1. Hepatobiliary Tutorial

2. 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 B 12, copper, iron. Excretion –Ammonia, bilirubin, steroid hormones, many drugs, alcohol, toxins

3. Normal liver: 1200 – 1600g

5. Acute liver injury Causes –Viruses –Alcohol –Toxins –Ischaemia Presentation –Fatigue, malaise, anorexia, jaundice

6. 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

7. Areas of hepatic necrosis

11. 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

12. 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

15. Alcohol

24. Consequences –Steatosis –Alcoholic hepatitis –Progression to chronic hepatitis –Progression to cirrhosis –Hepatocellular carcinoma

25. 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)

26. 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)

27. Hepatic necrosis due to paracetamol overdose

28. Consequences –Massive hepatic necrosis –Progression to chronic hepatitis –Progression to cirrhosis

29. Ischaemia

30. 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

31. Hepatic infarcts

32. Nutmeg liver

33. Centrilobular congestion

34. Centrilobular necrosis

35. Chronic liver injury Causes –Viruses –Alcohol –Toxins –Ischaemia –Autoimmune disease –Metabolic disease

36. 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

37. 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%

43. Metabolic disease Haemochromatosis Alpha1antitrypsin deficiency Wilson’s disease

45. Haemochromatosis

49. Affected organs –Liver, with cirrhosis –Heart, with cardiomyopathy –Pancreas, with diabetes mellitus –Skin, with pigmentation –Joints, with polyarthropathy –Gonads, with hypogonadotrophic hypogonadism

52. Diagnosis serum iron  % saturation  Serum ferritin  estimation of hepatic iron content DDx in liver – haemosiderosis - alcoholic liver disease – lipofuscin

53. Alpha 1 antitrypsin deficiency

54. 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 B 12, copper, iron. Excretion –Ammonia, bilirubin, steroid hormones, many drugs, alcohol, toxins

55. Chronic liver injury Presentation –Fatigue, malaise, anorexia –Synthesis Hypoalbuminaemia Coagulopathy –Storage and secretion Hypoglycaemia Vitamin deficiency Anaemia –Excretion Hyperammonaemia – hepatic encephalopathy, fetor Jaundice Hyperoestrogenism

56. Causes of Chronic Hepatitis Causes of Cirrhosis Definition Classification of cirrhosis –Aetiology –Size of nodules

57. Micronodular – Alcohol/Biliary/HaemoChromatosis

58. Macronodular – Viruses/Wilson’s/Alpha1AT

59. 1.Diffuse Nodularity, 2. Fibrotic bands, 3. Regenerative nodules

60. Consequences

64. Differential diagnosis of HCC Adenoma

65. Differential diagnosis of HCC Cholangiocarcinoma

66. Differential diagnosis of HCC Metastases