hepatobiliary tutorial. normal liver - functions synthesis –proteins: albumin, clotting factors...
TRANSCRIPT
Hepatobiliary Tutorial
Normal Liver - Functions
• Synthesis– Proteins: albumin, clotting factors– Bile– Cholesterol & lipoproteins
• Storage and secretion– Glucose– Fat-soluble vitamins (vitamins A, D, E and K)– Folate, vitamin B12 , copper, iron.
• Excretion– Ammonia, bilirubin, steroid hormones, many drugs,
alcohol, toxins
Normal liver: 1200 – 1600g
Acute liver injury
• Causes– Viruses– Alcohol– Toxins– Ischaemia
• Presentation– Fatigue, malaise, anorexia, jaundice
Viruses
• Hepatotrophic viruses– HAV– HBV +/- HDV– HCV– HEV– All cause viral hepatitis
• Other viruses– EBV– CMV– HSV– Affect liver as part of generalized infection– Immunocompetent and immunocompromised hosts
Areas of hepatic necrosis
Specific Features
• Portal tract lymphocytes• Piecemeal necrosis• Lobular lymphocytes• Focal hepatocyte necrosis in lobule
– Councilman bodies and ballooning degeneration
• HAV – plasma cell infiltrate• HBV – ground glass cells (HBsAg)• HCV – lymphoid aggregates, bile duct damage
Consequences
• Resolution• Fulminant acute hepatitis
– HAV, HBV, HDV, HEV in pregnancy
• Progression to chronic hepatitis– HBV +/- HDV, HCV
• Progression to cirrhosis– HBV +/- HDV, HCV
• Hepatocellular carcinoma– HBV, HCV
Alcohol
• Consequences– Steatosis– Alcoholic hepatitis– Progression to chronic hepatitis– Progression to cirrhosis– Hepatocellular carcinoma
Toxins• Examples• Types of liver damage
– Steatosis • ethanol, salicylates, methotrexate
– Centrilobular necrosis• Paracetamol, CCl4, halothane
– Diffuse necrosis• Halothane, isoniazid, paracetamol, -methyldopa
– Hepatitis -methyldopa, isoniazid, phenytoin
– Fibrosis• Ethanol, methotrexate, amiodarone
– Granulomas – sulphonamides, -methyldopa– Cholestasis – chlorpromazine, anabolic steroids, OCP– Vascular disorders – VOD (chemo), Budd Chiari (OCP/oestrogen)– Tumours – adenoma (OCP)
Toxins• Examples• Types of liver damage
– Steatosis • ethanol, salicylates, methotrexate
– Centrilobular necrosis• Paracetamol, CCl4, halothane
– Diffuse necrosis• Halothane, isoniazid, paracetamol, -methyldopa
– Hepatitis -methyldopa, isoniazid, phenytoin
– Fibrosis• Ethanol, methotrexate, amiodarone
– Granulomas – sulphonamides, -methyldopa– Cholestasis – chlorpromazine, anabolic steroids, OCP– Vascular disorders – VOD (chemo), Budd Chiari (OCP/oestrogen)– Tumours – adenoma (OCP)
Hepatic necrosis due to paracetamol overdose
• Consequences– Massive hepatic necrosis– Progression to chronic hepatitis– Progression to cirrhosis
Ischaemia
• Causes of ischaemia– Obstruction to inflow
• Hepatic arteries– Surgical trauma, arteritis
• Portal veins– Thrombosis due to pancreatitis/sepsis
– Outflow obstruction• Hepatic vein / IVC thrombosis (Budd-Chiari)• Destruction of central veins (Veno-occlusive disease)• Congestive heart failure
– Systemic hypoperfusion
Hepatic infarcts
Nutmeg liver
Centrilobular congestion
Centrilobular necrosis
Chronic liver injury
• Causes– Viruses– Alcohol– Toxins– Ischaemia – Autoimmune disease– Metabolic disease
Autoimmune disease
• Autoimmune hepatitis• Primary Biliary Cirrhosis• Primary Sclerosing Cholangitis
• Autoimmune hepatitis– AI destruction of hepatocytes– Portal tract inflammation– Lobular inflammation– Piecemeal and lobular necrosis– Middle aged women– Associated with other AI diseases– Antinuclear, anti-smooth muscle, antimitochondrial antibodies– Anti liver and kidney microsomal antibodies
Autoimmune disease
• PBC– AI destruction of intrahepatic bile ducts– Portal tract inflammation, granulomas, fibrosis– Absent/damaged bile ducts– Middle aged women, pruritus, cholestasis– Associated with other AI diseases– antimitochondrial antibodies
• PSC– Segmental fibrotic obliteration of bile ducts– PT inflammation, concentric bile duct fibrosis– Replacement of bile duct with fibrous scar– Middle aged men, cholestasis– Associated with UC in 70%
Metabolic disease
• Haemochromatosis
• Alpha1antitrypsin deficiency
• Wilson’s disease
Haemochromatosis
Haemochromatosis
Haemochromatosis
• Affected organs– Liver, with cirrhosis – Heart, with cardiomyopathy – Pancreas, with diabetes mellitus – Skin, with pigmentation – Joints, with polyarthropathy – Gonads, with hypogonadotrophic
hypogonadism
Diagnosis
• serum iron • % saturation • Serum ferritin • estimation of hepatic iron content
• DDx in liver– haemosiderosis - alcoholic liver disease– lipofuscin
Alpha 1 antitrypsin deficiency
Normal Liver - Functions
• Synthesis– Proteins: albumin, clotting factors– Bile– Cholesterol & lipoproteins
• Storage and secretion– Glucose– Fat-soluble vitamins (vitamins A, D, E and K)– Folate, vitamin B12 , copper, iron.
• Excretion– Ammonia, bilirubin, steroid hormones, many drugs,
alcohol, toxins
Chronic liver injury
• Presentation– Fatigue, malaise, anorexia– Synthesis
• Hypoalbuminaemia• Coagulopathy
– Storage and secretion• Hypoglycaemia• Vitamin deficiency• Anaemia
– Excretion• Hyperammonaemia – hepatic encephalopathy, fetor• Jaundice• Hyperoestrogenism
• Causes of Chronic Hepatitis
• Causes of Cirrhosis
• Definition
• Classification of cirrhosis– Aetiology– Size of nodules
Micronodular – Alcohol/Biliary/HaemoChromatosis
Macronodular – Viruses/Wilson’s/Alpha1AT
1. Diffuse Nodularity, 2. Fibrotic bands, 3. Regenerative nodules
Consequences
Differential diagnosis of HCC
Adenoma
Differential diagnosis of HCC
Cholangiocarcinoma
Differential diagnosis of HCC
Metastases