Microscopic anatomy of the liver and cirrhosis

Question 1

How much does a normal liver weigh?

Answer 1

1500g

Question 2

What are the 3 main structures found in the portal tract?

Answer 2

Hepatic artery
Hepatic vein
Bile duct

Question 3

What is the main cause of death due to alcohol toxicity?

Answer 3

Respiratory failure

Question 4

List the stages of chronic alcoholic liver disease?

Answer 4

Fatty liver (steatosis)
Hepatitis
Cirrhosis

Question 5

What enzyme is usually raised in chronic alcoholic liver disease?

Answer 5

Gamma glutamyl transferase

Question 6

List some examples of liver function tests

Answer 6

Bilirubin
Total protein
Albumin
Alanine Transaminase (ALT)
Aspartate Transaminase ( AST)
Alkaline Phosphatase( ALP)
Gamma Glutamyl Transferase ( GGT)

Question 7

What may be found on haematological tests of a person with chronic alcoholic liver disease?

Answer 7

Iron deficiency anaemia- lack of food
Folate and vitamin B12 deficiency
Raised INR- clotting factor dysfunctions- lack of vitamin K

Question 8

Why do patients with chronic liver disease bleed lots?

Answer 8

Lack of suitable clotting factors and vitamin K

Question 9

Describe the pathogenesis of alcoholic steatosis

Answer 9

Increased precursors for fat synthesis
Reduced breakdown of fat
Reduced hepatic excretion of fat
Fatty change of the liver is reversible on abstention

Question 10

List some causes of non-alcoholic fatty liver disease

Answer 10

1. Obesity
2. Type 2 diabetes
3. Drugs- methotrexate
4. Infection- hepatitis C

Question 11

Describe acute hepatitis

Answer 11

May be associated with jaundice
Patient will be very unwell
Polymorphs/neutrophils in the liver

Question 12

Describe chronic hepatitis

Answer 12

If the patient does not abstain, there is a risk of progression to fibrosis and cirrhosis
Lymphocytes infiltrate in the liver

Question 13

What does a green stain on biopsy represent?

Answer 13

Fibrosis

Question 14

Describe alcoholic cirrohsis

Answer 14

Irreversible end stage liver disease
Hallmark of cirrhosis – fibrosis/scarring and nodularity
Repeated inflammation and the healing process → regeneration of hepatocytes into nodules separated by scar tissue

Question 15

How is alcoholic cirrhosis classified?

Answer 15

Classified according to size of the nodules
Macro-nodular >3 mm
Micro-nodular < 3 mm

Question 16

Which sized nodule is most likely to develop into cancer?

Answer 16

Macro nodular

Question 17

List the causes of cirrhosis

Answer 17

alcohol (60 - 70% )
viral hepatitis ( B, C, D, E etc )
primary biliary cirrhosis
primary haemochromatosis
Wilson’s disease
alpha-1-antitrypsin deficiency
Cryptogenic

Question 18

What are the complications of cirrhosis?

Answer 18

Portal hypertension
Liver failure
Ascites
Hepatocellular carcinoma

Question 19

What are the signs of liver failure?

Answer 19

Jaundice
Hypoproteinaemia
Bleeding
Hepatic encephalopathy

Question 20

Describe portal hypertension. Explain why this is dangerous

Answer 20

The fibrosis causes portal hypertension
Blood flow through the liver is impeded
Blood finds an alternative route to the heart via the spleen and oesophagus leads to collateral circulation enlarged spleen & oesophageal varices
Risk of bleeding from varices – medical emergency

Question 21

What is the triad of portal hypertension?

Answer 21

Oesophageal varices
Cirrhosis
Splenomegaly

Question 22

List some causes of bleeding in an alcoholic patient

Answer 22

Oesophageal varices
Peptic ulcer
Mallory Weiss tear
Haemorrhagic gastritis
Reflux oesophagitis with ulceration

Question 23

What are mallory weiss tears?

Answer 23

Mallory Weiss tears occur at the oesophago-gastric junction when the patient vomits and retches against a closed cardiac sphincter

Question 24

What causes peptic ulcers?

Answer 24

The main causes of peptic ulcers are Helicobacter infection and Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

Question 25

Give some causes of death related to alcohol

Answer 25

Alcohol Toxicity ≤ 300mg/dl - novice drinker
≥ 350mg/dl - habitual drinker
RTAs: Legal limit 35mg/dl in breath ; 80mg/dl in blood

Sudden death in fatty liver due to metabolic acidosis resulting in arrhythmias

Haemorrhage:
Oesophageal varices
Acute gastritis/Peptic ulcer

Liver failure – acute/cirrhosis

Question 26

Describe hepatocellular carcinomas and how they are diagnosed

Answer 26

Hepatocellular carcinoma (HCC)  can arise as a complication of cirrhosis due to any cause, but alcohol related HCC is increasing
The blood test for  HCC is alpha feto - protein, which is raised, but not in all cases
Most common tumours are metastatic from GIT cancers

Question 27

List some complications of gall stones

Answer 27

Biliary colic
Acute cholecystitis
Empyema of gallbladder 
Perforation of gallbladder
Mucocoele of gallbladder
Porcelain gallbladder
Carcinoma of gallbladder
Obstructive jaundice
Secondary biliary cirrhosis
Ascending cholangitis
Liver abscess
Pancreatitis
Gallstone ileus