Pathology of the Liver Flashcards
acinar zones
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
acinar zones and injury
zone 3 most vulnerable
liver injury
very resistant
large functional reserve
severe parenchymal necrosis but heal entirely by restitution
permanent damage
pathogenesis of liver disease
insult to hepatocytes (grading) degree of inflammation (staging) degree of fibrosis cirrhosis
acute onset of jaundice
causes - viruses alcohol drugs bile duct obstruction
acetaminophen toxicity
confluent necrosis produces massive acute necrosis and liver failure
consequences of acute liver failure
complete recovery
chronic liver disease
death from liver failure
jaundice
yellowing of the skin due to bilirubin
liver disease is not the only cause
jaundice - classification by site and type
pre-hepatic
hepatic
post-hepatic
conjugated
unconjugated
pre-hepatic jaundice
too much harm to break down
haemolysis of all causes
haemolytic anaemias
unconjugated bilirubin
hepatic jaundice
liver cells injured or dead
acute liver failure alcoholic hepatitis
cirrhosis (decompensated)
bile duct loss
pregnancy
post-hepatic jaundice
bile cannot escape into the bowel
congenital biliary atresia
gallstones block CBDuct
strictures of CBDuct
tumours (Ca head of pancreas)
cirrhosis of liver
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
complications of cirrhosis
portal hypertension (porto-caval anastimoses)
oesophageal varices
caput medusa
haemorrhoids
ascites
liver failure
alcoholic liver disease
common pathology
biopsy - rule out another condition
pathology depends largely on the extent of alcohol abuse
individual factors
stages of alcoholic liver disease
REVERSIBLE fatty liver - steatosis hepatitis IRREVERSIBLE fibrosis cirrhosis
alcoholic liver disease outcoems
cirrhosis portal hypertension - varies, ascites malnutrition hepatocellular carcinoma social disintegration
non-alcoholic steatohepatitis NASH
non-drinkers
pathologically identical to alcoholic liver disease
occurs in patients with diabetes, obesity, hyperlipidaemia
on the increase
may lead to fibrosis and cirrhosis
viral hepatitis
may cause acute or chronic liver disease
A-E
hep A
faecal-oral spread
short incubation period
sporadic or endemic
directly cytopathic
no carrier state
mild illness, usually full recovery
hep B
spread by blood, blood products, sexually, vertically (in utero)
long incubation period
liver damage is by antiviral immune response
carriers exist
outcome is variable
hep C
spread by blood, blood products, possible sexually
short incubation period
often asymptomatic
disease waxes and wanes
tends to become chronic
hep B - outcome
fulminant acute infection (death)
chronic hepatitis
cirrhosis
hepatocellular carcinoma
asymptomatic (carrier)
hep C -outcome
chronic hepatitis
cirrhosis
chronic hepatitis
autoimmune disease
causes of chronic hepatitis
hep B and C primary biliary cirrhosis autoimmune hepatitis drug induced hepatitis primary sclerosing cholangitis
primary biliary cirrhosis
rare autoimmune disease, unknown aetiology
associated with autoantibodies to mitochondria
females 90%
biopsy = stage the disease
may see granulomas and blue duct loss
untreated bile duct loss
cholestasis liver injury inflammation fibrosis cirrhosis
autoimmune hepatitis
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
chronic drug-induced hepatitis
similar features to all other types of chronic hepatitis
may trigger an autoimmune hepatitis
chronic active process
causes are too many to list
drugs and the liver
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
primary sclerosis cholangitis
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
storage disease
haemochromatosis
wilsons disease
alpha-1-antitrypsin deficiency
iron and the liver
haemochromatosis is excess iron within the liver
PRIMARY
genetic condition, increased absorption of iron
SECONDARY
iron overload from diet, transfusions, iron therapy
primary haemochromatosis
inherited autosomal recessive condition
excessive absorption of iron from intestine, abnormal iron metabolism
worse in homozygotes, men
primary haemochromatosis
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
haemochromatosis - outcome
depends on genetics, therapy (venesection) and cofactors such as alcohol
cirrhosis
hepatocellular carcinoma
Wilsons disease
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
alpha-1-antitrypsin deficiency
inherited autosomal recessive disorder of production of an enzyme inhibitor
causes emphysema and cirrhosis
cytoplasmic globules of unscripted globules of protein in liver cells
primary tumours of the liver - rare
hepatocellular adenoma
hepatocellular carcinoma - hepatoma
secondary tumours of the liver - common
multiple
metastases from colon, pancreas, stomach, breast, lung, others …
hepatocellular adenoma
benign
females
may become large… can rupture or bleed
most remain asymptomatic
hepatocellular carcinoma
rare in europe
associated with HBV, HCV and cirrhosis
usually presents as a mass, pain, obstruction
usually advanced unless discovered incidentally
poor prognosis
