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SYSTEMIC PATHOLOGY > Hepatobiliary - liver injury and repair > Flashcards

Hepatobiliary - liver injury and repair Flashcards

1
Q

metabolic liver disease

A
  • P: Nonalcoholic fatty liver disease (NAFLD)
  • S: Amyloidosis
    P=primary (in), S=secondary (out)
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2
Q

toxic liver disease

A
  • P: Alcoholic liver disease (ALD)

- S: Drug-induced liver injury (DILI)

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3
Q

infectious liver disease

A
  • P: Viral hepatitis

- S: Extrahepatic/systemic infections (viruses, bacteria, fungi)

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4
Q

immune-mediated liver disease

A
  • P: Autoimmune hepatitis (AIH)
  • P: Primary biliary cholangitis (PBC)
  • P: Primary sclerosing cholangitis (PSC)
  • S: Systemic lupus erythematosus (SLE)
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5
Q

obstructive liver disease

A
  • P: Small intrahepatic biliary disorders (congenital/ acquired)
  • S: Extrahepatic obstructive lesions
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6
Q

vascular liver disease

A
  • P: Veno-occlusive disease (VOD)/ sinusoidal obstruction syndrome (SOS)
  • S: Heart failure
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7
Q

neoplasms

A
  • P: Hepatocellular carcinoma (HCC)

- S: Metastatic cancer

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8
Q

investigative tests to test hepatocyte function (3)

A

Serum aspartate aminotransferase (AST)
Serum alanine aminotransferase (ALT)
Serum lactate dehydrogenase (LDH)

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9
Q

investigative tests to test biliary excretory function (2 ways - 5 tests)

A
  1. level of substances normally secreted in bile:
    - Serum bilirubin – Total, unconjugated (indirect) and conjugated (direct)
    - Urine bilirubin
    - Serum bile acids
  2. Plasma membrane enzyme (produced when there is damage to bile canaliculus - high levels = bad)
    - Serum alkaline phosphatase (ALP)
    - Serum γ-glutamyl transpeptidase (GGT)
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10
Q

investigative tests to test hepatocytes synthetic function - based on serum protein levels

A
  • Serum albumin
    +ve = good
  • Coagulation factors: prothrombin (PT) and partial thromboplastin (PTT) times (fibrinogen, prothrombin, factors V, VII, IX, X)
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11
Q

investigative tests to test hepatocyte metab

A
  • Serum ammonia
  • Aminopyrine breath test (test for hepatic demethylation)
    +ve = good
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12
Q

investigative tests to test for infections (3)

A
  • Serology: IgM/IgG to HAV, anti-HBs
  • Microbiology: CMV/EBV PCR, cultures
  • Radiology (for suspected abscess): ultrasound HBS, CT abdomen, MRI liver
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13
Q

investigative tests to test for autoimmune diseases

A
  • Serology: anti-nuclear antibodies (ANA), smooth muscle antibodies (SMA)
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14
Q

investigative tests to test for bile duct obstruction (2)

A
  • Endoscopy: Endoscopic retrograde cholangiopancreatography
    (ERCP)/
    brushing cytology/
    biopsy
  • Radiology:
    Magnetic resonance cholangiopancreatography (MRCP)
    CT abdomen
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15
Q

mechanisms of liver injury and repair (3 steps)

A
  1. hepatocyte and parenchymal response
  2. scar formation and regression
  3. inflammation/ immunity
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16
Q
  1. hepatocyte and parenchymal response

- 3 possible types of responses

A
  • regeneration:
    Mitotic replication of hepatocytes/
    Activation of primary stem cell niche (canals of Hering)
    -> hepatocytes reach replicative senescence and there is stem cell activation (seen as ‘ductular reaction’)
  • Irreversible injury and cell death
    cell necrosis and apoptosis
  • Degenerative but potentially reversible changes
    Cellular swelling (ballooning degeneration)
    Steatosis (accumulation of fat)
    Cholestasis (accumulation of bilirubin)
17
Q
  1. scar formation and regression
A
  1. parenchymal transforming into dense fibrous tissue
    • Hepatic stellate cells activated and converted into highly fibrogenic myofibroblasts
  2. cirrhosis
    PORTAL/ periportal fibrosis
    -> portal-central and portal-portal bridging fibrosis / septa
    -> cirrhosis
  3. CELLULAR: Pericellular / perisinusoidal fibrosis
  4. Reversal of fibrosis / cirrhosis regression
18
Q
  1. inflammation/ immunity

- histo features

A

esp for hepatitis - eliminate infected hepatocytes

  • Lymphocytes, plasma cells, neutrophils, eosinophils, histiocytes / macrophages
  • Lymphoid aggregates
  • Granulomas
  • Microabscesses
19
Q

causes of ACUTE liver failure

A

caused by sudden massive injury
- Drugs/ toxins
- Acute Hepatitis A/B/E (autoimmune hepatitis)
[chronic liver failure: B/C - chronic and persistent]

20
Q

acute liver failure

gross + histo appearance

A

shrunken liver with wrinkled liver capsule

  • Massive necrosis - RBC extravasation
  • death of hepatocytes
  • Diffuse injury without obvious cell death - diffuse microvesicular steatosis (in fatty liver of pregnancy/ drug reaction)
21
Q

acute liver failure

complications

A

high mortality rate (80%) w/o transplant (cause of major loss in hepatic fn)

impact on liver:

  • coagulopathy: impaired hepatic synthetic fn
  • hepatic encephalopathy: impaired hepatic metabolism - liver cannot remove toxins -> brain damage
  • cholestasis: impaired bile excretion

impact on renal:
- Hepatorenal, hepatopulmonary syndrome
cause of vasodilation of vessels in the lungs -> shortness of breath

portal system:

  • Ascites
  • Portosystemic venous shunts
  • Congestive splenomegaly
  • hepatic encephalopathy
22
Q

causes of chronic liver failure (4)

A
  • Hep B/C infection
  • NAFLD (non-alcoholic fatty liver disease)
  • alcoholic liver disease, (cryptogenic)
  • liver cirrhosis
23
Q

liver cirrhosis**

A

transformation of liver into regenerative parenchymal nodules

  • fibrous bands - from scarring of liver
  • disturbed vascular architecture: vascular shunting
24
Q

liver cirrhosis **

  • clinical features
  • complications
A
  • anorexia, weight loss, weakness
  • Hepatic encephalopathy
  • Bleeding from oesophageal varices
  • Bacterial infections / sepsis
25
Q

chronic liver disease

- clinical presentation (4)

A
  • Cholestasis: buildup of bilirubin
    Jaundice -> pruritus (itch)
    Scleral icterus
- Hyperoestrogenemia
Palmar erythema
Spider angiomas
Hypogonadism
Gynaecomastia
  • Coagulopathy - easy bruising
- Portal hypertension
Ascites
Portosystemic venous shunts: 
Splenomegaly 
Hepatic encephalopathy: asterixis ‘hepatic flap’
26
Q

portal hypertension

causes

A
  • increased flow
  • increased resistance
  • prehepatic:
    Obstructive thrombosis or narrowing
    Massive splenomegaly with increased splenic vein blood flow
  • intrahepatic
    Cirrhosis
    Diffuse infiltrative processes (granulomatous inflammation, amyloid, malignancy)
    non-cirrhotic (Nodular regenerative hyperplasia)
  • post-hepatic
    Hepatic vein outflow obstruction
    Heart problems: right heart failure, constrictive pericarditis
27
Q

ascites definition

A

ascites = Accumulation of excess fluid in the peritoneal cavity

28
Q

hepatic encephalopathy pathogenesis from liver failure

A

liver failure:
increased ammonia
increase metabolism of ammonia -> glutamine in CNS

29
Q

splenomegaly pathogenesis from liver failure

A

LF: increase venous pressure -> congestion

-> Retention of leukocytes, erythrocytes and platelets in the spleen

30
Q

main consequences of liver failure

A

ABCDE

  • ammonia -> hepatic encephalopathy
  • bile retention
  • coagulopathy
  • distension (ascites)
  • esophageal varices
31
Q

chronic ingestion of alcohol pathogenesis (3)**

A

alcohol forms acetaldehyde

- hepatic steatosis: alcohol 
increase NADH/NAD+ ratio 
-> inhibit gluconeogenesis
-> promotes lipogenesis
causes intracellular lipid accumulation
  • alcoholic hepatitis:
    acetaldehyde can cause liver cell oxidative injury
  • alcoholic cirrhosis
32
Q

liver cirrhosis **

- gross and histo features

A 
gross: 
Enlarged early, shrunken late stage
Nodular surface
colour base on what causes it: 
yellow = fatty change
grey = viral hep 
green = jaundice
brown = Fe

histo:
- Bridging fibrous septa
- Regenerative liver nodules
- Inflammatory infiltrate
- Ductular proliferation in septa
- Cholestasis fibrous
- hepatocytes undergoing apoptosis
- chronic: groundglass appearance (flat hazy and uniformly dull cytoplasm)

SYSTEMIC PATHOLOGY (27 decks)

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