T9 Hepatobiliary pancreas I

Question 1

What is the Porta hepatis?

Answer 1

1. Portal vein
2. Hepatic artery
3. Common bile duct

• histology slide!

Question 2

What are the 3 zones of hepatocyte in trabeculae?

Answer 2

Zone 1: with the porta hepatis
Zone 2: he[tpcutes, sinusoid
Zone 3: With terminal hepatic venule

Question 3

Other than heptocytes and endothelial cells, which 2 types of cells can be found in hepatic lobules?

Answer 3

1. Kupffer cells - macrophages

2. Stellate cells - fibroblasts (> cirrhosis)

Question 4

Gross specimen of fatty liver?

Answer 4

Homogenous yellow discoloration of cut surface

Question 5

What are the risk factors for fatty liver/NAFLD and atherosclerosis respectively?

Answer 5

Common:

1. Hypertension
2. Hyperlipidemia
3. Hyperglycemia

Fatty liver
4. Central obesity

Atherosclerosis
4. Smoking

Question 6

WHO criteria for metabolic syndrome?

Answer 6

1. Hyperglycemia
2. Hypertension
3. Hyperlipidemia
4. Obesity
5. Microalbuminuria

(3/5 or 1+2)

Question 7

What are the 3 USG features of fatty liver?

Answer 7

1. Fixed homogenous echo-texture
2. Posterior attenuation
3. Hepatomegaly

Question 8

What are the 4 pathological histological features of NAFLD?

*Indistinguishable between ALD and NAFLD

Answer 8

1. Macrovesicular steatosis (nucleus displaced, c.f. nucleus not displaced in microvesicular steatosis)
2. Ballooning degeneration with Mallory-Denk bodies (cell injury with damaged intermediate filament)
3. Lobular necroinflammatory activity (c.f. portal-based in chronic HBV)
4. Perivenular and perisinusoidal fibrosis - a distinctive feature of fatty liver > bridging fibrosis > cirrhosis
   (in Sirius red stain for fibrotic tissue)

Question 9

What to expect in gross specimen of macro-nodular cirrhosis?

Answer 9

1. Numerous nodules >3mm @distributed diffusely within the liver
2. Hard, nodular capsule

Question 10

What to expect in a histological slide of acute viral hepatitis? (2)

Answer 10

1. Lobular necroinflammatory activity (away from portal tract)
2. Lymphocyte involvement (c.f. other acute inflammation with neutrophils!)

Question 11

Histology:
Q1
- Site: portal
- Process inflammation
- macronodular 
Suggestive etiology? 

Q2:

• Site: peri-venular
• Process: fibrosis
• micronodular
• Etiology?

Answer 11

Q1: Viral infection (periportal because first contact!! virus)

Q2: Alcohol/drugs
(perivenular because blood flow from portal triad > central vein)

Question 12

What to expect in a histological slide of chronic viral hepatitis? (3)

Answer 12

1. Portal-based necroinflammatory activity
2. Viral inclusions
   - Ground glass hepatocytes (HBsAg)/ Sanded nucleus (HBcAg)
3. Portal-based fibrosis

Question 13

What to determine the stage and the grade of chronic hepatitis?

Answer 13

Grade: necroinflammatory activity

Stage: the degree of fibrosis 
Stage 1: portal fibrosis 
Stage 2: portal/periportal fibrosis
Stage 3: Bridging fibrosis
Stage 4: cirrhosis

Question 14

Etiology of liver cirrhosis?

Answer 14

1. Infection
   - viral: HBV, HCV
   - non-viral
2. Metabolic
   - ALD/ NAFLD
   - Hemochromatosis (iron)
   - Wilson’s disease (copper)
   - alpha1-antitrypsin deficiency
3. Immune
   - PSC (Primary sclerosing cholangitis)
   - Primary biliary cholangitis
4. Drug-induced
   - Hepatotoxic agents e.g. anti-TB drugs (rifampicin, isoniazid)
   - Aflatoxin

Question 15

Child Pugh score? + Physical examination?

Answer 15

Albumin - ankle, sacral edema
Bilirubin - jaundice
Clotting profile - bruising
Distended abdomen - ascites, shifting dullness
Encephalopathy - confusion, flapping tremor

Question 16

Gross specimen of esophageal varices? (2)

Answer 16

1. Ruptured esophagus with bleeding

2. Columns of distended, tortuous submucosal veins

Question 17

Pathogenesis of esophageal varices?

Answer 17

• Portal fibrosis and portal hypertension
• cirrhosis/chronic liver failure
  > failed to detoxify NO from the gut
  > splanchnic arteriolar vasodilation
  > increased portal blood flow
• portosystemic shunt

Question 18

Starling’s law?

Pathogenesis of ascites?

Answer 18

Starling’s law:

• increased hydrostatic pressure due to portal hypertension
• decreased oncotic pressure due to hypoalbuminemia

Ascites

• reduced effective circulating volume
• activation of RAAS (renin-angiotensin-aldosterone)
• renal retention of fluid

Question 19

Etiology of fulminant hepatitis? (3)

Answer 19

1. Drugs
   - Dose-dependent - paracetamol (1)
   - Dose independent: Anti-TB drugs (1)
2. Viral infection (1)
   - 2% acute viral infection
   - 1% HBV, HCV
   - higher risk if HDV co-infection
   - 20% HEV infection of pregnant women

Question 20

Briefly describe paracetamol liver toxicity and why alcohol consumption with paracetamol worsens it.

Answer 20

Paracetamol requires cytochrome P450&raquo_space;> NAPQI (toxic), requires glutathione&raquo_space;> non-toxic

• Alcohol depletes glutathione