pathology of liver and cirrhosis

Question 1

how much does a normal liver weigh?

Answer 1

1,500g

Question 2

describe the limits of alcohol toxicity? 6

Answer 2

• Legal driving limit= 80mg/dl
• Naïve drinker- very drunk= 200mg/dl
• Naïve drinker, risk of death= 300mg/dl
• Chronic drinker, risk of death >350md/dl
• Some patients can tolerate up to 600mg/dl before death
• There is no antidote for alcohol toxicity

Question 3

what is the cause of death in alcohol toxicity? 2

Answer 3

• The cause of death is depression of the respiratory centre in the mid-brain.
• This is exacerbated if the patient also takes CNS depressant drugs like benzodiazepines and opiates

Question 4

what are the features of chronic alcoholic liver disease? 3

Answer 4

• Fatty change (steatosis)
• Hepatitis
• Cirrhosis

Question 5

what enzyme is usually raised in chronic alcohol misuse?

Answer 5

• Gamma glutamyl transferase, can be raised in other conditions but alcohol induces production of this enzyme

Question 6

describe some liver functions tests? 8

Answer 6

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

Question 7

what is displayed in haematological tests in chronic alcohol misuse? 5

Answer 7

• Fe deficiency anaemia- decreased Hb and decreased MCV
• Folate and B12 deficiency- increased MCV
• Clotting factors related abnormalities- raised INR

Question 8

why do patients with chronic liver disease have the tendency to bleed? 5

Answer 8

• Reflux oesophagitis
• Haemorrhagic gastritis
• Peptic ulcers
• Oesophageal varices
  Vitamin K deficiency causes tendency to bleed as it is required for some clotting factors

Question 9

what is the pathogenesis of alcoholic steatosis? 4

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

what are the other causes of fatty liver? 6

Answer 10

• Obesity
• Type 2 DM
• Hyperlipidaemia
• Drugs (methotrexate)
• Hepatitis X infection
• Rapid weight loss due to the breakdown of peripheral fat as a source of energy

Question 11

describe the different types of alcoholic hepatitis? 6

Answer 11

• Acute:
• May be associated with jaundice
• Patient will be very unwell
• Polymorphs and neutrophils in the liver
• .
• Chronic:
• If the patient does not abstain, there is a risk of progression to fibrosis and cirrhosis
• Lymphocytes infiltrate in the liver
• The inflammation starts in the portal tracts

Question 12

what are the complications associated with taking a liver biopsy?5

Answer 12

• pain
• Bleeding
• Bile peritonitis due to injury to the gallbladder
• Pneumothorax due to injury to the lungs
• Sepsis and abscess formation

Question 13

describe alcoholic cirrhosis? 4

Answer 13

• 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
• Classified according to size- macro-nodular >3mm, micro-nodular< 3mm

Question 14

what can cause cirrhosis? 7

Answer 14

• Alcohol
• Viral hepatitis (B, C, D, E)
• Primary biliary cirrhosis- autoimmune inflammatory process which destroys the bile ducts and replaces them with scarring and fibrosis
• Primary haemochromatosis= a genetic abnormality resulting in excess iron absorption
• Wilson’s disease= a genetic abnormality resulting in excess coper accumulation
• Alpha-1-antitrypsin deficiency= genetic abnormality associated with emphysema
• Cryptogenic cirrhosis= term applied when all known causes have been excluded, usuallt end stage cirrhosis

Question 15

what are the complications of cirrhosis? 4

Answer 15

• Portal hypertension
• Liver failure- jaundice, hypoproteinaemia, bleeding, hepatic encephalopathy
• Ascites
• Hepatocellular carcinoma

Question 16

describe portal hypertension? 8

Answer 16

• 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  collateral circulation  enlarged spleen and oesophagus varices
• Risk of bleeding from varices- medical emergency
• Triad of portal hypertension:
• Cirrhosis
• Oesophageal varices
• Splenomegaly

Question 17

what can cause bleeding in an alcoholic patient? 5

Answer 17

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

Question 18

describe combined Mallory Weiss tear and peptic ulcer? 3

Answer 18

• Mallory Weiss tears occur at the oesophagus-gastric junction when the patient vomits and retches against a closed cardiac sphincter
• The main causes of peptic ulcers are helicobacter infection and non-steroidal anti-inflammatory drugs (NSAIDS)
• Alcohol irritates the gastric mucosa and exacerbates the effects of above

Question 19

describe alcohol related deaths? 5

Answer 19

1. Alcohol Toxicity:
   ≤ 300mg/dl - novice drinker
   ≥ 350mg/dl - habitual drinker
2. RTAs: Legal limit - 35mg/dl in breath; 80mg/dl in blood
3. Sudden death in fatty liver due to metabolic acidosis resulting in cardiac arrhythmias
4. Haemorrhage: oesophageal varices; acute gastritis and peptic ulcers
5. Liver failure – acute/cirrhosis

Question 20

describe tumours of the liver? 2

Answer 20

• Most common tumours are metastatic from the GIT

- Primary cancer: hepatocellular carcinoma, associated with raised alpha-feto protein

Question 21

describe the complications of gall stones? 13

Answer 21

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