ and ____ of other organs, in addition to changes in ___.
fibrosis & atrophy; skin pigmentation
104
An autosomal recessive disease characterized by loss of function mutation of ATP7B, leading to impaired copper excretion in oil and failure to incorporate copper into ceruloplasmin:
Wilson disease (metabolic liver disease)
105
Wilson disease is caused by a ____ mutation in the ____ gene
loss-of-function; ATP7B
106
In Wilson disease, there is an increased amount of ___ In circulation that causes ____
unbound copper; hemolysis
107
What disease is characterized by an accumulation of toxic levels of copper in organ, mostly the liver, brain and eye:
wilson disease
108
Discuss the morphology seen with Wilson disease:
Variable morphology in the liver such as fatty change, hepatitis (acute or chronic), and ultimately cirrhosis
Kayser-Fleishcer rings in the eye (which are despots of copper in the limbus of the cornea)
109
Deposits of copper in the limbus of the cornea is seen in ____ disease. What is this called?
Wilson Disease (metabolic liver disease); Kayser-Fleischer rings
110
What can be seen in the following image?
Kayser-Fleischer rings
111
Acute/chronic liver disease or neuropsysiciatric signs may be the presenting features of what metabolic disease?
wilson disease
112
How is Wilson disease diagnosed?
- decreased serum ceruloplasmin
- increased hepatic copper content
- increased urine copper
113
How is wilson disease treated?
- copper chelation therapy & zinc-based therapy (inhibits copper uptake in the gut)
114
Why might zinc-based therapy be utilized to treat Wilson disease?
because zinc inhibits copper uptake in the gut
115
Metabolic liver disease that is autosomal recessive, characterized by mutations resulting in misfiling and loss of function of alpa-1AT, which normally inhibits proteases (particularly neutrophil proteases)
alpha-1 anti-trypsin deficiency
116
Alpha-1 anti-trypsin deficiency is an autosomal recessive disorder, with mutations resulting in misfiling and loss of function of alpha-1AT. What does alpha-1AT normally function to do?
Normally inhibits proteases (particularly neutrophil proteases)
117
alpha-1AT is synthesized mainly by:
hepatocytes
118
Alpha-1AT is mainly synthesized by hepatocytes, but the abnormal form accumulates in the hepatocytes resulting in:
apoptosis
119
Alpha-1AT is mainly synthesized by hepatocytes, but the abnormal form accumulates in the hepatocytes resulting in apoptosis.
Before they die, hepatocytes accumulates _____ which may progress to ___ and eventually ___
cytoplasmic globular inclusions; hepatitis; cirrhosis
120
Clinically, the only effective treatment for severe cases of alpha-1 anti-trypsin deficiency is:
liver transplant
121
In alpha-1 anti-trypsin deficiency, the ___ is also often involved resulting in ___. (especially if ___)
lung; emphysema; patient smokes
122
- Focal nodular hyperplasia
- Cavernous hemangioma
- Hepatocellular adenoma
These are all:
benign hepatic tumors
123
- Hepatocellular carcinoma (HCC)
- metastatic tumors to the liver (much more common)
These are all:
malignant hepatic tumors
124
What type of hepatic tumor is being described below? Is this benign or malignant?
- may be single or mutliple
- develop in non-cirrhotic liver
- though to result from focal chronic hypoperfusion of an area of the liver, resulting in scarring and compensatory hyperperfusion leading to focal hepatocyte hyperplasia
- most common in younger women (ages 20-50)
focal nodular hyperplasia; benign
125
_____ can microscopically resemble cirrhosis, but it is actually a focal lesion:
Focal nodular hyperplasia
126
What type of hepatic tumor is being described below? Is this benign or malignant?
- usually arises in non-cirrhotic liver
- most common in reproductive age women
- stimulated by estrogen
- sheets of sheets of hepatocytes, normal to atypical
- rare cases progress to malignancy
hepatocellular adenoma
127
Why is hepatocellular adenoma most common in reproductive women?
because it is stimulated by estrogen
128
-What type of hepatic tumor is being described below?
- Most common liver benign liver tumor
- Tumors of benign blood vessels
- variably dilated
cavernous hemangioma
129
In hepatocellular adenoma, the mass may sometimes be:
hemmorhagic
130
What type of hepatic tumor is being described below? Is this benign or malignant?
- incidence varies widely throughout the world (highest in Eastern Asia and sub-saharan Africa)
- Exposure to HBV and aflatoxin (aspergillus flavus) markedly cause an increased risk
- incidence in western countries rising, mainly due to increase HCV
- Chronic liver diseases (particular in a background of cirrhosis) are the most common setting for this tumor to develop
- Main risk factors include: HBV, HCV, aflatoxin exposure , and increasingly NAFLD
hepatocellular carcinoma; malignant
131
Inferior and adherent to the liver:
gallbladder
132
The function of the gallbladder is to:
concentrate, store, and excrete bile
133
The gallbladder receives dilute bile from the:
common hepatic duct
134
In response to hormones from enteroendocrine cells (for example cholecystokinin), or to parasympathetic stimulation, the gallbladder:
contracts, and delivers bile to the duodenum via the cystic duct and the common bile duct
135
The gallbladder delivers bile to the duodenum via:
cystic duct and common bile duct
136
The gallbladder delivers bile to the duodenum in response to:
hormones from enteroendocrine cells or to parasympathetic stimulation
137
Label the following image:
A: pyloric valve
B: stomach
C: pancreas
D: pancreatic duct
E: duodenum
F: common bile duct
G: gallbladder
H: cystic duct
138
Layers of the gallbladder wall include: (4)
1. mucosa
2. muscularis externa
3. connective tissue/adventitia
4. serosa
139
The gallbladder mucosa contains:
epithelium and lamina propria
140
The gallbladder mucosa contains occasional ___ near the neck
mucous glands
141
The gallbladder mucosa surface epithelium is:
simple columnar
142
The gallbladder mucosa surface epithelium is simple columnar that resembles:
intestinal absorptive cells
143
The gallbladder mucosa surface epithelium is simple columnar with ____ complexes, ______, and _____ surrounding intercellular spaces
apicolateral junctional complexes; short microvilli; complex lateral plications
144
Gallstones are also termed:
cholelithiasis
145
Gallstones affect:
10-20% of adults in US
146
The two main types of gallstones include:
cholesterol stones & pigment (bile salt) stones
147
Cholesterol stone risk factors include: (4)
1. dyslipidemia
2. female
3. insulin resistance
4. gallbladder stasis
148
Pigment stone risk factors include: (3)
1. chronic hemolysis (malaria & sickle cell)
2. biliary infection
3. various GI disorders (including crohns disease)
149
What can be seen in the following image?
cholesterol stones
150
What can be seen in the following image?
pigment stones
151
Gallstones (cholelithiasis) may result in:
acute or chronic cholecystitis
152
Gallbladder carcinoma occurs at _____ age, with slight ____ predominance
older age; female
153
At the time of diagnosis of gallbladder carcinoma, the gallbladder is usually not:
resectable
154
The mean 5-year survival for gallbladder carcinoma is approximately:
5-12%
155
Gallbladder carcinoma is thought to arise primarily in background of:
chronic gallbladder inflammation
156
