Liver Tumours Overview and Histology

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Questions and Answers

What is the primary characteristic of chronic pancreatitis?

Complete pancreatic function restoration

Normal pancreatic duct structure

Acute inflammation without fibrosis

Patchy, irreversible fibrosis and ongoing inflammation (correct)

Which of the following is NOT a symptom of chronic pancreatitis?

Steatorrhoea and malabsorption

Dull, epigastric pain radiating to the back

Nausea without vomiting (correct)

Secondary diabetes mellitus

What is the role of imaging in the diagnosis of chronic pancreatitis?

Routine follow-up imaging is recommended

Eliminates the need for other diagnostic methods

Only useful in early stages of the disease

Helpful only in advanced disease (correct)

Which statement about pancreatic pseudocysts is true?

They are associated with pancreatic surgery or trauma Signup and view all the answers

Which treatment option is commonly used for managing chronic pancreatitis?

Enzyme supplements and analgesia Signup and view all the answers

Which of the following is classified as a malignant liver tumor?

Hepatocellular carcinoma Signup and view all the answers

What is the primary characteristic that differentiates a malignant neoplasm from a benign one?

Malignant neoplasms invade surrounding tissues. Signup and view all the answers

Which type of tumor is most commonly associated with the use of anabolic steroids or oral contraceptives?

Hepatic adenoma Signup and view all the answers

Which type of primary liver malignancy is specifically a carcinoma arising from the intrahepatic bile ducts?

Intrahepatic cholangiocarcinoma Signup and view all the answers

What is the most common primary cancer that leads to liver metastases?

Colorectal cancer Signup and view all the answers

Which condition is defined as the inflammation of the gallbladder?

Acute cholecystitis Signup and view all the answers

What is the term for the condition resulting from an obstruction of the extra hepatic bile duct?

Extrahepatic biliary obstruction Signup and view all the answers

Which of the following is a significant risk factor for developing pancreatitis?

Excessive alcohol consumption Signup and view all the answers

What is the most common cause of ascending cholangitis?

Gallstones Signup and view all the answers

Which of the following is NOT typically associated with acute pancreatitis?

Cholecystitis Signup and view all the answers

What does Charcot’s triad consist of?

Fever, jaundice, and right upper quadrant pain Signup and view all the answers

What is a major complication associated with severe acute pancreatitis?

Pseudocyst Signup and view all the answers

Which imaging technique is often used to investigate extrahepatic bile duct obstruction?

Ultrasound Signup and view all the answers

What is typically the first line of treatment for starting acute cholangitis?

Urgent decompression Signup and view all the answers

Which of the following is a benign cause of extrahepatic bile duct obstruction?

Cholesterol polyps Signup and view all the answers

What is the possible mortality association with severe acute pancreatitis?

50% in the first week Signup and view all the answers

What is one reason for the high mortality rate in severe acute pancreatitis?

Systemic inflammatory response syndrome (SIRS) Signup and view all the answers

Which of the following is a risk associated with necrotizing inflammation in pancreatitis?

Secondary infections Signup and view all the answers

What is a key characteristic of metastatic liver disease compared to cirrhosis?

It presents with multiple pale deposits. Signup and view all the answers

Which immunohistochemical marker is associated with identifying metastatic tumors from the large intestine?

CK20 Signup and view all the answers

In high incidence areas, hepatocellular carcinoma typically presents with what progression?

Young patients with cirrhosis or preceding symptoms. Signup and view all the answers

What is the most effective initial treatment for early-stage hepatocellular carcinoma?

Resection Signup and view all the answers

What role does alpha-fetoprotein (AFP) play in the context of hepatocellular carcinoma?

It is a tumor marker that supports diagnosis. Signup and view all the answers

What is the primary factor influencing the prognosis of hepatocellular carcinoma?

The staging of cancer. Signup and view all the answers

Which of the following best describes the prevention strategy for hepatocellular carcinoma?

Vaccination against HBV to prevent chronic liver disease. Signup and view all the answers

What is a common characteristic of liver metastasis histology compared to primary liver tumors?

Presence of identifiable primary tumor markers. Signup and view all the answers

What type of cancer arises from the bile duct epithelium?

Cholangiocarcinoma Signup and view all the answers

Which of the following statements about pancreatic adenocarcinoma is TRUE?

It accounts for the majority of pancreatic cancer deaths. Signup and view all the answers

What is the most common site for cholangiocarcinoma?

Bifurcation of the common hepatic duct Signup and view all the answers

What are the typical symptoms of advanced pancreatic carcinoma?

Painless obstructive jaundice and anorexia Signup and view all the answers

Which of the following risk factors for pancreatic carcinoma is considered strong?

Smoking Signup and view all the answers

Which histological feature is common in hepatocellular carcinoma (HCC)?

Pleomorphic tumor cells resembling hepatocytes Signup and view all the answers

What is the role of the CA 19-9 serum marker in pancreatic cancer?

It is a marker for response and relapse assessment. Signup and view all the answers

Which of the following is a rare association with intrahepatic cholangiocarcinoma?

Chronic fluke infestation Signup and view all the answers

What type of pancreatic tumors are classified by the hormone type they produce?

Pancreatic neuroendocrine tumors Signup and view all the answers

Which statement accurately describes the prognosis of pancreatic carcinoma?

The outlook is generally poor due to late presentation. Signup and view all the answers

What is a defining characteristic of a pancreatic pseudocyst compared to a true cyst?

It does not have an epithelial lining. Signup and view all the answers

Which condition is most likely to cause pancreatic insufficiency without clinical chronic pancreatitis?

Cystic fibrosis Signup and view all the answers

In chronic pancreatitis, which symptom is primarily associated with the impaired exocrine function?

Steatorrhoea and malabsorption Signup and view all the answers

What is considered a common complication of pancreatic pseudocysts?

Fistula or blood vessel damage Signup and view all the answers

Why is the diagnosis of chronic pancreatitis often challenging?

Symptoms are typically mild and non-specific. Signup and view all the answers

In advanced stages of liver metastasis, which symptom is primarily associated with rising bilirubin levels?

Jaundice Signup and view all the answers

Which immunohistochemical marker is used to identify melanoma in liver metastases?

S100 Signup and view all the answers

What is a common consequence of hepatocellular carcinoma in patients with cirrhosis in high incidence areas?

Co-presentation with cirrhosis Signup and view all the answers

Which diagnostic method is frequently employed for assessing liver nodules greater than 1cm in patients with cirrhosis?

Contrast-enhanced imaging Signup and view all the answers

What aspect significantly influences the prognosis of hepatocellular carcinoma treatment outcomes?

Degree of liver function impairment Signup and view all the answers

Which of the following statements regarding liver metastases is TRUE?

They are often indicated by multiple pale deposits. Signup and view all the answers

What is the recommended treatment for isolated colorectal metastases to the liver?

Surgical resection Signup and view all the answers

Which factor is NOT a common cause of chronic liver disease associated with hepatocellular carcinoma?

Autoimmune disorders Signup and view all the answers

Which type of liver tumor is considered the most common primary malignancy in adults?

Hepatocellular carcinoma Signup and view all the answers

What is the primary risk factor associated with the development of hepatic adenomas?

Use of anabolic steroids Signup and view all the answers

Which of the following conditions is classified as a benign liver lesion?

Hepatic adenoma Signup and view all the answers

Which type of cancer commonly leads to liver metastases?

Pancreatic carcinoma Signup and view all the answers

What distinguishes extrahepatic bile duct obstruction from other forms of bile duct obstruction?

It involves blockages outside of the liver. Signup and view all the answers

Cholangiocarcinoma primarily arises from which type of cells?

Cholangiocytes Signup and view all the answers

What is the most significant consequence of acute cholecystitis?

Perforation of the gallbladder Signup and view all the answers

Which of the following is a typical symptom of acute pancreatitis?

Severe upper abdominal pain Signup and view all the answers

What is a potential complication of acute pancreatitis associated with systemic inflammatory response syndrome (SIRS)?

Disseminated intravascular coagulation (DIC) Signup and view all the answers

Which condition is characterized by the blockage of the extrahepatic bile duct leading to infection in stagnant bile?

Ascending cholangitis Signup and view all the answers

What is the primary mode of diagnosis for acute pancreatitis beyond clinical evaluation?

Blood tests showing elevated amylase Signup and view all the answers

In the context of causes of acute pancreatitis, which factor is least commonly associated?

Coronary artery disease Signup and view all the answers

Which treatment modality is often employed to manage stones causing extrahepatic bile duct obstruction?

ERCP with sphincterotomy Signup and view all the answers

What does Charcot's triad include as its hallmark symptoms?

Jaundice, fever, right upper quadrant pain Signup and view all the answers

Which of the following indicates a severe form of acute pancreatitis?

Necrotizing inflammation of the pancreas Signup and view all the answers

What condition can lead to secondary infection after extensive necrosis in severe acute pancreatitis?

Pseudocyst formation Signup and view all the answers

What is a significant factor that characterizes a biliary stricture leading to extrahepatic bile duct obstruction?

Previous surgical intervention Signup and view all the answers

How does acute pancreatitis typically trigger a systemic inflammatory response syndrome (SIRS)?

By initiating an irreversible cascade of pancreatic enzyme activation Signup and view all the answers

What is the most common location for cholangiocarcinoma?

Hilum of the liver Signup and view all the answers

Which statement correctly describes the histological features of hepatocellular carcinoma (HCC)?

Pleomorphism is evident among tumor cells Signup and view all the answers

Which tumor is characterized by the growth of ductal adenocarcinoma?

Pancreatic (ductal) adenocarcinoma Signup and view all the answers

Which symptom is typically associated with tumors located in the head of the pancreas?

Painless obstructive jaundice Signup and view all the answers

What is a recognized risk factor for developing pancreatic carcinoma?

Smoking Signup and view all the answers

What is a common clinical feature of pancreatic neuroendocrine tumors?

Hormones causing clinical symptoms Signup and view all the answers

What distinguishes Klatskin tumors from other cholangiocarcinomas?

Obstruction of the bifurcation of the common hepatic duct Signup and view all the answers

What assessment tool is often used for evaluating response or relapse in pancreatic carcinoma?

CA 19-9 serum marker Signup and view all the answers

What is the primary reason for the poor prognosis of pancreatic carcinoma?

Presentation with vague symptoms and late diagnosis Signup and view all the answers

Which of the following best describes the embryological origin of the pancreatic exocrine tissue?

Endoderm Signup and view all the answers

Study Notes

Liver Tumours

Non-neoplastic lesions (e.g., cysts, haemangiomas) can mimic neoplasms
Benign vs. Malignant
Primary vs. Secondary
Commoner Primary Liver Tumours
- Benign
  - Hepatic adenoma (associated with anabolic steroids and oral contraceptive pills)
  - Bile duct adenoma (rare)
  - Haemangioma
- Malignant
  - Hepatocellular carcinoma (HCC) (associated with cirrhosis/chronic hepatitis)
  - Intrahepatic cholangiocarcinoma
  - Haemangiosarcoma (rare)
Secondary Tumours/Liver Metastases
- Most common "liver tumour" in Europe/North America
- Primary in GI tract, lung, breast
- Metastases obstruct bile flow:
  - Early: Few symptoms, alkaline phosphatase elevated
  - Late: Rising bilirubin, jaundice
- Poor prognosis
- Identify primary site for treatment
- Surgery possible for isolated colorectal metastases

Immunohistochemistry in Liver Metastasis Histology

CK20, CDX2: Large intestine
TTF1: Lung
S100, Melan A, HMB, SOX10: Melanoma

Hepatocellular Carcinoma (HCC)

Relatively uncommon in Europe/North America
Common in East and SE Asia/Africa
Associated with cirrhosis (>90%)
Can occur in non-cirrhotic fibrotic HBV livers
Single mass or multifocal, may have vascular invasion
Presentation
- High incidence areas: Co-present with cirrhosis in young patients
- Low incidence areas: Decompensation of cirrhosis, vague and changing symptoms
Diagnosis
- Radiology: US, CT, MRI
- Assessment of nodules >1cm or enlarging
- Alpha-fetoprotein (AFP) "tumour marker"
- Biopsy rarely necessary
Screening
- High risk patients (compensated cirrhosis) every 6/12 months: US, AFP blood test
Prevention
- Treatment of underlying chronic liver disease
- Prevention of chronic liver disease (HBV vaccination)
Treatment
- Resection if early
- Liver transplant (OLT)
- Local ablative treatments: radiofrequency, chemoembolization
Prognosis
- Depends on stage, liver function, comorbidity
- Typically poor, but 5-year survival of 50% in selected cases
Aetiology
- Cirrhosis (HBV/HCV/HFE > other causes)
- Chronic HBV directly oncogenic?
- Aflatoxins: fungal contaminants of food stores

Cholangiocarcinoma

Adenocarcinoma arising from bile duct epithelium
- Intrahepatic or extrahepatic location
Most common site at hilum of liver
- Klatskin tumour: Obstructing bifurcation of common hepatic duct
Intrahepatic cholangiocarcinoma: Minority of primary liver malignancy (10%)
Associations
- Primary sclerosing cholangitis (PSC)
- Rare: Chronic fluke infestation, congenital biliary abnormalities
Diagnosis difficult and often late, outcome poor
Selected cases: Surgical resection
Typically palliative obstruction with stent placement

Pancreas

Retroperitoneal location
2 components:
- Exocrine (98%): Makes digestive enzymes
- Endocrine: Islets of Langerhans, hormones
Exocrine: Glandular acini grouped into lobules, secretions drain via ducts

Pancreatic Tumours

Exocrine Pancreas
- Malignant: Pancreatic (ductal) adenocarcinoma
- Other less common tumours, sometimes cystic
- May be benign or have intermediate behaviour
- Some recognised as precursors to pancreatic cancer
Endocrine
- Pancreatic neuroendocrine tumours: Rare
- Behaviour difficult to predict
- Classified by hormone type produced
- Hormone may cause clinical symptoms
- Associated with parathyroid hyperplasia and pituitary adenomas in MEN type 1 syndrome

Pancreatic Carcinoma

Adenocarcinoma arising from pancreatic ducts
Common: 5th/6th rank of cancer deaths
Male > Female, 80% > 60 years
60-70% from head, rest from body & tail
Spread
- Direct local: Peritoneum (vessels, nerves), duodenum, CBD = "locally advanced"
- Lymph nodes or to liver (50% metastatic at diagnosis)
Risk Factors (relatively weak):
- Smoking, diabetes mellitus, chronic pancreatitis
- Family history (5%)
Symptoms
- Typically symptomatic only with advanced disease
- Easily missed
- Anorexia, weight loss
- Painless obstructive jaundice (tumours in head)
- Vague abdominal pain, may radiate to the back
- Rare: Palpable mass, thrombotic tendency (migratory thrombophlebitis = Trousseau's sign)
Diagnosis
- CA 19-9 serum marker for pancreatico-biliary cancer (not useful in diagnosis, used for response/relapse assessment)
- Imaging (US, CT, EUS), FNA cytology via EUS
- Avoid unnecessary invasive investigation
Prognosis
- 5-year survival low for men, older age group
- Presents late, vague symptoms, poor outlook
Clinical Problem
- Gallbladder "polyps" often identified at US
- Question: Could they be neoplasms of the gallbladder (adenomas or carcinomas?)
- If small/non-progressive: Likely to be harmless non-neoplastic cholesterol "polyps"

Causes of Extrahepatic Bile Duct Obstruction

Gallstones in common bile duct
Tumour
- Adenocarcinoma of pancreas
- Extrahepatic bile duct adenocarcinoma
Benign stricture (post-operative or PSC)
Mass outside CBD/CHD compressing duct
- Mirizzi Syndrome: External compression from stone in neck/cystic duct of gallbladder
- Primary tumour or metastases in lymph nodes

Extrahepatic Bile Duct Obstruction

Courvoisier's Law: Historic interest only
Investigation
- US shows dilated ducts above obstruction
- Cause may need MRCP or EUS
- ERCP for diagnosis if treatment considered
Treatment
- Decompression +/- treat cause
  - Stones: ERCP with sphincterotomy +/- stone removal, via CBD exploration at surgery (laparoscopic or open)
  - Stricture: Stent
  - Tumour: Stent (usually via ERCP)

Ascending (Acute) Cholangitis

Infection in static, obstructed bile
High fever, pain, jaundice = Charcot's Triad
Add hypotension, altered mental state = Reynold's Pentad
Requires urgent decompression

Hepatic Abscess

Biliary tract disease a/w ascending infection most common cause
Seeding from systemic sepsis may sometimes be the cause
Historically, common cause was spread via portal vein from intra-abdominal sepsis
Treatment: Drain and antibiotics (Amoebic abscess)

Acute Pancreatitis

Acute inflammation of pancreas
10-20/million, mortality ?5% (higher if severe)
Single or recurrent attacks
Pathogenesis
- Premature (intra-pancreatic) activation of pancreatic enzymes
- Once initiated, irreversible cascade (auto-digestion)
- May trigger systemic inflammatory response syndrome (SIRS) if severe
Obstructing stone at lower CBD causes reflux of bile/concentration of pancreatic juices
Alcohol: Direct toxic effect

Severity of Acute Pancreatitis

Mild Acute Pancreatitis (80% cases)
- Self-limiting disease
- Oedematous pancreatitis on imaging, non-necrotizing
Severe Acute Pancreatitis (20% cases)
- Necrotizing inflammation of pancreas and surrounding tissue

Effects of Severe Acute Pancreatitis

Systemic inflammatory response syndrome (SIRS): Hypovolaemia, hypotension, ARDS, acute renal failure, DIC
Hypocalcaemia, hyperglycaemia, ileus
Local Complications
- Extensive necrosis (acute necrotic collection), risk secondary infection
- Later: Pseudocyst, fistula
Mortality: Two phases
- First week (~50%): SIRS and complications
- Second week (~50%): Necrosis and sepsis

Causes of Acute Pancreatitis

Gallstones: 50% men and women
Alcohol: Very common case
Post-ERCP (5%)
Idiopathic (10%): Biliary microlithiasis
Miscellaneous uncommon causes (5%): Trauma, ischaemia, major surgery, drugs, viral, hypercalcaemia, hyperlipidaemia, hereditary pancreatitis

Diagnosis of Acute Pancreatitis

Symptoms: Epigastric pain, may radiate into back, 'acute abdomen'
If severe: Differential diagnosis: MI, ruptured AAA, perforated or ischaemic abdominal organ
Blood Tests: Blood amylase higher than 3X normal (amylase short half life), Lipase used in future?
If equivocal, use radiology
Identify cause, avoid immediate laparotomy

Chronic Pancreatitis

Patchy, irreversible fibrosis, ongoing inflammation
Pancreatic function impaired: Exocrine > endocrine
Distortion of ductal system: Strictures, dilatation, cysts, pancreatic ductal stones
Causes:
- Alcohol
- Idiopathic
- Childhood causes: Including cystic fibrosis
- CF more typically a/w pancreatic insufficiency due to damage but without clinical 'chronic pancreatitis'

Chronic Pancreatitis

Symptoms: Pain (dull, epigastric, radiating to back), weight loss, steatorrhoea and malabsorption, secondary diabetes mellitus
Treatment: Analgesia (opiates), enzyme supplements
Diagnosis: Difficult, sometimes diagnosis of exclusion, amylase not useful, tests of pancreatic function not routine, imaging in advanced disease

Pancreatic Pseudocyst

Collection of pancreatic fluid in disrupted tissue in or adjacent to pancreas
Defined wall but not a true cyst (no epithelial lining)
Causes: Acute or chronic pancreatitis, pancreatic surgery, or trauma
Complications: Pain/pressure, infection, erosion with fistula or blood vessel damage
Aspirate or drain by endoscopy or surgery

Liver Tumours

Non-neoplastic liver lesions can mimic tumours, such as cysts, haemangiomas, regenerative lesions and abscesses.
Imaging techniques like ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) help differentiate these.

Primary Liver Tumours

Benign: Liver cell adenoma (associated with anabolic steroids/OCPs), bile duct adenoma (rare), haemangioma.
Malignant: Hepatocellular carcinoma (HCC, liver cell carcinoma, hepatoma), intrahepatic cholangiocarcinoma (intrahepatic bile duct adenocarcinoma), haemangiosarcoma (rare).

Secondary Liver Tumours/Metastases

Most common "liver tumour" in Europe and North America.
Typically arise from primary cancers in the gastrointestinal (GI) tract, lung, or breast.
Other malignancies can infiltrate the liver, including lymphoma and leukaemia.
Metastases can obstruct bile flow, leading to jaundice and elevated alkaline phosphatase levels.
Poor prognosis but treatment depends on identifying the primary site of origin.
Isolated colorectal metastases may be surgically treated.

Immunohistochemistry in Liver Metastasis Histology

Useful for identifying the primary cancer site.
Markers include CK20, CDX2 (large intestine), TTF1 (lung), S100, Melan A, HMB, SOX10 (melanoma).

Hepatocellular Carcinoma (HCC)

Relatively uncommon in Europe and North America but common in East/Southeast Asia and Africa.
Strongly associated with cirrhosis/chronic hepatitis (over 90%).
Can occur in non-cirrhotic fibrotic HBV livers.
Can present as a single mass or multifocal, with possible vascular invasion.
Metastases are less common than in other cancer types.
Presentation:
- High-incidence areas: May present with or precede cirrhosis in younger patients.
- Low-incidence areas: Occurs with decompensation of cirrhosis, vague symptoms.
Diagnosis:
- Radiology: US, specific contrast-enhanced CT and/or MRI protocols to assess nodules greater than 1 cm or those enlarging.
- Alpha-fetoprotein (AFP): Tumour marker.
- Biopsy rarely necessary.
Screening:
- High-risk patients (compensated cirrhosis): US every 6-12 months.
- AFP blood test: Not specific or sensitive enough alone.
Prevention:
- Treating the underlying cause of chronic liver disease.
- Preventing chronic liver disease (HBV vaccination).
Treatment:
- Resection if early.
- Liver transplantation (OLT).
- Local ablative treatments: Radiofrequency, arterial chemoembolization.
Prognosis:
- Depends on stage, liver function impairment, and co-morbidity.
- Generally poor but 5-year survival of 50% in selected cases.
Aetiology:
- Cirrhosis (HBV/HCV/HFE more common than other causes).
- Chronic HBV directly oncogenic.
- Aflatoxins (fungal contaminants of food stores).

Cholangiocarcinoma

Adenocarcinoma arising from bile duct epithelium.
Location: Intrahepatic or extrahepatic.
Most common site: Hilum of the liver.
Klatskin tumour: Obstructing bifurcation of the common hepatic duct.
Intrahepatic cholangiocarcinoma: Minority of primary liver malignancies (10%).
Associations: Primary sclerosing cholangitis (PSC).
Diagnosis: Difficult and often late, with poor outcome.
Selected cases: Surgical resection.
Typically: Palliative obstruction with stent placement.

Pancreas Overview

Retroperitoneal location.
Two embryologically distinct components:
- Exocrine (98%): Produces digestive enzymes.
- Endocrine: Islets of Langerhans, secreting hormones.
Exocrine composed of glandular acini grouped into lobules.
Exocrine secretions drain via ducts, joining to form the pancreatic duct.

Pancreatic Tumours

Exocrine pancreas:
- Malignant: Pancreatic (ductal) adenocarcinoma.
- Other less common tumours, sometimes cystic, may be benign or have intermediate behaviour.
- Some recognised as precursors to pancreatic cancer.
Endocrine:
- Pancreatic neuroendocrine tumours are rare.
- Behaviour is difficult to predict.
- Classified by the hormone type produced.
- Hormone may cause clinical symptoms.
- Associated with parathyroid hyperplasia and pituitary adenomas in inherited MEN type 1 syndrome.

Pancreatic Carcinoma

Adenocarcinoma arising from pancreatic ducts.
Common: 5th/6th by rank of cancer deaths.
Male predominance, 80% over 60 years old.
Location: 60-70% from head, rest from body and tail.
Spread:
- Direct local: Peritoneum, vessels, nerves, duodenum, common bile duct (CBD) = "locally advanced."
- Lymph nodes or to liver (50% metastatic at diagnosis).
Risk factors:
- Smoking, diabetes mellitus, chronic pancreatitis, family history (5%).
Symptoms:
- Typically only symptomatic with advanced disease.
- Easily missed.
- Anorexia, weight loss.
- Painless obstructive jaundice (tumours in head).
- Vague abdominal pain, may radiate to back.
- Rare: Palpable mass, thrombotic tendency.
  - Trousseau's sign: Migratory thrombophlebitis.
Diagnosis:
- CA 19-9: Serum marker for pancreaticobiliary cancer, used for response/relapse assessment.
- Imaging (US, CT, endoscopic ultrasound [EUS]), fine needle aspiration (FNA) cytology via EUS.
- Avoid unnecessary invasive investigation.
Prognosis:
- 5-year survival low, particularly in older men.
- Presents late, vague symptoms, poor outlook.
Gallbladder "polyps":
- Often identified on US.
- Most likely harmless non-neoplastic cholesterol "polyps."
- If small and non-progressive, unlikely to be neoplastic.

Causes of Extrahepatic Bile Duct Obstruction

Gallstones in the common bile duct.
Tumour:
- Pancreatic adenocarcinoma.
- Extrahepatic bile duct adenocarcinoma.
Benign stricture (post-operative or PSC).
Mass outside the CBD/common hepatic duct (CHD) compressing the duct:
- Mirizzi syndrome: External compression from a stone in the neck/cystic duct of the gallbladder.
- Primary tumour or metastases in lymph nodes.

Extrahepatic Bile Duct Obstruction

Courvoisier's Law: Historic interest only.
Investigation:
- US shows dilated ducts above the obstruction.
- Cause may need further investigation by MRCP or EUS.
- ERCP may be performed for diagnosis if treatment is considered.
Treatment:
- Decompression: +/- treating the cause.
- Stones:
  - ERCP with sphincterotomy +/ - stone removal.
  - CBD exploration at surgery (laparoscopic or open).
- Stricture: Stent.
- Tumour: Stent.
- Stenting: Usually via ERCP.

Ascending (Acute) Cholangitis

Infection in static, obstructed bile.
Charcot's triad: High fever, pain, jaundice.
Reynolds pentad: Adds hypotension and altered mental state.
Requires urgent decompression.

Hepatic Abscess

Commonest cause: Biliary tract disease with ascending infection.
Less common cause: Seeding from systemic sepsis.
Historically: Common cause was spread via the portal vein from intra-abdominal sepsis.
Treatment: Drain and antibiotics.
Amoebic abscess: Separate entity.

Acute Pancreatitis

Acute inflammation of the pancreas.
10-20/million, mortality approximately 5% (higher if severe).
Single or recurrent attacks.
Pathogenesis:
- Premature (intra-pancreatic) activation of pancreatic enzymes.
- Irreversible enzymatic cascade (auto-digestion).
- Can trigger systemic inflammatory response syndrome (SIRS) if severe.
- Obstructive stone at the lower end of the CBD causes reflux of bile/concentration of pancreatic juices.
- Alcohol has a direct toxic effect.

Severity of Acute Pancreatitis

Mild acute pancreatitis (80%):
- Self-limiting disease.
- Interstitial oedematous acute pancreatitis on imaging, non-necrotizing.
Severe acute pancreatitis (20%):
- Necrotizing inflammation of the pancreas and surrounding tissue (peri-pancreatic fat).

Effects of Severe Acute Pancreatitis

Systemic inflammatory response syndrome: Hypovolemia, hypotension, acute respiratory distress syndrome (ARDS), acute renal failure, disseminated intravascular coagulation (DIC).
Hypocalcemia, hyperglycemia, ileus.
Local complications: Extensive necrosis (acute necrotic collection), risk of secondary infection, pseudocyst formation, fistula.
Mortality: Two phases:
- First week (50%) associated with SIRS and complications.
- Second week (50%) associated with necrosis and sepsis.

Causes of Acute Pancreatitis

Gallstones (50%): More common in men and women.
Alcohol (common).
Post-ERCP (5%).
Idiopathic (10%): Biliary microlithiasis.
Miscellaneous/uncommon causes (5%):
- Trauma, ischemia, major surgery.
- Drugs, viral infections.
- Hypercalcemia, hyperlipidemia.
- Hereditary pancreatitis.

Diagnosis of Acute Pancreatitis

Symptoms: Epigastric pain, may radiate into back.
- May present as an "acute abdomen," requiring surgical evaluation.
- If severe: Differential diagnosis must include MI, ruptured AAA, perforated or ischaemic abdominal organ.
Blood tests:
- Blood amylase greater than 3x normal (short half-life).
- Lipase may be used in the future.
- If equivocal, imaging may be needed.
Treatment:
- Identify the cause and avoid immediate laparotomy.

Chronic Pancreatitis

Patchy, irreversible fibrosis and ongoing inflammation.
Impaired pancreatic function (exocrine > endocrine).
Distortion of the ductal system:
- Strictures, dilatation, cysts behind strictures, pancreatic ductal stones.
Causes:
- Alcohol.
- Idiopathic.
- Childhood causes, including cystic fibrosis.
- Cystic fibrosis: More typically associated with pancreatic insufficiency without clinical "chronic pancreatitis."

Chronic Pancreatitis

Symptoms:
- Pain (dull, epigastric, radiating to the back).
- Weight loss.
- Steatorrhea and malabsorption.
- Secondary diabetes mellitus.
Treatment: Analgesia (opiates), enzyme supplements.
Diagnosis: Difficult, sometimes diagnosis of exclusion.
- Amylase not useful.
- Tests of pancreatic function not routine.
- Imaging in advanced disease.

Pancreatic Pseudocyst

Collection of pancreatic fluid in disrupted tissue within or adjacent to the pancreas.
Defined wall but not a true cyst (no epithelial lining).
Causes: Acute or chronic pancreatitis, pancreatic surgery, or trauma.
Complications: Pain/pressure, infection, erosion with fistula or blood vessel damage.
Treatment:
- Aspirate or drain by endoscopy or surgery.

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This quiz covers the essential aspects of liver tumours, including the differentiation between benign and malignant types, primary versus secondary tumours, and the common characteristics of primary liver tumours. It also touches on the role of immunohistochemistry in analyzing liver metastasis histology.

Liver Tumours Overview and Histology

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Questions and Answers

What is the primary characteristic of chronic pancreatitis?

Which of the following is NOT a symptom of chronic pancreatitis?

What is the role of imaging in the diagnosis of chronic pancreatitis?

Which statement about pancreatic pseudocysts is true?

Which treatment option is commonly used for managing chronic pancreatitis?

Which of the following is classified as a malignant liver tumor?

What is the primary characteristic that differentiates a malignant neoplasm from a benign one?

Which type of tumor is most commonly associated with the use of anabolic steroids or oral contraceptives?

Which type of primary liver malignancy is specifically a carcinoma arising from the intrahepatic bile ducts?

What is the most common primary cancer that leads to liver metastases?

Which condition is defined as the inflammation of the gallbladder?

What is the term for the condition resulting from an obstruction of the extra hepatic bile duct?

Which of the following is a significant risk factor for developing pancreatitis?

What is the most common cause of ascending cholangitis?

Which of the following is NOT typically associated with acute pancreatitis?

What does Charcot’s triad consist of?

What is a major complication associated with severe acute pancreatitis?

Which imaging technique is often used to investigate extrahepatic bile duct obstruction?

What is typically the first line of treatment for starting acute cholangitis?

Which of the following is a benign cause of extrahepatic bile duct obstruction?

What is the possible mortality association with severe acute pancreatitis?

What is one reason for the high mortality rate in severe acute pancreatitis?

Which of the following is a risk associated with necrotizing inflammation in pancreatitis?

What is a key characteristic of metastatic liver disease compared to cirrhosis?

Which immunohistochemical marker is associated with identifying metastatic tumors from the large intestine?

In high incidence areas, hepatocellular carcinoma typically presents with what progression?

What is the most effective initial treatment for early-stage hepatocellular carcinoma?

What role does alpha-fetoprotein (AFP) play in the context of hepatocellular carcinoma?

What is the primary factor influencing the prognosis of hepatocellular carcinoma?

Which of the following best describes the prevention strategy for hepatocellular carcinoma?

What is a common characteristic of liver metastasis histology compared to primary liver tumors?

What type of cancer arises from the bile duct epithelium?

Which of the following statements about pancreatic adenocarcinoma is TRUE?

What is the most common site for cholangiocarcinoma?

What are the typical symptoms of advanced pancreatic carcinoma?

Which of the following risk factors for pancreatic carcinoma is considered strong?

Which histological feature is common in hepatocellular carcinoma (HCC)?

What is the role of the CA 19-9 serum marker in pancreatic cancer?

Which of the following is a rare association with intrahepatic cholangiocarcinoma?

What type of pancreatic tumors are classified by the hormone type they produce?

Which statement accurately describes the prognosis of pancreatic carcinoma?

What is a defining characteristic of a pancreatic pseudocyst compared to a true cyst?

Which condition is most likely to cause pancreatic insufficiency without clinical chronic pancreatitis?

In chronic pancreatitis, which symptom is primarily associated with the impaired exocrine function?

What is considered a common complication of pancreatic pseudocysts?

Why is the diagnosis of chronic pancreatitis often challenging?

In advanced stages of liver metastasis, which symptom is primarily associated with rising bilirubin levels?

Which immunohistochemical marker is used to identify melanoma in liver metastases?

What is a common consequence of hepatocellular carcinoma in patients with cirrhosis in high incidence areas?

Which diagnostic method is frequently employed for assessing liver nodules greater than 1cm in patients with cirrhosis?

What aspect significantly influences the prognosis of hepatocellular carcinoma treatment outcomes?

Which of the following statements regarding liver metastases is TRUE?

What is the recommended treatment for isolated colorectal metastases to the liver?

Which factor is NOT a common cause of chronic liver disease associated with hepatocellular carcinoma?

Which type of liver tumor is considered the most common primary malignancy in adults?

What is the primary risk factor associated with the development of hepatic adenomas?

Which of the following conditions is classified as a benign liver lesion?

Which type of cancer commonly leads to liver metastases?

What distinguishes extrahepatic bile duct obstruction from other forms of bile duct obstruction?

Cholangiocarcinoma primarily arises from which type of cells?

What is the most significant consequence of acute cholecystitis?

Which of the following is a typical symptom of acute pancreatitis?

What is a potential complication of acute pancreatitis associated with systemic inflammatory response syndrome (SIRS)?

Which condition is characterized by the blockage of the extrahepatic bile duct leading to infection in stagnant bile?

What is the primary mode of diagnosis for acute pancreatitis beyond clinical evaluation?

In the context of causes of acute pancreatitis, which factor is least commonly associated?

Which treatment modality is often employed to manage stones causing extrahepatic bile duct obstruction?

What does Charcot's triad include as its hallmark symptoms?

Which of the following indicates a severe form of acute pancreatitis?

What condition can lead to secondary infection after extensive necrosis in severe acute pancreatitis?

What is a significant factor that characterizes a biliary stricture leading to extrahepatic bile duct obstruction?

How does acute pancreatitis typically trigger a systemic inflammatory response syndrome (SIRS)?

What is the most common location for cholangiocarcinoma?

Which statement correctly describes the histological features of hepatocellular carcinoma (HCC)?

Which tumor is characterized by the growth of ductal adenocarcinoma?

Which symptom is typically associated with tumors located in the head of the pancreas?