Pathology of the Liver

Question 1

acinar zones

Answer 1

each zone is centered on the line connecting two portal triads and extends outwards to the two adjacent central veins

zone 1 = periportal
zone 2 = mid acinar
zone 3 = pericentral

Question 2

acinar zones and injury

Answer 2

zone 3 most vulnerable

Question 3

liver injury

Answer 3

very resistant
large functional reserve

severe parenchymal necrosis but heal entirely by restitution

permanent damage

Question 4

pathogenesis of liver disease

Answer 4

insult to hepatocytes
(grading) 
degree of inflammation 
(staging)
degree of fibrosis
cirrhosis

Question 5

acute onset of jaundice

Answer 5

causes - 
viruses
alcohol
drugs
bile duct obstruction

Question 6

acetaminophen toxicity

Answer 6

confluent necrosis produces massive acute necrosis and liver failure

Question 7

consequences of acute liver failure

Answer 7

complete recovery
chronic liver disease
death from liver failure

Question 8

jaundice

Answer 8

yellowing of the skin due to bilirubin

liver disease is not the only cause

Question 9

jaundice - classification by site and type

Answer 9

pre-hepatic
hepatic
post-hepatic

conjugated
unconjugated

Question 10

pre-hepatic jaundice

Answer 10

too much harm to break down

haemolysis of all causes
haemolytic anaemias
unconjugated bilirubin

Question 11

hepatic jaundice

Answer 11

liver cells injured or dead

acute liver failure alcoholic hepatitis
cirrhosis (decompensated)
bile duct loss
pregnancy

Question 12

post-hepatic jaundice

Answer 12

bile cannot escape into the bowel

congenital biliary atresia
gallstones block CBDuct
strictures of CBDuct
tumours (Ca head of pancreas)

Question 13

cirrhosis of liver

Answer 13

final common endpoint for liver disease
irreversible

defined by bands of fibrosis separating regenerative nodules of hepatocytes

macro nodular or mircronodular (alcoholic)

alteration of hepatic microvasculature

loss of hepatic function

Question 14

complications of cirrhosis

Answer 14

portal hypertension (porto-caval anastimoses)
oesophageal varices
caput medusa
haemorrhoids

ascites

liver failure

Question 15

alcoholic liver disease

Answer 15

common pathology

biopsy - rule out another condition

pathology depends largely on the extent of alcohol abuse
individual factors

Question 16

stages of alcoholic liver disease

Answer 16

REVERSIBLE
fatty liver - steatosis
hepatitis
IRREVERSIBLE
fibrosis
cirrhosis

Question 17

alcoholic liver disease outcoems

Answer 17

cirrhosis
portal hypertension - varies, ascites
malnutrition
hepatocellular carcinoma
social disintegration

Question 18

non-alcoholic steatohepatitis NASH

Answer 18

non-drinkers

pathologically identical to alcoholic liver disease

occurs in patients with diabetes, obesity, hyperlipidaemia

on the increase

may lead to fibrosis and cirrhosis

Question 19

viral hepatitis

Answer 19

may cause acute or chronic liver disease

A-E

Question 20

hep A

Answer 20

faecal-oral spread

short incubation period

sporadic or endemic

directly cytopathic

no carrier state

mild illness, usually full recovery

Question 21

hep B

Answer 21

spread by blood, blood products, sexually, vertically (in utero)

long incubation period

liver damage is by antiviral immune response

carriers exist

outcome is variable

Question 22

hep C

Answer 22

spread by blood, blood products, possible sexually

short incubation period

often asymptomatic

disease waxes and wanes

tends to become chronic

Question 23

hep B - outcome

Answer 23

fulminant acute infection (death)

chronic hepatitis

cirrhosis

hepatocellular carcinoma

asymptomatic (carrier)

Question 24

hep C -outcome

Answer 24

chronic hepatitis

cirrhosis

Question 25

chronic hepatitis

Answer 25

autoimmune disease

Question 26

causes of chronic hepatitis

Answer 26

``` hep B and C primary biliary cirrhosis autoimmune hepatitis drug induced hepatitis primary sclerosing cholangitis ```

Question 27

primary biliary cirrhosis

Answer 27

rare autoimmune disease, unknown aetiology associated with autoantibodies to mitochondria females 90% biopsy = stage the disease may see granulomas and blue duct loss

Question 28

untreated bile duct loss

Answer 28

``` cholestasis liver injury inflammation fibrosis cirrhosis ```

Question 29

autoimmune hepatitis

Answer 29

commoner in females associated with other AI diseases chronic hepatits pattern numerous plasma cells autoantibodies to smooth muscle, nuclear or LKM, raised IgG may have trigger

Question 30

chronic drug-induced hepatitis

Answer 30

similar features to all other types of chronic hepatitis may trigger an autoimmune hepatitis chronic active process causes are too many to list

Question 31

drugs and the liver

Answer 31

innumberable drugs can damage the liver may be dose related or idiosyncratic can cause hepatitis, granulomas, fibrosis, necrosis, failure, cholestasis or cirrhosis can mimic any liver disease

Question 32

primary sclerosis cholangitis

Answer 32

chronic inflammatory process affecting intra- and exrta- hepatic bile ducts leads to periductal fibrosis, duct destruction, jaundice and fibrosis associated with ulcerative colitis males increased risk of malignancy in bile ducts and colon

Question 33

storage disease

Answer 33

haemochromatosis wilsons disease alpha-1-antitrypsin deficiency

Question 34

iron and the liver

Answer 34

haemochromatosis is excess iron within the liver PRIMARY genetic condition, increased absorption of iron SECONDARY iron overload from diet, transfusions, iron therapy

Question 35

primary haemochromatosis

Answer 35

inherited autosomal recessive condition excessive absorption of iron from intestine, abnormal iron metabolism worse in homozygotes, men

Question 36

primary haemochromatosis

Answer 36

iron deposited in liver, asymptomatic for years eventually deposited in portal connective tissue and stimualtes fibrosis cirrhosis if not treated predisposes to carcinoma also causes diabetes, cardiac failure and impotence

Question 37

haemochromatosis - outcome

Answer 37

depends on genetics, therapy (venesection) and cofactors such as alcohol cirrhosis hepatocellular carcinoma

Question 38

Wilsons disease

Answer 38

inherited autosomal recessive disorder of copper metabolism copper accumulates in liver and brain (basal ganglia) kayser-fleischer rings at corneal limbus low serum caeruloplasmin causes chronic hepatitis and neurological deterioration

Question 39

alpha-1-antitrypsin deficiency

Answer 39

inherited autosomal recessive disorder of production of an enzyme inhibitor causes emphysema and cirrhosis cytoplasmic globules of unscripted globules of protein in liver cells

Question 40

primary tumours of the liver - rare

Answer 40

hepatocellular adenoma | hepatocellular carcinoma - hepatoma

Question 41

secondary tumours of the liver - common

Answer 41

multiple | metastases from colon, pancreas, stomach, breast, lung, others ...

Question 42

hepatocellular adenoma

Answer 42

benign females may become large... can rupture or bleed most remain asymptomatic

Question 43

hepatocellular carcinoma

Answer 43

rare in europe associated with HBV, HCV and cirrhosis usually presents as a mass, pain, obstruction usually advanced unless discovered incidentally poor prognosis