Liver Pathology

Question 1

What is ballooning degeneration?

What are conditions in which it occurs? (3)

Answer 1

Ballooning degernation is depletion of ATP with loss of volume control

It results from severe cell injury including ischemia, cholestasis, toxicity due to alcohol

Question 2

What are causes of macrosteatosis? (list)

Answer 2

Obesity, alchol, drugs/toxins, HepC, ischemia, TPN, CF, metabolic

Question 3

What are causes of microsteatosis?

Answer 3

Fatty liver of pregnancy
Drugs (valproate)
Toxins
Inherited diseases
Reye's syndrome

Question 4

What are causes of unconjugated hyperbilirubinemia?

Answer 4

Physiologic jaundice
Bilirubin overproduction: hemolysis, hematomas, dyserythropoiesis
Diminished bilirubin uptake (RH failure)
Inherited disorders: UGT1A1- Cigler Najjar and Gilbert Syndrome

Question 5

What is kernicterus?

Answer 5

Complication of severe unconjugated hyperbilirubinemia– circulating free bilirubin crosses BBB and desposits within neurons of basal ganglia

Question 6

What are some of the pathologic appearances of cholestasis in liver? (3)

Answer 6

Feathery degeneration of hepatocytes

Rosetting/psuedoglandular arrangement of hepatocytes in prolonged cholestasis

Portal expansion and bile duct proliferation in obstructive cholestasis

Question 7

What are two major types of hepatocellular necrosis?

Answer 7

Cytolytic: irreversible ballooning of hepatocytes due to defective osmotic regulation resulting in cell swelling/death. Toxic cause

Coagulative: architecture of dead tissue preserved; results from ischemic damage

Question 8

Describe the difference between confluent and zonal necrosis

Answer 8

Confluent: Death of groups of adjacent hepatocytes (“like a geographic area”)

Zonal: confluent necrosis that exhibits a zonal distribution in the lobule

Question 9

What are the lab measurements that are taken to evaluate liver disease?

Answer 9

Hepatocyte integrity: AST, ALT, LDH
Biliary function: BR, bile acids, canalicular enzymes (Alk-Phos, GGT)
Synthetic function: Albumin, coagulation factors, ammonia

Question 10

What is the mechanism for chronic injury outcome?

Answer 10

Chronic injury==>Kipper cell activation==>Activation of stellate cells==>liver fibrosis==>Cirrhosis

Question 11

Describe the gross/histological appearance of cirrhosis

What are the leading cause of cirrhosis?

Answer 11

Gross: parenchymal nodules surrounded by fibrous tissue
Histo: islands of parenchyma with tons of fibrotic tissue between

Leading causes: HepB/C, NAFLD, alcoholic liver disease

Question 12

Acute Liver Failure:

What are most common causes? What are complications of liver failure? (2)

Answer 12

Common causes: Viral hepatitis (worldwide), acetaminophen overdose (West)

Complications include cerebral edema/intracranial hypertension

Question 13

Describe the histological appearance of acetaminophen toxicity

Answer 13

Confluent coagulative necrosis involving mid-zones (II/III)

Question 14

Describe gross and histological appearance for fulminant liver failure

Answer 14

Gross: significantly shrunken liver
Histo: parenchymal loss results in central vein and portal tract looking very similar due to reticulin collapse (“accordion collapse of veins”)

Question 15

Contrast the morphological features of acute vs. chronic hepatitis

Answer 15

Acute: Ballooning degeneration, apoptosis, cholestasis, little mononuclear infiltrate

Chronic: Bridging necrosis, dense mononuclear infiltrate, fibrosis of portal veins

Question 16

Describe the etiologies associated with variety of inflammatory cell types

Answer 16

Hepatotropic viruses: lymphocytes
Bacteria: neutrophils
Mycobacteria/fungi: granulomas
Autoimmune: lymphocytes/plasma cells
Drugs: eosinophils
Transplant rejection: eosinophils and lymphocytes

Question 17

Describe the histological features for acute hepatitis (2)

Answer 17

Hepatocellular injury with lobular inflammation

Giant cells

Question 18

What are types of necrosis observed with severe acute hepatitis? (2)

Answer 18

Confluent necrosis due to parenchymal collapse

Bridging necrosis resulting in portal-portal or portal-central linking

Question 19

What are etiologies of granulomatous hepatitis (5)

Answer 19

Infections: TB
Foreign body reactions
Drug reactions
Autoimmune disease
Primary biliary cirrhosis

Question 20

What are the etiologies for chronic hepatitis? (4)

Answer 20

Chronic viral hepatitis
Autoimmune hepatitis
Metabolic diseases: A1antitrypsin deficiency or Wilson’s disease
Drugs

Question 21

What do grade and stage measure in liver biopsy of chronic hepatitis case?

Answer 21

Grade: severity of inflammation and cellular injury
Stage: extent of fibrosis

Question 22

What is interface activity?

Answer 22

Interface activity refers to inflammation/hepatocellular injury at border between portal tract and the lobule (“limiting plate”)

Question 23

Describe morphological features of HepB vs. HepC

Answer 23

Both: lobular and portal infiltration
HepB: Evidence of antigen on staining (surface/core antigen), ground glass hepatocytes (accumulation of HepB surface protein)

HepC: More pronounced fat infiltration (steatosis)

Question 24

Describe epidemiology of autoimmune hepatitis

Answer 24

Female preponderance (70-90%)
Association with other autoimmune diseases (PSC)

Question 25

What are the difference types of autoimmune hepatitis (2)

Answer 25

Type I: anti-SMA/ANA with peak incidence 16-30yo

Type II: anti-LKM, peak incidence 10yo

Type II is more aggressive

Question 26

Describe the histology of autoimmune hepatitis?

Answer 26

chronic hepatitis (lobular hepatitis) with plasma cell infiltrate