liver and biliary Flashcards
what does the liver process?
amino acids, carbs, lipids and vitamins
causes of jaundice?
hemolytic anemia, hepatitis, obstructive flow
pt. comes to clinic looking yellow and white of eyes are yellow what should be on your differential
jaundice
pt comes in with unexplained anorexia and says they have hereditary hemochromatosis what organ is being affected and what is wrong with it?
the liver is cirrhotic
you suspect a pt. has cirrhosis of the liver what are the top non rare causes of it?
alcohol abuse, chronic viral hepatitis, biliary disease, hereditary hemochomatosis, cryptogenic
what are some rare causes of cirrhosis of the liver?
wilsons, alpha antitrypsin deficiency, cardiac cirrhosis
pathologically what kind of nodules would you find on a liver with cirrhosis?
mixed
what is infiltrating the liver when it is cirrhotic?
cytokines, fibrin
cirrhosis of the liver is mostly a silent progress? T/F
true
if somebody dies of liver cirrhosis what is mostly of?
portal hypertension, liver failure, hepatocellular carcinoma
example of a prehepatic portal hypertension?
portal V thrombosis
example of a post hepatic portal hypertension
bud chiari syndrome due to thrombosis of the hepatic v.
what condition of the heart should be considered if they have bud chiari?
right sided heart failure
what are most of the cases of cirrhosis of the liver?
intraheptic
why would somebody with portal hypertension present with hepatic encephalopathy?
increased ammonia
what are the clinical findings of a pt. who has portal hypertension
ascites, splenomegaly, hepatic encephalopathy, venous shunts,
what are some examples of venous shunts when somebody has portal hypertension?
internal hemorrhoids, esophageal varices, caput medusa
***triad of bud chiari?
abdominal pain, ascites, hepatomegaly
some other symptoms of budd chiari?
acute rapid abdominal pain, jaundice, hepatomegaly, increased LFTs and encephalopathy
HAV/ hep A is spread how
enterically: fecal matter and poor hygiene
when HAV is carried through from the intestines to the liver does in enter the blood stream?
no
is HAV asmyptomatic?
yes
does HAV cause chronic hep, carrier state or predispose the pt. to cirrhosis or hepatocellular carcinoma?
no
HBV spread how?
- blood products
- sex
- IV drugs
- perinatal
- healthcare workers
are pt. with HBV asymptomatic most of the time or symptomatic?
asymptomatic
if a pt. has symptomatic HBV that is mild what is the likely hood of recovery?
good
fulimant hepatitis is when what happens?
massive liver necrosis
what can chronic hepatitis lead to?
hepatic carcinoma which is an important role in hepatocellular carcinoma
or
cirrhosis of the liver
the majority of pt. that have symptomatic HBV _______
recover
when inspecting an acute HBV liver under a microscope you notice ?
- cellular infiltrate throughout the lobule
- ballooning of the cytoplasm of degenerative cells
- councilman bodies
- mononuclear cell infiltrate in portal areas
Hep c is the leading cause for what?
chronic liver disease
HCV is spread by
- mainly blood products
- sometimes sex
- mother to child
what can pt.’s with HCV develop?
DM
When considering how a pt. will present to clinic with HCV will they present as asymptomatic or will they show signs of progression to chronic disease of the liver?
most pt. will progress to chronic disease of the liver
Hep D replicates on where under what circumstances?
in the liver when HBV is present
who is most likely to get HDV?
drug addicts and multiple transfusion individuals
hep E is contracted how?
water borne infection
is HEV associated iwth chronic liver disease?
no
HEV has a high mortality rate among which pt.?
pregnant women and HIV
which hepatitis virus has a dual infectin that protects against the HIV replication?
HGV
how is HGV spread?
- blood to blood products
- maybe sex
- hemodialysis pt.
grossly how will the liver look with viral hepatitis?
enlarged
micro. how would the liver look with viral hep?
- multifocal areas of necrosis with lymphocytic infiltrates
- ballooning degeneration of the hepatocytes
- councilman bodies
how would pt. present if they had symptoms of viral hepatitis?
fever, HA and nasea, vomiting, myalgia, enlarged and tender liver, jaundice with dark urine,
what would you find elevated in the serum of a pt. with viral hep?
AST/SGOT is elevated the most
leading cause of liver disease in USA is?
alcohol abuse
3 forms of liver disease due to alcohol intake?
hepatic steatosis
alcoholic hepatitis
cirrhosis
what are the mild reversible changes of the live in somebody who is an alcoholic?
macrovesicular steatosis
what would you find microscopically in alcoholic hepatitis
eosinophilic inclusions known as mallory bodies
alcoholic cirrhosis is it irreversible or reversible?
it is irreversible
alcoholic cirrhosis, is it seen more in men or women?
women
is alcoholic cirrhoiss micro or macro?
micro
Macorvesicular steatosis is seen with what stain?
oil red O stain
key findings of chronic alcoholic liver disease?
Macrovescular steatotis
- mallory bodies
- ballooning degeneration of hepatocytes
- micronudular cirrhosis
stage one of alcoholic liver disease?
steatosis - macrovescular
2nd stage of alcoholic liver disease
- mallory bodies/neutrophils
- ballooning hepatocytes
stage 3 of alcoholic liver disease?
micronodular cirrhosis of liver
what are some inborn errors of metabolism and pediatric liver disease?
wilsons, hemochromatosis, a1-antitrypsin
what is hemochromatosis?
excessive accumulation of body iron which is that deposited into the parenchymatous organs/liver and pancrease
what is a primary cause of hemochromatosis?
genetic defect/autosomal recessive
secondary cause of hemochromatosis?
- iron overload
- parentral iron
- hemolytic anemias
- aplastic anemia = suppressed BM
how would the cells appear in a hemochromatosis pt. microscopically?
yellow and golden color
kupffer cells full of granular brown deposits
what are some symptomatic findings in a pt. that has hemochromatosis?
liver- micronodular cirrhosis pancreas - diabetes Heart- restrictive cardiomegaly skin- bronze joints - arthritis gonads - hypogonadism = amenorrhea and impotence
what type of stain are the hepatocytes positive for?
prussian blue
wilsons disease also known as?
hepatolenticular degeneration
in wilsons disease fails to enter circulation in the form of what?
ceruloplasmin
what causes the build up of cu in the body in wilsons disease?
absorbed cu fails to enter the circulation in the from of ceruloplasmin and decreased biliary excretion of cu causing liver injury which causes the spill over of cu
where does the spilled over cu accumulate?
- putamen of the basal ganglia
- kayser fleicher rings
how would you Dx. the pt. with wilsons?
- a decrease in ceruloplasmin level
- increased hepatic cu
- increased urinary excretion of cu (body fails to absorb so it excretes and spills over into the body)
how does the liver look grossly in a pt. with wilsons?
golden, and has mixed nodules
a1- antitrypsin deficiency/ AAD causes?
over release of neutrophil elastase at the site of inflammation causing desctruction
what does a AAD lead to?
emphysema
hepatitis
liver cirrhosis
what stain is used for liver in AAD pt.?
PAS
in the lungs of a pt. that has AAD what do you see?
panlobular emphysema
causes of secondary biliary cirrhosis
cholelithiasis
strictures from previous surgery
malignancies of biliary tree and head of pancreas
prolonged obstruction and secondary inflammation will lead to?
periportal fibrosis > scarring and nodule formation = biliary cirrhosis
primary billiary cirrhosis is commonly caused by what?
autoimmune disease: ulcerative colitis, chrons disease
which enzyme is affected by antibodies in a pt. with an autoimmune disease that results in biliary cirrhosis?
pyruvate dehydrogenase
AKA antimitochondrail AB
specifically which malignancies will result in billiary cirrhosis?
adenocarcinoma of the head of the pancreas, and cancers of the biliary tree
microscopically what would you see in billiary cirrhosis?
- demolished biliary duct
- chronic inflammation in portal areas
- bile duct destruction
Kasai procedure is for pt. that have wat?
biliary atresia
what is formed in a kasai procedure?
rou-en-Y connection
what is reyes syndrome and who does it occur in?
use of salicylates (ASA) in past especially in children.
how would a pt. present to clinic with reyes syndrome?
- febrile with URI –> recovery
- -> projectile vomiting –> delirium and stupor
what happens to the body when a pt. has reyes syndrome?
mitochondrial injury to the liver, brain and muscle
what type of steatosis to the liver does reyes cause?
microvesicular
what stain is used to see panlobular arrangment of lipid
oil red O stains
is there hepatocyte necrosis or inflammation with reyes?
no
the two type of tumors that are caused by contraceptives in women in there childbearing years that and benign?
focal nodular hyperplasia & liver cell hepatocellular or hepatic adenoma
what is a cavernous hemangioma?
congential vascular channel defect
what is the most common bengign lesion of the liver?
cavernous hemangioma
how does the tumors appear on the liver with cavernous hemangioma
red blue nodules less than 2cm
what is different about the growth of the liver cell adenoma?
they are hormone dependent
the liver cell adenoma is benign what kind of characteristic does it have?
well demarcated
where would you commonly see the liver cell adenoma?
beneath the capsule
complication of a liver cell adenoma?
rupture leading to severe hemorrhage
and very rarely may develop into malignancy
what is the likelyhood of a pt. having primary carcinoma of the liver?
relatively uncommon
what do the primary carcinoma of the liver arise from?
hepatocytes
is hepatocellular carcinoma/HCC more common in men or women?
men
what may cause HCC?
- cirrhosis of the liver due to HBV and HCV
- dietary aflatoxins from aspergillus
- chemicals such as thoratrast
what is a more common form of HCC? 1ry or 2ry?
2ry by METS
what are the most common 1ry sites of cancer that spread to form 2ry HCC?
lung
breast
colon
pancreas
what is focal nodular hyperplasia?
benign tumor like lesion due to a vascular disturbance
what may you see microscopically in a liver that has focal nodular hyperplasia of the liver
- hepatocellular nodules
- central stellate scar
- radiating fibrous septa
- lymphocytic infiltrate
- has large feeder artery in capsule
for a FNH liver what stain is used?
actin immunohistochemistry
mesenchymal hamartoma of liver is what?
-uncommon benign tumor of childhood
- multiple cycsts grossly
-
what is the etiology of mesenchymal hamartoma of liver?
- primary bile dust plate malformation
vs - abnormal mesodermal development
what does the mesenchymal hamartoma consists of?
mesenchyme, bile ducts, hepatocyte cords and cysts
which brain tumor that occurs in children spread to the liver
neuroblastoma
forty year old woman pt. comes to clinic and says they had abdominal surgery what was it?
cholelithiasis
what are the 2 types of stone you can find in a pt. that had gallstones?
cholesterol(yellow) and pigment (dark green)
which stones found in gallbladder are associated with chronic hemolysis?
pigment stones
what is the only pathway for cholesterol elimination
bile
when would gallstones be acquired?
the [cholesterol] exceeds solubilizing capacity of bile causing solid cholesterol monohydrate crystals
fat fertile and forty is a saying used for what
to describe who is more likely to get choleslithiasis
what is almost always associated with gallstones?
cholecystitis
acute calculuous cholecystitis is what?
acute inflammation of the gallbladder that has stones
obstruction of what in the gallbladder will lead to acute calculuous cholecystitis?
neck or the cystic duct
what is the most common complication of gallstones?
acute calculuous cholecystitis
pathologically how would the gall bladder appear with acute calculuous cholecystitis
- enlarged with red adematous wall
- serous coat covered with fibrinous or suppurative exudate
- mucosal ulcerations
- stones are present
clinically how would a pt. with acute calculuous cholecystitis present?
- upper abdominal pn. that radiates –> shoulder
- colicky with stones
- fever
- nausea
- vomiting
- right subcostal region is tender
- distended gallbladder
what bacteria may cause chronic cholecystitis
e coli
what are some causes of cholecystitis
- repeated bouts of acute cholecystitis
- stones
- ## supersaturation of bile
how would the gallblader appear grossly?
- contracted
- thick grey wall
- stones
tumors of the gallbladder are common or uncommon more in women?
common
if somebody has a tumor of the gallbladder where is located?
the biliary tract?
pt. comes in and says that have gallbladder cancer and they caught late what is the outlook?
death
pathologically what kind of tumor would be located in the gallbladder?
adenocarcinoma
if a pt. comes in with symptoms of cholelithiasis what must the Dr. test for because they present with the same clinical signs?
adenocarcinoma of the gallbladder
