Undergarduate medical practicals

1. Hepatobiliary
System

2. Topics
Liver Cirrhosis
Amoebic Liver Abscess
Actinomycotic Granuloma
Hepatocellular Carcinoma

4.  Diffuse scarring of liver characterized by loss of
lobular architecture and formation of
regenerative nodules.
 Characteristics
 Involves entire liver
 Loss of normal architecture
 Regenerative nodules separated by fibrotic bands
 Alternate necrotic and regenerative areas
Cirrhosis

5. Alcohol
Viral hepatitis (HBV, HCV)(POST NECROTIC)
Biliary obstruction (BILIARY)
Hemochromatosis (PIGMENT)
Wilson’s disease
Autoimmune
Drugs and toxins
Idiopathic
Causes of Cirrhosis

6. Alcohol, Autoimmune
Biliary obstruction (biliary)
Chronic viral hepatitis (HBV, HCV) (post-necrotic)
Drugs and toxins
Hemochromatosis (pigment)
Idiopathic
Wilson’s disease
Causes of Cirrhosis

7. WHO divided cirrhosis into 3 categories based on morphological
characteristics of the hepatic nodules
 Micronodular
 Nodules <3 mm
 Uniform
 no portal tract or central vein identified
 Alcoholic, biliary, hemochromatosis
 Macronodular
 Nodules >3mm
 Variably sized (not uniform)
 Nodules may contain portal tract and central vein
 Post necrotic
 Mixed
Classification of cirrhosis

8. Micronodular cirrhosis

9. Macronodular cirrhosis

10. Gross

11. Microscopy

12. Micronodular cirrhosis

13. 3 major forms of hepatic abscess identified by their causative
microorganisms:
Pyogenic
 Polymicrobial - 80%
 E. coli, Klebsiella pneumoniiae, Proteus spp., pseudomonas, Streptococcus
milleri
Amoebic
 Entamoeba histolytica - 10%
Fungal
 Candida species <10%
Hepatic Abscess

14. Caused by a gram positive anaerobic filamentous bacteria, Actinomyces
israelii.
A chronic, suppurative and granulomatous disease
The organism spreads to liver from intestinal lesion via the portal
channels.
GROSS
 Multiple,
 Small,
 Ragged
 Contain colonies of these organisms (sulphur granules)
Actinomycotic abscess

15. Gross

16. Microscopy
Splendore- Hoeppeli phenomenon

17. Caused by spread of the trophozoites of Entamoeba histolytica from
intestinal lesions through portal vein.
Common in developing countries.
GROSS
 Solitary lesion
 Superoposterior right lobe
 Lining of abcess is gray white
 Because of haemorrhage into the abscess cavity it shows a
 Chocolate colored,
 Odourless,
 Pasty material resembling anchovy sauce.
Amoebic Liver Abscess

18. Amoebic Liver Abscess

19. Anchovies

20. Anchovy Sauce

21. Amoebic Liver Abscess

22. Primary
 Hepatocellular carcinoma(90%)—arises from hepatocytes
 Cholangiocarcinoma(10%)—arises from intrahepatic bile duct
epithelium.
 Mixed--uncommon
Metastatic
Carcinoma Of Liver

23. Unifocal (expanding type)
 Large mass
 Yellow brown
 Right lobe of liver
Multifocal
 Widely distributed nodules of variable sizes
Diffusely infiltrative
 Involving the entire liver
Hepatocellular Carcinoma

24. Gross

25. Gross

26. Microscopy
Small cell variant Large cell variant

29. Microscopy

30. Flask shaped undermined ulcer in colon ameba with ingested rbcs

31. MICRONODULAR MACRONODULAR
(HOBNAIL LIVER)
Liver shrinks Nodules >3mm
Nodules <3mm, diffuse, vary little in size not uniform in size

32. PATHOPHYSIOLOGY

33. IN A CUT SECTION, THE UNIFORM SMALL NODULES OF
REGENERATING HEPATOCYTES ARE MORE OBVIOUS

34. STAGES
 ALCOHOLIC STEATOSIS
 Droplets of fat in hepatocytes displacing nuclei to periphery
 ALCOHOLIC HEPATITIS
 Centrilobular necrosis
 Ballooning degeneration
 Mallory bodies
 Pericellular and perivenular fibrosis
 ALCOHOLIC CIRRHOSIS
Mallory bodies – intracytoplasmic eosinophilic inclusion seen in perinuclear locations, d/t
accumulation of intermediate filaments
CIRRHOSIS - ALCOHOL

35. Normal liver fatty liver regenerative nodules in cirrhosis
surrounded by fibrosis

36. HBV infection (MACRONODULAR)
Chemicals
Alfatoxin, vinyl chloride
Metal storage disases
Hemochromatosis or Wilson’s disease
Food additives like nitrosamines and butter yellow
Alpha 1 antitrypsin deficiency.
RISK FACTORS FOR HCC

37. HEPATOCELLULAR CARCINOMA- GROSS

38. HEPATOCELLULAR CARCINOMA

39. THE ENTIRE SURFACE OF THE LEFT LOBE AND MOST OF THE
RIGHT LOBE OF THE LIVER HAVE AN IRREGULAR NODULAR
APPEARANCE, DUE TO THE PRESENCE OF CIRRHOSIS AND
HEPATOCELLULAR CARCINOMA.

40. Ranges from well differentiated to highly anaplastic lesions.
In well differentiated HCC cells resembling normal hepatocytes are
present in trabecular, acinar or pseudoglandular pattern.
In poorly differentiated HCC cells are pleomorphic with anaplastic giant
cells.
HEPATOCELLULAR CARCINOMA-MICROSCOPY

41. THIS BIOPSY SPECIMEN SHOWS IRREGULAR TRABECULAE OR CORDS OF
MALIGNANT HEPATOCYTES WITH ENLARGED NUCLEI THAT CONTAIN NUCLEOLI,
CONSISTENT WITH A WELL-DIFFERENTIATED HEPATOCELLULAR CARCINOMA.

42. AMEBIC LIVER ABCESS

43. ANCHOVY SAUCE APPEARANCE

44. Most common in cecum and ascending colon.
E – histolytica cysts are infectious forms, ingested, resistant to gastric
acid.
Ameba attach to the colonic epithelium and burrow into lamina propria.
They create a flask shaped ulcer with narrow neck and broad base.
AMEBIC ULCER - COLON

45. ENTAMOEBA HISTOLYTICA TROPHOZOITE WITH
INGESTED RBCS