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imed3004 > Medical Conditions of the Liver > Flashcards

Medical Conditions of the Liver Flashcards

1
Q

What are the types of pathologies that affect the liver?

A

“medical” conditions which are conditions that affect the entire liver. Can be acute or chronic and treated with medical therapy.

“surgical” conditions are localised lesions that may be amenable to resection.

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2
Q

What are the main histological patterns of disease that affect the liver?

A

Hepatitis - Inflammation of the liver

Steatosis - Fatty liver

Cholestasis - Retention of bile.

THERE CAN BE OVERLAP

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3
Q

What are the features of acute hepatitis?

A

< 6 months

Symptoms include insidious onset with fatigue, nausea, RUQ pain, tenderness, and jaundice.

Lasts 2 - 4 weeks and resolves

Minority progress to acute liver failure

Multiple disparate causes

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4
Q

What are the features of chronic hepatitis?

A

> 6 months

Symptoms not often present but they include weakness, tiredness, and malaise.

Often identified on screening blood tests

Aetiology dictates progression rate of damage and development of cirrhosis and carcinoma

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5
Q

What causes acute hepatitis?

A

Viral (hep A and E (majority) and B, C, and D. CMV, EBV, and HSV in immunosuppressed patients.

Other infections (Toxoplasmosis, Q fever, Leptospirosis, Brucellosis)

Alcohol

Drugs (paracetamol)

Toxins (Mushrooms, carbon tetrachloride)

Ischaemia

Autoimmune conditions

Metabolic (Wilson’s disease)

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6
Q

What causes chronic hepatitis?

A

Viral (hep B and C)

Alcohol

Drugs (methotrexate, amiodarone, isoniazid)

Autoimmune hepatitis (AIH)

Biliary (Primary biliary cholangitis PBC, or Primary Sclerosing Cholangitis)

Metabolic (alpha-1-antitrypsin deficiency, hereditary haemochromatosis, Wilson’s disease)

NAFLD (Non-Alcoholic Fatty Liver Disease)

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7
Q

What causes the majority of cases of chronic liver disease?

A

Hepatitis C

Alcohol

Hepatitis B

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8
Q

What causes hepatitis’ histological pattern?

A

Viral hepatitis

Autoimmune hepatitis

Drug/Alcohol

Primary Biliary cholangitis (PBC)/ Primary Sclerosing Cholangitis (PSC)

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9
Q

What causes steatosis (fatty liver)?

A

Alcohol

NAFLD / NASH (non-alcoholic steato-hepatitis)

Drugs - methotrexate and amiodarone

Hepatitis C virus

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10
Q

What causes cholestasis?

A

Primary biliary cholangitis

Primary sclerosing cholangitis

Extra-hepatic biliary obstruction

Drugs

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11
Q

What is cholestasis?

A

Retention of bile due to biliary tract disease

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12
Q

What is hepatitis?

A

A necro-inflammatory process comprising inflammation, hepatocyte necrosis and repair involving portal and lobular regions

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13
Q

What are the histological features of hepatitis?

A

Portal tract inflammation (lymphocytes, macrophages, neutrophils, plasma cells, eosinophils, granulomas)

Limiting plate (interface hepatitis)

Lobular inflammation and hepatocyte necrosis

Repair - macrophages, hepatocyte regeneration +/- fibrosis which may progress to cirrhosis

This pattern repeats constantly.

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14
Q

What are the types of steatosis and what commonly causes each type?

A

Macrovesicular: One vacuole filling the cytoplasm that is variable in size but often large. Caused by: alcohol (acute hepatitis), NASH (non-alcoholic steatohepatitis), drugs (methotrexate and amiodarone), and hepatitis C virus

Microvesicular: Multiple small vacuoles filling cytoplasm of a hepatocyte. Caused by: Reyes syndrome (URTI, childhood aspirin), acute fatty liver, drugs, congential metabolic disease (urea cycle disorders, jamaican vomiting disease)

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15
Q

What is cholestasis? What are its histological features?

A

Bile is blocked in canaliculi resulting in:

Feathery degeneration of hepatocytes

Bile plugs

Cell death with inflammation

Bile ductule proliferation at edge of portal tracts

Fibrosis - cirrhosis

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16
Q

What are the types of cholestasis conditions?

A

Pre hepatic: Excess bilirubin production (RBC breakdown)

Intrahepatic: Inborn errors, drugs, PBC, PSC

Post-hepatic: Extra-hepatic biliary obstruction (eg gallstones)

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17
Q

What are the 4 stages of primary bile cholangitis?

A

Duct lesion - duct damage, portal inflammation, granulomata

Ductular proliferation - expanded portal tracts interface hepatitis

Scarring - fibrosis, loss of bile ducts

Cirrhosis

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18
Q

What ar ethe types of primary sclerosing cholangitis?

A

Large duct vs small duct. Concentric fibrosis around ducts resulting in epithelial necrosis and duct loss

19
Q

What does liver biopsy tell us?

A

Assess whether hepatitic, steatotic, cholestatic, fibrotic, or overlap of several types.

Rarely can be used in isolation for a diagnosis. Must be combined with serological, clinical, and/or radiological evidence.

Not infrequently a non-specific pattern.

However, some aetiologies can produce characterstic patterns that may be highly suggestive of a particular cause.

20
Q

What are the histological features of HCV?

A

Low grade hepatitis

Lymphoid aggregates

Steatosis

Apoptotic cells

21
Q

What are the histological features of HBV infection? What else should be seen for diagnosis

A

Ground glass hepatocytes

Hep. B surface antigen.

22
Q

What are the histological features of auto-immune hepatitis? What else should be seen for diagnosis

A

Florid lobular and portal inflammation, interface hepatitis, hepatocyte “resettes” plasma cells.

Serological and clinical history should be investigated

23
Q

What histological patterns are associated with hepatitis caused by celebrex?

A

Hepatitis with eosinophils

24
Q

What are the histological features of alcohol liver disease?

A

Fat

Mallory’s hyaline

Cytoplasmic structural filaments

Neutrophils

25
Q

What causes nonalcoholic fatty liver disease? What causes it to progress to non-alcoholic steatohepatitis? What can NASH become?

A

Obesity/overnutrition which progresses due to genetic predisposition. NASH can transition to liver cancer or cirrhosis

26
Q

What are the histological features of non-alcoholic steatohepatitis?

A

Fat

Ballooned hepatocytes

Inflammation

Sinusoidal fibrosis

27
Q

What are the features of non-alcoholic steathepatitis?

A

Presence of fibrotic damage as well as fat, ballooned hepatocytes, inflammation and sinusoidal fibrosis.

28
Q

What are the classes of biliary diseases?

A

Primary biliary cholangitis (cirrhosis)

Primary sclerosing cholangitis

Extra-hepatic biliary obstruction

29
Q

What are the histologicla features of biliary diseases?

A

Inflammation/damage centered on bile ducts

Cholestasis

Bile ductule proliferation

Hepatocyte damage

Fibrosis

PBC shows duct damage, portal inflammation, and granulomas then fibrosis and bile ductule proliferation.

PSC shows concentric fibrosis around ducts and inflammation.

30
Q

How are inborn errors detected?

A

Using specific stains.

31
Q

What tests are used to investigate liver disease?

A

Liver function tests (LFTs): Enzymes, bilirubin, synthetic function (albumin and prothrombin)

Infective agents (antibodies or PCR to HAV, HBV, HCV, etc)

Serology - auto-immune Abs, Iron studies, etc

Tumour markers

Imaging +/- FNA for mass lesions

Liver biopsy (used for diagnosis, grading, and staging of disease)

32
Q

What is cirrhosis?

A

Diffuse alteration of the normal architecture by fibrous septa separating nodules of regenerating hepatocytes

End point of many disease processes where there are cycles of necrosis/inflammation and repair/fibrosis.

33
Q

What are the causes of cirrhosis?

A

Alcohol/drugs

Viral hepatitis

A, B, C, D, E, F, G, EBV, CMV, etc

Auto-immune hepatitis

Metabolic diseases

Genetic haemachromatosis (iron overload)

Alpha-1-antitrypsin deficiency

Wilson’s disease

Biliary tract disease (PBC, PSC)

Non-alcoholic steatohepatitis

Idiopathic

34
Q

What are the important features of cirrhosis?

A

Nodules of regenerating hepatocytes

Fibrous septae

35
Q

What are the clinical symptoms and signs of cirrhosis?

A

No symptoms, abnormal liver function tests

Non-specific symptoms and signs (malaise, abdominal pain and tenderness RUQ, and hepatomegaly - smooth or irregular)

Signs/symptoms of liver failure

Multi-organ failure / death

36
Q

How is cirrhosis treated?

A

Remove/treat aetiology (anti-viral medication, stop drinking alcohol/stop medication, immunosuppression, remove iron and copper)

Support and await repair/regeneration

Transplant

37
Q

What is the medical definition of acute liver failure?

A

Rapid deterioration of liver function in a previously healthy individual which results in coagulopathy (impaired protein synthesis), or hepatic encephalopathy (alteration in mental status).

38
Q

What are the types of acute liver failure?

A

Hyperacute is within 1 week

Acute is 1 - 4 weeks

Subacute is 4 - 12 weeks

39
Q

What causes acute liver failure?

A

Drugs/alcohol

Viral hepatitis

Auto-immune hepatitis

Metabolic diseases

Idiopathic

40
Q

What does a liver look like after acute liver failure?

A

Swollen soft and yellow.

Hepatocytes die and get resorbed.

41
Q

What does a liver that has undergone a paracetamol overdose look like?

A

Forms nutmeg liver which has peri-central necrosis

42
Q

How is acute liver failure treated?

A

Liver transplant

43
Q

What is needed for a liver transplant?

A

Blood group matched donor

44
Q

What are the indications for a liver transplant?

A

End stage chronic liver disease

Acute liver failure

Hepatic neoplasms (usually primary neoplasms rarely metastases, often in the setting of chronic liver disease)

imed3004 (50 decks)

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