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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
Name some causes of chronic hepatitis.
Hepatitis viruses (all) Autoimmune liver disease Genetic/deposition disease (e.g. Wilson's)
26
Name some causes of hepatic vascular disease.
Vascular disease | - venous obstruction
27
What is the difference between grade and stage of liver disease?
Grade - severity (activity of inflammation) Stage - severity of fibrosis (how close are they to cirrhosis)
28
What are the aims of management of diffuse liver disease?
Reduce symptoms Reduce inflammation Prevent or slow progression of fibrosis
29
What is the treatment of diffuse liver disease?
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
What is the issue with drug-induced liver disease?
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
What are the main differentials for masses (space-occupying or focal) within the liver?
``` Inflammatory Benign lesions Cancer - metastases - hepatocellular carcinoma ```
32
How do you categorise focal liver lesions/space-occupying lesions?
``` Non-neoplastic - developmental/degenerative e.g. cysts - inflammatory (e.g. abscess) Neoplastic - benign - malignant ```
33
What is the most common type of liver cyst?
Von Meyenberg complex | - simple biliary hamartoma
34
Name the benign types of focal liver lesions
``` Liver cell - hepatocellular adenoma Bile duct - bile adenoma (rare) Blood vessel - haemangioma ```
35
Name the malignanct types of focal liver lesion.
``` Liver cell - Hepatocellular carcinoma Bile duct - cholangiosarcoma Blood vessel - angiosarcoma Non-liver tissue - metastases ```
36
Briefly describe a hepatic adenoma.
``` 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
When does a hepatocellular carcinoma arise?
In cirrhosis | Associated with elevated serum alpha feto-protein
38
What are the normal functions of the liver?
Protein, carbohydrate and fat metabolism Plasma protein and enzyme synthesis Storage of proteins, glycogen, vitamins and metals Immune functions
39
What are the signs and symptoms related to abnormal liver structure and function?
``` 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
What blood tests can effect liver function?
``` 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
What liver imaging is available for imaging of masses?
US of abdomen CT of abdomen ERCP/MRCP
42
Describe the asymptomatic model of liver disease.
Abnormal LFTs Abnormal upper abdominal imaging Abnormalities incidental or on screening
43
Describe the symptomatic model of liver disease.
``` Symptoms likely to relate to the liver - jaundice - ascites (portal hypertension) General symptoms - pruritus - malaise - anorexia ```
44
Describe the presentation of acute hepatitis?
Short history of RUQ tenderness and malaise | Elevated AST/ALT (sometimes bilirubin)
45
What is the most common cause of liver disease in the Western world?
Fatty liver disease - steatosis - steatohepatitis
46
How does fatty liver disease typically present?
Acute or chronic 'hepatitis' | Asymptomatic abnormal LFTs
47
Name some drugs that can damage a liver.
Methotextae Amiodarone Steroids Paracetamol
48
Where is the pathology of hepatitis C often found?
In the portal tracts | - chronic inflammation with lymphoid aggregates
49
What is the definition of chronic hepatitis?
Liver inflammation (abnormal LFTs) for at least 6 months
50
When a biopsy of a liver with chronic hepatitis is taken, what is assessed and why?
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
What is the clinical presentation of chronic cholestatic disease?
Chronic liver disease - e.g. itch (symptoms of excess bile acids) Abnormal LFTs - mainly ALP and GGT (mild)
52
What is primary biliary cirrhosis?
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
What is the treatment for primary biliary cirrhosis?
No cure Ursodeoxycholic acid eases symptoms and slows progression Liver transplantation - end-stage
54
How does alpha-1 antitrypsin deficiency cause genetic/deposition in the liver?
The deficiency is due to lack of secretion, not lack of production - accumulation in hepatocytes
55
What is the main form of hepatic vascular disease?
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
What can cause liver abscesses?
Ascending cholangitis Hydatid Other parasitic disease
57
What is cholangiocarcinoma?
Adenocarcinoma of the bile ducts | - either intra- or extra-hepatic
58
What is the prognosis of a cholangiocarcinoma?
Poor
59
What type of cancer commonly metastasises to the liver?
Adenocarcinoma (or any carcinoma) | - especially from the GI tract due to the portal blood supply
60
What is the treatment for metastatic liver cancer?
Chemotherapy | Single metastases may be resected

GI/Liver (12 decks)

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