HistoPath - Liver CPC Flashcards
What may cause high bilirubin
Pre-hepatic: Haemolysis, Gilbert’s
Hepatic: Hepatitis, cirrhosis, Liver failure
Post-hepatic: Obstruction, Cholecystitis, pancreatic Ca
What makes the endothelial cells of the liver unique
The endothelial cells are discontinuous - there are spaces between cells and between the endothelium and hepatocytes (Space of Disse)
What investigations should be done for an isolated raised bilirubin
Is it pre-hepatic, hepatic or post hepatic?
a. Pre-hepatic: haemolysis → FBC + blood film
b. Hepatic → repeat LFTs
c. Post-hepatic: Obstructed
What is the Van den Bergh reaction
Measures serum bilirubin via fractionating
Direct reaction: conjugated
Indirect reaction: Unconjugated
What are the considerations for jaundice in children
Need to know whether unconjugated or conjugated.
Jaundice is normal >24h, but bilirubin should be unconjugated (liver immaturity + fall in the Hb in early life)
If it does not settle, other rare causes should be looked for including hypothyroidism, other causes of haemolysis (including Coomb’s test or DAT) and the unconjugated bilirubin will be useful
What is Gilbert’s syndrome and what is its inheritance
A common condition that causes an isolated raised bilirubin in the absence of any deranged liver values
Causes jaundice that is worsened by fasting
Recessive inheritance (50% carry the gene)
What is the prevalence of Gilbert’s syndrome
1 in 20
What is the pathophysiology of Gilbert’s syndrome
UDP glucoronyl transferase activity is reduced to 30%
Unconjugated bilirubin tightly albumin bound → does NOT enter urine
Which measurements assess liver function
Prothrombin time (most representative)
Bilirubin
Albumin (production is slow)
How is hep A transmitted and what is the timeline for infection
Faeco-oral transmission
- Virus excreted in the 4 weeks before becoming ill (incubation)
- IgM response
- Jaundice develops
- IgG response → immunity
What is the timeline for hepatitis B infection
- Infection
- Hbe antigen production - acutely infectious, exposed to the LIVE virus
- Anti-Hbe production to neutralise Hbe Ag
- Anti-Hbc and anti-Hbc IgM production
What is seen on histology of the liver for alcoholic hepatitis
“clear spaces” - fatty change (due to reversible fatty change in the liver)
Mallory hyaline bodies - pink, dense material
Neutrophils and lymphocytes present
Damaged hepatocytes
Brown/green pigment (bile) due to accumulation
Collagen stains blue to show collagen surrounding hepatocytes (scarring)
What are the defining histological features of liver damage
Liver cell damage (Balloon cells with Mallory hyaline, mixed neutrophilic and lymphocytic)
Inflammation
Fibrosis
Fatty change
Mega/giant mitochondria seen
What is the management for alcoholic hepatitis
Vitamin B1
Thiamine
Stop drinking
Supportive
Nutrition
What does vitamin B1 deficiency cause
Beri-Beri
What are the clinical signs of chronic liver disease
Multiple spider naevi
Palmar erythema
Gynaecomastia (liver is unable to break down oestradiol)
Dupuytren’s contracture (fourth finger most commonly affected)
What are the features of portal hypertension
Splenomegaly
Visible veins
Ascites
What is a flap on examination indicative of
Liver failure
What are the functional deficits in liver failure and what can it lead to
Synthetic function
Clotting factor and albumin -> bleeding tendencies
Clearance of bilirubin -> jaundice
Clearance of ammonia
Can lead to encephalopathy
What is the histology of liver failure
Gross: pale liver, made up of fat, uniform nodules with a cuff of fibrous tissue around each, whole liver involved
Micro: nodule of regenerating hepatocytes with a fibrous cuff around the nodule
Why may liver failure lead to encephalopathy and varices
Scarring between the portal tracts and portal veins which allows the blood to bypass the hepatocytes (intra-hepatic shunting of blood), while formation of varices/haemorrhoids are extra-hepatic shunts
What are the causes of liver cirrhosis
Fatty liver disease (alcoholic and non-alcoholic) -> micronodular
Viral hepatitis (Hep B, C and D) -> macronodular
Haemochromatosis (iron)
Wilson’s disease (copper)
Primary biliary cholangitis
Primary sclerosing cholangitis
Give examples of portal-systemic anastomoses
Oesophageal varices
Rectal varices
Umbilical vein recanalising
Spleno-renal shunt
What do scratch marks suggest in liver disease
Obstruction of the bile ducts → bile salts/acids enter the skin
What is Courvoisier’s law
Gall bladder is palpable in a jaundiced patient - likely to be pancreatic cancer (and NOT gallstones)
Gallstones = Gall bladder becomes thickened and fibrosed → cannot enlarge
