Pathology of liver

Question 1

Name 5 common symptoms of liver disease

Answer 1

• Ascites
• Dyspepsia (indigestion)
• Nausea & vomiting
• Abdominal pain in UPPER RIGHT QUADRANT
• Jaundice

Question 2

What are findings found generally, in the face and hands for liver disease

Answer 2

General - abdominal distention, caput medusa (distended and engorged superficial veins) and pallor

Face - Angular cheilitis, pale, swollen lips, xanthoma and K-F rings

Hands - clubbing (cirrhosis), palmar creases, bruising

Question 3

Investigations for liver disease? (5)

Answer 3

• Blood tests (LFTs and FPC)
• Plain x-ray
• MRI, Ultrasound, CT
• Core needle Biopsy

Question 4

Describe the structure of the liver.

How is the blood drained?

Answer 4

Portal triad - Hepatic artery + Hepatic portal vein + bile duct
CENTRAL VEIN is surrounded by 6 portal triads

Blood from liver is drained via central vein

Question 5

Describe the zones of the liver…

Answer 5

Zone 1 - Periportal lobule – closest to hepatic vein (most susceptible to toxic and viral injury)

Zone 2 - Midzonal region

Zone 3 - Centrilobular area – adjacent to
central vein
Most susceptible to ischaemic injury

Question 6

Describe the aetiology, pathogenesis, complications, pathological appearance of chronic venous congestion

Answer 6

Aetiology - congestive heart failure
Pathogenesis - ➢ LHF → ↓ CO → Increased venous pressure → reduced BLOOD FLOW in the liver → transient
ISCHAEMIA
➢ RHF → Pooling of blood in IVC and hepatic veins → reduced blood flow in the liver → transient
ischaemia

Complications - pulmonary oedema

Pathological appearance - macroscopic- NUTMEG liver (dark spots dilated and congested hepatic veins and pale are unaffected.
microscopic - nutmeg in zone 3

Question 7

Describe the pathogenesis and morphological/aetiological classifications of cirrhosis.

Answer 7

➢ CHRONIC liver disease → Regeneration of hepatocytes disorganised → FIBROSIS & NODULES form

Morphological - micronodular (nodules less than 3mm)
Macronodular - nodules more than 3mm)

Aetiological - viral hepatitis, alcohol, hemochromatosis, autoimmune liver disease

Question 8

What causes micronodular cirrhosis and what is its appearance?

Answer 8

❖ Commonly caused by CHRONIC ALCOHOLISM
❖ Regenerative nodules surrounded by FIBROUS CT making the nodules shrink
❖ Liver YELLOISH colour & FATTY CHANGE due to alcohol
❖ ↓ liver parenchyma

Question 9

What causes macronodular cirrhosis and what is its appearance?

Answer 9

❖ Commonly caused by VIRAL HEP B or C, toxins, poisoning
❖ Globally affected
❖ Causes are ACUTE with not enough time for fibrous bands to form around nodules → nodules
are bigger

Question 10

How does bronzed diabetic occur and how does this affect someone?

Answer 10

❖ Occurs in HAEMOCHROMATOSIS
❖ Due to FAULTY GENE that causes the body to ABSORB TOO MUCH IRON from food

❖ Excess iron is stored in LIVER, PANCREAS & SKIN (in that order)

Question 11

How is alcoholic cirrhosis caused?

Answer 11

❖ Caused by CHRONIC ALCOHOLISM
❖ Progression of ALCOHOLIC LIVER INJURY
❖ Cellular energy is diverted from essential metabolism (Eg. Fat metabolism) to alcohol
metabolism → LIPID ACCUMULATION → alcohol stimulates COLLAGEN synthesis → FIBROSIS

Question 12

How is non-alcoholic cirrhosis caused?

Answer 12

❖ Progression of NON-ALCOHOLIC FATTY LIVER DISEASE 
❖ Caused by:
▪ Obesity 
▪ Diabetes mellitus 2
▪ Hypertension 
▪ ↑ cholesterol 
▪

Question 13

What causes acute hepatitis?

Answer 13

➢ ALL VIRAL HEPATITIS
• Pathogenesis
➢ Virus secretion → symptoms → jaundice → Liver failure/recovery/carrier
• Complications
➢ Hep B & C has ↑ chance of developing CIRRHOSIS & HEPATOCELLULAR CARCINOMA

Question 14

What are the 4 types of primary tumours (liver)

Answer 14

Hepatocellular Carcinoma Adenocarcinoma of HEPATOCYTES
Cholangiocarcinoma Adenocarcinoma of the BILE DUCTS
Angiosarcoma Neoplasm of the VASCULAR ENDOTHELIUM
Hepatoblastoma Malignant tumour in CHILDHOOD

Question 15

What are the causes, history, examination and investigations for primary hepatocellular carcinoma?

Answer 15

❖ Causes: 
▪ Hep B or C – Hep B most common cause 
▪ Hepatic Cirrhosis – Eg. Haemochromatosis  
❖ History: 
▪ Alcohol consumption 
▪ Previous viral hepatitis infection 
▪ Exposure to blood products 
▪ Any other sites of lumps – lymph nodes
❖ Examination: 
▪ Jaundiced inc. sclera 
▪ Cutaneous bruising 
▪ Weight loss 
❖ Investigation: 
▪ Alpha-fetoprotein 
— Wil be ↑ 
▪ Biopsy
LFTs

Question 16

Talk about the symptoms, metastasis, macroscopic appearance, examinations and investigations for secondary tumours

Answer 16

Symptoms
Weight loss, jaundice

Metastasis
Lung, GI, pancreas, bowel, breast

Macroscopic
appearance
Often deposited as WHITE lesions
EXCEPTION – Metastasis from malignant MELANOMA will cause BROWN/BLACK deposits

Examination 
Symptoms associated with liver cancer 
o Ascites, jaundice, fever, weight loss 
Symptoms associated with cancer of other organs
Investigation Ultrasound, CT scan 
Barium test (ERCP)
Biopsy core needle
LFts

Question 17

Describe medical emergencies, modifying treatment plans an oral manifestations relating to liver disease.

Answer 17

1. Medical Emergencies 
❖ Bleeding 
❖ Haematemesis – vomiting blood 
2. Modifying treatment plan 
❖ ↓ capacity to DETOXIFY & EXCRETE drugs 
▪ Be aware not to OVERDOSE on paracetamol, aspirin 
▪ Can cause liver toxicity 
❖ Haemorrhagic tendency 
▪ Check INR 
▪ Suture after dental extraction
❖ Possible cross-infection risk 
▪ Patients may have VIRAL HEPATITIS – esp. Hep B 
▪ Use SINGLE USE INSTRUMENTS 
3. Oral Manifestations
❖ Jaundice – on face & sclera 
❖ Cutaneous bruising – hands & face