Hepatology Quiz: Liver Diseases and Conditions

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Questions and Answers

Which zone of the liver is most susceptible to damage from hypotension and congestion?

Periportal Zone

Zone 2

Zone 1

Zone 3 (correct)

What is the primary cause of a 'nutmeg' appearance in the liver?

Left heart failure

Portal vein thrombosis

Hepatic artery thrombosis

Right heart failure or hepatic vein thrombosis (correct)

A patient presents with symptoms including anorexia, nausea, vomiting, and jaundice. Which of the following patterns of hepatitis serology is suggestive of acute hepatitis B infection?

HBsAg positive, Anti-HBc total positive, IgM fraction negative

HBsAg positive, Anti-HBc total positive, IgM fraction positive (correct)

HBsAg negative, Anti-HBc total negative, IgM fraction positive

HBsAg negative, Anti-HBc total positive, IgM fraction negative

Based on the provided information, what clinical finding suggests a significant volume depletion in the patient?

Orthostatic hypotension and tachycardia Signup and view all the answers

If a patient's urinalysis shows positive bilirubin, what is the most likely cause?

Liver disease or obstruction of bile flow Signup and view all the answers

Which of the following is NOT a risk factor for Hepatitis B infection?

Intravenous drug use Signup and view all the answers

Based on serology, which of the following hepatitis infections the patient does not have?

Hepatitis C Signup and view all the answers

What symptom in the patient is most indicative of a liver issue?

Jaundice Signup and view all the answers

What is the typical ratio of AST to ALT in alcoholic hepatitis?

2:1 Signup and view all the answers

Which of the following is NOT a typical clinical presentation of cirrhosis?

Decreased risk of infection Signup and view all the answers

What is the primary mechanism of organ toxicity in hemochromatosis?

Abnormal accumulation of iron in parenchymal organs Signup and view all the answers

Which of the following is the most common genetic liver disorder identified in infants and children?

Alpha-1 antitrypsin deficiency Signup and view all the answers

What is the underlying cause of the protein accumulation in alpha-1 antitrypsin deficiency?

Reduced synthesis of normal alpha-1 antitrypsin Signup and view all the answers

Which histological feature is most indicative of the acute phase of hepatitis?

Councilman bodies Signup and view all the answers

Which of the following is a common complication of portal hypertension seen in cirrhosis?

Caput medusae Signup and view all the answers

What are the two mutations in the HFE gene that have been described in hemochromatosis?

C282Y and H63D Signup and view all the answers

What is a distinctive histologic finding associated with chronic hepatitis B?

Ground glass hepatocytes Signup and view all the answers

Which of the following is a typical characteristic of chronic hepatitis C?

Portal lymphoid infiltration Signup and view all the answers

Secondary hemochromatosis can be caused by which of the following?

Disorders of erythropoiesis and treatment of the diseases with blood transfusions. Signup and view all the answers

What is a key diagnostic feature of autoimmune hepatitis on liver biopsy?

Plasma cell infiltration Signup and view all the answers

What term describes the pattern of severe liver cell destruction seen in fulminant hepatitis?

Massive hepatic necrosis Signup and view all the answers

Which of the following is NOT typically associated with progression or severity of hepatitis C?

Female gender Signup and view all the answers

A patient with chronic hepatitis has normal ALT and AST levels, and no symptoms. How long should the infection last to be considered chronic?

6 months Signup and view all the answers

Besides viral infections, which of the following could also cause fulminant hepatitis?

Wilson’s disease Signup and view all the answers

What is the most typical microscopic finding in alcoholic hepatitis?

Mallory bodies Signup and view all the answers

Which of the following is a common characteristic of autoimmune hepatitis?

High ALT and AST (300-500 mg/dl) Signup and view all the answers

Study Notes

Liver Pathology

Liver Pathology Objectives: Students will be able to identify and describe the clinicopathological features of common liver lesions, including hepatitis (viral and autoimmune), cholestasis (PBC, PSC), metabolic disorders (fatty liver, hemochromatosis, Alpha-1 antitrypsin deficiency), and liver tumors.

Liver Pathology - Zone 3

Zone 3 Location: Zone 3 is located adjacent to the central vein.
Oxygen Supply: It receives the least oxygen supply.
Risk of Hypotension/Congestion: This zone is at a higher risk of hypotension and congestion.

Liver Pathology - Congestion

Causes: Right heart failure or hepatic vein thrombosis .
Appearance: The liver can exhibit a "nutmeg" appearance if congested.
Microscopical Findings (microscopic images): Normal hepatocytes, portal tracts, central veins, areas of central hemorrhagic necrosis, dilated sinusoids.

Case Study - Hepatitis B

Patient Demographics: 30-year-old homosexual man.
Presenting Complaint: Anorexia, nausea, vomiting, and malaise.
Medical History: Multiple sexual partners, unprotected anal and anal-oral sex, history of alcohol consumption.
Weight Loss: Lost 10 pounds.
Physical Examination: Thin, ill-appearing, decreased blood pressure upon sitting, increased pulse, fever, mild right upper quadrant abdominal tenderness, enlarged liver (percussed 3 cm below costal margin with 13 cm span), jaundice.
Laboratory Results: Elevated AST (1240 U/L), ALT (1650 U/L), Alkaline Phosphatase (198 U/L), Total bilirubin (12.0 mg/dL), Direct bilirubin (8.0 mg/dL); Positive HBsAg, positive Anti-HBc Total, positive IgM fraction.

Liver Pathology - Laboratory Results (additional)

Hematocrit: 48%
White blood cell count: 6,000/μL with normal differential
Electrolytes: Normal
Creatinine: 1.2 mg/dL
Other laboratory tests: Negative for anti-HAV IgM, anti-HCV, anti-delta, anti-HIV. Urine analysis - pH 7.2, golden brown, trace protein, negative glucose, positive bilirubin (3+).

Diagnosis

Diagnosis: Acute Hepatitis B

Acute Phase of Hepatitis B

Microscopic Findings: Inflammatory cell infiltration, ballooning degeneration, Councilman bodies.

Chronic Hepatitis B

Microscopic Findings: Ground glass hepatocytes.

Hepatitis B Overview

Severity: Usually subclinical, can lead to fulminant hepatic failure, chronic liver disease, and cirrhosis.
High Risk: Lifetime risk of hepatocellular carcinoma is 40% for men, and 15% for women.
Transmission: Spread through contact with infected patients or chronic viral carriers through intimate/sexual contact, intravenous drug abuse, contaminated blood, or infected instruments. Transmission is also possible via maternal to infant delivery.
Acute Infection: Development of immunity following acute infection, or development of chronic hepatitis or chronic carrier state.
Chronic Infections: <5 years 30-90%, ≥5 years 5-10%. Immunostains are helpful for chronic disease identification. Carrier state: antigenemia >6 months, normal ALT and AST, no symptoms. Carrier state occurs in 10%.

Hepatitis C

Discovery: Genome identified in 1989.
Prevalence: Major worldwide, leading indication for liver transplantation. 4 million US citizens have anti-HCV; 2.7 million have detectable virus.
Progression to Chronicity: High rate, 85% develop chronic disease, and 15-20% develop cirrhosis.
Factors Promoting Progression: Alcohol use increases risk and severity, age at acquisition > 40, male gender, hepatitis B or HIV coinfection.

Acute Phase of Hepatitis C

Microscopic Findings: Lobular and portal inflammation, dying cells with glassy, eosinophilic cytoplasm, inflammation in triads.

Chronic Hepatitis C

Microscopic Findings: Portal lymphoid infiltration, fatty changes, bridging fibrosis may show early cirrhosis.

Grading of Chronic Hepatitis C (G0-G3)

Grading system: Used to assess the severity of inflammation in the liver tissue.

Staging of Fibrosis (S0-S3)

Staging system: Used to determine the severity of liver scarring or fibrosis.

Autoimmune Hepatitis

Prevalence: 70% are women, usually aged 20-45, 60% develop other autoimmune disorders such as rheumatoid arthritis, thyroiditis, Sjogren's syndrome, and ulcerative colitis.
Diagnosis: Diagnosis of exclusion, negative viral markers, elevated IgG, and presence of autoantibodies such as antinuclear antibody, anti-smooth muscle actin antibody, anti-liver-kidney-microsomal antibody. Increased ALT and AST levels are typically observed in the 300-500 mg/dl range.
Microscopic Findings: Interface hepatitis, plasma cell infiltration.

Fulminant Hepatitis

Description: Uncommon complication of acute viral hepatitis, massive hepatic necrosis. Marked by very rapid progression from the onset of initial symptoms to hepatic encephalopathy in 2-3 weeks' time.
Causes: Drugs (acetaminophen, carbon tetrachloride, halothane, isoniazid, rifabutin), viruses (hepatitis B and A), acute fatty liver of pregnancy, hepatic vein obstruction, hyperthermia, ischemia, tumor, Wilson's disease.
Microscopic Findings: Extensive necrosis with scattered residual bile ducts.
Diagnosis: Determined through careful history, physical examination, and complete laboratory studies.
Treatment: Liver transplant.

Metabolic Disorders (additional)

Fatty Liver: Microscopic findings of steatosis, macrovesicular fatty change.
Hemochromatosis: Microscopic findings of iron stain.
Alpha-1 antitrypsin deficiency: Microscopic findings of PAS positive hyaline globules.

Alcoholic Hepatitis

Description: Acute form of alcohol-induced liver injury from prolonged period of high alcohol consumption.
Severity Spectrum: Ranging from asymptomatic derangement of liver enzymes to fulminant liver failure.
Diagnosis: Based on thorough history, physical examination, and a review of laboratory tests.
Characteristic: AST/ALT is approximately 2:1.
Outcomes: Steatosis, Hepatitis, Cirrhosis can follow depending on the severity of the exposure and abstinence periods

Cirrhosis

Description: Fibrosis, scar tissue and regenerative nodules are the key features.
Causes: Chronic liver disease and various other factors.
Clinical Presentations: Progressive liver failure, complications related to portal hypertension, development of hepatocellular carcinoma.
Additional features: Caput medusae, splenomegaly, esophageal varices, hepatocellular carcinoma.

Hepatocellular Carcinoma

Frequency: Fifth most common malignancy worldwide.
Risk Factors: Chronic hepatitis B or C, infant HBV carriers, cirrhosis, aflatoxin exposure, smoking, other less common factors such as thorotrast exposure and androgenic steroids. Higher in blacks than whites.
Age: 60+ with cirrhosis or ages 20-40 without cirrhosis.
Microscopic features: Thickened hepatocyte cores, loss of sinusoids, abnormal reticulin network.

Fibrolamellar Hepatocellular Carcinoma (HCC)

Rarity: 1-2% of HCC cases in the United States, rare in other regions.
Age: Young age, mean 25 years.
AFP levels: Normal AFP levels.
Location: Usually in noncirrhotic liver, left lobe dominance.
Prognosis: Better prognosis.

Cholangiocarcinoma

Prevalence: 5-30% of primary liver malignancies.
Associations: Primary sclerosing cholangitis, congenitally dilated bile ducts, thorium dioxide exposure, anabolic steroids, intrahepatic lithiasis, clonorchis and opisthorchis infections.

Metastatic Carcinoma

Origin: Cancer spreading from other organs to the liver.

Benign Hepatocellular Mass Lesions

Focal Nodular Hyperplasia: Benign lesion more common in young women, thought to be related to abnormal vasculature, sometimes stimulated by oral contraceptives. Usually incidental findings.
Hepatic Adenoma: Rare hepatocellular neoplasm, almost exclusively in young women, often associated with oral contraceptive use, usually regresses after cessation of drugs, commonly present with abdominal mass, pain, or hemorrhage. AFP is usually normal.

Summary - Histologic Features - Liver Tumors

Hepatocellular Carcinoma: Thickened hepatocyte cores, loss of sinusoids, abnormal reticulin network.
Benign Tumors:
- Hepatic adenoma: Encapsulated, loss of portal triads, single focal lesion, central scar on gross inspection, histologically resembles cirrhosis.
- Focal Nodular Hyperplasia: Single focal lesion, central scar (gross), histologically similar to cirrhosis.

Case Study - Different Liver Conditions

Patient characteristics: Patients with different liver conditions, including advanced symptoms such as ascites, severe muscle wasting, vomiting blood, progressive loss of energy, and other related complaints. Results can include symptoms such as itchy skin, jaundice or yellowed eyes, swollen belly, enlarged liver.
Family History: Often includes a substantial amount of alcohol use.

Liver Pathology - Laboratory Results (additional cases)

Various Laboratory tests: hematocrit,WBC, prothrombin time, AST, ALT, ALP, Total bilirubin, Total protein, albumin, alcohol, ammonia, amylase, lipase, HBsAg, Anti-HBc, Anti-HCV, autoantibodies, and more.

Additional Case Details and Information

Detailed patient accounts: Varying durations of experiencing symptoms, history of surgical/medical procedures that involved blood products.
Imaging findings: CT scan details may include the size of the liver mass.
Biopsy results: Detailed descriptions of the biopsy findings.
Outcome: Information on further treatment, patient refusal or patient death.
Autopsy: Findings from autopsy and related detailed accounts

Primary Biliary Cirrhosis (PBC)

Type of Disease: Autoimmune chronic cholestatic disease.
Cause: Destruction and loss of intrahepatic bile ducts.
Demographics: 90% of cases observed in women, mid-aged.
Early detection: Often discovered during an asymptomatic phase based on abnormalities detected through laboratory tests.
Laboratory findings: Elevated alkaline phosphatase, positive antimitochondrial antibody. Jaundice, pruritus, and fatigue are common, jaundice develops as the disease is severe, abdominal pain in the upper right quadrant may occur.
Characteristics: Microscopical findings include cholestasis, and parenchymal fibrosis (cirrhosis).

Primary Sclerosing Cholangitis (PSC)

Cause: Progressive fibroobliterative destruction of extra and intrahepatic bile ducts.
Cause: likely autoimmune, but pathogenesis remains unknown.
Association: strong association with ulcerative colitis and Crohn’s disease (80% and 5% of PSC cases respectively are associated with these diseases), particularly in males, typically younger than 45 years old.
Characteristics of Presentation: "Onion skin" fibrosis.

Summary of Liver Pathology

Patterns: Hepatitic pattern, Cholestatic pattern, Metabolic pattern.

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Description

Test your knowledge on liver diseases with this quiz covering key concepts like symptoms, serology patterns, and causes of conditions such as hepatitis and cirrhosis. Questions focus on clinical findings and mechanisms of liver toxicity. Perfect for medical students and healthcare professionals.