Liver

Question 1

What is the space between the hepatocytes and the endothelium

Answer 1

The ‘Space of Disse’ – the spaces between the hepatocytes and the endothelium (discontinuous organisation) of the sinusoids meaning that the blood comes into contact with the all the liver enzymes

Question 2

What is the arrangement of hepatocytes and sinusoids

Answer 2

Hepatic artery, portal vein and bile duct sit on outside with sinusoid bringing these past the hepatocytes to the central vein

Question 3

Difference between zone 1 and 3 damage

Answer 3

Zone 1 is directly hepatoxic substances

Zone 3 is hypoxic or metabolised damage due to it being closer to the central vein and further from the artery

Question 4

How is paediatric jaundice treated

Answer 4

o Phototherapy

Converts bilirubin into lumirubin + photo-bilirubin

Question 5

What inheritance is Gilberts syndrome

Answer 5

Autosomal Recessive

Question 6

What happens in Gilberts syndrome

Answer 6

UDP glucuronyl transferase activity is reduced to 30%

The bilirubin in Gilbert’s is worsened by fasting

Question 7

What is the main marker of liver function

Answer 7

Pro-thrombin time

Question 8

Causes of pre hepatic jaundice

Answer 8

Haemolysis

Question 9

Cause of hepatic jaundice

Answer 9

Gilberts
Infective Hepatitis
Alcoholic Hepatitis
PBC

Question 10

Cause of post hepatic jaundice

Answer 10

Obstructive- stones

Pancreatic cancer

Question 11

What can the ratio of ALT to AST inform you

Answer 11

ALT > AST = other forms of hepatitis

AST > ALT = alcoholic hepatitis

Question 12

Hepatitis A- transmission and disease course

Answer 12

ofAEco-oral transmission route – food or men-on-men sex
o Contaminated water is often the major source E.G. Recent shellfish consumption

o Acute – asymptomatic, or – nausea, D+V, fever, jaundice, RUQ pain
 Onset = 2-6 weeks; symptoms last = ~8 weeks
 After viral titres start to drop, you get a rise in IgM antibodies and you become unwell with jaundice
 If you survive the initial few weeks, you will produce IgG antibodies and from that point onwards you are cured, and you are immune

Treatment- supportive, avoid alcohol

Question 13

Hepatitis B- transmission and disease course

Answer 13

Only 5-10% go chronic

Routes of infection:
 Sex (more commonly through unprotected sex than HCV)
 Vertically (mother - child)
 Blood products

o Normally acute presentation (can be acute ± chronic)
 Hepatitis symptoms – fever, jaundice, N+V, RUQ pain)

o Chronic carriers (bottom image) never clear the HBsAg however infectivity decreases with time

Acute- supportive, Chronic- anti-viral

Question 14

Hepatitis C- transmission and disease course

Answer 14

60-80% go chronic

o Features of HCV:
 Blood-product spread
 Normally results in an asymptomatic presentation leading to a chronic infection (60-80%)
 Can be treated and eradicated with anti-virals (~100% clearance rates)

Question 15

What conditions are HBV and HCV associated with

Answer 15

o HBC and HCV may be associated with:
 HCC (Hepatocellular carcinoma) – seen in SBAs with:
• “Hx of jaundice, hepatomegaly, weight loss”, “raised aFP”

 History of thalassaemia (hints at recurrent blood transfusions) – leading to chronic infection:
• Blood transfusions are a major risk factor for HCV (90%) and a minor risk factor for HBV (10%)
o HCV is much more likely to become chronic than HBV

Question 16

Disease course of HDV

Answer 16

Requires HBV infection

Question 17

Hepatitis E- transmission and disease course

Answer 17

o fAEco-oral transmission route – food or men-on-men sex- uncooked pork/shellfish

o Acute – asymptomatic, or – nausea, D+V, fever, jaundice, RUQ pain
 Onset = 2-6 weeks; symptoms last = ~8 weeks

Question 18

Histology of an alcohol damaged liver

Answer 18

Liver cell damage (ballooning ± Mallory-Denk bodies)
Inflammation
Fibrosis

Question 19

What does a nutmeg liver mean

Answer 19

Venous congestion (Budd-Chiari, congestive HF, etc.)

Question 20

Features of chronic STABLE (alcoholic) liver disease:

Answer 20

o Palmar erythema Spider naevi (>5)
o Gynaecomastia (failure of liver to break oestradiol down)
Dupuytren’s contracture

Question 21

Features of portal HTN

Answer 21

o Visible veins- varices and caput medusa
o Ascites
o Splenomegaly

Question 22

Signs and symptoms of post hepatic jaundice

Answer 22

o Severely jaundiced
o Cachectic
o Palpable gall bladder
o Multiple scratch marks – suggest obstructive jaundice
 It is ONLY post-hepatic causes of jaundice that make you itchy
 They only appear in the blood stream when the bile duct is physically blocked

Question 23

Courvoisier’s Law

Answer 23

If the gallbladder is palpable in a jaundiced patient, the cause is unlikely to be gallstones (i.e. it is more likely to be pancreatic cancer) – will also be a PAINLESS jaundice

Question 24

Where does pancreatic cancer usually metastasise to

Answer 24

Liver- do to hepatic portal vein

Question 25

Acute vs chronic hepatitis histology

Answer 25

• Acute hepatitis - spotty necrosis
• Chronic hepatitis - piecemeal necrosis, hepatocyte necrosis, fibrosis, nodules of regenerating hepatocytes, Bridging from the portal vein to central vein

Question 26

Micro-nodular vs. macronodular hepatitis causes

Answer 26

o Micronodular = alcoholic hepatitis, biliary tract disease

o Macronodular = viral hepatitis, Wilson’s disease, A1AT

Question 27

Stages of alcoholic liver disease and their histology

Answer 27

1. Hepatic steatosis – fat droplets in hepatocytes
2. Alcoholic hepatitis – ballooning ± Mallory Denk bodies
3. Alcoholic cirrhosis – micronodular fibrosis (small nodules + bands of fibrous tissue)

Question 28

Most common cause of chronic hepatitis

Answer 28

o Non-alcoholic fatty liver disease

 Simple steatosis
 NASH (Non-alcoholic steatohepatitis) – steatosis + hepatitis