Liver Pathology Flashcards
what does liver failure lead to?
- increased susceptibility to infection
- increased susceptibility to toxins and drugs
- increased blood ammonia due to failure to clear ammonia via urea cycle leading to hepatic encephalopathy
define acute liver failure
rapid failure of the liver’s metabolic and synthetic function in a patient without a known pre-existing liver disease
how is acute liver failure classified?
based on the time interval between the initial onset of jaundice and the development of encephalopathy
what are the causes of acute liver failure?
paracetamol overdose - UK
acute viral hepatitis - worldwide
what is the presentation of acute liver failure?
- jaundice
- presence of risk factors (e.g. known paracetamol overdose)
- hepatomegaly
- signs of liver encapholapthy (lethargy, poor memory, liver asterixis, confusion)
- abdominal pain
- nausea and vomiting
What investigations would you carry out in acute liver failure?
- LFTs - high bilirubin, very high ALT and AST in paracetamol overdose
- clotting screen - PT time increased
- U&Es - renal failure is a known complication of ALF
- FBC
- Blood type and screen
- ABG - acidosis and lactate
- paracetamol level
- viral hepatitis serology
- autoimmune hepatitis markers
- pregnancy test
- abdominal ultrasound with doppler (hepatic vessel thrombosis, hepatomegaly)
how would you manage acute liver failure?
- hospitalisation
- liver transplant assessment
- neurological status monitoring for encephalopathy
- monitor blood glucose, electrolytes and blood cultures (increased risk of infection)
- look for underlying cause and treat (acetylcysteine for paracetamol overdose, methylprednisolone for autoimmune hepatitis)
- fluid resuscitation and maintenance
what type of tumours are most liver cancers?
metastatic (90%)
what is the main primary liver cancer? from where does this cancer arise?
hepatocellular carcinoma (thought to arise from hepatic stem cells)
what are the causes and risk factors of hepatocellular carcinoma?
- viral hepatitis
- chronic alcoholism
- family history of liver disease
- primary biliary cirrhosis
- hereditary haemochromatosis
- aflatoxin exposure
- smoking
- advanced age (>70)
what is the presentation of hepatocellular carcinoma?
vague, non-specific symptoms
- fatigue
- fever
- weight loss
- lethargy
- dull ache in right upper quadrant (uncommon but characteristic of hepatocellular carcinoma)
- ascites
- jaundice
- irregular, enlarged, craggy, tender liver
what investigations are carried out when suspecting hepatocellular carcinoma?
- LFTs (raised AST and ALT - AST:ALT ratio >2, likely alcoholic liver disease)
- Alpha fetoprotein - raised in most cases
- routine bloods - platelets low, clotting prolonged
- imaging - US, Staging CT, MRI liver, biopsy or percutaneous fine-needle aspiration (not advised if tumour is operable as can lead to seeing of the tumour)
what is the management of hepatocellulr carcinoma?
- surgical resection or transplantation
- image-guided ablation
- alcohol ablation
- transarterial chemoembolisation (TACE)
what is the criteria used to decide suitability for liver transplant?
milan criteria:
- one lesion smaller than 5 cm or 3 lesions smaller than 3 cm
- no extra-hepatic manifestations
- no vascular infiltration
which cancers commonly metastasise to the liver?
- bowel
- breast
- pancreas
- stomach
- lung
how are metastatic cancers of the liver managed?
- surgery if the metastasis is confined to the liver and primary tumour is under control
- transarterial embolisation
what are simple liver cysts?
fluid-filled epithelial-lined sacs
what is the presentation of simple liver cysts?
- usually asymptomatic
- often detected incidentally on imaging
- abdominal pain
- nausea
- early satiety (mass effect)
what investigations are carried out for simple liver cysts?
- LFTs - typically normal
- Tumour markers - CEA and CA19-9 can sometimes be elevated
- ultrasound - black spherical well-defined mass with no septations
what is the management of simple liver cysts?
- most cysts require no intervention
- cysts >4cm, follow-up US at 3, 6 and 12 months to check for growth
- if symptomatic - US-guided aspiration or laparoscopic de-roofing
what is polycystic liver disease?
characterised bu the presence of >20 cysts in the liver
what is polycystic kidney disease caused by?
one of two autosomal dominate conditions:
- autosomal dominant polycystic kidney disease (mutations in PKD1 and PKD2 genes)
- autosomal dominant polycystic liver disease
what is the presentation of patients with polycystic liver disease?
- majority are asymptomatic
- abdominal pain as cysts grow in size
- hepatomegaly
- urinary tract symptoms if there is renal disease (PKD)
what investigations re carried out when suspecting polycystic liver disease?
- LFTs - normal (ALP can sometimes be raised)
- Renal function tests
- Ultrasound for definitive diagnosis
what is the management of polycystic liver disease?
- asymptomatic patients don’t need treatment
- monitored regularly as the disease progresses
- surgery - resection of severe areas
- US-guided aspiration
- laparoscopic de-roofing of cysts
what are the indications for surgery in polycystic liver disease?
- intractable symptoms
- inability to rule out malignancy from imaging alone
- prevention of malignancy
what are cystoadenomas?
non-invasive mucinous cystic neoplasms
pre-malignant lesions (can undergo malignant transformation into cystadenocarcinomas)
what is the presentation of cystic neoplasms?
- usually asymptomatic
- abdominal pain
- anorexia
- nausea
- fullness
- bloating
what investigations are carried out when suspecting cystic neoplasm?
- LFTs (often normal, ALP can be slightly elevated)
- CEA and CA19-9 can be slightly elevated
- US scan
- CT imaging with contrast
- **aspiration or biopsy should be avoided if cystic neoplasm is suspected - can cause seeding of malignancy)
what are the features of a cystic neoplasm on imaging?
- septations (divisions)
- wall enhancement
- nodularity
how are cystic neoplasms managed?
liver lobe resection (both cyst adenomas and cystadenocarcinomas) -> histopathology to confirm diagnosis
what are hydatid cysts?
cysts caused by infection with tapeworm echinococcus granulosus.
what is the route of transmission of the causative organism of hydatid cysts?
faeco-oral
what is the presentation of hydatid cysts?
- can remain asymptomatic for many years
- vague abdominal pain
- jaundice or cholangitis (if biliary system involved)
- vomiting
- dyspepsia
- early satiety
- anaphylaxis if a cyst ruptures
what are the investigations that are carried out when suspecting a hydatid cyst?
- LFTs (often normal, unless biliary tree affected, then presents like cholangitis)
- FBC - eosinophilia
- echinococcal antibodies
- Ultrasound scan (calcified, spherical lesions with multiple septations)
- CT imaging with contrast
what is the management of hydatid cysts?
- if asymptomatic, monitor
- cyst deroofing
- radiological drainage and injection of a scolicidal agent (prevents dissemination of the parasite during surgery)
- combination of anti-microbials
- aspiration is not recommended as can rupture and cause anaphylaxis
what are the common causes of liver abscess?
- Cholecystitis
- cholangitis
- diverticulitis
- appendicits
- septicaemia
what is the presentation of a liver abscess?
- Fever
- rigors
- abdominal pain - RUQ tenderness
- bloating
- nausea
- anorexia
- weight loss
- fatigue
- jaundice
- possible hepatomegaly
- signs of shock if the abscess ruptures
what investigations are carried out when suspecting liver abscess?
- FBC (leucocytosis)
- LFTs (raised ALP, deranged ALT, deranged bilirubin)
- Blood culture
- Ultrasound
- CT imaging with contrast
how does a liver abscess appear on ultrasound?
- poorly defined lesion
- hyper- and hypo-echoic areas (light and dark)
- +/- gas bubbles
- +/- septations
how is a liver abscess managed?
- resuscitation and stabilisation (don’t forget sepsis)
- appropriate antibiotic therapy
- drainage of abscess using image-guided (US or CT) aspiration
- manage underlying cause
- surgery if the abscess has ruptured or is refractory to antibiotic treatment
