Liver, gallbladder, biliary tract

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jaz_walker
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270652
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Liver, gallbladder, biliary tract
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2014-04-15 10:41:01
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pathology
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pathology
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  1. 1. Easter egg: liver abscesses and granulomatous disease exist.
    They are caused by systemic disease.
  2. 2. How is cirrhosis defined?
    The diffuse process characterised by fibrosis and the conversion of normal liver acrhitecture into structurally abnormal nodules.
  3. 3. A 27 year old male on HAART treatment presents with elevated AST and ALT on routine screening. Biopsy shows mmicrovesiular steatosis. How serious is this?
    Incidental - relatively common.
  4. 4. A 40 year old woman tells you she has metabolic syndrome. She therefore has 2 of which 4 features?
    Obesity, insulin resistence, dyslipidaemia, hypertension.
  5. 5. Three processes are central to cirrhosis. What are they?
    Death of hepatocytes, extracellular matrix deposition, vascular reorganisation.
  6. 6. A 15 day old baby has jaundiced skin, dark urine, light stools and hepatomegaly. Conjugated hyperbilirubinaemia. What are the 2 main causes of this?
    Extrahepatic biliary atresia, neonatal hepatitis.
  7. 7. What are the 3 main causes of excess bilirubin production?
    Haemolytic anaemia, resorption of internal haemorrhage, ineffective erythropoiesis.
  8. 8. What are the two pathways of primary biliary sclerosis to end-stage liver disease?
    Portal hypertension or chronic cholestasis.
  9. 9. A 3 year old presents with pernicoius vomiting, lethargy and hepatomegaly. They appear jaundiced. \Bilirubin, ammonia, AST and ALT are elevated. Biopsy shows microvesicular steatosis. What are you concerned about and what is your next investigation?
    Reye syndrome. CT head - cerebral oedema.
  10. 10. A 59 year old woman presents with jaundice and oedema. You note palmar erythema and spider naevae. Blood results show hypoalbuminaemia, hyperammonaemia. What are you concerned about?
    Chronic liver disease.
  11. 11. A 59 year old woman with liver failure presents with shortness of breath on exertation. You note clubbing of his fingers. What are you concerned about?
    Portopulmonary hypertension.
  12. 12. A 62 year old woman with known liver failure presents with shortness of breath and cyanosis. ABG shows aterial hypoxaemia. What are you concerned about?
    Hepatopulmonary syndorme.
  13. 13. A 54 year old man presents with small, atrophic testes. You note hepatomegaly. Biopsy shows hemosiderin deposition in the pancreas and an OGTT is positive for diabetes mellitus. What are you considering?
    Hemochromatosis.
  14. 14. A 36 year old woman presents with ascites. Biopsy shows hepatocyte necrosis, cytolysis, apoptosis and bridging necrosis. There is hepatocyte proliferation and inflammation of the portal tracets. What class of damage is this and what is the most likely cause?
    Acute viral hepatitis. Hepatitis A.
  15. 15. A 36 year old woman presents with ascites. Biopsy shows hepatocyte injury. There is bridging inflammation and necrosis. There is fibrosis and formation of bridging firbous septa. What class of damage is this and what is the most likely cause?
    Chronic viral hepatitis. Hepatitis C.
  16. 16. A 37 year old man presents with diabetes. You note a greyish tinge to his skin. Liver biopsy shows deposition of hemosiderin. What complication may you look for?
    Cardiomegaly.
  17. 17. A 28 year old male complains of right upper quadrant pain. Biopsy shows panlobular parenchymal necrosis. What disease might you consider?
    Sickle cell disease.
  18. 18. A 41 year old woman is diagnosed with primary sclerosing cholangitis. What else might you expect her to have and what malignancy might you be concerned about?
    Ulcerative colitis. Cholangiocarcinoma.
  19. 19. A 50 year old caucasian woman presents with right upper quadrant pain. A pale yellow stone is removed from the gall bladder. What is likely to be the constituents of this stone?
    Cholesterol.
  20. 20. A 54 year old woman presents with right upper quadrant pain. A dark stone is found in the gall bladder. What is likely to be the constituents of this stone?
    Pigment.
  21. 21. A 36 year old woman presents with ascites. Biopsy shows hepatocellular damage. There is a ground glass appearance of hepatocytes. What is the cause of this?
    Hepatitis B virus.
  22. 22. A 36 year old woman presents with ascites. Biopsy shows bile duct epithelial cell proliferation and lymphoid aggregate formation. What is the cause of this?
    Hepatitis C virus.
  23. 23. A 56 year old woman presents with ascites. She dies several hours later. On autopsy, there is patchy involvement of the liver. The liver is small and limp, with areas of muddy-red mush, with blotchy bile staining. What is the cause of this?
    Massive hepatic necrosis, probably due to viral cause.
  24. 24. A 56 year old woman presents with ascites. She dies several hours later. On autopsy, the liver has grossly evident focal scarring, with widespread nodularity. What is the cause of this?
    Chronic hepatitis.
  25. 25. What is the classic triad of hemochromatosis?
    cirrhosis, hepatomegaly, skin pigmentation and diabetes mellitus.
  26. 26. A 24 year old female presents with psychosis. LFTs are disregulated. Caeruloplasmin is low. What is the diagnosis and what part of the brain is most affected?
    Wilson disease. Basal ganglia.
  27. 27. A 79 year old man dies of liver failure. Autopsy shows the liver contains fibrous septa, and parenchymal nodules. What is the likely state of the liver?
    Cirrhosis.
  28. 28. A 79 year old man presents with liver failure. Biopsy shows ductular reactions at the periphery of nodules, which has proliferating endothelial cells, myofibroblasts and inflammatory cells. What is the likely state of the liver?
    Cirrhosis.
  29. 29. What is the most common cause of portal hypertension?
    Cirrhosis.
  30. 30. A 40 year old woman has an incidental finding of raised ALT and AST. What is the most common cause?
    NAFLD.
  31. 31. A 59 year old woman presents with jaundice. Bloods show unconjugated bilirubin and B12 deficiency. What is the most likely cause?
    Ineffective erythropoiesis due to pernicious anaemia.
  32. 32. A 65 year old man has known GI adenocarcinoma. He presents with jaundice. Bloods show unconjugated bilirubin. What is the most likely cause?
    Resorption of blood from internal haemorrhage.
  33. 33. A 34 year old woman presents with jaundice. She is on the oral contraceptive pill. She has conjugated hyperbilirubinaemia. What is the most likely cause?
    Drug induced canclicular membrane dysfunction. due to oral contraceptives.
  34. 34. A 59 year old man presents with jaundice. high ALP, high conjugated bilirubin, low faecal elastase. What is the most likely cause?
    Carcinoma of head of the pancreas.
  35. 35. A 28 year old male presents with jaundice. He has raised and fluctuating unconjugated hyperbilirubinaemia. His LFTs are otherwise normal. What is the most likely cause?
    Gilbert syndrome.
  36. 36. A 35 year old female is noted to have hepatomegaly. Raised conjugated bilirubin. Otherwise LFTs are normal. What is the most likely cause?
    Dubin-Johnson syndrome.
  37. 37. A 59 year old woman presents with jaundice. Bloods show unconjugated bilirubin. AST and ALT are raised, ALP are normal. What is the most likely group of causes?
    Diffuse hepatocellular disease. e.g. viral or drug-induced hepatitis, cirrhosis.
  38. 38. A 29 year old woman presents with a pharyngitis and cervical lymphadenopathy. She also has mild hepatosplenomegaly. What is the most likely viral cause of this?
    Epstein-Barr virus.
  39. 39. A 42 year old woman presents with raised ALP whilst undergoing routine screening for another condition. Biopsy shows non-suppurative destruction of small and meidum sized intrahepatic bile ducts. There are anti-mitochondrial autoantibodies. What is this and how might you treat it?
    Primary biliary sclerosis. Early treatment with oral ursodeoxycholic acid.
  40. 40. A 43 year old woman presents with intense itching. She has raised ALP and non-suppurative destruction of small and medium sized intrahepatic bile ducts. What is this and what are you concerned about?
    Primary biliary sclerosis.Hepatic decompensation.
  41. 41. A 42 year old woman presents with raised ALP whilst undergoing routine screening for another condition. Biopsy shows non-suppurative destruction of small and medium sized intrahepatic bile ducts. There is florid duct lesions, which include lymphocyting inflammation and granulomas. There are anti-mitochondrial autoantibodies. What is this and what extrahepatic symptoms may you find?
    Primary biliary sclerosis. Sjogren syndrome.
  42. 42. A 53 year old man presents with a liver mass and weight loss. The gallbladder is resected and shows desmoplasia, causing a firm, gritty consistency. There is no bile pigment in the tumour cells. What is this and what is a risk factor for it?
    Cholangiocarcinoma. primary sclerosing cholangitis.
  43. 43. A 81 year old male presents at hospital with alcohol withdrawal. Another healthcare worker notes icterus. Biopsy shows macrovesicular steatosis, which is most prominent around the central vein. There is intracytoplasmic fat. There is some fibrosis, which is in a perisinusoidal 'chicken wire fence' pattern. What is this and what stage is it in?
    fatty liver disease. early stage.
  44. 44. A 81 year old male presents at hospital with alcohol withdrawal. Another healthcare worker notes icterus. Biopsy shows macrovesicular steatosis, which is most prominent around the central vein. There is intracytoplasmic fat. There is central-portal fibrous septa. What is this and what stage is it in?
    fatty liver disease. middle stage (before cirrhosis).
  45. 45. A 81 year old male presents at hospital with alcohol withdrawal. Another healthcare worker notes icterus. Biopsy shows a micronodular pattern of cirrhosis. The liver is yellow-tan, fatty, and enlarged. What is this and what stage is it in?
    fatty liver disease. late stage (cirrhotic).
  46. 46. A 81 year old male presents at hospital with alcohol withdrawal. Another healthcare worker notes icterus. The patient dies of unknown cause. Autopsy shows a brown, shrunken, nonfatty organ composed of micronodular cirrhotic nodules. On microscopy there is no fat accumulation. What is this and what stage is it in?
    fatty liver disease. end stage.
  47. 47. A 39 year old woman is on methotrexate for her rheumatoid arthiritis. On examination, you note hepatosplenomegaly. Biopsy shows periportal and pericellular fibrosis. What is this and which 2 other drugs can cause a similar effect?
    Fibrosis and cirrhosis. isoniazid and enalapril can cause a similar effect.
  48. 48. A 71 year old man has been on an 11 day drinking binge. He has been complaining of a skin itch for the past day. Liver biopsy shows microvesicular fat deposits and mallory bodies. What is this and which drug can cause a similar effect?
    Steatohepatitis. amiodarone causes a similar pattern.
  49. 49. A 16 year old female presents with cholestasis. Liver biopsy shows oval cytoplasmic globules, which are strongly positive with a periodic acid-Schiff stain. She has mild emphysema. What is this and which gene is associated?
    alpha 1-antitrypsin deficiency. PiZZ.
  50. 50. A 82 year old man complains of shortness of breath. There are mildly elevated LFTs. Liver biopsy shows nutmeg liver. What is this due to?
    Centrilobular necrosis due to right sided cardiac decompensation.
  51. 51. A 56 year old woman has just begun hormone replacement therapy. She has noticed some yellowing of her sclera. Biopsy shows hepatocellular cholestasis. There is no inflammation. What is this?
    Cholestasis due to oestragen.
  52. 52. A 49 year old man has been taking antibiotics for a RTI. He notices some jaundice. Biopsy shows cholestasis with lobular inflammation and necrosis. What is this?
    Cholestatic hepatitis.
  53. 53. A 72 year old man has been taking steroids for his temporal arteritis. He has been complaining of jaundice for the past 2 days. Biopsy shows macrovesicular steatosis. What is this?
    NASH.
  54. 54. A 41 year old woman presents with abdominal pain. She takes the oral contraceptive pill. Examination shows ascites and hepatomegaly. CT shows thrombotic occlusion of the hepatic vein. What is this?
    Budd-Chiari syndrome.
  55. 55. A 49 year old woman from the tropics presents with jaundice. Biopsy shows apoptotic hepatocytes which are intensely eosinophilic: 'councilman bodies'. What is this?
    Yellow fever.
  56. 56. A 64 year old woman presents with jaundice. She has a history of Graves disease. Serum IgG is raised, autoantibodies are raised. ANA is raised. Biopsy shows confluent necrosis and abundant plasma cells. What is this?
    Autoimmune hepatitis.
  57. 57. A 48 year old woman returning from Iran presents with a fever, raised heart rate and respiratory rate. Blood cultures are positive. Bilirubin and urea and ALP are raised. Liver biopsy shows prominent activated Kupffer cells and mild protal inflimmation. What is this?
    Cholestasis of sepsis. canalicular cholestasis. Ductular cholestasis would be worse.
  58. 58. A 62 year old woman presents with severe itching. LFTs are grossly deranged. Biopsy shows feathery degeneration, with ballooned hepatocytes, with prominent Mallory-Denk bodies. There is hepatomegaly. There is cholestasis which is periportal. What is this?
    Primary biliary sclerosis.
  59. 59. A 76 year old man has a bone marrow transplantation for CLL. He has elevated LFTs. The sinusoidal endothelium is damaged. The central vein is occluded by cells and newly formed collagen. There is fibrosis in the sinusoidal spaces. What is this?
    Sinusoidal obstruction syndrome.
  60. 60. A 79 year old woman is noted to have a liver nodule on endoscopic laparotomy. On biopsy the nodule is well-circumscribed, wth endothelial cell-lined vascular channels. It is soft and directly below the capsule. What is this?
    Cavernous haemangionoma.
  61. 61. A 41 year old woman is noted to have a liver nodule on endoscopic laparotomy. It is well-demarcated but poorly encapsulated. There are hyperplastic, hepatocyte nodules with a central, stellate fibrous scar. What is this?
    Focal nodular hyperplasia.
  62. 62. A 31 year old woman who takes oral contraceptive pills is discovered to have a nodule on endoscopy. On biopsy it is wiell demarcated but poorly encapsulated. It is pale, and 5 cm large. On histology, it has sheets and cords. Portal tracts are absent. What is this?
    Hepatic adenoma. most commonly due to oestragen taking.
  63. 63. A 38 year old Korean woman presents with jaundice. There is no cirrhosis. There is a multifocal lesion of nodules of various size. There is a snakelike mass in the portal vein which extense into the inferior vena cava. What is this?
    Hepatic cell carcinoma.
  64. 64. A 38 year old Korean woman with a history of Hep C infection presents with a sudden worsening of ascites. There is cirrhosis. There is a unifocal lesion, with widened liver cell plates, pseudoacinar structures and abnormal bile canaliculi. What is this?
    Hepatic cell carcinoma.
  65. 65. A 38 year old Korean woman presents with painless hepatomegaly. There is diffuse infiltration. What is this?
    Hepatic cell carcinoma.
  66. 66. A neonate presents with cholestasis. She has normal birth weight and postnatal weight gain. Liver biopsy shows inflammation and fibrosing stricture of the hepatic bile ducts. There is ductular retraction and portal tract oedema. What is this?
    Biliary atesia.
  67. 67. A 62 year old man from Chile presents with painless jaundice. Gallbladder is excised and shows a cauliflower-like mass which is very firm. What is this?
    Gallbladder adenocarcinoma.
  68. 68. A 41 year old man presents with hepatomegaly. You find ascites, oesophageal varices and elevated AST and ALT. What kind of circulatory problem do they have?
    Impaired intrahepatic blood inflow.
  69. 69. A 32 year old woman with Factor V Leiden presents with ascites. You find abdominal pain, elevated ALT and AST, and jaundice. What kind of circulatory problem do they have?
    Hepatic vein outflow obstruction.
  70. 70. A 32 year old female on oral contraception presents with haemoptysis. She has oesophageal varices, splenomegaly and intestinal ongestion. What kind of circulatory problem does she have?
    Impaired liver blood inflow.
  71. 71. A 61 year old man has been diagnosed with hemochromatosis. What kind of liver malignancy may you be concerned about?
    hepatocellular carcinoma.
  72. 72. What kind of patient gets hepatic artery thrombosis?
    Liver transplant patients.
  73. 73. A 38 year old woman is comatose after a RTA. She has been on total parenteral nutrition for 1 month. What liver findings might this cause?
    Steatosis.
  74. 74. A 47 year old man presents with ascites. Biopsy shows microvesicular steatosis. What might you be concerned about?
    Severe acute liver dysfunction.
  75. 75. What two forms of hepatocellular dysplasia exist?
    Large cell change and small cell change.
  76. 76. A 63 year old man presents with jaundice. Biopsy shows hepatocyte balooning, Mallory-Denk bodies and neutrophil infiltration. Which 2 conditions are you considering?
    ALD, NAFLD.
  77. 77. Which 4 viruses (except hepatitis viruses) can cause liver infection?
    EBV, CMV, HSV, yellow fever.
  78. 78. A 51 year old male with a history of tuberculosis presents with hepatomegaly. Biopsy shows hepatocyte injjury, fibrosis, inflammation. Hep C titre is absent. Which drug might be mimicing chronic hepatitis?
    Isoniazid.
  79. 79. A 43 year old man takes a paracetamol overdose. Which enzymes are involved in paracetamol breakdown?
    p-450 cytochromes.
  80. 80. A 48 year old woman develops jaundice and dies. Autopsy shows a swollen, red-purple liver, with a tense capsule. On microscopy, there is sevre centrilobular congestion. Major veins have thrombi. Which syndrome is present?
    Budd-Chiari syndrome.
  81. 81. A 32 year old man is noticed to have persistently elevated levels of ALP. Radiology shows chronic inflammation in the large ducts. Biopsy shows smaller ducts have no inflammation, but circumferential fibrosis and 'union skinning'. There is a tombstone scar on sone of the small ducts. ?
  82. 82. A 32 year old man presents with a fever, right upper quadrant tenderness and acute jaundice. Biopsy shows a tombstone scar in a small bile duct. ?
  83. 83. A 32 year old man presents with progressive fatigue and chronic jaundice. He dies soon afterwards. Autopsy shows a cirrhotic, green liver. Biopsy shows biliary intraepithelial neoplasia. ?

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