Normal structure of liver Normal function of liver
- Slides: 135
Normal structure of liver
Normal function of liver ü Metabolic (glucose homeostasis…) ü Synthetic (albumin, coagulation factors) ü Storage (glycogen, triglycerides, Fe, Cu, vitamins soluble in fat) ü Catabolic (endogenous substances – hormones…, exogenous substances – drugs, alcohol…) ü Excretoric (bile)
Histologic examination ü Necropsy ü Excision during laparotomy ü Fine needle punction ü Percutaneous punction biopsy • unguided • laparoscopic • guided (Sono, CT) • transjugular
Liver biopsy Representativeness Quality Clinical data Reproducibility Diagnosis
Representativeness ü ü • • ü Biopsy represents approx. 1/500 000 of organ Ideal biopsy (Scheuer, Mac. Sween) 2 cm length more than 4 (8) portal tracts Borderline representativeness contact CLINICIAN!! Non-representative
Quality Clinical data ü Clear and sufficient • clinical outcome, history • etiology • biochemical findings, other markers (oncomarkers, markers of autoimmunity…) • treatment • previous histology • preliminary diagnosis! ü Unclear • contact CLINICIAN!! ü Insufficient and confusing
Quality Diagnosis ü Diagnosis • recent diagnostic praxis (grading and staging of chronic hepatitis…) • recent diagnostic textbooks - contact CLINICIAN!! ü Methods • biopsy - contact CLINICIAN!! • immunohistochemistry, ELMI - contact CLINICIAN!! • experimental
Recently used diagnostic textbooks
Histologic examination – special stains and methods ü Haematoxylin/eosin ü Fouchet – bile (green), collagen (red) ü Fe, Cu – Fe pigment, Cu pigment ü Gömori – reticulin mesh ü Orcein – HBs. Ag ü PAS, Müller – mucopolysaccharides ü Immunohistochemistry (HBs. Ag, HBc. Ag, a 1 fetoprotein, CEA, hepatocytes – OCH 1 E 5) ü ELMI (metabolic diseases) ü PCR (HBV DNA, HCV RNA, …)
Damage of hepatocytes ü Type (ischemic-coagulation necrosis, piecemal necrosis, apoptosis) ü Extent (monocellular, focal, submassive, bridging: C-C; C-P) ü Localization (centrolobular, periportal, midzonal) ü Course • regeneration, healing ad integrum • regeneration + fibrosis: cirrhosis • acute liver failure: coma and death
Liver failure ü Jaundice ü Hypoalbuminemia ü Coagulopathy ü Hyperamonemia ü Increase of levels of cytosolic enzymes ü Endocrine complications ü Hepatoencephalopathy ü Hepatorenal syndrome ü Coma
Necrosis of liver: damage of hepatocytes
Cirrhosis ü Nodular rearrangement ü Morphology • micronodular • macronodular
Cirrhosis: etiology ü Alcohol (60 -70%) ü Chronic hepatitis (10%) ü Cryptogenic (10 -15%) ü Biliary (primary, secondary) ü Haemochromatosis (primary, secondary) ü Metabolic diseases (tyrosinemia, galactosemia) -very rare
Cirrhosis: complications ü Portal hypertension ü Liver failure ü Hepatocellular carcinoma
Portal hypertension ü Prehepatic (tumor, infection, pancreatitis, pregnancy, peroral contraceptives) ü Intrahepatic – most frequent (cirrhosis, fibrosis) ü Posthepatic (congestive cardiac failure, Budd-Chiari syndrome, venoocclusive disease) ü Signs: • portosystemic shunts • splenomegaly • ascites
Cirrhosis
Cirrhosis
Cirrhosis
Cirrhosis + hepatocellular carcinoma
Cirrhosis: Masson staining
Cirrhosis: Fouchet staining
Cirrhosis
Cirrhosis: active
Cirrhosis: biliary
Dysplasia
Dysplasia
Hepatitis: etiology ü Infectious (acute, chronic) • viruses (most often) • bacteria (TBC, malaria, salmonelosis, leptospirosis, …) • parazites (ecchinococcus) • protozoal (amebiasis) ü Non-infectious (acute, chronic) • autoimmune • metabolic • drug induced • cryptogenic
Viral hepatitis HAV HBV HDV Non A Non B HCV HEV HFV HGV RNA DNA RNA Pikornavirus Hepadnavirus Defektní virus RNA RNA Flavivirus Kalicivirus Togavirus Flavivirus
Viral hepatitis: HBV+HDV
Viral hepatitis: HBs. Ag, ground glass
Viral hepatitis: HBs. Ag, Orcein staining
Viral hepatitis: HBc. Ag, immunohistochemistry
Viral hepatitis: HBc. Ag, electron microscopy
Viral hepatitis: course ü Acute (HAV, HBV, HCV, HDV, HEV) ü Chronic (HBV, HBV + HDV, HCV) • risk of cirrhosis development • risk of hepatocellular carcinoma development ü Fulminant (HBV, HCV)
Acute hepatitis ü Gross finding – oedematous, red liver ü Microscopic finding • focal necrosis • bridging necrosis • panacinar/multiacinar necrosis • periportal necrosis ü Hepatocytes • polymorphism • balooning degeneration
Acute hepatitis ü Inflammation • polynuclear/mononuclear infiltration • activation of Kupfer’s cells ü Other changes • cholestasis • damage of bile ducts ü Regeneration
Fulminant hepatitis ü Gross finding - soft consistency ü Microscopic finding – complete necrosis of parenchyma ü Course • liver failure - coma - death • regeneration – postnecrotic cirrhosis
Acute hepatitis: HBV
Acute hepatitis
Acute hepatitis
Acute hepatitis
Acute hepatitis: regeneration
Fulminant hepatitis: HBV
Fulminant hepatitis: HBs. Ag, Orcein staining
Chronic hepatitis: etiology ü HBV, HBV+HDV, HCV ü Autoimmune ü Drug induced ü Wilson’s disease ü a 1 anti-trypsin deficiency ü Cryptogenic
Chronic hepatitis: clinical definition Clinical symptoms of hepatitis more than: ü 6 months ü 12 months in HCV
Chronic hepatitis: morphology ü Inflammation ü portal • periportal • lobular ü Necrosis/apoptosis • piecemal • bridging • focal ü Fibrosis ü Deposits (Cu, PAS globules, …)
Chronic hepatitis - portal + steatosis, HCV
Chronic hepatitis: portal
Chronic hepatitis: periportal
Chronic hepatitis: periportal
Chronic hepatitis: HCV, transition into the cirrhosis
Autoimmune chronic hepatitis ü Females, young/middle age ü Autoantibodies – ANA, AMA ü Autoimmune „overlap“ syndromes • lupus erythematodes • arthritis
Autoimmune chronic hepatitis - ANA
Autoimmune chronic hepatitis - AMA
NASH: non-alcoholic steatohepatitis ü Hepatomegaly ü Increase of aminotransferases ü Histological picture – similar to alcoholic hepatitis without alcohol consumption • macrovesicular steatosis • lobular hepatitis and necrosis • balooning of hepatocytes • fibrosis
NASH: non-alcoholic steatohepatitis Epidemiologic signs of NASH ü Females ü Obesity ü DM of II type, hyperglycaemia
NASH: non-alcoholic steatohepatitis Diseases related to NASH ü Acquired metabolic diseases (obesity, DM, hyperlipidemia, parenteral nutrition) ü Inherited metabolic diseases (Wilson’s disease, abetalipoproteinaemia, tyrosinaemia) ü Surgery (jejunoileal bypass, extensive resections of small intestine. . . ) ü Drugs, toxins (amiodarone, glucocorticoids, tamoxifen, synthetic estrogens…)
Toxic and drug induced liver damage ü Anorganic substances ü Organic substances ü Industrial and plant substances ü Poisons/venoms ü Drugs ü Alcohol
Toxic and drug induced liver damage: effect ü Expectable ü Non-expectable (idiosyncratic)
Toxic and drug induced liver damage : forms ü Necrosis ü Steatosis • macrovesicular (alcohol, corticoids) • microvesicular (tetracyklin, aspirine) ü Cholestasis (steroids-anabolic, contraceptives) ü Hepatitis mild (aspirin, synthetic penicilines) ü Hepatitis serious (halotan) ü Chronic periportal hepatitis (sulphonamides)
Toxic and drug induced liver damage : forms ü Granulomatous hepatitis (phenylbutazone) ü Vascular lesions (contraceptives, cytostatics) ü Hyperplasia, neoplasia (contraceptives)
Alcoholic Liver Disease (ALD) ü Steatosis (90%) ü Fibrosis (perivenular, pericellular) ü Steatofibrosis ü Alcoholic hepatitis ü Alcoholic cirrhosis ü Mallory hyaline ü Cholestasis ü Siderosis ü Hepatocellular carcinoma ü Dif. dg: NASH
Alcoholic Liver Disease (ALD) : steatosis
Alcoholic Liver Disease (ALD) : steatosis
Alcoholic Liver Disease (ALD) : steatofibrosis
Alcoholic Liver Disease (ALD) : cholestasis
Alcoholic Liver Disease (ALD) : Mallory hyaline
Alcoholic Liver Disease (ALD) : Mallory hyaline
Alcoholic Liver Disease (ALD) : steatohepatitis
Alcoholic Liver Disease (ALD) : steatohepatitis
Alcoholic Liver Disease (ALD) : steatohepatitis, cholestasis, Mallory hyaline
Metabolic liver disease ü Haemochromatosis ü Wilson’s disease ü a 1 anti-trypsin deficiency ü Glycogenoses
Haemochromatosis ü Excessive accumulation of iron in parenchymatous organs ü Primary (idiopatic), secondary ü Cirrhosis, diabetes mellitus, pigmentation of skin ü Dif. dg. of brown pigment within the liver • Fe (haemochromatosis) • Cu (Wilson’s disease) • lipopigment (brown atrophy of liver, lipopigment dystrophy)
Haemochromatosis
Haemochromatosis
Haemochromatosis
Brown atrophy of liver: dif. dg.
Wilson’s disease ü Hepatolenticular degeneration ü Low levels of ceruloplasmin ü Increase of Cu in liver and urine ü Morphology • steatosis • acute hepatitis • chronic hepatitis • glycogen nucleus (also typical in DM) • increased amount of Cu pigment
Wilson’s disease : Cu pigment
Wilson’s disease/DM: glycogen nucleus
Wilson’s disease/DM: glycogen nucleus
a 1 anti-trypsin deficiency ü Low levels of a 1 AT (inhibitor of proteases) ü Emphysema of lungs ü Liver changes (cholestasis, cirrhosis) • PAS positive acidophilic globular inclusions in the cytoplasm • ELMI – complementary diagnosis
Circulatory disorders of the liver ü Disorders of arterial system ü Disorders of portal system ü Disorders of venous system ü Disorders of lobular system
Disorders of arterial system Infarct of the liver ü Rare ü Thrombosis, compression, obliteration of a. hepatis branch (polyarteritis nodosa, …) ü Pale ü Dif. dg. : • Zahn infarct (occlusion of intrahepatic branch of v. portae): no necrosis, local congestion of sinusoids and secondary atrophy
Liver infarct
Disorders of portal system Thrombosis and occlusion of v. portae ü Extrahepatal (phlebitis, pancreatitis, surgery, trauma) ü Intrahepatal (invasion of tumor)
Thrombosis of v. portae
Disorders of venous system ü Thrombosis of hepatic veins (Budd-Chiari syndrome) • causes: polycytemia vera, pregnancy, contraceptives, intraabdominal malignant tumors, hepatocellular carcinoma • centrilobular necrosis and congestion, fibrosis ü Venoocclusive disorder • complication of bone marrow transplantation (5 -25%) – chemotherapy, radiotherapy • Bush-tea (pyrrolizidine alcaloids) • obliteration of hepatic veins – subendothelial accumulation of colagen and reticulin, perivenular fibrosis, perivenular hemosiderin
Budd-Chiari
Disorders of lobular system ü Occlusion of sinuses • eclampsy • Sickle cell anaemia ü Systemic circulation • passive congestion • centrilobular necrosis • nutmeg liver (venostasis/steatosis)
Congestion
Pathology of intrahepatal bile ducts ü Secondary biliary cirrhosis (SBC) ü Primary biliary cirrhosis (PBC) ü Primary sclerosing cholangitis (PSC)
SBC ü Obstruction of extrahepatal bile ducts: atresia, lithiasis, tumor, iatrogenic ü Striking cholestasis
PBC ü Autoimmune (AMA), ü Majority of females ü Coincidency: Sjögren sy. , arthritis, thyreoiditis, vasculitis, . . ü Hepatomegaly, ü 4 stages • I - granulomatous destruction of ducts • II - ductular proliferation and periportal hepatitis • III - scarring, necrosis, septal fibrosis • IV - cirrhosis
PSC ü Autoimmune (ANA) ü Inflammation and obliterative fibrosis of bile ducts ü Coincidency: IBD (Inflammatory Bowel Disease – ulcerative colitis, m. Crohn)
PBC: I. stage
PBC: I. stage
PBC: II. stage
PBC: III. stage
Patology of liver during pregnancy ü Preeclampsy/eclampsy • HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets • fibrin within the sinusoids • hematomas (fatal rupture of liver) ü Acute microvesicular steatosis during pregnacy (third trimester) ü Cholestasis during pregnancy (third trimester)
Transplantation ü Liver disorders related to bone marrow transplantation ü Liver disorders related to liver transplantation
Liver disorders related to bone marrow transplantation Time Cause Before transplantation Viral hepatitis Tumor infiltration Day 0 -25 Drug related damage Venoocclusive disease Day 25 -100 Acute GVHD (destruction of bile ducts, endothelitis, necrosis of hepatocytes) Opportune infections Day 100 - Chronic GVHD (involvement of portal tracts, destruction of bile ducts, endothelitis) Viral hepatitis Fulminant hepatitis („rebound“ phenomenona)
Liver disorders related to liver transplantation Time Cause 1. week Acute rejection (necrosis, inflammation) Technical complication (vascular anastomoses…) Non-functionality (primary) 2. week-2. month Opportune infections Acute rejection Drug related damage 2. month - Chronic vascular rejection (vasculitis) Vanishing bile ducts syndrome Viral hepatitis
Tumors of liver ü Tumor-like lesion ü Benign tumors ü Malignant tumor
Tumor-like lesions ü Focal nodular hyperplasia ü Nodular regeneratory hyperplasia (lack of fibrosis) ü Cysts ü Hamartoma (von Meyenburg complex) ü Inflammatory pseudotumor
Nodular regeneratory hyperplasia
Benign tumors ü Adenoma • hepatocellular (lack of portal tracts!) • cholangiogenic (lack of bile production, less than 1 cm, subcapsular) ü Haemangioma • subcapsular • cavernous • bleeding risk during punction!
Cavernous haemangioma
Malignant tumors ü Hepatocellular carcinoma (HCC) • subvariant – fibrolamelar carcinoma ü Cholangiogenic carcinoma (lack of bile production) • peripherial • extrahepatal -Klatskin tumor ü Hepatoblastoma (embryonal, teratoid, …) ü Angiosarcoma, malignant haemangioendothelioma ü Metastases (most often) • GIT, lung, kidney
HCC
HCC
HCC
HCC
Cholangiogenic carcinoma
Biliary system: cholelithiasis ü 10 -20% of population ü Cholesterol concrements (females, obesity, steroids, hyperlipidemia) ü Pigmented/bilirubine concrements (biliary infection, haemolysis) ü Blockage of bile ducts (acute cholangoitis, sepsis, biliary cirrhosis, pancreatitis) ü Irritation of gallbladder (cholecystitis, carcinoma) ü Valve-like blockage (hydrops) ü Perforation, fistula
Cholecystolithiasis
Cholecystolithiasis
Cholecystitis ü Acute • empyema of gallbladder • gangrenous cholecystitis • acalculous cholecystitis (postoperative, trauma, burns, sepsis, …) ü Chronic • fibroproduction (thickening of the wall, adhesion) • chronic inflammmation • dystrophic calcification (risk of carcinoma development) • hydrops
Chronic cholecystitis
Carcinoma of gallbladder Adenocarcinoma ü Infiltrating ü Exophytic ü Early invasion into the liver – poor prognosis!
Carcinoma of gallbladder
Other disorders of biliary system ü Atresia of bile ducts (rapid progression, uncelar etiopathogenesis, cirrhosis) ü Cholesterolosis (strawberry gallbladder) ü Choledocholithiasis (risk of ascendent cholangoitis, intrahepatic abscess and sepsis, risk of biliary cirrhosis) ü Tumors of papilla Vateri (ampuloma, periampular carcinoma – difficult diagnosis)
Exocrine pancreas: acute pancreatitis ü • • • ü • • Causes cholelithiasis, alcohol, surgery, trauma, idiopathic Most serious form acute haemorrhagic necrotizing pancreatitis Morphology nekrosis of pancreas nekrosis of fat tissue (steatocytonecrosis, Balzer’s necrosis) haemorrhagy Complication, healing abscesses pseudocysts duodenal obstruction multiorgan failure
Pancreatonecrosis
Pancreatonecrosis
Steatocytonecrosis: omentum
Steatocytonecrosis: omentum
Exocrine pancreas: chronic pancreatitis ü • • ü • • Causes alcohol, hyperlipidemia, hypercalcemia, hereditary Morphology fibrosis reduction of acines obstruction of ducts chronic inflammatory infiltration (lymphocytes, plasmocytes) Complications calcifications, pseudocysts, thrombosis v. lienalis diabetes steatorrhea jaundice
Chronic pancreatitis
Exocrine pancreas: tumors ü Cystic tumors (5%) • mucinous cystadenoma • mucinous cystadenocarcinoma ü Carcinoma of pancreas • Adenocarcinoma, various degree of differentiation • Head (early diagnosis - jaundice), body, tail (difficult diagnosis, late detection) • Often - fibroproduction (dif. dg. chron. pancreatitis) • Trosseau syndrome – migratory thrombophlebitis in 10%
Carcinoma of pancreas
Carcinoma of pancreas
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