Liver

Question 1

Signs of liver disease
Acute and chronic

Answer 1

icterus (jaundice), hepatomegaly, tenderness in right hypochondrium, peripheral edema

Question 2

Signs of liver disease
Chronic

Answer 2

splenomegaly, palmar erythema, spider angiomas, gynecomastia and testicular atrophy, Dupuytren contracture, parotid enlargement, clubbing, white nails (leukonychia), muscle wasting

Question 3

Classification of jaundice
Pre-hepatic

Answer 3

excess production (predominantly UNconjugated) (hemolytic anemia, increased blood resorption from hemorrhage, ineffective erythropoiesis)

Question 4

Classification of jaundice
Post-hepatic

Answer 4

Impaired bile flow (predominantly conjugated)
Gallstones, Ca head of pancreas and extrahepatic bile ducts
Biliary atresia common in neonates (

Question 5

Classification of jaundice: Hepatic

Answer 5

Reduced uptake (predominantly UNconjugated)
Drugs (interfere with membrane carrier system)
Diffuse liver disease (ex: viral hepatitis, cirrhosis)
Impaired conjugation (predominantly UNconjugated)– physiologic disease of newborn
Decreased excretion (predominantly conjugated)– drugs, transporter deficiency
Impaired bile flow (

Question 6

Check alkaline phosphatase and GGTs levels to differentiate

Answer 6

primarily biliary duct disease vs primarily hepatic damage 🡪 will be higher in biliary duct disease

Question 7

Portal triad –

Answer 7

bile duct, portal vein, hepatic artery

Question 8

Limiting plate

Answer 8

1st layer of cells surrounding portal triad

Question 9

Sinusoids

Answer 9

discontinuous endothelial cells between 2 hepatocytes, will take blood from portal vein/hepatic artery to central vein

Question 10

Viral pathology will affect mostly zone

Answer 10

1

Question 11

Drugs will predominantly affect zone

Answer 11

2

Question 12

Bile duct damage will be in zone

Answer 12

1

Question 13

heart failure damage will be in zone

Answer 13

3

Question 14

Ballooning degeneration

Answer 14

irregularly clumped cytoplasm

Question 15

Feathery degeneration

Answer 15

ine foamy cytoplasm because of detergent action of bile salts

Question 16

Clinical pathologic syndromes

Answer 16

asymptomatic infection, carrier state, acute hepatitis, chronic hepatitis (more than 6 months), fulminant hepatitis

Question 17

Chronic hepatitis

Answer 17

Chronic necro-inflammatory diseases in which hepatocytes rather than biliary structures are the main target
Clinical disease process of more than 6 months duration

Question 18

Viral hepatitis

Answer 18

Most common infective disease of the liver
However the term viral hepatitis is used for group of diseases caused by a group of hepatotropic viruses 🡪 hepatitis viruses A to E

Question 19

Hepatitis A

Answer 19

Caused by ssRNA virus
incubation period is 2-6 weeks
Does not cause chronic hepatitis
no carrier state

Question 20

Hepatitis B

Answer 20

Caused by enveloped DNA virus, long incubation period 4-26 weeks
Present in all pathological and physiological fluids
Transmission occurs by: transfusion of blood and blood products, sexual intercourse, IV drug abuse, homosexuals, needle stick injuries

Question 21

Hepatitis C

Answer 21

Most important cause of transfusion associated hepatitis and chronic liver disease
Incubation period is 1-3 weeks, much more propensity for chronicity, ssRNA
Inherently unstable virus so no vaccine yet
Persistent infection and chronicity are hallmark

Question 22

Fulminant hepatitis

Answer 22

clinical hepatic insufficiency that progresses rapidly to hepatic encephalopathy within 2-3 weeks
Viral hepatitis is the most important cause

Question 23

Alpha-1 antitrypsin deficiency

Answer 23

Autosomal recessive disorder
Markedly low levels of alpha antitrypsin (is protease inhibitor)
Is a glycoprotein encoded by PiMM gene in chromosome 14
Synthesized by liver
PiZZ is homozygote form (markedly reduced levels)
Forms with markedly reduced levels have lung disease (emphysema)

Question 24

Autoimmune hepatitis

Answer 24

Common in females, morphological features of chronic hepatitis, high titers of IgG (lot of plasma cells
Anti-nuclear and anti-smooth muscle antibodies (ANA/ASMA)
Anti-LKM (liver kidney microsomal type) antibodies
Responds to immunosuppressive therapy

Question 25

Primary biliary cirrhosis

Answer 25

Possibly autoimmune – anti-mitochondrial antibodies (AMA) in 90% Disease of middle aged women

Question 26

Primary sclerosing cholangitis

Answer 26

Inflammation, fibrosis, and dilatation of intrahepatic and extrahepatic ducts ERCP – beading of the biliary tree Males > females P-ANCA in ~80% cases Association with chronic ulcerative colitis

Question 27

Alcoholic liver disease

Answer 27

20 grams of alcohol in women or 60 grams in men can produce liver injury when consumed daily for years hepatic steatosis, alcoholic hepatitis (inflammation and steatohepatitis), variable amount of fibrosis to cirrhosis Mallory hyaline/bodies – tangled skeins of intermediate filaments, seen as eosinophilic cytoplasmic inclusions

Question 28

Non-alcoholic fatty liver disease

Answer 28

Changes like ALD in non-drinkers, steatosis with or without hepatitis Risk factors – obesity (insulin resistance, HLDs) Usually asymptomatic – mild elevation of serum transferases, may lead to cirrhosis

Question 29

Alcohol – increased

Answer 29

increased fat synthesis and FFA, decreased FA oxidation, decreased VLDL export, steatohepatitis, stop drinking

Question 30

Obesity – increased

Answer 30

ncreased FFA, increased FA oxidation, decreased VLDL export, steatohepatitis, diet exercise

Question 31

Hemochromatosis

Answer 31

Excessive accumulation of iron Primary/genetic AR (HFE gene on chromosome 6) – increased Fe2+ absorption, common in males, rarely manifests in bone before 40 Secondary/acquired Characterized by mononuclear cirrhosis, DM, skin pigmentation Treatment – phlebotomy

Question 32

Cirrhosis

Answer 32

bridging fibrous septa, parenchymal nodules created by regeneration, architectural disruption usually features of portal HTN and liver failure,

Question 33

Budd-Chiari syndrome)

Answer 33

clot/thrombus in hepatic vein

Question 34

Liver cell adenoma

Answer 34

Commonly associated with oral contraceptive pill (also anabolic steroids) May spontaneously hemorrhage and may undergo malignant transformation May be fetal during pregnancy

Question 35

Focal nodular hyperplasia

Answer 35

No relation to oral contraceptive pills, F:M = 4:1, most often small (may be very large), central scar on CT/MRI, normal liver spleen scan, resect if symptomatic or uncertain diagnosis

Question 36

Hepatocellular carcinoma

Answer 36

most common malignant tumor worldwide strongly related to prevalence of HBV

Question 37

Metastatic carcinoma

Answer 37

Most common malignant tumor involving the liver Common primary sites in adults – colon, pancreas, lung, breast