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Pathology of Hepatitis

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  • 1. Never offer the devil a ride.
    He will always want to be in the driving seat…!
    BK
  • 2. 2
    CPC 4.2.2
    George, 62 year old farmer from Tully, presents to his GP with fatigue. His wife has asked him to consult you as his eyes look a bit yellow'.
    Fatigue: Progressing 2wk. Unable to get out.
    nausea : no
    vomiting/haematemesis : no
    Anorexia, wt loss: yes thinks lost a bit of weight.
    bowel habit : constipated, stool pale, no blood.
  • 3. 3
    CPC 4.2.2
    Fever: no
    Bleeding/bruising : no
    cough/dyspnoea : no
    previous episodes : 2 x episodes fatigue last 2 years; first attack preceeded by 2 weeks of fever. saw GP - blood tests : 'showed liver not working so well'. then felt better and has not been to see GP since. This time he feels much worse.
    other PMH of note? 'never sees doc'; has never been in hospital; no regular medication
    no OTC/herbal remedies
    SH : married; 3 adult children. Moved to Australia from Greece 26 years ago. Banana farmer
  • 4. 4
    Laboratory Investigations:
    FBC: Hb 13.8 g/dl, PCV 45%; WBC 7000/mm3, 70% N, 25% L; Platelets 200,000/mm3
    Blood film: Normocytic, normochromic cells
    Bilirubin: Total serum Bilirubin = 98 μmol/l, (Direct 67)
    Liver enzymes:
    Aspartate amino transferase (AST) = 62 U/l
    Alanine amino transferase (ALT) = 110 U/l
    Alkaline Phosphatase = 116 U/I
    Serum Protein: Total protein = 61 g/l, Albumin = 20 g/l,
    Hepatitis B Surface Antigen (HbsAg): Positive
  • 5. 5
    Differential Diagnosis:
    Viral fever -?
    Yellow fever, Relapsing fever, Dengue, Ebola,
    Leptospirosis (common in Tully) - ?
    Hepatitis – Acute / Chronic - ?
    Chronic Hepatitis B – why chronic?
    History & presentation in Hep. A & C ?
    Other causes of Jaundice?
    Alcoholic liver disease ?
    Toxins, chemical, Reyes syndrome?
    Anemia - ?
    Malignancy - ?
  • 6. 6
    Jaundice Clinical Diagnosis
  • 7. 7
    Pathology of HepatitisViral & Alcoholic
    Dr. Venkatesh M. Shashidhar.
    Assoc.Prof & Head of Pathology
  • 8. 8
    1.5 kg, wedge shape
    4 lobes, Right, left, (Caudate, Quadrate)
    Double blood supply
    Hepatic arteries
    Portal – Venous blood
    Normal
  • 9. 9
    CT Upper abdomen - Normal
    Liver
    Stomach
    Aorta
    Spleen
    Lung
    Lung
  • 10. Normal Liver - Infant
    Much larger, both lobes, below costal margin – palpable*
  • 11. 11
    Normal Liver
  • 12. 12
    Normal Liver – MicroscopyAcinus – showing zones 1, 2 & 3.
    Central Vein
    Blood Flow
    Portal Triad
  • 13. 13
    Structure of Liver Lobule
    Portal Triad: Art, Vein, BD
  • 14. 14
    Acinus LobuleFunctional Anatomic
    3
    Zone 1 – Toxin damage. Zone 3 – Ischemic damage
  • 15. Jaundice
    15
    • Overproduction of bilirubin
    • 16. Impaired bilirubin uptake.
    • 17. Block in metabolism
    • 18. Impaired transport.
    • 19. Obstruction to bile excretion.
  • 16
    Liver Function Tests: Interpretation
    Synthesis / function defect.
    Total protein & albumin low, PT prolonged why?
    Bile Obstruction.
    Alk Phos – markedly increased – why?
    Hepatocyte Injury.
    ALT, AST - high. – why?
    Alk Phos – moderately increased. – why?
    Other:
    GGT – increased with alcohol use. – why?
    Viral serology -
    Auto-Antibody panel.
    Clinical Features
  • 17
    Clinical Features - Pathogenesis
    Decreased Albumin synthesis
    Hepatorenal syndrome
  • 47. Jaundice in liver failure
    18
  • 48. 19
    Diseases of Liver:
    Hepatitis: Inflammation of Liver
    Viral, Alcohol, immune, Drugs, Toxins, parasites
    Acute, Chronic & Fulminant – types.
    Billiary obstruction – gall stones.
    Cirrhosis – diffuse scarring & regeneration.
    Carcinoma - Hepatocellular & Bile duct.
    Congenital: metabolic, cysts, tumors.
  • 49. Viral Hepatitis:
  • 50. 21
    Viral Hepatitis: Introduction
    Viral Hepatitis:
    Specific – Heptitis B, C, D (serum),A, E
    Non-Specific - Many viruses CMV, EBV, etc.
    Acute, Chronic (CPH, CAH), Fulminant.
    Specific viral hepatitis important cause of morbidity & mortality.
    Horizontal transmission – Blood.. Sex.
    Vertical transmission – Mother to fetus.
    Hepatitis  Cirrhosis  Hepatic Ca. (not in A/E)
  • 51. 22
    Viral Hepatitis: Microbiology
  • 52. 23
    Hepatitis A
    'faecal-oral' spread, Travel / exposure.
    Relatively short incubation period (2-6wk)
    Epidemics common, may be sporadic.
    Direct cytopathic virus (immune in B & C)
    No carrier state – prolonged immunity.
    Usually mild illness, full recovery usual.
    Rarely – severe or fulminant.
    IgM Ab is diagnostic. (no IgG tests).
  • 53. 24
    Viral Hepatitis A: Serology
  • 54. 25
    Hepatitis B
    Spread by blood, Sex & vertical.
    Relatively long incubation period (4-26wk)
    liver damage by antiviral immune reaction
    carrier state exists.
    Relatively serious infection – chronic,
    Complications: cirrhosis, carcinoma.
    Diagnosis: Viral serology (HBsAg)
  • 55. 26
    Viral Hepatitis B: Serology
    Sequence of serologic markers for hepatitis B viral hepatitis demonstrating (A) acute infection with resolution and (B) progression to chronic infection.
  • 56. 27
    Pathogenesis of Hepatitis A & B:
  • 57. 28
    History Hep B Virus:
    In 1965 - Dr. Blumberg who was studying haemophilia, found an antibody in two patients which reacted against an antigen from an Australian Aborigine. Later the antigen was found in patients with serum type hepatitis and was initially designated "Australia Antigen". Later proved to be hepatitis B virus surface antigen (HBsAg). Dr. Blumberg was awarded the Nobel Prize in 1976.
  • 58. 29
    Pathogenesis:
    Ingestion / inoculation
    Replication - Viremia
    Liver – major site replication.
    Cellular immune response.
    Apoptosis, necrosis of hepatocytes.
    Inflammation - Hepatitis
    Bridging Hepatocyte necrosis (Central vein, portal triad)
    Fibrosis – patchy/bridging
    Cirrhosis – extensive fibrosis with loss of archetecture & regenerating nodules.
    Liver Failure, Coma, Carcinoma..
  • 59. 30
    Pattern of Liver Damage
    Zonal – Toxin/Hypoxia
    Bridging – Viral & severe
    Interface – CAH, Immune
    Apoptotic – Acute Viral
  • 60. 31
    Spectrum of Viral Hepatitis:
    Carrier state / Asymptomatic phase
    Acute hepatitis – fever, icterus.
    Chronic Hepatitis – non specific.
    Chronic Persistent Hepatitis (CPH)
    Chronic Active Hepatitis (CAH)
    Fulminant hepatitis – massive necrosis
    Cirrhosis – total fibrosis.
    Hepatocellular Carcinoma
  • 61. 32
    Acute Hepatitis:
    Swelling and Apoptosis
    Piecemeal or Bridging, panacinar necrosis
    Diffuse Inflammation – lymphocytes, Macrophages.
    Ground glass hepatocytes – HBV
    Mild fatty change – HCV.
    Portal inflammation and Cholestasis
  • 62. 33
    Acute viral Hepatitis:
  • 63. 34
    Acute viral Hepatitis:Apoptotic cells.
  • 64. 35
    Acute viral Hepatitis:Apoptotic cell.
  • 65. 36
    Acute viral Hepatitis:
  • 66. 37
    Acute viral Hepatitis:
  • 67. 38
    Acute viral Hepatitis C:
  • 68. 39
    Ground glass Hepatocytes:
  • 69. 40
    Chronic Hepatitis:
    Persistent CPH
    Limited Periportal inflammation.
    Mild Periportal fibrosis
    No hepatocyte Necrosis.
    LFT normal or mild change.
    Late cirrhosis
    Active CAH
    Extensive Inflammation
    More fibrosis.
    Necrosis of hepatocytes.
    LFT abnormal.
    Early cirrhosis & other complication.
  • 70. 41
    Liver Biopsy – viral Hepatitis-C
  • 71. 42
    Liver Biopsy - CAH:
  • 72. 43
    Chronic Active viral Hepatitis:
  • 73. 44
    Chronic Persistent Hepatitis:
  • 74. 45
    Liver Biopsy – CPH:
    Inflammation
    No Necrosis
  • 75. 46
    Acute - Hepatitis - Chronic
  • 76. 47
    Viral – Steatosis - Alcoholic
    Microvesicular (viral) Macrovesicular(alcoholic)
  • 77. 48
    Fulminant Hepatitis:
    Hepatic failure with in 2-3 weeks.
    Reactivation of chronic or acute hepatitis
    Massive necrosis, shrinkage, wrinkled
    Collapsed reticulin network
    Only portal tracts visible
    Little or massive inflammation – time
    More than a week – regenerative activity
    Complete recovery – or - cirrhosis.
  • 78. 49
    Fulminant Hepatitis:
  • 79. 50
    Fulminant Hepatitis:
  • 80. 51
    Fulminant Hepatitis:
  • 81. 52
    Fulminant Hepatitis:confluent necrosis().
  • 82. 53
    Clinical Spectrum of HBV inf:
  • 83. 54
    Outcomes of HBV Infection:
  • 84. “Nearly all men
    can stand adversity,
    but if you want to
    test a man's character,
    give him power”
    —  Abraham Lincoln
  • 85. Laboratory DiagnosisViral Hepatitis
  • 86. 57
    Viral Hepatitis C: Serology
  • 87. Hepatitis B – Lab result interpret
  • 88. 59
    Cirrhosis
    End stage of diffuse liver disease. scaring with regenerating nodules. (liver failure)
    Normal Cirrhosis 
  • 89. The past has gone and future you cannot see.
    The present, when you can do something, that is the Gift (Present) with which you can make your future & past memorable.
    - Sai Baba
    "The past, the present and the future are really one: they are today."
    -Harriet Beecher Stowe
  • 90. Alcoholic Liver Disease
  • 91. 62
    Incidence is increasing…!
  • 92. 63
    Chronic Alcoholism:
    Clinical Features:
  • 93. 64
    Alcoholic Liver Injury:
    Ethyl alcohol : Common cause of acute/Chronic liver disease
    Alcoholic Liver disease - Patterns
    Fatty change,
    Acute hepatitis (Mallory Hyalin)
    Chronic hepatitis with Portal fibrosis
    Chronic Liver failure
    Cirrhosis
    All reversible except cirrhosis stage.
  • 94. 65
    Alcoholic Liver Injury: Pathogenesis
    Acetaldehyde – metabolite – hepatotoxic
    Diversion of metabolism to alcohol
    Fat storage – fatty change. Cell swelling..
    Rupture Fat necrosis  severe inflammation  fibrosis.
    Alcohol stimulates collagen synthesis
    Inflammation, Portal bridging fibrosis
    Micronodular cirrhosis.
  • 95. 66
    Alcoholic Liver Damage
    Ito Cells
  • 96. 67
    Alcoholic Liver Injury: Pathogenesis
    Diversion of fat metabolism to alcohol – fat storage.
    Acetaldehyde – hepatotoxic – denatures Proteins
    Increased peripheral release of fatty acids.
    Alcohol stimulates collagen synthesis
    Mutant ALDH2 gene with low activity enzyme is observed in Caucasians but is found in some 40% of Orientals (autosomal dominant).
    Acetaldehyde
  • 97. 68
    Safe drinking…
    High Risk
    Intermediate
    Low Risk
  • 98. 69
    Risk of Alcohol injury
    1 Unit = 10ml = 8gm
  • 99. 70
    Alcoholic Liver Damage
  • 100. 71
    Alcohol Toxicity:
  • 101. 72
    Alcoholic Fatty Liver
  • 102. 73
    Alcoholic Fatty Liver
  • 103. 74
    Alcoholic Fatty Liver
  • 104. 75
    Alcoholic Fatty Liver
  • 105. Diffuse fatty liver - un-enhanced CT.
    Normal
    Hamer O W et al. Radiographics 2006;26:1637-1653
    ©2006 by Radiological Society of North America
  • 106. 77
    Alcoholic Fatty Liver - CT
  • 107. 78
    Alcoholic Fatty Liver - CT
  • 108. 79
    Alcoholic Liver- Mallory's hyalin
  • 109. 80
    Alcoholic Fatty change:
  • 110. 81
    Alcoholic Fatty change & Mallory Hyalin:
  • 111. 82
    Alcoholic Fatty Liver
  • 112. 83
    Alcoholic Fatty Liver - collagen stain
  • 113. 84
    Alcoholic Cirrhosis:
  • 114. 85
    Alcoholic Fatty Liver - collagen stain
  • 115. Alcoholic Hepatitis:
    86
    • Centrilobular necrosis. Ballooned degenerating hepatocytes (BC) Mallory bodies (MB) Many Neutrophils, few lymphocytes & Macrophages.
    • 116. The central vein(or terminal hepatic venule (THV), is encased in connective tissue (C) (central sclerosis). Fat-laden hepatocytes (F) are evident in the lobule. The portal tract displays moderate chronic inflammation.
  • 87
    Alcoholic Liver Injury: Complications
    Pancreatitis – Acute or Chronic. Due to ischemic damage to pancreas.
    Alcoholic hepatitis – similar to viral hepatitis.
    Fulminant hepatitis
    Alcoholic Cirrhosis – Micronodular.
    Alcohol & Medical students
    http://www.m-c-a.org.uk/about_us/about_mca
  • 117. Drug Induced Zonal Hepatitis:
    88
    • Autopsy specimen in a case of acetaminophen overdose.
    • 118. Prominent hemorrhagic necrosis of the centrilobular zones of all liver lobules.
    • 119. greater activity of drug-metabolizing enzymes in the central zones.
    • 120. Other agents that produce such injury are carbon tetrachloride, acetaminophen, toxins of the mushroom Amanita phalloides.
    • 121. Patients either die in acute hepatic failure or recover without sequelae.
  • Reye Syndrome:
    89
    • Acute disease of children
    • 122. Microvesicular steatosis, hepatic failure, and encephalopathy.
    • 123. Cerebral edema and fat accumulation are reported in the brain.
    • 124. The symptoms usually begin after a febrile illness, commonly influenza or varicella infection, and are said to correlate with the administration of aspirin,
    • 125. Pathogenesis remains unknown.
    • 126. Uncommon, possibly as a result of decreasing use of aspirin in children.
  • Toxemia of Pregnancy:
    90
    • Hypertension, proteinuria, edema and coagulation abnormalities (pre-eclampsia) and convulsions and coma (eclampsia).
    • 127. HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count) can also occur in pre-eclamptic women.
    • 128. Patchy hemorrhages over capsule
    • 129. Intravascular coagulation
    • 130. Fibrin thrombi in portal vessels.
    • 131. Hepatocellular necrosis.
  • 91
    Pathology of Cirrhosis
  • 132. 92
    Cirrhosis
    End stage of diffuse liver disease. scaring with regenerating nodules. (liver failure)
    Normal Cirrhosis 
  • 133. 93
    Post hepatitis Liver Cirrhosis
    Shrunken, irregular nodularity, (macro nodular) fibrous septa.
  • 134. 94
    MRI Cirrhosis
  • 135. 95
    Liver Biopsy – Cirrhosis:
  • 136. 96
    Liver Biopsy – Cirrhosis
  • 137. 97
    Liver Biopsy – Cirrhosis
  • 138. 98
    Introduction
    Cirrhosis is common end result of many chronic liver disorders.
    Diffuse scarring of liver – follows hepatocellular necrosis of hepatitis.
    Inflammtion – healing with fibrosis - Regeneration of remaining hepatocytes form regenerating nodules.
    Loss of normal architecture & function.
  • 139. 99
    Etiology of Cirrhosis
    Alcoholic liver disease 60-70%
    Viral hepatitis 10%
    Biliary disease 5-10%
    Primary hemochromatosis 5%
    Cryptogenic cirrhosis 10-15%
    Wilson’s, 1AT def rare
  • 140. 100
    Alcoholic Cirrhosis
  • 141. 101
    Micronodular cirrhosis:
  • 142. 102
    Pathogenesis:
    Hepatocyte injury leading to necrosis.
    Alcohol, virus, drugs, toxins, genetic etc..
    Chronic inflammation - (hepatitis).
    Bridging fibrosis.
    Regeneration of remaining hepatocytes Proliferate as round nodules.
    Loss of vascular arrangement results in regenerating hepatocytes ineffective.
  • 143. 103
    Clinical Features
    Hepatic encephalopathy
  • 144. 104
    Pathogenesis of Ascitis:
    Hepatorenal Syndrome
  • 145. 105
    Cirrhosis – Portal hypertension
    Cirrhosis-obstruction
    Portal hypertension
    Splenomegaly
    transudation - Ascites
  • 146. 106
    Causes of Portal Hypertension:
  • 147. 107
    Ascitis in Cirrhosis
  • 148. 108
    Cirrhosis:
  • 149. 109
    Ascitis in Cirrhosis
  • 150. 110
    Gynaecomastia in Cirrhosis
    ?
    ?
    ?
    ?
  • 151. 111
    Ascitis in congenital Cirrhosis
  • 152. 112
    Normal / Cirrhosis Liver
  • 153. 113
    Micronodular cirrhosis:
  • 154. 114
    Biliary Cirrhosis
  • 155. 115
    Cirrhosis with bile stasis
  • 156. 116
    Cirrhosis with bile stasis
  • 157. 117
    Primary Biliary Cirrhosis - Micronodular
  • 158. 118
    Liver Biopsy – Cirrhosis
  • 159. 119
    Palmar erythema & Spider nevi
    ? Pathogenesis
  • 160. 120
    Hepatocellular Carcinoma
  • 161. 121
    Cirrhosis with carcinoma:
  • 162. 122
    Nutmeg Liver:
    Chronic Passive Congestion – Heart failure.
    Venous stasis - right atrium - hypoperfusion retrograde congestion – IVC & SVC.
    Central zone (Zone-3) – congestion and necrosis.
    Hemorrhage – RBCs in zone-3 - Mottled appearance (nutmeg).
    Symptoms are similar to those of chronic hepatitis - Ascites, distended abdomen, ankle edema, Hepatic encephalopathy, confusion.
  • 163. 123
    Nutmeg Liver-Cardiac Sclerosis
  • 164. 124
    Liver Metastasis:
    Multiple
    Clear demarcation
    Hemorrhage / Central necrosis (+/-)
    Microscopy depends on type.
  • 165. Miscellaneous Conditions
    125
  • 166. 126
    Hepatosplenic schistosomiasis:
    Schistosoma Mansoni / haematobium
    Granulomas in the liver.
    Fibrotic reaction around egg
    Pipe stem Portal Fibrosis
    Cirrhosis, spleenomegaly, ascitis.
  • 167. 127
    Hepatosplenic schistosomiasis:
    Schistosoma Mansoni / haematobium
    Granulomas in the liver.
    Fibrotic reaction around egg
    Pipe stem Portal Fibrosis
    Cirrhosis, spleenomegaly, ascitis.
  • 168. "It's not the will to win, but the will to prepare to win that makes the difference."
    Bear Bryant1913-1983, Football Coach
  • 169. 129
    CPC-2.2– HBS–Hepatitis
    Basic science - Core Learning Issues:
    anatomy and histology of the liver & Spleen
    Portal circulation.
    Liver Functions & Bilirubin metabolism (RBC, Hb)
    Viral Hepatitis – epidemiology,virology.
    Pathology Core Learning Issues:
    Pathology of liver, Hepatitis. Causes, types, gross & microscopic morphology.
    Jaundice – clinical and pathological types
    Acholuric, obstructive, hemolytic, hepatic.
    Laboratory investigations.
    Pathology of cirrhosis & its complications.
  • 170. 130
    51y M, Alcoholic: Look at Arrow ? Pathogenesis.
    Porta-systemic shunt
    Hyper-oestrogenemia
    Portal hypertension
    Hypo-albuminemia
    Decreased vit-K
  • 171. Pathogenesis - typical of which virus?
    HAV
    HBV
    HCV
    HDV
    Non Specific
  • 172. 42y M, alcoholic, recurrent fatigue. Liver biopsy. ? Diagnosis
    Acute Hepatitis
    Chronic Active hepatitis.
    Chronic Persistant hepatitis.
    Fulminant Hepatitis.
    Cirrhosis.
  • 173. A 42year travelling salesperson has routine medical test for insurance. Following initial testing he was advised liver biopsy. This is a image of his Liver Biopsy. What is the most likely diagnosis?
    Acute Viral Hepatitis
    Alcoholic hepatitis.
    Chronic viral Hepatitis.
    Post viral cirrhosis.
    Alcoholic Cirrhosis.
  • 174. 69y Female, Chronic bronchitis. Died following chronic Cardiac failure. Liver specimen. Likely diagnosis?
    Alcoholic Hepatitis
    Dubin-Johnson Syndrome
    Alcoholic cirrhosis
    Nutmeg liver
    Metastatic deposits
  • 175. 135
    HBsAg Positive,
    Anti HBcAg Positive
    Anti HBcAg IGM Negative
    Anti HBsAg Negative
    Viral serology interpretation:
    Acute Viral Hepatitis
    Immunised against Hep. B
    Chronic Hepatitis B
    Hepatitis B carrier stage
    Fulminant hepatitis B
  • 176. 136
    HBsAg Negative,
    Anti HBcAg Negative
    Anti HBcAg IGM Negative
    Anti HBsAg Positive
    Viral serology interpretation:
    Acute Viral Hepatitis
    Immunised against Hep. B
    Past Hepatitis B
    Hepatitis B carrier stage
    Fulminant hepatitis B
  • 177. 137
    HBsAg Negative,
    Anti HBsAg Positive
    Anti HBcAg Positive
    Anti HBcAg IGM Negative
    Viral serology interpretation:
    Acute Viral Hepatitis B
    Immunised against Hep. B
    Past Hepatitis B
    Hepatitis B carrier stage
    Carrier state of Hepatitis B
  • 178. 138
    Protein (Total) 59 g/L
    Albumin 30 g/L
    Globulin 29 g/L
    Bilirubin (Total) 27 μmol/L
    ALP 71 U/L
    GGT 523 U/L
    ALT 79 U/L
    AST 151 U/L
    Lab Investigations interpretation:
    Alcoholic Liver disease
    Acute Viral Hepatitis.
    Past Hepatitis B
    Hepatitis B carrier stage
    Carrier state of Hepatitis B
  • 179. 139
    Lab Investigations interpretation:
    Urea 5.8 mmol/L
    Creatinine 80 μmol/L
    Protein (Total) 66 g/L
    Albumin 35 g/L
    Globulin 31 g/L
    Bilirubin (Total) 192 μmol/L
    Bilirubin (Conj.) 130 μmol/L
    ALP 203 U/L
    GGT 470 U/L
    ALT 6055 U/L
    AST 4860 U/L
    Alcoholic Liver disease
    Past Hepatitis B
    Acute Viral Hepatitis.
    Hepatitis B carrier stage
    Carrier state of Hepatitis B
  • 180. 28y M, alcoholic, homosexual icterus and fever. Liver biopsy. ? diagnosis
    Acute viral hepatitis
    Hemolytic anemia
    Chronic persistent hepatitis
    Alcoholic fatty liver.
    Alcoholic Hepatits.
  • 181. 62 year Male, malaise, lethargy since 2 years. Liver mildly enlarged. No jaundice. Liver function tests normal. Image from liver biopsy. Most likely diagnosis?
    Alcoholic fatty liver.
    Acute viral hepatitis.
    Fulminant hepatitis.
    Chronic viral hepatitis.
    Alcoholic Cirrhosis.
  • 182. 34y M, icterus and fever. Liver biopsy. ? diagnosis
    Acute Hepatitis
    Chronic Persistent Hepatitis.
    Chronic active Hepatitis
    Fulminant Hepatitis
    Cirrhosis
  • 183. 22y M, alcoholic, 3wk fatigue, icterus & fever. Liver biopsy. ? Identify the structure
    Mallory hyaline
    Apoptotic cell
    Viral inclusion
    Hepatocyte necrosis
    Inflammatory cell
  • 184. 56y chronic alcoholic, 2 days fever, abdomen distended, tender, tap yielded cloudy yellow fluid with 98% neutrophils, Blood culture E.coli. Patient dies 3 days later. Image shows his liver.
    A1 antitrypsin deficiency
    HEV infection
    Hereditary hemochromatosis
    Primary sclerosing cholangitis
    Alcoholic cirrhosis
  • 185. 58y M, alcoholic, distended abdomen & icterus. Liver biopsy. ? diagnosis
    Chronic active hepatitis.
    Chronic Persistant hepatitis.
    Hepatocellular carcinoma.
    Cirrhosis
    Chronic alcoholic hepatitis.
  • 186. 146
    51y M, Alcoholic: Look at Arrow ? Pathogenesis.
    Porta-systemic shunt
    Hyper-oestrogenemia
    Portal hypertension
    Hypo-albuminemia
    Decreased vit-K
  • 187. 51y M, Alcoholic, surgery for pigmented skin lesion: Liver specimen. Likely diagnosis?
    Amoebic Liver abscesses
    Multiple Liver Infarcts
    Alcoholic Hepatitis
    Macronodular cirrhosis
    Metastatic deposits
  • 188. 59y Male, Alcoholic, presents with fatigue, anorexia. Normal liver function tests. Liver specimen. Likely diagnosis?
    Dubin-Johnson Syndrome
    Alcoholic cirrhosis
    Alcoholic Hepatitis
    Fatty Liver
    Metastatic deposits
  • 189. 22y M, alcoholic, 3wk fatigue, icterus & fever. Liver biopsy. ? Identify the structure
    Mallory hyaline
    Apoptotic cell
    Viral inclusion
    Hepatocyte necrosis
    Inflammatory cell
  • 190. 28y Male, 3 weeks after visiting east Timor, presents with malaise, fatigue, loss of appetite. Mild icterus. AST & ALT mild elevation. Total bil 3.9mg/dl (Direct 2.8). Which of the following would be positive?
    Anti HBs
    IgM anti-HDV
    Anti HCV
    IgM anti HAV
    Anti HBc
  • 191. 28y Male, 3 weeks after visiting east Timor, presents with malaise, fatigue, loss of appetite. Mild icterus. AST & ALT mild elevation. Total bil 3.9mg/dl (Direct 2.8). Which of the following would be positive?
    Anti HBs
    IgM anti-HDV
    Anti HCV
    IgM anti HAV
    Anti HBc
  • 192. 41y Female, increasing malaise, 10kg weight loss since last year. Developed coma and died. Specimen of her Liver. Most likely etiologic agent?
    Aspirin abuse
    Ferrous sulphate
    Acetaminophen
    Aflatoxins
    Raw Oysters.
  • 193. A 48y man referred following high ALT in health screening. HCV immunoassay +ve. Past h/o appendectomy 10 years ago. Examination is normal. Which of the following tests would determine if he has Chronic HCV infection?
    Repeat EIA for anti HCV Ab.
    Recombinant immunoblot assay (RIBA)
    Alpha-fetoprotein levels.
    HCV RNA test.
    Direct, indirect & total bilirubin assay.
  • 194. 154
    Learn from the mistakes of others. You can't live long enough to make them all yourself…!
    61% of 5th year students exceeded ‘sensible’ limits
    Drugs and alcohol were taken mainly for pleasure and were perceived as a normal part of life for many students… Capability of advising patients…?
    http://www.lycaeum.org/research/researchpdfs/1996_webb_1.pdf
  • 195. 155
    CPC-2.2– Major Pathology CLI:
    Pathology of Acute & Chronic Liver injury.
    Hepatitis – Causes, Types, Pathophysiology, Gross & Microscopic Pathology. Complications.
    Common types: Viral (Specific & Non specific), Alcoholic & Drug induced.
    Pathophysiology of Jaundice, Clinical & Pathological types.
    Pathology of cirrhosis – Classification, morphology & Complications.
    Pathology of Alcoholic Liver disease – Pathophysiology, types & complications.
  • 196. 156
    CPC-2.2– Minor Pathology CLI:
    Hemosiderosis & Hemochromatosis.
    Pathogenesis of Hepatic coma, Liver failure.
    Primary Biliary cirrhosis.
    Hepatocellular carcinoma.
    Liver cysts & tumours – adenoma, hyperplasia & cancer.
    Amoebic liver abscess & Hydatid disease of liver.
    Congenital liver disorders – enzyme disorders.
  • 197. 157
    Clinical Case Study
  • 198. 158
    Case # 2 - ? Diagnosis
    60yr Male, 8 month slowly developing weakness, mild icterus.
    PE: Mild Abdominal tenderness, No organomegaly. Mild Scleral icterus.
    Labs: ALT: 52 (N= 8-33 U/L)
    AST: 58 (N= 4-36 U/L)
    Alk Phos: 150 (N= 20-130 u/L)
    Bilirubin 3.9 (N= 0.1-1.2 mg/dL) (direct 1.8)
    T Protein 4.8 (N= 6.0-7.8 g/dL)
    Albumin 2.5 (N= 3.2-4.5 g/dl)
    PT = 16 sec (N= 11-14.7 sec )
    Differential diagnosis?
    What further investigations?
  • 199. 159
    Diagnosis pathway:
    ALT: 52
    AST: 58
    Alk Phos: 150
    Bilirubin 3.9 (direct 1.8)
    Jaundice?
    Mild increase, Mixed (combined)
    Synthesis?
    Total protein, albumin – Low & PT abnormal.
    Obstruction & Bilirubin Clearance ?
    Alk Phos is up a bit – but not high – some obstruction.
    Hepatocyte Direct Injury:
    ALT & AST are up a bit, but not dramatically.
    Discussion:
    Chronic Mild compromise - chronic Active hepatitis. (In CPH LFT will be normal)
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    28y Male, 3 weeks after visiting east Timor, presents with malaise, fatigue, loss of appetite. Mild icterus. AST & ALT mild elevation. Total bil 3.9mg/dl (Direct 2.8). Which of the following would be positive?
  • 201. 161
    Alcohol Metabolism: