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GI diseases > Pathology of the Liver > Flashcards

Pathology of the Liver Flashcards

1
Q

Acute liver failure is when there is an insult to the liver causing damage, what are the causes?

A

Viruses.
Alcohol.
Drugs.
Bile duct obstruction.

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2
Q

Jaundice is one of the symptoms for liver failure, describe it?

A 
Yellowing of the skin due to high levels of bilirubin.
Three classifications:
Pre-hepatic.
Hepatic.
Post-hepatic.
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3
Q

Describe Pre-hepatic jaundice?

A

There is too much haem to break down - increased amount of breakdown of Haemoglobin leads to increased production of bilirubin

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4
Q

Describe Hepatic Jaundice?

A

It is when liver cells have died or are injured.

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5
Q

Describe Post-hepatic jaundice?

A

It is when bile cannot escape into the bowel.

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6
Q

What is Liver Cirrhosis?

A

It is due to chronic inflammation to the liver due to damage to liver cells, when the liver cells heal they create scar tissue (fibrosis). Band of fibrosis separate the regenerative nodules of hepatocytes and in addition the fibrosis affects blood flow in the liver leading to increased resistance in the vessels (Portal hypertension).

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7
Q

What are the four main causes of liver cirrhosis?

A

Alcoholic liver disease.
Non-alchoholic fatty liver disease.
Hep B.
Hep C.

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8
Q

What are the less main causes of liver cirrhosis?

A

Autoimmune hepatitis.
Primary Billiary cirrhosis.
Drugs like methotrexate.

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9
Q

What are the signs and symptoms for liver cirrhosis?

A

Jaundice - raised levels of bilirubin
Heptomegaoly/ although the liver can get smaller also.
Splenomegaly - due to portal hypertension.
Spider naevi - Telangiectasia (swollen blood vessels) that have a central arteriole and small vessels radiating away (looks like the extensions of a spiders web.
Ascites.

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10
Q

What is the difference between compensated and decompensated cirrhosis?

A

Compensated - Chronic liver disease, portal hypertension more likely to be present. Liver still operates okay and less symptoms.
Decompensated - acute liver failure (due to infection or other). More likely to have jaundice, Ascites. Liver is not really working anymore.

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11
Q

Describe one of the complications of liver cirrhosis - ascites?

A

Fluid leaks out of the capillaries in the liver and bowel into the peritoneal cavity due to increased pressure in the portal system (increased resistance due to cirrhosis => increased pressure). The drop in fluid in the system leads to decreased blood pressure entering the kidneys. The kidneys then response to the low blood pressure by producing renin which leads to increased aldosterone secretion.
The increased aldosterone causes fluid and sodium to be reabsorbed into the kidneys causing a fluid overload.
Cirrhosis causes a transudativ meaning low protein content.

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12
Q

How might you treat ascites (complication of liver cirrhosis)?

A

Low sodium diet.
Spironolactone - anti aldosterone diuretic.
Paracentesis (ascitic tap or ascitic drain).

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13
Q

How would you treat liver cirrhosis?

A

Low sodium, high protein diet.
Manage the complications.
Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma.

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14
Q

Describe the progression of alcoholic liver disease?

A
  1. Alcoholic related fatty liver - drinking leads to a build-up of fat in the liver. If drinking stops this process reverses in around 2 weeks.
  2. Alcoholic hepatitis -
    Drinking alcohol over a long period causes inflammation in the liver sites. Binge drinking can have the same effect. Mild cases of this should be reversible.
  3. Cirrhosis
    Irrevisble damage to the liver. Fibrosis has occured and stopping drinking prevents further damage and continued drinking can have deadly consequences.
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15
Q

What other factor other than alcohol helps to determine how bad the effects of alcoholic liver disease will be?

A

What genetic predispositions a person has.

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16
Q

What is Non-alchoholic steatohepatitis (NASH)?

A

It happens in non-drinkers but is almost pathologically almost identical to alcoholic liver disease (fat is deposited in liver cells).
Occurs in patients with diabetes, obesity and hyperlipidaemia.

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17
Q

Does NASH follow a similar path to cirrhosis as alcoholic liver disease?

A

Yes it does!
Before Non-alchoholic steatohepatitis there is Non-alchoholic fatty liver disease, then it goes to NASH, then fibrosis and then cirrhosis of the liver.

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18
Q

What is hepatitis?

A

It is inflammation of the liver, it can be mild or life threatning where there is large amounts of liver cell necrosis.

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19
Q

What are the causes of hepatitis?

A 
Alcoholic hepatitis.
Non-alchoholic fatty liver disease.
Viral hepatitis.
Autoimmune hepatitis.
Drug induced hepatitis.
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20
Q

Describe Hep A?

A 
Faecal-oral spread.
Poor hygiene.
Gay men.
Acute hepatitis. 
Mild illness usually full recovery.
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21
Q

What are the types of viral hepatitis?

A

Hep A - Hep E.

Although Hep D is only found with Hep B and it exacerbates Hep B.

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22
Q

Describe Hep B

A

It is spread by multiple ways:
Spread by blood to blood, through sex, vertically (mother to child).
Long incubation period.
Liver damage is by antiviral immune response.

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23
Q

Describe Hep C?

A

Spread by blood, possible through sexual transmission.
Short incubation period.
Often leads to chronic hepatitis or cirrhosis.
Most common, many become chronic infection and there’s no vaccination however it is curable with direct acting antiviral medications.

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24
Q

What are common outcomes of someone with a diagnosis of hepatitis B?

A 
Chronic hepatitis.
Cirrhosis.
Hepatocellular carcinoma.
Death
Asymptomatic (carrier).
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25
Q

What is primary biliary cirrhosis?

A

It is an autoimmune condition of unknown aetiology whereby the immune system attacks teh small bile ducts in the liver. It Casues obstruction of bile outflow (known as cholestasis), the back pressure of the bile obstruction and the overall disease process ultimately leads to fibrosis, cirrhosis and liver failure.

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26
Q

Why do people with primary biliary cirrhosis get xanthelasma (cholesterol deposits in the skin)?

A

Because cholesterol is not able to leave the liver through bile ducts and get into the intestines, it builds up in the blood leading to increased risk of CVD but also cholesterol deposits on the skin.

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27
Q

What is autoimmune hepatitis?

A

It is a rare cause of chronic hepatitis that is more frequent in women.

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28
Q

What is primary sclerosing cholangitis?

A

It is a condition where the intrahepatic or extrahepatic ducts become strictured and fibrotic, it causes an obstruction to bile outflow in to the intestines.
Sclerosing refers to stiffening and hardening of the ducts.
Cholangitis is inflammation of the bile duct.

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29
Q

Describe Haemochromatosis?

A

It is an iron storage disorder that leads to a person having too much iron being deposited in the tissues.
The human Haemochromatosis protein (HFE) gene is located on chromosome 6.
The Haemochromatosis genetic mutation is autosomal recessive.

30
Q

What are the complications of haemochromatois?

A

The complications include cirrhosis due to iron being deposited in portal connective tissue leading to fibrosis.
Cardiac failure.
Impotence.
Hepatocellular carcinoma.

31
Q

What is Wilson’s disease?

A

It is an inherited autosomal recessive disorder that causes there to be an excessive accumulation of copper in the body. It is caused by the Wilson disease protein on chromosome 13.
Patients often present with hepatic, psychological or neurological problems.

32
Q

Describe alpha-1-antitrypsin deficiency?

A

Inherited autosomal recessive disorder of production of a protease inhibitor called alpha 1 antitrypsin. Leads to an excess of protease enzymes that attack the liver leading to emphysema and cirrhosis.

33
Q

What are the main causes of chronic liver disease (remember that a chronic liver disease is one that causes cirrhosis, there are plenty of other diseases that are chronic and affect the liver but they don’t cause cirrhosis)?

A

Alcohol, Non-alcoholic fatty liver disease, Hepatitis B and Hepatitis C.

34
Q

Why does NAFLD occur?

A

It happens due to fat being deposited in liver cells, the fat interferes with the function of the liver cells.

35
Q

What can NAFLD progress to?

A

Hepatitis and Cirrhosis.

36
Q

Which investigations are used for NAFLD?

A

Liver ultrasound - would confirm hepatic steatosis (fatty liver). It does not tell you the severity, the liver function or if there is fibrosis though.
Enhanced liver fibrosis (ELF) blood test - First line for assessing liver fibrosis but is not readily available in many places.

37
Q

What is the genetic component that causes primary biliary cirrhosis to be an autoimmune condition?

A

M2 subsection of the antimitochondrial antibodies.

38
Q

What are the symptoms of Primary Biliary cirrhosis?

A

Usually asymptomatic.
Fatigue, Itch without a rash (due to raised bile acid in the blood), xanthelasma (due to backlog of cholesterol it gets deposited on the skin), xanthomas (bigger cholesterol deposits), jaundice due to increased bilirubin.
Usually a middle age women

39
Q

What is primary biliary cirrhosis?

A

It is an autoimmune condition whereby the immune system attacks the small bile ducts in the liver.
It leads to obstruction of the outflow of bile leading to choleostasis (reduced bile flow).
The reduced bile flow leads to bile acids, bilirubin and cholesterol (which are usually excreted through the bile duct) getting backlogged and going into the blood.

40
Q

How is primary biliary cirrhosis diagnosed?

A

Cholestatic LFT.
Liver Biopsy.
Positive antimitochondrial antibodies (AMA’s).

41
Q

What is the treatment for primary biliary cirrhosis?

A

Ursodeoxycholic acid reduces the intestinal absorption of cholesterol.

42
Q

Describe the differences between Type 1 and type 2 autoimmune hepatitis? (Who gets, what gene, commonality)

A

Type 1:
Adults.
Anti-nuclear antibodies, anti-smooth muscle antibodies.
More common.

Type 2:
Children and young adults.
Anti-liver kidney microsomes-1 (anti-LKM1).
Rare.

43
Q

How is autoimmune hepatitis diagnosed?

A 
Elevated transaminases (ALT and AST) levels and elevated IgG levels. 
Liver biopsy.
44
Q

How is chronic hepatitis treated?

A

High dose steroids, prednisolone and immunosuppressants like azathioprine.

45
Q

Bile obstruction (something that occurs in both primary biliary cirrhosis and primary sclerosing cholangitis) causes what to the liver?

A

hepatitis (liver inflammation), fibrosis and cirrhosis.

46
Q

What are the complications of cirrhoisis?

A

Ascites.
Encephalopathy.
Variceal bleeding.
Hepatocellular Carcinoma.

47
Q

Describe ascites?

A

It is build up of protein containing fluid in the peritoneal cavity usually due to portal hypertension due to liver cirrhosis. As there will be an increase in pressure in the portal system, fluid leaks out from the capillaries into the peritoneal cavity. The drop in circulating volume caused by fluid loss into the peritoneal cavity leads to a reduction in pressure to the kidneys. The kidneys then sense the lower pressure and release renin that leads to increased aldosterone release. This causes reabsorption of fluid and sodium in the kidneys leading to a fluid and sodium overload.

48
Q

How is ascites managed?

A

Low sodium diet.

Spironolactone (anti-aldosterone diuretic).

49
Q

What is hepatic encephalopathy

A

It is the build up of toxins that affect the brain, most importantly ammonia which is produced by bacteria and absorbed by the gut (the ammonia isn’t getting broken down due to an impairment in the liver).

50
Q

How is hepatic encephalopathy treated?

A

Laxatives (lactulose) as they promote the excretion of ammonia before it can be absorbed by the gut.
Antibiotics (rifaxamin)- they reduce the number of intestinal bacteria producing ammonia.

51
Q

Describe what varices are in relation to portal hypertension?

A

It happens due to the portal hypertension that occurs in liver cirrhosis. When the veins coming into the liver have anastomosed due to the back-pressure they begin to become swollen and tortuous. These are called varices.

52
Q

Where do varices occur in the portal system?

A

Gastro-oesophageal junction.
Ileocaecal junction.
Rectum.
Anterior abdominal wall via the umbilical vein.

53
Q

What procedure is TIPS?

A

It is transjugular intra-hepatic portosystemic shunt.
It is a procedure whereby a wire (with guidance via x-ray) is passed into the jugular vein, down the vena cava and into the liver via the hepatic vein. A connection is then made through the liver tissue between the hepatic vein and he portal vein and a stent is put in place.

54
Q

What treatment is done for treating variceal bleeding?

A

Resuscitation is first line if their heart stops.
Terlipressin is 2nd line, it is a vasoconstrictor that slows the bleeding at the varices.
Endoscopy can be done followed by banding.
Last resort you can do TIPS to reduce the pressure.

55
Q

The basics of focal liver lesions are that:
Solid liver lesions in older patients are likely to be …
Solid liver lesions in chronic liver disease patients (cirrhosis or active hepatitis B) are more likely to be ….
In non cirrhotic patients, the most common solid liver tumour is….

A

Malignant cancer that has come from a metastases in the absence of chronic liver disease.
Primary liver cancer than metastases or benign tumours.
Haemangioma.

56
Q

Which liver lesions are benign?

A

Haemangioma.
Focal nodular hyperplasia.
Adenoma.
Liver cysts.

57
Q

Which liver lesions are malignant?

A

Primary liver cancers: Hepatocellular carcinoma, Cholangiocarcinoma.
Metastases.

58
Q

Describe Haemangioma?

A

Benign tumour, no need for treatment.

59
Q

Describe Focal nodular hyperplasia?

A

hyperplastic response to abnormal arterial flow.

60
Q

Describe hepatic adenoma?

A

Associated with contraceptive hormones and anabolic steroids.
In men, it is likely to become malignant so resect.

61
Q

What is the main differences between a hepatic adenoma and a focal nodular hyperplasia?

A

Both are hypervascular, however, an adenoma is purely a hepatocyte tumour, whilst a focal nodular hyperplasia will contain all the liver ultrastructure including the bile ductules.

62
Q

What are the three main cystic liver lesions?

A

Simple cyst.
Polycystic liver disease.
Liver abscess.

63
Q

Describe a simple cyst?

A

Liquid collection lined by epithelium, most of the time it is asymptomatic.
No treatment required.

64
Q

Describe polycystic liver disease?

A

Symptoms depend on the size of the cysts (symptoms such as abdominal pain).
Conservative treatment is used to halt the cyst growth.

65
Q

Descirbe liver absecess?

A

They cause high fevers and give you abdominal pain.

Treatment is usually to give empirical broad spectrum antibiotics and then aspirate.

66
Q

Describe the risk factors for Hepatocellular carcinoma?

A

(It is the most common cause of primary liver cancer (80% hepatocellular carcinoma to 20% cholangiocarcinoma).)
The main risk factors are liver cirrhosis due to:
Viral hepatitis.
Alcohol.
Non alcoholic fatty liver disease.
Other chronic liver disease.
(Patients with chronic liver disease are screened for HCC).

67
Q

Describe the aetiology for cholangiocarcinoma?

A

It is associated with primary sclerosing cholangitis (although only 10% of people with this kind of cancer have had PSC before).
Usually presents 50+ unless the person has PSC.

68
Q

What are the symptoms of Liver cancer?

A

Often it is asymptomatic until very late on which makes the prognosis very poor. There are non-specific symptoms though that occur like weight loss, abdominal pain, anorexia nausea and vomiting, jaundice (cholangiocarcinoma often presents with painless jaundice similarly to pancreatic cancer).

69
Q

What are the investigations for liver cancer?

A

For hepatocellular carcinoma the investigation is alpha-fetoprotein.
For cholangiocarcinoma the investigation is CA10-9.
CT and MRI are used for for diagnosis and staging for cancer.

70
Q

What is the treatment for hepatocellular carcinoma.

A

As it is usually diagnosed very late on it has a very poor prognosis.
Resection of the early disease and Liver transplant can be curative if the cancer is isolated.
In general HCC is resistant to chemotherapy and radiotherapy.
Kinase inhibitors are used to prolong life potentially for months including sorafenib, regorafenib and lenvatinib.

71
Q

What is the treatment for cholangiocarcioma?

A

Similarly to hepatocellular carcinoma, cholangiocarcinomas have poor prognosis unless diagnosed very early.
It is also in general resistant to chemotherapy and radiotherapy, however ERCP can be used to place a stent in the bile duct where the cholangiocarcinoma is compressing the duct, this improves symptoms as it allows for drainage of bile.

GI diseases (14 decks)

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