Pathology- Liver Flashcards
where is the liver
in the upper right hypochondrian
what is the periportal zone
area nearest blood supply- receives most oxygenated blood
what is the mid acinar zone
zone between periportal and pericentral
whyacinar zone furthest from blood supply most at risk to injury
as is cut off from the blood supply
what happens when the liver is acutely injured
liver is very resistant- Some liver insults can produce severe parenchymal necrosis but heal entirely by restitution
when does liver injury leave permanent damage
when injury chronic
what is the pathogenesis of liver disease
insult- inflammation- fibrosis- cirrhosis
what can cause insult to hepatocytes
viral, drug, toxin, antibody
what is acute liver failure
acute onset of jaundice (raised bilirubin)
what can cause acute liver failure
viruses, alcohol, drugs, bile duct obstruction
what is acetoaminophen toxitiy
poisoning of the liver, seen in suicides- confluent necrosis produces massive acute necrosis and liver failure
what are the possible outcomes of acute liver failure
complete recovery, chronic liver disease, death from liver failure
how is jaundice classified
site; pre, hepatic and post hepatic
type: conjugated, unconjugated
what is pre-hepatic jaundice
when there is too much haemolysis resulting in too much bilirubin being delivered to the liver
what can cause pre hepatic jaundice
haemolysis of all causes, haemolytic anaemias, unconjugated bilirubin, sickle cell disease
what is unconjugated bilirubin
not water soluble as not bound to other substances
what is hepatic jaundice
when the liver cells are injured or dead
what causes hepatic jaundice
acute liver failure, alcoholic hepatitis, cirrhosis (decompensated), bile duct loss, pregnancy
what is post hepatic jaundice
when the bile cannot escape into the bowl
what can cause post hepatic jaundice
congenital biliary atresia, gall stones blocking the common bile duct, strictures of the common bile duct, tumours at head of pancreas
is cirrhosis reversible
no
what are the characteristic features of cirrhosis
bands of fibrosis seperating regenerative nodules of hepatocytes, alteration of microvasculature, loss of hepatic function
what are the causes of cirrhosis
alcohol, hep b and c, iron overload, gallstones, cirrhosis, autoimmune liver disease
why is liver function impaired in cirrhosis
as healthy areas cut off from circulation and cannot receive or transmit substances in blood
what are the complications of cirrhosis
portal hypertension,
ascites,
liver failure
how can portal hypertension present
oesophageal varices, caput medusa, haemorrhoids
what makes up the portal vein
superior mesenteric and splenic vein
what are the other clinical features of chronic liver disease and cirrhosis
oedema (reduced albumin)
ascites (reduced albumin and increased aldosterone and portal hypertension)
haematemesis (ruptured varices)
spider naevi and gynaecomastia
coma (toxins still in blood)
purpura and bleeding (reduced clotting factor synthesis
infection (reduced kupffer cells)
what does alcohol cause in the liver
fatty liver- releases fatty acids and triglycerides
what injurs hepatocytes in alcoholic liver disease
acetaldehyde- metabolite of ethanol
what causes the laying down of collagen in alcoholic liver disease
fibroblasts
when does alcohol injury become irreversible
after months-years
what is steatosis
fatty liver
is a fatty liver reversible
yes
what else can cause a fatty liver
NASH Pregnancy Drugs Nutritional Diabetes (type 2) HepCV (type 3)
what are the features of alcoholic hepatitis
Hepatocyte necrosis
Neutrophils
Mallory Bodies
Pericellular fibrosis
what is massons trichrome
in alcoholic cirrhosis when defined bands of cirrhosis separates regenerative nodules
what are the possible outcomes of alcoholic liver disease
cirrhosis portal hypertension- varices and ascites malnutrition hepatocellular carcinoma social disintegration
what is NASH
non alcoholic steatohepatitis
what are the features of NASH and what causes it
pathologically identical to alcoholic liver disease
diabetes, obesity, hyperlipidaemia
what is now the commonest cause of liver cancer
NASH because of obesity
what viruses other than hep can cause viral heptatitis
ebstein barr,
yellow fever,
herpes simplex,
cytomegalovirus
what is delta agent
hepatitis D
how is Hep a spread
faecal oral
what is the incubation period of hep a
2-6 weeks
what does it mean the hep a is directly cytopathic
infection causes structural changes in a host cell
is there a carrier state in hep B
No- recovery or death (death v rare)
what is the usual outcome for hep a infection
mild illness followed by full recovery
what type of degeneration is seen in the liver during hep a
ballooning degeneration- sign of hepatocyte injury
how is hep B spread
blood, blood products, sexually, vertically (utero)
what damages the liver in Hep b
the antiviral immune response
is there a carrier state in hep b
yes
what are the outcomes of hep b infections
acute hepatitis followed by resolution
acute hep with liver failure, death
chronic inflammation either:
- non progressive
- progressive, cirrhosis, liver failure
hepatocellular carcinoma
is there a vaccine for hep b
ye
how is hep c spread
blood, blood products, possibly sexually
does hep c have a long/ short incubation period
short
why is there not a vaccine for hep c
as lots of virus subgroups, need a good antigen to develop vaccine
what is the usually course of hep c
usually assymptomatic, tends to become chronic
what does hep c increase your risk of
heptocelullar carcinoma
what does chronic viral hepatitis look like on microscopy
dense portal chronic inflammation - portal triad surrounded by inflammatory cells: mainly lymphocytes
what are inflammatory cells in acute inflammation
neutrophils
what is piecemeal necrosis and what causes it
interface hepatitis- when inflammatory cells infiltrate into the liver and obscure the border of the portal area
seen in chronic viral hepatitis
what is a councilman body
a dead hepatocyte
what is bridging fibrosis
when fibrosis caused by chronic viral hepatitis bridges between two portal areas
what does bridging fibrosis do to the liver
causes it to shrink- scar tissue is hard and contracts
what are the micro and macro nodules found in cirrhosis
macrondule> 3mm in diameter
micronodule <3mm in diameter
what are the outcomes of hep B
fulminant (severe or sudden onset) acute infection -> death
chronic hepatitis
cirrhosis-> from progressive to chronic
hepatocellular carcinoma increased risk
asymptomatic (carrier)
what is the outcome of hep c
chronic hepatitis
death
what autoimmune diseases can cause chronic hepatitis
primary biliary cirrhosis
autoimmune hepatitis
primary sclerosing cholangitis
who is more likely to get primary biliary cirrhosis
females 90%
what might be seen on biopsy of primary biliary cirrhosis
granulomas and bile duct loss
how is PBC staged
biopsy
what does primary biliary cirrhosis involve pathologically
chronic portal inflammation causes destruction of the bile duct- bile ducts inflamed, granulomas around ducts
what is a granuloma
collection of histoctyes
what is a histocyte
macrophage
why does PBC give you a green liver
as bile gets trapped in the liver because of the bile duct injury
what can untreated PBC lead to
cholestasis, liver injury, inflammation, fibrosis, cirrhosis
what is cholestasis
a reduction or blockage of bile flow
who is autoimmune hep more common in
females
what pathological pattern in seen in autoimmune hep
chronic hepatitis pattern- portal inflammation
what else in seen histologically in autoimmune hepatitis
the presence of numerous plasma cells, antibodies to sooth muscle or LKM, IgG
when can LKM be raised
in acute of chronic liver fialure
what is the process of chronic drug induced hepatitis
chronic active process
what might drug induced hepatitis trigger
autoimmune hepatitis
what is primary sclerosing cholangitis
chronic inflammatory process affecting intra and extra hepatic bile ducts
what does primary sclerosing cholangitis lead to
periductal fibrosis, duct destruction, jaundice and fibrosis
what is primary sclerosing cholangitis associated with
ulcerative collitis
who is more likely to get primary scleroing cholangitis
males
what does primary sclerosing cholangitis increase your risk of
malignancy in bile ducts and colon
what is seen microscopically of PSC
cholangitis= inflammation of the ducts
periductal onion-skinning fibrosis
name three liver storage diseases
haemochromatosis, wilsons disease, alpha-1-antitrypsin deficiency
what is haemochromatosis
excess iron in the liver
what causes primary haemochromatosis
genetic condition, increased absorption of iron
what causes secondary haemochromatosis
iron overload from diet, transfusions, iron therapy
what inheritance pattern does primary haemochromatosis folllow
autosomal recessive
what processes cause primary haemochomatosis
excess absorption of iron from intestine, abnormal iron metabolism
in who is primary haemochromatosis worse in- why
men as they are homozygotes
when and why does primary haemochromatosis produce symptoms
iron deposited in liver, asymptomatic for years until deposited in portal connective tissue and stimulated fibrosis
what can primary haemochromatosis cause
predisposes to carcinoma
causes diabetes, cardiac failure and impotence
what is seen on the microscopy of haemochromatosis
iron accumulation- brown pigments in the hepatocyte
how is iron accumulation in haemochromatosis confirmed via microscopy
perls stain- goes blue
what happens if haemochromatosis goes left untreated
cirrhosis, hepatocelluar carcinoma
what is wilson’s disease
inherited autosomal recessive disorder of copper metabolism where copper accumulates in the liver and brain
what are the clinical signs of wilsons disease
kasyer-fleischer rings at corneal limbus, low serum caeruloplasmin
what does wilsons disease lead to
chronic hepatitis and neurological deterioration
what is an alpha-1-antitrypsin deficinecy
inherited automsomal recessive disorder of production of an enzyme inhibitor
what does an alpha-1-antitrypsin deficiency cause
empysema and cirrhosis
what is seen microscopically in aplha-1-antitrypsin deficiency
cytoplasmic globules of unsecreted globules of protein in liver cells- accumulates in liver and causes hepatocyte damage
what are the two main primary tumours of the liver
hepatocellular adenoma (benign)
hepatocellular carcinoma (hepatoma)
who is more likely to get hepatocellular carcinoma
females- associated with oestrogen
what is hepatocellular carcinoma associated with
HBV, HCV and cirrhosis
how does HCC usually present
as a mass, pain or obstruction
what is the prognosis for HCC
usually poor
what are the two histopathological types of HCC
hepatocytic- looks like hepatocytes
cholangio- looks like bile ducts
