Hepatobiliary Pathology 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
hepatocytes plates; sinusoidal spaces
3
Q
The center of the lobule is a _______, into which the ______ drain
A
central vein (venue); sinusoids
4
Q
Where do the sinusoids drain?
A
Into the central venule
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 vein, as well as a bile duct:
A
Portal triads at the angles of the hexagon
7
Q
What do the portal triads at the angle of the hexagons 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 from?
A
Hepatic artery and the portal vein
9
Q
Branches of what vessels travel in the portal triads?
A
hepatic artery & portal vein
10
Q
Blood from the triads enter 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
sub lobular 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 & conjugation of drugs, toxins, and etc.?
A
makes substances not easily excreted by the kidney more hydrophilic, to enhance excretion
16
Q
Hepatocytes function to make substances not easily exerted 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 & 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
Heptocytes produce bile (an 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 & 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
Carbohydate 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 describe either _____ or ____ changes
reversible or non-reversible
26
What type of hepatocytes injury is being described:
accumulation of fat (steatosis) and/or accumulation of bilirubin
Reversible changes
27
What type of hepatocytes injury is being described:
Necrosis and/or apoptosis
Non-reversible changes
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 ____
Cirrhhosis
36
Situation in which the liver is made up of nodules of regenerating hepatocytes surrounded by dense bands of collagen:
Liver cirrhosis
37
Acetaminophen injestion, 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 and coagulation defects
39
If a patient presents with nausea/vomiting, jaundice, fatigue, followed by encephalopathy and coagulation defects you would most likely diagnosis 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
Symptoms ranging from behavior 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 & 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 & 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 liver 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
An esophageal varice is an example of a _____ and may result from _____
Portosystemic shunt; portal hypertension
55
Increased 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, & E
57
Hepatitis A:
1. Usually ____ & ____
2. caused by:
3. ____ route of transmission
4. symptoms include:
5. infections 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, 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 incures an 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. varies widely
2. hepatocellular carcinoma
3. 2 billion
4. africa & asia
5. parenteral
6. approximately 95% effective
7. detection of HBsAg, anti-HBcAg, HBV DNA by PCR
59
The clinical course of hepatitis B varies widely, including:
1. Acute hepatitis with clearance & recovery
2. nonprogresssive 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 incurs 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
What is a typical presentation of hepatocytes in Hep B infection?
Ground glass appearance
65
Hepatitis C:
1. Affects approximately ____ people worldwide
2. _____ route of transmission
3. Acute infection is generally asymptomatic in _____ % of cases but ____% of cases develop persistent, chronic infections - leading to cirrhosis in about ___% over 2 to 3 decades
4. Those that develop cirrhosis from hep C are at an increased risk of ______
5. Diagnosis:
6. Treatment:
1. 170 million people
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 lifecycle to progress
2. ____route of transmisison
3. Diagnosis:
4. Describe coinfection:
5. Describe superinfection:
1. HBV
2. Parenteral
3. Detecting HDV RNA
4. clincial indistinguishable form HBV infection, usually self-limited
5. HBV carrier exposed 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 & HDV
70
Hepatitis E:
1. ______ transmission (_____)
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
Aside 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 flora)
73
The seeding of bacteria in a liver infection is via:
blood
74
What two types of liver infection-causing bacteria are responsible for seeding via blood?
1. S. Aureus
2. Salmonella Type
75
If a liver infection is caused by bacteria, the result may be:
An abscess
76
Describe some parasite causes of liver infection:
1. worms (Shistosomiasis, liver flukes, echinococcus)
2. entameoba histolytica
77
List the following features that are see with chronic, progressive disorder of autoimmune hepatitis:
1. presence of autoantibodies
2. responds to immunosuppression
3. may have a genetic predisposition
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 & inflammation (especially plasma cells)
2. may lead to cirrhosis
82
List the patterns of liver injury associated with drugs and toxins:
1. fatty change (microvesicular or marovesicular)
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:
Acetominophen, carbon tetrachloride, mushroom toxins (amanita phalloides- "death cap")
87
Drug reactions that cause injury to the liver may be predictable (_____) or unpredictable (____)
intrinsic; idiosyncratic
88
An example of a predictable (intrinsic) drug reaction in the liver:
Acetominophen
89
An example of an unpredictable (idiosyncratic) drug reaction in the liver:
Chloropromazine
90
Both feature varying degrees of steatosis, steatohepatitis, and gradually increasing fibrosis which may eventually progress to cirrhosis:
Fatty liver disease (alcohol & 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 example of steatohepatitis:
-malaise
-anorexia
-upper abdominal discomfort
93
Condition of the liver that is becoming increasingly common, associated with type II diabetes, 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 death 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 & 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 absorption
101
Mutation of the gene ______ is the most common mutation causing hereditary hemochromatosis
HFE
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 and atrophy; skin pigmentation
104
An autosomal recessive disease characterized by loss of function mutation of ATP7B, leading to impaired copper excretion in bile 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 increase amount of _____ in circulation that causes ____
unbound copper; hemolysis
107
What disease is characterized by an accumulation of toxic levels of copper in organs, 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-Fleischer rings in the eye (which are deposits 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 sen in the following image:
Kayser-Fleischer rings
111
Acute/chronic liver disease or neuropsychiatric signs be the presenting features of what metabolic liver 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 misfolding and loss of function of alpha-1-AT 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 misfolding and loss of function of alpha-1AT. What is 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 accumulate _______ which may progress to _____ and eventually _____
Cytoplasmic globular inclusions; hepatitis & eventually cirrhosis
120
Clinically, the only effective treatment for severe cases of alpha-1-AT deficiency is:
Liver transplant
121
In cases of alpha-1AT deficiency, the _____ is also often involved resulting in _____ (especially if ____)
lung; emphysema; (especially if the patient smokes)
122
-focal nodular hyperplasia
-cavernous hemangioma
-hepatocellular adenoma
These are all:
Bengin 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 multiple
-Develop in non-cirrhotic liver
-Though to result from focal chronic hypo perfusion 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; benign
127
Why is hepatocellular adenoma most common in reproductive age women?
because it is stimulated by estrogen
128
What type of hepatic tumor is being described below.
- most common benign liver tumor
-tumors of benign blood vessels, variably dilated
Cavernous hemangioma
129
In hepatocellular adenoma, the mass may sometimes be ______
hemorrhagic
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 & Subsahara Africa)
-exposure to HBV and aflatoxin (aspergillus flavus_ markedly caused increased risk
-incidence in western countries rising mainly due to increased HCV
-chronic liver diseases (particularly 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 & 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 & the common bile duct
135
The delivers bile to the duodenum via:
cystic duct & 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 dict
G- gallbladder
H- cystic duct
138
Layers of the gallbladder wall include: (4)
1. mucosa
2. muscular externa
3. connective tissue/adventitia
4. serosa
139
The gallbladder mucosa contains ___ and ____
epithelium & 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 intracellular spaces
apicolateral junctional complexes; short microvilli; complex lateral plications
144
Gallstones are also termed:
Cholelithiasis
145
Gallstones affect ______ adults in the US
10-20%
146
The two main types of gallstones include:
cholesterol gallstone & pigment (bile salt) stone
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 Crohn disease)
149
What can be seen in the following image?
Cholesterol stones
150
What can be seen in the following image?
Pigment stones
151
Gall stones (cholelithiasis) may result in:
acute and/or chronic cholecystitis
152
Gallbladder carcinoma occurs at a ____ 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
