Liver Histology

Question 1

What are the parts of the liver acini?

Answer 1

Central vein (middle drains into hepatic vein)

Hepatic artery, vein and bile ductule

Between these two areas are hepatocytes which are split up with venules, arterioles and bile canaliculi as well as sinusoids

Question 2

What are the causes of raised BR?

Answer 2

Pre hepatic (unconjugated - haemolysis - FBC and blood film)
Hepatic (disease, repeat LFTs)
Post hepatic (obstructive)

Question 3

What is the van den Bergh reaction?

Answer 3

The van den Bergh reaction measures serum bilirubin via fractionation.

Question 4

How does the van den Bergh reaction work?

Answer 4

A DIRECT reaction measures CONJUGATED bilirubin. The addition of methanol causes a complete reaction, which measures total bilirubin (conjugated plus unconjugated); the difference measures UNCONJUGATED bilirubin (an INDIRECT reaction).

Question 5

Is paediatric jaundice normal?

Answer 5

Yes - should be unconjugated BR due to liver immaturity, may also have Hb drop early on

Question 6

In which conditions do abnormal paediatric jaundice present?

Answer 6

> Hypothyroidism

> Causes of haemolysis (Coombes test/ DAT)

Question 7

What is phototherapy?

Answer 7

Converts bilirubin into two other compounds, lumirubin and photobilirubin which are isomers that do not need conjugation for excretion.

Question 8

In an adult with isolated raised BR, what is the next step?

Answer 8

Repeat with fasting BR to exclude other causes

Question 9

What condition would cause an isolated and asymptomatic raised BR?

Answer 9

Gilbert’s syndrome

Question 10

How common is Gilbert’s disease and how is it inherited?

Answer 10

Common- 1 in 20 (5-6% of the population)

Recessive

Question 11

How do we elucidate gilbert’s?

Answer 11

Worsened by fasting

However, phenobarbital reduces levels

Question 12

What causes Gilbert’s?

Answer 12

UDP glucuronyl transferase activity reduced to 30%​

Unconjugated bilirubin tightly albumin bound and does NOT enter urine.

Question 13

How is liver function measured?

Answer 13

Albumin
Clotting factors
Bilirubin

Question 14

How is liver damage measured?

Answer 14

ALT
AST
ALP
GGT

Question 15

Name some causes for prehepatic, hepatic and post hepatic jaundice

Answer 15

Pre hepatic: Gilberts and haemolysis

Hepatitis: Viral, alcoholic, cirrhosis

Post hepatic: gallstones, pancreatic ca.

Question 16

How do you discern hepatitis causes?

Answer 16

Viral: titres blood
AI: Biopsy
Alcoholic: Hx and biopsy

Question 17

Which Antibodies are related to HepA?

Answer 17

IgM and IgG

Question 18

Which molecules are related to HepB?

Answer 18

HBsAg
HBeAg
Anti-HBc
Anti-HBc IgM
Anti HBs
Anti HBe

Question 19

What are the defining histological features of alcoholic hepatitis?

Answer 19

Liver damage: Ballooning, Mallory Denk bodies

Inflammation (neutrophilia)

Fibrosis (collagen around every cell)

Fatty change and mega mitochondria

Question 20

What is the treatment for alcoholic hepatitis?

Answer 20

Supportive care
Alcohol cessation
Nutritional support incl. vitamins like B1

Occasionally steroids

Question 21

What are signs of chronic stable liver disease?

Answer 21

Gynaecomastia
Spider naevi
Palmar erythema
Dupytrens contractures

Question 22

What does caput medusae signify?

Answer 22

Portal hypertension- pressure in the umbilical vein

Question 23

What are signs of portal hypertension?

Answer 23

Visible veins
Splenomegaly
Ascites

Question 24

What is lost in liver failure?

Answer 24

> Synthetic function
failed clotting factor and albumin
failed clearance of BR
failed clearance of ammonia

> (encephalopathy)

Question 25

What is the sequelae of alcoholic hepatitis?

Answer 25

Alcoholic hepatitis
Chronic stable liver disease
Portal hypertension
Liver failure

Question 26

What are the sites of porto-systemic anastomosis?

Answer 26

Oesophageal varices​

Rectal varices​

Umbilical vein recanalising​

Spleno-renal shunt​

Question 27

What causes itching in jaundice?

Answer 27

Bile salts in obstructive jaundice

Question 28

What is courvoisiers law?

Answer 28

In the presence of jaundice, if the gall bladder is palpable, the cause is unlikely to be gall stones.​

(This is because a gall bladder with stones is usually small and fibrotic and incapable of being large.)

Question 29

What investigations are appropriate for obstructive jaundice?

Answer 29

US Abdo

-> dilated bile ducts

Question 30

What is the coombes test for?

Answer 30

Autoimmune haemolytic anaemia

Question 31

What is a sign that the enterohepatic circulation is intact?

Answer 31

Urobilinogen in the urine

Question 32

What is PT time?

Answer 32

12-14s

Question 33

What is the best marker of liver function?

Answer 33

Prothrombin time (function: clotting)

Question 34

If AST and ALT are very high and Alk Phos is high where is the issue in a jaundice patient?

Answer 34

Hepatic jaundice

Question 35

What is the timeline of hepatitis A?

Answer 35

virus in faeces/ infectious 2-6 weeks
IgM 3-12 weeks
IgG 5+ weeks

Question 36

What is the timeline of Hepatitis B?

Answer 36

HBs Ag - 1-6wks
HBe Ag - 1.5-4 wks
Anti HBc - 2 wks +
Anti HBc IgM - 2-9 wks
Anti HBe (true infection not vaccine) - 3-10+ wks
Anti HBs - 6.5 +
(Chronic Hep B in notes)

Question 37

What does Kwashiorkor cause?

Answer 37

Fatty Liver

Question 38

Which vein is involved in caput medusa?

Answer 38

Umbilical vein

Question 39

What happens to the gallbladder when there are gallstones?

Answer 39

Small