Liver Pathology Flashcards by Katya Angoua

Cirrhosis

Chronic end stage liver disease with diffuse fibrosis, diffuse loss of lobular architecture, diffuse formation or regenerative nodules

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Cirrhosis etiology

Liver damage by excess alcohol
Liver damage by viruses ( HBV, HCV, HBV+D)

Biliary disease
Congenital diseases ( Wilson’s disease, a-1 anti trypsin deficiency, galactoseMia,tyrosinosis)
Drugs ( a-methyl dopa, anti cancer ).
Cryptogenic

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Fibrosis in cirrhosis

Irréversible

Bundles of portal portal , portal central , central , broad bands, that replace adjacent lobules

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Loss of architecture in cirrhosis

Done by diffuse scars

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Nodules formation in cirrhosis

Micronodular (less than 3mm)

Macronodular (more than 3mm)

Mixed nodular cirrhosis

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Pathogenesis of cirrhosis

Causative agent
Fibrosis by type 1&3 collagen in space of disse and lobules
Impaired nutrients and solutes diffusion
Loss of fenestrations in sinusoids
Mpaired transfer of products (albumin, lipoproteins, clotting factors) hepatocytes into blood
Fibrous tissue by ito cells due to cytokines Etc
Portal hypertension due to increased resistance in sinusoids caused by narrowing, nodules and fibrosis compressing portal vein

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Complications of portal hypertension

Ascites
Portosystemic shunt
Congestive splenomegaly
Hepatic encephalopathy

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Pathogenesis of ascites in cirrhosis

Sinusoidal hypertension
Hypoproteinemia
Low peritoneal reabsorption of fluid
interstitial leakage from capillaries due to portal hypertension
renal retention of sodium and water from secondary hyperaldosteronism

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Hepatocellular failure

Progressive
Loss of function over 80% to see failure symptoms.
70-95% mortality

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Features of hepatic failure

Jaundice 
hypoalbuminemia 
coagulation defects
Hyperammonemia
Fetor hepaticus
High hepatic enzyme in serum 
Gynecomastia
Testicular atrophy
Male hypogonadism
Palmar erythema
Spider angiomas
Muscle wasting 
Hypoglycemia
Hepatic encephalopathy

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Hepatic encephalopathy

Metabolites normally processed and eliminated by the liver gain entrance to the brain

Brain edema , severe loss of hepatic function, neurological signs , hyper reflexia, seizures, asterixis

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Hepatorenal syndrome

Appear like renal failure with no intrinsic morphologic or functional causes for renal failure

Drop in renal output 
Rising bun and creatinine 
Hyperosmolar urine with no protein 
Abnormal sediment 
Low sodium

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Complications of cirrhosis

Portal HPT (ascites, haemorrhoids, varices, splenomegaly)

Hepatocellular failure p

Hepatocellular ca

IInfections pneumonia duodenal ulcers TB

Circulatory disturbances- clubbing of fingers, cyanosis, peripheral vasodilation

Anorexia and wasting

Hypothermia

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Hepatic adenoma

Benign tumors of hepatocytes that occur mostly in women ( because of oral pill)

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Focal nodular hyperplasia

Nodular lesion that resembles cirrhosis

5 to 15 cm

Can protrude and can be pedunculated

Has central scar where fibrous septa radiate

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Most common tumor of the liver

Hepatic hemangioma’s

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Hepatic hemangioma incidence

All ages

both sexes

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What type of tumor is more common primary or secondary

Secondary

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Type of malignant tumor

Hepatocellular carcinoma’s( to hepatitis , mostly HBV)
Hepatoblastoma ( young childhood)
Angiosarcoma (vinyl chloride ..)

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Main primary malignant tumors of liver

Hepatocellular carcinoma (90%)

Cholangiocarcinomas(10%)

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Cholangiocarcinoma linked to

Thorotrast and opistorchis infections

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Hepatocellular carcinoma pathogenesis

HBV or HCV repeated cycles of replication

Accumulation of mutations
HBV x protein disrupt growth mechanism control
Aflatoxins activated and form mutagenic DNA adducts

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Etiology of hepatocellular carcinoma

HBV
HCV
Cirrhosis
Haematochromatosis
Tyrosinosis
Drugs 
Chemicals

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Morphology of hepatocellular carcinoma

Enlarged liver
Paler
Yellowish necrotic areas
Areas of hemorrhage

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Variant fibrolamellar type

``` Good prognosis Not associated to HBV or cirrhosis Affects young male and females in 20-40 Well differentiated hepatocytes Fibrous stroma ```

Steatosis

Accumulation of fat in hepatocytes

Cholestasis

Accumulation of bilirubin in hepatocytes

Most severe consequence of liver disease

Liver failure

Acute liver disease

Sudden and massive hepatic destruction | Encephalopathy and coagulopathy that occurs within 26weeks of initial liver injury

Chronic liver failure

Progressive and insidious liver injury over decades leading to hepatic failure

Acute on chronic liver failure

Unrelated acute injury superimposes on a well compensated late stage chronic disease

Mortality rate in persons with hepatic failure without transplant

80%

Etiology of acute liver injury

Drugs and toxins (acetaminophen) | Hepatitis (autoimmune, A,B,E)

Acute liver failure morphology

``` Massive hepatic necrosis Broad parenchyma loss Islands of regenerating hepatocytes Liver initially enlarged (hepatocytes swelling, inflammatory infiltrates, edema) then Shrunken liver ```

Clinical presentation of acute liver failure

``` Nausea Vomiting Jaundice Encephalopathy (subtle behavior abnormalities, confusion, stupor, deep coma...) Coagulation defects (vit k and clotting factors synthesis impairment ) Alteration of bile formation Cholestasis Portal hypertension Hepatorenal syndrome ```

Hepatorenal syndrome

Renal failure occurring in liver failure

Etiology of chronic hepatic failure

Chronic hepatitis b , c Non alcoholic fatty liver Alcoholic liver disease Cirrhosis

Portal hypertension types

Prehepatic Intrahepatic Post hepatic

Major prehepatic conditions

Obstructive thrombosis Massive splenomegaly Narrowing of portal vein

Major posthepatic conditions

Severe right sided heart failure Constrictive pericarditis Hepatic vein outflow obstruction

Major intrahepatic conditions

Cirrhosis Schistosomiasis Fatty change Sarcoidosis

Complications of portal hypertension

Ascites Pprtosystemic venous shunts Congestive splenomegaly Hepatic encephalopathy

Ascites

Accumulation of excess fluid in peritoneal cavity

Main cause of ascites

Cirrhosis

Type of fluid in ascites

Serous

Mnemonic for causes of acute liver failure

``` A : acetaminophen, Hepatitis (A and autoimmune) B : Hepatitis B C : Hepatitis C, cryptogenic D: Drugs/toxins, hepatits D E: Hepatitis E , esoteric causes F : fatty change of micro-vesicular type ```

Is hepatitis A self limited and benign

Yes.

Can HAV give chronic hepatitis

Can HAV give rise to acute liver failure ?

Rarely. Fatality rate very low also ( 0.1-0.3%)

Symptoms of HAV

Non specific Fatigue Loss of appetite Jaundice

HAV mode of transmission

Ingestion of contaminated water and foods | Shed in stool so feco oral contamination

HAV prevention

Vaccination

Marker of acute infection of HAV

IgM

Lifelong immunity in HAV ?

Possibly by igG anti HAV

Différent Fate of hepatitis B

``` Acute hepatitis Non progressive chronic hepatitis Progressive chronic hepatitis ( ending either cirrhosis) Acute hepatic failure Asymptomatic carrier state ```

HBV Transmission

Horizontal transmission Minor breaks in the skin Sex Drug abuse

Prevention HBV

Vaccination

Major cause of liver disease worldwide

HCV

HCV risk factors

Drug abuse Mutiplr sex partners Surgery Needle stick injury

HCV family

Flaviridae

Gross morphology of acute viral hepatitis

Normal liver or slightly mottled

Histologic morphology of hepatitis

Lymphoplasmacytic infiltrate Spotty necrosis Lobular hepatitis May have Necrosis (cytoplasmic remnants, cell membrane rupture, hepatocytes dropout) May have apoptosis (hepatocytes shrink, eosinophils, pyknosis, karryorhexis)

Main toxic agent causing chronic liver failure

Alcohol

Most common cause of acute liver failure necessitating liver transplantation in the US

Acetaminophen

Forms of alcoholic liver disease

Hepatocellular steatosis/ fattychange Alcoholic hepatitis Steatofibrosis

Alcoholic liver disease morphology - hepatic steatosis

fatty liver with accumulation of lipid droplets that push nucleus aside Large liver yellow and greasy

Is fatty change reversible

Yes

Alcoholic liver disease morphology - alcoholic hepatitis

Hepatocytes swelling and necrosis Mallory denk bodies ( clumped amorphous eosinophils in hepatocytes) Neutrophilic reaction - accumulate around degenerating hepatocytes

Alcoholic liver disease morphology - alcoholic steatofibrosis

Sclerosis of central veins Chicken wire fence pattern (perisinusoidal scar accumulates in space of disse and spread outward encircling hepatocytes ) Cirrhosis installs Micronodular(laennec cirrhosis)

Are women more predispose to hepatic injury ?

Yes

Non alcoholic fatty liver disease causes

Insulin resistance giving hepatic steatosis Hepatocellular oxidative injury in liver cell necrosis

Non alcoholic fatty liver disease histologies

Mononuclear cells Less neutrophils Mallory denk bodies

Most reliable diagnostic tool for NAFLD

Biopsy for fatty

Hemochromatosis

Excessive iron absorption | Deposit in parenchymal organs ( liver, pancreas..)

Secondary hemochromatosis

Accumulation of iron due to excess parentéral administration of iron

Hemochromatosis presentation

Micronodular cirrhosis Diabetes mellitus Abnormal skin pigmentation Hepatomegaly Abd pain

Wilson disease

Impaired copper excretion into bile