Liver pathology I

Question 1

Review normal liver anatomy below

Answer 1

Question 2

Review the slide below on hepatic microarchitecture

____ is a space that houses ___ cells that initiate fibrosis when the liver is injured

How is the liver divided into zones? Which zone is the most prone to ischemia and why?

Answer 2

The Space of Disse is the space that has stellate cells (become activated when liver is injured and initiate fibrosis >> cirrhosis)

The liver is divided into zones based on oxygenation: Zone 1 being the most oxygenated (closest to portal tract) and Zone 3 being the least oxygenated (and thus the most affected by ischemia)

Question 3

Label the liver below. Is this normal or diseased liver?

Answer 3

*see slide*

Normal liver, no fibrosis

Hepatic cords: sinusoid >> hepatocytes >> sinusoid (should be no thicker than 1-2 cells If thicker, worry about neoplasm)

Limiting plate: the fibrous tissue at the end of the portal tract (according to Wikipedia: ring of hepatocytes abutting connective tissue of portal triad)

**refer to lecture ppt for slide on portal triad**

Question 4

There are different stains used to visualize the liver.

Which stain is used to detect liver fibrosis?

Which stain is also used to detect fibrosis, but detecting type 3 collagen?

Which stain would be used to detect conditions involving iron, e.g. hemochromatosis?

Answer 4

Trichome stain is used to detect fibrosis (type I collagen)

Reticulin stain detects fibrosis by looking at type III collagen

Iron stain is used to stain for iron (e.g. hemochromatosis or iron overload)

Question 5

What are the pathologies below? (label and define each)

Answer 5

Top left: steatosis (fat accumulation in liver cells)

Top right: cholestasis (literally bile stasis)

Bottom: ballooning degenaration - hepatocyte swelling

Question 6

What is the pathology below?

Answer 6

Necrosis (lots of uncontrolled release of cell contents >> redness)

Apoptosis: apoptotic bodies

Question 7

Hepatitis is characterized by infiltration of which inflammatory cells?

Answer 7

Inflammation of the liver is characterized by lymphocyte infiltrate (not neutrophils like everywhere else)

Question 8

What is the pathology below?

Answer 8

Left: liver cirrhosis

Characterized by nodules surrounded by fibrous bands

Also has bile ductules - fake bile ducts, w/ advanced disease

Question 9

Fill in the blanks below

Answer 9

Remember that injury involving the bile ducts will result in elevated bilirubin + alk phos, injury involving the hepatocytes results in elevated AST/ALT

Question 10

Fill in the table of non-neoplastic liver diseases

Answer 10

*see below*

Question 11

Acute hepatitis primarily affects what unit of the liver?

What are 4 characteristics of this disease?

Chronic hepatitis mainly affects the ___ and is characterized by interface activity, inflammation (+/-), apoptotic bodies and ___ (hint: leads to cirrhosis)

Answer 11

Acute hepatitis mainly affects lobules

Characterized by: lymphocytes, lobular disarray + ballooning degeneration, apoptotic bodies, +/- necrosis in severe cases

Chronic hepatitis mainly affects the portal tract and is characterized by interface activity, inflammation (+/-), apoptotic bodies and fibrosis

Question 12

What is the pathology on the left?

Answer 12

Acute hepatitis

*notice the apoptotic body - black arrow, and the lymphocyte infiltrate*

Question 13

What is the pathology below?

Answer 13

Submassive hepatic necrosis

Question 14

Describe the difference between staging and grading in chronic hepatitis. Which is reversible and which is not?

Answer 14

Grade is a measure of how much inflammation there is and is therefore reversible w/ treatment

Stage is a measure of how much fibrosis there is and is therefore irreversible (generally)

Question 15

Study the slide below on staging in chronic hepatitis

Answer 15

Question 16

Long standing chronic hepatitis increases risk of ___

Answer 16

Long standing chronic hepatitis increases risk of hepatocellular carcinoma

**long standing bile duct injury increases risk of cholangiocarcinoma**

**cirrhosis in general increases the risk of hepatocellular carcinoma**

Question 17

A pt comes in with suspicion of viral hepatits. You do a biopsy and you notice ground glass hepatocytes. You also do serology and you confirm the presence of anti-HBc IgM and HBs Ag.

Which hepatitis virus is on your differential?

Answer 17

Hepatitis B

Question 18

A different pt comes to you presenting with jaundice and scleral icterus and is suspected to have viral hepatitis. You do a biopsy and you observe lymphoid follicles in the portal tract + mild steatosis. You later learn that the pt is also an IV drug user.

Which hepatitis virus is on your differential?

Answer 18

Hepatitis C

Question 19

A 33 year old female pt comes in w/ severe chronic hepatitis. On biopsy, you observe extensive interface activity, bridging necrosis and the presence of plasma cells. You later treat the pt w/ prednisone and she responds well.

Which hepatitis category is in your differential?

Answer 19

Autoimmune hepatitis

(note the pix below w/ plasma cells)

Question 20

What is the pathology below?

Answer 20

Autoimmune hepatitis

Question 21

A patient presents with elevated liver enzymes on routine physical exam. Serology is performed and the patient is found to have Hepatitis C. Which of the following histologic features is most compatible with chronic HCV infection?

A.Ground glass hepatocytes

B.Inflammatory portal based infiltrate composed of mostly plasma cells

C.Lobular inflammation without significant portal inflammation

D.Portal and periportal fibrosis

Answer 21

D. Portal and periportal fibrosis

Question 22

Unlike in hepatitis, fibrosis in fatty liver disease occurs around ___ and results in a “chicken-wire fence” pattern

Steatosis is characterized by __ in liver cells

Steatohepatitis is characterized by steatosis, ___, +/- ___

Answer 22

Unlike in hepatitis, fibrosis in fatty liver disease occurs around the central vein and results in a “chicken-wire fence” pattern

Steatosis is characterized by fat in liver cells (pushed nucleus aside)

Steatohepatitis is characterized by steatosis, ballooning, +/- inflammation

Question 23

What is the pathology below?

Answer 23

Fatty liver

Question 24

The slide below indicates what pathology?

Answer 24

Steatohepatitis (inflammation, ballooning, fat droplets + Mallory bodies but don’t necessarily have to see these. if present, suggests alcholic fatty liver)

Question 25

A patient undergoing bariatric surgery is noted to have a nodular liver. Biopsy is taken which shows marked steatosis with inflammation and Mallory body formation. Trichrome stain shows pericellular “chicken-wire” fibrosis. What is likely to occur as he loses weight following surgery?

A.The fat and fibrosis will decrease

B.The fat will decrease, but the fibrosis will stay the same

C.Both the fat and fibrosis will stay the same

D.The fat and fibrosis will get worse

Answer 25

B. Fat decreases but since fibrosis is irreversible, it won’t change

Question 26

Hemochromatosis is caused by excessive ___ deposition in parenchymal organs and involves cirrhosis, diabetes, “bronze diabetes” (skin pigmentation) and cardiomyopathy

How is this disease treated?

Answer 26

Hemochromatosis is caused by excessive iron deposition in parenchymal organs and involves cirrhosis, diabetes, “bronze diabetes” (skin pigmentation) and cardiomyopathy

Treatment: phlebotomy, chelation

Question 27

Review this slide on normal iron absorption

Answer 27

Question 28

In hemochromatosis, iron overload is due to reduced hepcidin caused by the mutation ___

Answer 28

In hemochromatosis, iron overload is due to reduced hepcidin caused by the mutation C282Y in HFE3

**reduced hepcidin = more iron leaving the enterocyte via ferroportin >> systemic iron overload

Question 29

What is the pathology below?

Answer 29

Hemochromatosis (all the blue is iron)

Question 30

___ is synthesized in the liver and normally inhibits proteases. A mutation in this protein (most common = __) results in a misfolded protein that accumulates in the ER of hepatocytes

Answer 30

alpha 1 antitrypsin is synthesized in the liver and normally inhibits proteases. A mutation in this protein (most common = PiZ) results in a misfolded protein that accumulates in the ER of hepatocytes

**increased risk of liver disease due to other causes, and increased risk of panlobular emphysema - lack of alpha 1 antitrypsin in the lungs**