Hepatobiliary System

Topics

Liver CirrhosisAmoebic Liver AbscessActinomycotic GranulomaHepatocellular Carcinoma

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

AlcoholViral hepatitis (HBV, HCV)(POST NECROTIC)Biliary obstruction (BILIARY)Hemochromatosis (PIGMENT)Wilson’s diseaseAutoimmuneDrugs and toxinsIdiopathic

Causes of Cirrhosis

A lcohol, AutoimmuneB iliary obstruction (biliary)Chronic viral hepatitis (HBV, HCV) (post-necrotic)Drugs and toxinsHemochromatosis (pigment)IdiopathicW ilson’s disease

Causes of Cirrhosis

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

Micronodular cirrhosis

Macronodular cirrhosis

Gross

Microscopy

Micronodular cirrhosis

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

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

Gross

Microscopy

Splendore- Hoeppeli phenomenon

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

Amoebic Liver Abscess

Anchovies

Anchovy Sauce

Amoebic Liver Abscess

Primary

Hepatocellular carcinoma(90%)—arises from hepatocytes

Cholangiocarcinoma(10%)—arises from intrahepatic bile duct epithelium.

Mixed--uncommon

Metastatic

Carcinoma Of Liver

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

Gross

Gross

Microscopy

Small cell variant Large cell variant

Microscopy

Flask shaped undermined ulcer in colon ameba with ingested rbcs

MICRONODULAR MACRONODULAR(HOBNAIL LIVER)

Liver shrinks Nodules >3mmNodules <3mm, diffuse, vary little in size not uniform in size

PATHOPHYSIOLOGY

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

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 CIRRHOSISMallory bodies – intracytoplasmic eosinophilic inclusion seen in perinuclear locations, d/t

accumulation of intermediate filaments

CIRRHOSIS - ALCOHOL

Normal liver fatty liver regenerative nodules in cirrhosis surrounded by fibrosis

HBV infection (MACRONODULAR)Chemicals

Alfatoxin, vinyl chlorideMetal storage disases

Hemochromatosis or Wilson’s diseaseFood additives like nitrosamines and butter yellowAlpha 1 antitrypsin deficiency.

RISK FACTORS FOR HCC

HEPATOCELLULAR CARCINOMA- GROSS

HEPATOCELLULAR CARCINOMA

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.

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

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

AMEBIC LIVER ABCESS

ANCHOVY SAUCE APPEARANCE

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

ENTAMOEBA HISTOLYTICA TROPHOZOITE WITH INGESTED RBCS