Liver and Biliary Path Flashcards
What is Glisson Capsule
Another name for the liver capsule that is involved in nociception
What are the functions of each of the 3 classes of liver lobules?
- Classic Lobule: blood flow and synthetic function
- Portal Lobule: bile synthesis and excretion
- Hepatic Acinus: blood flow and involved in disease
Only clotting factor not made in hepatocytes.
Factor VIII, made in endothelial cells
Which hepatocytes make up the “limiting plate”?
The cells that line the portal tract and are the first cells exposed to the blood coming from the portal vein
What is the function and location of Ito cells?
Stellate cells
- store vitamin A
- synthesize growth factors for the liver
- secrete collagens
- involved in cirrhosis
- located in the space of Disse
Describe the structure of the hepatic sinusoids.
Sinusoids are lined with fenestrated endothelial cells. These endothelial cells separate the Space of Disse from the sinusoid lumen that contains all the RBCs. The fenestrations are too small for RBCs to get thru but big enough for the microvilli of the hepatocytes to penetrate and contact RBCs flowing in the sinusoids for detox and metabolism.
What is ballooning degeneration in liver disease?
Swelling of the hepatocytes seen on microscopy due to hepatic insult.
One condition that can cause Midzonal and/or periportal hepatic necrosis?
Eclampsia
What two things are required in order for the liver to regenerate?
- The insult needs to stop
2. The connective tissue framework needs to be intact
What hepatocellular response to injury results in irreversible liver damage?
Fibrosis
What two cell layers in the gallbladder missing compared to the rest of the GI tract?
Muscularis mucosa
Submucosa
What are councilman bodies?
Apoptotic cells found in the liver
What are the two types of fat accumulation in the liver and causes of each?
- Macrovesicular: metabolic or toxic injury
2. Microvesicular: Reye Syndrome, pregnancy, tetracycline or valproic acid use, HIV nucleoside analogs.
Top two causes of chronic hepatitis.
- Viral
2. Drug-Induced
Top 4 causes of Hepatic Cirrhosis
- Alcohol
- Viral
- NASH/NAFLD
- Biliary Disease
Four general early signs of liver cirrhosis seen on physical exam.
- Spider Angiomata
- Palmar Erythema
- Gynecomastia
- Ascites
What is a Cruveilhier-Baumgarten murmur?
Humming sound or bruit heard in the epigastric vessels in a patient with cirrhosis.
Common neurological sign seen on PE in patients with cirrhosis.
Asterixis
A patient with liver disease and high levels of ammonia in the blood will most likely also have what condition?
Hepatic Encephalopathy
Only test that can confirm a liver cirrhosis diagnosis.
Liver biopsy
Hepatitis viruses transmitted fecal oral route.
Hep A and Hep E
Antibody that is prominent during an acute phase Hep A infection.
IgM
does not cause a chronic infection, IgG takes over after infection
Only Hep virus that is a DNA virus.
Hep B
HepB antigen detected in the blood that leads to the worst prognosis.
Envelop surface antigen
HbeAg
Best therapeutic treatment to help prevent flare up with Hep B infection.
Remove alcohol from diet
What does a blood test containing Hep B surface antibodies indicate?
That the patient either had a Hep B infection or got the vaccine (contains only the surface antigen).
What does a blood test containing Hep B surface antigens indicate?
Currently acutely infected patient
What does a blood test containing Hep B core antibodies indicate?
Had the infection at one point but have cleared it and no longer infected.
(they will also have Hep B surface antibodies)
Mode of transmission of Hep B
Contact with contaminated blood.
Mode of transmission of Hep C
Shared IV needles
Blood test that indicates Hep C infection.
Serum cryoglobulinemia
-mainly means blood with immunoglobulins that precipitate (solidify and separate from the fluid) at low temperature
Serological Test for Hep C
Enzyme Immuno-Assay (EIA)
-can be negative if patients haven’t seroconverted yet
What is unique about a Hep D infection compared to all the other Hepatitis viruses and how is it treated?
It is harmless alone. Requires a “co-infection” with Hep B and then becomes a very dangerous superinfection.
Treat by prophylaxis to Hep B
Group of patients that is at most risk of dying from a Hep E infection.
Pregnant patients
Main microbe to worry about with liver transplants or organ donors in general.
CMV
Main route bacteria use to colonize and infect the liver.
Biliary system
-bacteria spread thru the duodenum and pass retrograde thru ampulla of vater
Only group of patients that experience mycotic infections of the liver.
Immunocompromised
fungal infection
What is the difference between Toxic agents and sensitizing agents that cause liver injury?
- Who is affected
- How the dose influences symptoms
- when symptoms appear
- histology
Toxic:
- Everyone affected
- Symptoms get worse with higher dose
- Symptoms appear right away
- Liver histo looks typical for toxic insult
Sensitizing:
- Only sensistive pts. affected
- Symptoms are not dose related
- Symptoms appear wks or mos after dose
- Histology similar to viral hepatitis
Most useful biochemical test to confirm Alcoholic hepatitis diagnosis.
Rise in Gamma Glutamyl Transferase (GGT) enzyme
Major hepatotoxin found in moldy food, rice corn, and can cause fatty liver, Hepatocellular carcinoma, Reye syndrome etc.
Aflatoxin B
Hepatotoxin that causes central lobular necrosis in hepatocytes.
Amanita Phalloides mushroom toxin
Hepatotoxin that comes from handling kerosene. Liver biopsy shows nuclear inclusions.
Lead
Major drug that can lead to cholestasis and liver injury.
Oral Contraceptive medications
How can drug-induced hepatitis be distinguished form viral hepatitis?
History only
Drug that can lead to microvesicular steatosis.
Valproic Acid
Drug that can lead to phospholipidosis in the liver.
Amiodarone
What is indicated on biopsy when the description is: Rosetting periportal hepatocytes?
Autoimmune Hepatitis
What would be high in the serum in a patient with autoimmune hepatitis?
Autoantibodies: AMA, SMA, LKM
Which gene is mutated in patients with Hereditary Hemochromatosis?
HFE gene
What is the transferrin saturation (%), ferritin levels (men and women), and treatment for a patient with Hereditary Hemochromatosis?
Transferrin: 45% saturation
Ferritin: Males >200 Females >150
Treatment: phlebotomy
How can Alpha-1-antitrypsin deficiency be diagnosed?
Accumulated AAT appears as inclusions within hepatocytes that stain positively with periodic acid-Schiff (PAS) reagent but resist digestion by diastase
How is Wilson Disease diagnosed and treated?
D: elevated 24hr. urinary copper excretion
T: D-penicillamine
What does a nutmeg liver indicate?
Central Lobular venous congestion due to heart failure
What is Budd-Chiari Syndrome?
Occlusion of hepatic veins that drain into the IVC. Can either be sudden (embolus) which leads to fulminant cirrhosis within days, or slow and fibrotic which presents similar to a liver in a patient with chronic heart failure
What is Gilbert Syndrome?
Mutation in glucuronyl transferase enzyme used to conjugate bilirubin. Unconjugated hyperbilirubinemia occurs but is not severe.
Condition in which patients have a black liver but it’s normal.
Dubin Johnson Syndrome: defective transporters from the hepatocytes to the biliary tract. Results in a conjugated hyperbilirubinemia.
What is the cause of Familial Recurrent Intrahepatic Cholestasis of Pregnancy?
High estrogen levels in the 3rd trimester. Most dangerous for the baby.
Treatment for primary biliary cirrhosis.
Ursodeoxycholic acid (UDCA)
What is Primary Sclerosing Cholangitis?
Inflammation and occlusion of the bile ducts that leads to liver cirrhosis. Bile ducts have a “beading” X-ray appearance.
Condition associated with PSC and treatment for PSC.
Treat: Ursodeoxycholic acid (UDCA) or transplant
90% have ulcerative colitis
What are the 4 risk factors for gall stones?
Fat, Female, Fertile, 40
Which medication is known to cause gall stones?
Oral Contraceptives
