Liver n biliary

Question 1

what is the blood supply of the liver?

Answer 1

portal vein

hepatic artery

Question 2

what are the cells of the liver?

Answer 2

Hepatocytes
Bile ducts
Blood vessels
Endothelial cells
Kupffer cells 
Stellate cells

Question 3

what is the function of kupffer cells?

Answer 3

are the resident macrophagees of liver

Question 4

what is the function of stellate cells?

Answer 4

• stores vit A. acts like fibroblasts - lays down collagen - so very. important in cirrhosis pathophysiology

Question 5

which are the most metabolically active cells of the liver?

relevance?

Answer 5

the hepatocytes in zone 3*

this is where paracetamol and alcohol is metabolised

*remember there are 3 zones in the liver

Question 6

what is the relevance of the zones in the liver?

Answer 6

the portal tract is in zone 1, oxygen coming into the liver is richest supply in zone 1 and reduces along the course to zone 3.

zones important in metabolism of diff things

Question 7

what is special about liver endothelial cells?

Answer 7

they do not sit on a basement membrane

they are discontinuous - not attached / packed together

are fenestrated - many holes in them - allows bloods to pass from sinusoids into space of disse where it then contacts hepatocytes

Question 8

what special cells are found in hepatic sinusoids?

Answer 8

kupffer cells - sit on endothelial cells

Question 9

what happens to liver cells in liver injury?

Answer 9

Kupffer activated

Endothelial cells:

• lose fenestrations
• become tightly packed together
• > affects hepatocyte blood supply and nutrition

Activated stellate cells beging to lay down collagen

Hepatocytes lose microvilli

Question 10

what are the features of cirrhosis?

Answer 10

1. whole liver involved
2. fibrosis
3. nodules of regenerating hepatocytes
4. distortion of liver vascular architecture:
   intra- and extra- hepatic (e.g. gastro-oesophageal) shunting of blood - so you get unfiltered toxic blood going to heart and then to rest of bodyl

intra hepatic shunt - from portal tract straight into central vein
extra hepatic - doesnt go through liver at all

Question 11

how can we classify cirrhosis?

Answer 11

according to aetiology:

1) alcohol / insulin resistance
2) viral hepatitis etc

Question 12

what are the complications / consequences of cirrhosis?

Answer 12

1. Portal hypertension
2. Hepatic encephalopathy
3. Liver cell cancer ; eg HCC

Question 13

what are the causes of acute and chronic hepatitis ?

Answer 13

Acute:

1. viruses; Hep A-E (all of them )
2. drugs; paracetamol

Chronic:

1. viral hepatitis; B,C,D (only some)
2. drugs ; isoniazid
3. auto-immune

Question 14

in which case may cirrhosis bee reversible?

Answer 14

if of viral origin - aggressive treatment of th viral infection

Question 15

which histological pattern is associated with acute hepatitis?

cause?

Answer 15

spotty necrosis

cause - hepatocyte damage + lymphocyte infiltration, all across the liver

it is not neutrophil infiltration as would expect because, the condition is clinically acute but it takes weeks to develop

Question 16

define grade and stage in hepatitis?

Answer 16

severity of inflammation = grade

severity of fibrosis = stage (more important - determines risk of cirrhosis)

Question 17

what is the pattern of fibrosis in chronic hepatitis?

Answer 17

starts within the portal tract and spreads outwards

Question 18

Interface hepatitis (“piecemeal necrosis”), may be found in ___?

Answer 18

chronic hepatitis

Question 19

what are the forms of alcoholic liver disease?

prognosis?

Answer 19

1) fatty liver
2) alcoholic hepatitis
3) cirrhosis

prognosis - all carry risk of developing cirrhosis.
fatty liver is reversible when stop drinking alcohol

Question 20

balloon hepatocytes are pathognomic for?

Answer 20

Alcoholic Hepatitis

Question 21

what are the histological features of Alcoholic Hepatitis?

Answer 21

Ballooning of hepatocytes ( +/- Mallory Denk Bodies)
Apoptosis
Pericellular fibrosis
Mainly seen in Zone 3

Question 22

what is the key inflammatory cell in; Alcoholic Hepatitis

Answer 22

Neutrophil polymorph

Question 23

what are the features of Non-alcoholic fatty liver disease (NAFLD) including non-alcoholic steatohepatitis (NASH)?

Answer 23

Histologically looks like alcoholic liver disease

Due to insulin resistance associated with raised BMI and diabetes

Question 24

what is the epidemiology, aetiology and diagnostics for PRIMARY BILIARY CHOLANGITIS?

Answer 24

Previously primary biliary cirrhosis.
F> M

Bile duct loss associated with chronic inflammation (with granulomas) -> ‘granulomatous destruction of bile ducts’

Diagnostic test is detection of anti-mitochondrial antibodies - AMA
+ liver biopsy where you can see granuloma

Question 25

what is the epidemiology, aetiology and diagnostics for PRIMARY SCLEROSING CHOLANGITIS ?

Answer 25

M > F
Periductal bile duct fibrosis leading to loss
Associated with ulcerative colitis

Increased risk of cholangiocarcinoma

Diagnostic test is bile duct imaging - beading appearance!

Question 26

what is the aetiology of HAEMOCHROMATOSIS?

Answer 26

Genetically determined increased gut iron absorption
Gene on chromosome 6 (HFe)

Parenchymal damage to organs secondary to iron deposition (bronzed diabetes - due to pigmentation of the skin + damage to exocrine pancreas = diabetes)

Question 27

what is HAEMOSIDEROSIS?

prognosis?

Answer 27

Exceess of iron deposition;

accumulation of iron in macrophages - in the liver kupffer cells - liver macrophages

-excess blood transfusions; eg SS, B thal

does not lead to cirrhosis

Question 28

what is the epidemiology, aetiology and diagnostics for Wilsons disease?

Answer 28

Accumulation of copper due to failure of excretion by hepatocytes into the bile
Assessed by biopsy or biochemistry
Genes on chromosome 13

Accumulates in the liver and CNS (hepato-lenticular degeneration) including Kayser-Fleishcer rings

Question 29

how can we stain for copper in liver?

Answer 29

Rhodanine stain;

golden-brown color against the blue counterstain.

Question 30

what is the aetiology of autoimmune hepatitis? rx?

Answer 30

Active chronic hepatitis with plasma cells that are making ASMA;

Anti-smooth muscle actin antibodies in the serum

rx: Responds to steroids

Question 31

what might you see on histology of autoimmune hepatitis?

Answer 31

plasma cells

clock faced nuclei

Question 32

ALPHA-ONE ANTITRYPSIN DEFICIENCY can lead to which conditions?

Answer 32

Hepatitis and cirrhosis

Question 33

list the causes of Hepatic Granulomas ?

Answer 33

Specific causes:
PBC
drugs

General causes:
TB
Sarcoid etc

Question 34

the following are which kind of tumours:

1) liver cell adenoma
2) bile duct adenoma
3) haemangioma

Answer 34

benign liver tumours

adenomas dont have capsules - well dermacated but no capsules

Question 35

the following are which kind of tumours:

1. hepatocellular carcinoma
   
   2. hepatoblastoma
   3. cholangiocarcinoma
   4. haemangiosarcoma

Answer 35

malignant liver tumours - PRIMARY

Question 36

why is the liver a common site of metastatic cancer?

Answer 36

Portal Venous System - drains many sites

Question 37

how canyou tell something is adenocarcinoma on histology?

Answer 37

gland forming with mucin

Question 38

what are the associations of Cholangiocarcinoma?

Answer 38

Associated with:
PSC
Worm infections
Cirrhosis

Can arise from:
intrahepatic ducts
extrahepatic ducts (including gall bladder)