Liver Duval Lecture Flashcards
What are the different types of hepatic injury?
- Inflammation (hepatitis)
- Degeneration
- Necrosis
- Fibrosis (irreversible)
- Cirrhosis (irreversible)
What are the irreversible types of hepatic injury?
- Fibrosis
- Cirrhosis
What are the different types of hepatocyte degeneration?
- Ballooning
- Foamy
- Steatosis
Describe ballooning degeneration of hepatocytes
- Swollen cells with clumped chromatin
- Toxic, immune
Describe foamy degeneration of hepatocytes
- Swollen cells with diffuse foamy appearance
- Retained biliary material
Describe steatosis
- Fatty degeneration of hepatocytes
- Microvesicular (ETOH, Reyes, AFLP)
- Macrovesicular (ETOH, DM, obesity)
What are the different types of hepatocyte necrosis?
- Coagulative
- Apoptosis
- Lytic
Describe coagulative necrosis
- Poorly stained cells, “mummified”
- Ischemic
Describe apoptosis of hepatocytes
- Toxic, immune
- Councilman bodies
Describe lytic necrosis
Hydropic degeneration (osmotic swelling)
Describe bilirubin metabolism (pathology)
- Breakdown of senescent RBCs
- Bind to serum albumin
- Hepatocellular uptake
- Glucuronides excreted into bile
- Deconjugation in gut to urobilinogens
Describe unconjugated (indirect) hyperbilirubinemia (pathology)
- Water insoluble, tightly bound to albumin
- Cannot excrete in urine
- Toxic (kernicteris)
Describe conjugated (direct) hyperbilirubinemia (pathology)
- Water soluble, loosely bound to albumin
- Excreted in urine
- Nontoxic
What can cause unconjugated hyperbilirubinemia (pathology)?
- Increased production (e.g. hemolytic anemia)
- Decreased uptake
- Decreased conjugation (e.g. hepatitis)
What can cause conjugated hyperbilirubinemia (pathology)?
- Decreased excretion
- Impaired bile flow (e.g. obstruction)
What are disorders a/w jaundice (pathology)?
- Physiologic in newborns
- Crigler Najjar I
- Crigler Najjar II
- Gilbert syndrome
- Dubin Johnson syndrome
- Rotor’s syndrome
What is Crigler Najjar I?
- A/w jaundice
- Increased unconjugated bilirubin due to lack of enzyme UGT
- Fatal
What is Crigler Najjar II?
- A/w jaundice
- Increased unconjugated bilirubin due to partial enzyme defect
- Nonfatal
What is Gilbert Syndrome?
- A/w jaundice
- Mild increased unconjugated due to reduced enzyme activity and impaired uptake
What is Dubin Johnson syndrome?
- A/w jaundice
- Increased conjugated bilirubin due to defective excretion
What is Rotor’s syndrome?
- A/w jaundice
- Asymptomatic increased conjugated bilirubin due to defective uptake and excretion
What causes cholestasis (pathology)?
- Hepatocellular dysfunction
- Biliary obstruction
Morphology of cholestasis
- Bile stained liver
- Foamy degeneration
- Distension/proliferation of upstream bile ducts
- Bile lakes
- Ultimately, fibrosis and cirrhosis
Features of cholestasis (pathology)
- Enlarged hepatocytes
- Dilated canaliculi
- Apoptosis
- Bile pigment in Kupffer cells
- Bile duct proliferation
- Bile retention
- Periportal degeneration
How much destruction of the liver needs to occur to produce hepatic failure?
80-90%
Morphology of hepatic failure
- Massive necrosis (viral, toxic, immune)
- Chronic liver disease
- Necrosis absent (Reyes, TCN, AFLP)
Describe hepatic encephalopathy (pathology)
- Metabolic disorder of CNS/neuro
- Severe loss of hepatic function
- Shunting of blood around diseased liver
Describe hepatorenal syndrome (pathology)
- Renal failure in setting of liver failure
- Reduced urine output
- Hyperosmolar urine with low Na
Morphology of liver cirrhosis
- Bridging fibrosis
- Regenerative nodules
- Diffuse architectural disruption
Causes of portal HTN (pathology)
- Prehepatic (thrombosis of portal vein, splenomegaly)
- Intrahepatic (cirrhosis, fatty change)
- Posthepatic (R HF, pericarditis)
What are non-hepatic viruses that can cause hepatitis?
- EBV
- CMV/herpes
- Yellow fever
- Adeno, rubella, entero
IgM antiHAV in Hepatitis A indicates:
Acute infection
IgG antiHAV in Hepatitis A indicates:
Immunity
What are the different states of clinical viral syndromes?
- Carrier state
- Asymptomatic infection
- Acute infection
- Chronic infection
- Fulminant
Acute infection by viral hepatitis consists of which stages?
- Incubation
- Symptomatic pre-icteric
- Symptomatic icteric
- Convalescence
Morphology of acute hepatitis
- Mixed inflammation
- Ballooning degeneration
- Cholestasis
- Councilman bodies
- Fatty change
Morphology of chronic hepatitis
- Early: portal inflammation
- Progression: periportal and bridging inflammation
- Late: post-necrotic cirrhosis
Describe fulminant hepatitis (pathology)
- Onset of disease to encephalopathy in 2-3 weeks
- MC viral (HBV more than HCV)
Morphology of fulminant hepatitis
- Diffuse or random areas of necrosis
- Shrunken organ
- Scarring
- Post-necrotic cirrhosis
Describe autoimmune hepatitis (pathology)
- Chronic hepatitis with immune abnormalities
- MC female
- Responds to immunosuppression
How can toxic liver injury occur (pathology)?
- Direct toxicity of agent
- Conversion to toxic species
- Immune mediated injury
Morphology of steatosis alcoholic liver disease
- Micro or macrovesicular
- Initially centrilobular
- Large, yellow, soft, greasy
- Completely reversible with abstinence
Morphology of alcoholic hepatitis
- Ballooning degeneration
- Mallory bodies
- Polys
- Fibrosis
Morphology of alcoholic cirrhosis
- Brown, shrunken, nonfatty
- Micronodular to mixed micro/macro (Laennec’s)
- Only 10-15% of alcoholics, females MC
- Cirrhosis can develop without having prior steatosis/hepatitis
