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GI/Liver > Pathology of the Liver > Flashcards

Pathology of the Liver Flashcards

1
Q

What are the four components of normal liver structure?

A 
Vasculature 
- incoming portal vein and hepatic artery
- outgoing hepatic vein
Parencyhmal liver cells
Biliary system
Connective tissue matrix 
- normally not that much
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2
Q

Which component of the liver increases in quantity during pathology?

A

Connective tissue matrix

- increases in cirrhosis

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3
Q

What is the interface (limiting plate)?

A

A border of hepatocytes that separates the portal tract from the parenchyma

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4
Q

What are the broad categories of causes of liver injury?

A 
Drugs and toxins
Abnormal nutrition/metabolism
Infection
Obstruction to bile or blood flow
Genetic/deposition disease
Neoplasia
Others
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5
Q

What is the definition of acute inflammation?

A

An agent causes injury, but is then removed
- only lasts for days/weeks
N.B. - Fulminant - severe, acute and rapidly progressing towards liver failure

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6
Q

What is the definition of chronic inflammation?

A

An agent causes liver injury, and then persists

  • lasts for months/years
    e. g. alcohol or viral hepatitis
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7
Q

What is acute-on-chronic liver inflammation?

A

Chronic liver disease often presents with acute exacerbations plus evidence of underlying chronicity
- e.g. fibrosis

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8
Q

Which component of the liver is most commonly targeted by injurious agents?

A

Parenchyma

  • bile ducts and blood vessels are rarer main targets
  • however, as they are all interconnected, damage to one component leads to damage of the rest
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9
Q

Simply, what is cirrhosis?

A

End-stage liver disease

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10
Q

What is the definition of cirrhosis?

A
  • diffuse process with
  • fibrosis and
  • nodule formation
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11
Q

Outline the clinical approach to liver disease.

A

History, symptoms and signs by examination
Investigations
- blood tests, LFTs, haematol, viral and autoimmune serology, metabolic tests
- radiology - at least US
Usually yields a firm diagnosis, or at least tell us whether it is diffuse or a space-occupying lesion

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12
Q

List the histological patterns of diffuse liver disease.

A 
Acute hepatitis
Acute cholestasis or cholestatic hepatitis
Fatty liver disease
Chronic hepatitis
Chronic biliary/cholestatic disease
Hepatic vascular disease 
Deposition/genetic causes
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13
Q

Describe the histology of autoimmune acute hepatitis .

A 
Diffuse hepatocyte injury (swelling)
Some dead cells (spotty necrosis)
Inflammatory cell infiltrate in all areas
- portal tract
- interface
- parenchyma
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14
Q

Describe the histology of a liver after paracetamol overdose.

A

Viable liver in some places

Some places undergo massive necrosis

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15
Q

What are the causes of acute cholestasis?

A 
Extrahepatic biliary obstruction
Drug injury (e.g. antibiotics)
Hepatitis viruses (especially A&E)
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16
Q

Describe the histology of acute cholestasis.

A

Brown bilepigment seen in the bile ducts (bilirubin)

May have acute hepatitis

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17
Q

Describe the histology of hepatitis B in the liver.

A

Ground glass cytoplasm in hepatocytes
- accumulation of surface antigen
Fibrosis

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18
Q

What are the main causes of chronic cholestatic disease?

A

Primary biliary cirrhosis

Primary sclerosing cholangitis

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19
Q

What is the histology of chronic biliary cholestatic disease?

A

Focal, portal-predominant inflammation and fibrosis with bile duct injury
PBC - granulomas

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20
Q

Name some causes of genetic/deposition liver disease.

A

Haemochromatosis (iron)
Wilson’s disease (copper)
Alpha-1-antitrypsin deficiency

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21
Q

How can you test a liver for iron deposits?

A

Perl’s stain shows excess iron as blue

- normally no blue stain is present

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22
Q

Name some specific causes of diffuse liver disease.

A 
Hepatitis viruses (A, B, C, D and E)
Drug injury
Extrahepatic biliary obstruction 
Autoimmune liver disease
Alcohol
Metabolic syndrome (obesity)
Chronic biliar disease (e.g. PBC)
Vascular disease (e.g. venous obstruction)
Genetic/deposition (e.g. haemochromatosis)
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23
Q

Name some causes of acute hepatitis.

A

Hepatitis virus (all)
Drug injury
Autoimmune liver disease

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24
Q

Name some causes of fatty liver disease.

A

Drug injury
Alcohol
Metabolic syndrome (e.g. obesity)

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25
Q

Name some causes of chronic hepatitis.

A

Hepatitis viruses (all)
Autoimmune liver disease
Genetic/deposition disease (e.g. Wilson’s)

26
Q

Name some causes of hepatic vascular disease.

A

Vascular disease

- venous obstruction

27
Q

What is the difference between grade and stage of liver disease?

A

Grade
- severity (activity of inflammation)
Stage
- severity of fibrosis (how close are they to cirrhosis)

28
Q

What are the aims of management of diffuse liver disease?

A

Reduce symptoms
Reduce inflammation
Prevent or slow progression of fibrosis

29
Q

What is the treatment of diffuse liver disease?

A

Specific treatment against cause
- e.g. removal or alcohol or drug, weight loss, optimal diabetic control, anti-virals or immunosuppression
Supportive treatment
- e.g for severe acute hepatitis or for cirrhosis in general

30
Q

What is the issue with drug-induced liver disease?

A

It is very common but mimicks other liver diseases

  • can cause almost any pattern of liver disease
  • will be a differential for cause in most cases (especially acute hepatitis and acute cholestatic hepatitis)
31
Q

What are the main differentials for masses (space-occupying or focal) within the liver?

A 
Inflammatory
Benign lesions
Cancer
- metastases
- hepatocellular carcinoma
32
Q

How do you categorise focal liver lesions/space-occupying lesions?

A 
Non-neoplastic
- developmental/degenerative e.g. cysts
- inflammatory (e.g. abscess)
Neoplastic
- benign
- malignant
33
Q

What is the most common type of liver cyst?

A

Von Meyenberg complex

- simple biliary hamartoma

34
Q

Name the benign types of focal liver lesions

A 
Liver cell
- hepatocellular adenoma
Bile duct
- bile adenoma (rare)
Blood vessel
- haemangioma
35
Q

Name the malignanct types of focal liver lesion.

A 
Liver cell
- Hepatocellular carcinoma
Bile duct
- cholangiosarcoma
Blood vessel
- angiosarcoma
Non-liver tissue
- metastases
36
Q

Briefly describe a hepatic adenoma.

A 
Rare, benign tumour of the hepatocytes of the liver
Mainly in young women
- associated with hormonal therapy
Risk of bleeding and rupture 
- large excision required
37
Q

When does a hepatocellular carcinoma arise?

A

In cirrhosis

Associated with elevated serum alpha feto-protein

38
Q

What are the normal functions of the liver?

A

Protein, carbohydrate and fat metabolism
Plasma protein and enzyme synthesis
Storage of proteins, glycogen, vitamins and metals
Immune functions

39
Q

What are the signs and symptoms related to abnormal liver structure and function?

A 
Abnormal biliary system
-  accumulation of bilirubin (jaundice)
- accumulation of bile acids (pruritis)
Abnormal parenchyma
- RUQ pain
- liver failure (once <25% of function)
- hormonal changes in chronic disease
Abnormal vasculature and abnormal connective tissue matrix
- portal hypertension
40
Q

What blood tests can effect liver function?

A 
Liver function tests
- ALT
- AST
- ALP
- bilirubin
- GGT
- albumin 
Liver-related haematology tests
- PT time
Synthetic function
- albumin
- PT time
Viral serology
Autoimmune serology 
Tests for liver metabolic/genetic disease
- iron
- copper
- alpha-1 antitrypsin
41
Q

What liver imaging is available for imaging of masses?

A

US of abdomen
CT of abdomen
ERCP/MRCP

42
Q

Describe the asymptomatic model of liver disease.

A

Abnormal LFTs
Abnormal upper abdominal imaging
Abnormalities incidental or on screening

43
Q

Describe the symptomatic model of liver disease.

A 
Symptoms likely to relate to the liver
- jaundice 
- ascites (portal hypertension)
General symptoms
- pruritus 
- malaise
- anorexia
44
Q

Describe the presentation of acute hepatitis?

A

Short history of RUQ tenderness and malaise

Elevated AST/ALT (sometimes bilirubin)

45
Q

What is the most common cause of liver disease in the Western world?

A

Fatty liver disease

  • steatosis
  • steatohepatitis
46
Q

How does fatty liver disease typically present?

A

Acute or chronic ‘hepatitis’

Asymptomatic abnormal LFTs

47
Q

Name some drugs that can damage a liver.

A

Methotextae
Amiodarone
Steroids
Paracetamol

48
Q

Where is the pathology of hepatitis C often found?

A

In the portal tracts

- chronic inflammation with lymphoid aggregates

49
Q

What is the definition of chronic hepatitis?

A

Liver inflammation (abnormal LFTs) for at least 6 months

50
Q

When a biopsy of a liver with chronic hepatitis is taken, what is assessed and why?

A

Activity (grade)
- degree of inflammation (of the portal, interface and parenchyma)
- guides treatment
Stage (amount of fibrosis)
- prognosis
Numerical score assigned - fascilitates follow-up and monitoring of treatment

51
Q

What is the clinical presentation of chronic cholestatic disease?

A

Chronic liver disease
- e.g. itch (symptoms of excess bile acids)
Abnormal LFTs
- mainly ALP and GGT (mild)

52
Q

What is primary biliary cirrhosis?

A

An auto-immune disease with serum anti-mitochondrial antibodies (AMA) and high IgM
Not cirrhotic from outset, but usually progresses to fibrosis then cirrhosis over years

53
Q

What is the treatment for primary biliary cirrhosis?

A

No cure
Ursodeoxycholic acid eases symptoms and slows progression
Liver transplantation - end-stage

54
Q

How does alpha-1 antitrypsin deficiency cause genetic/deposition in the liver?

A

The deficiency is due to lack of secretion, not lack of production
- accumulation in hepatocytes

55
Q

What is the main form of hepatic vascular disease?

A

Hepatic vein outflow obstruction

  • e.g. hepatic vein thrombosis (often fatal)
    • > prothrombotic tendancy predisposes
    • > early identification permits anti-coagulation
  • lesser degress are more common (e.g. nodular regenerative hyperplasisa
56
Q

What can cause liver abscesses?

A

Ascending cholangitis
Hydatid
Other parasitic disease

57
Q

What is cholangiocarcinoma?

A

Adenocarcinoma of the bile ducts

- either intra- or extra-hepatic

58
Q

What is the prognosis of a cholangiocarcinoma?

A

Poor

59
Q

What type of cancer commonly metastasises to the liver?

A

Adenocarcinoma (or any carcinoma)

- especially from the GI tract due to the portal blood supply

60
Q

What is the treatment for metastatic liver cancer?

A

Chemotherapy

Single metastases may be resected

GI/Liver (12 decks)

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