1. Integrated practical 17-12-2013 Dr Shaesta Naseem
Hepatobiliary system
Integrated practical
Dr Shaesta Naseem

2. Normal anatomy and histology

3. Classical anatomic landmarks in the average 1400-1800 gram adult liver.

4. The classical view of liver tissue from a liver biopsy, H&E stained.

5. Normal Liver

6. What is the direction of venous blood flow, portal to central, or vice versa? Ans: From the point of view of anatomy, physiology, and pathology, you must clearly understand the DIRECTION is:
Portal vein
Sinusoids
Central vein
Hepatic Veins
IVC

7. Gross and histopathology

8. Chronic hepatitis

9. “swollen” liver?

10. Chiefly Portal Inflammation
The inflammation of hepatitis starts in the portal triad areas, with increasing severity it extends to the sinusoids.
Chiefly Portal Inflammation

11. Viral Hepatitis
Individual hepatocytes are affected by viral hepatitis. Viral hepatitis A rarely leads to signficant necrosis, but hepatitis B can result in a fulminant hepatitis with extensive necrosis. A large pink cell undergoing "ballooning degeneration" is seen below the right arrow. At a later stage, a dying hepatocyte is seen shrinking down to form an eosinophilic "councilman body" below the arrow on the left.

12. “FULMINANT” Acute Viral Hepatitis
Note complete COLLAPSE of lobules, and only remnants of biliary epithelium.
“FULMINANT” Acute Viral Hepatitis

13. Chronic hepatitis: Section from this liver biopsy show:
Moderate chronic inflammatory cells infiltration consisting of lymphocytes and histiocytes in both portal tracts and liver parenchyma.
Piecemeal necrosis, hepatocytes swelling and “spotty” hepatocytes necrosis are also noticed.

14. Hepatic cirrhosis

15. Organ: Liver Dx: macronudular cirrhosis (HBV)
Gross picture shows multiple nodules of variable sizes with fibrosis. The major complications are portal hypertension ,hepatic failure and hepatocellular carcinoma.
Organ: Liver Dx: macronudular cirrhosis (HBV)

16. How can a blind man differentiate cirrhosis from metastatic disease?
Answer: In cirrhosis there are no “SMOOTH” areas between nodules.

17. IRREGULAR NODULES SEPARATED BY PORTAL-to-PORTAL FIBROUS BANDS

18. Cirrhosis
• Very low power microscopic view of the liver.
• The parenchyma shows darker tan nodules of varying sizes.
• These nodules are composed of hepatocytes.
• The paler areas in between are collagen.

19. CIRRHOSIS, TRICHROME STAIN

20. Cirrhosis of the liver: Section of liver show:
Loss of lobular architecture and formation of regenerative nodules of variable size and shape, surrounded by fibrous tissue.
Each nodules consists of liver cells without any arrangement and with no central vein.
Large number of proliferated bile ducts and chronic inflammatory cells are present in fibrous tissue.

21. Hepatocellular carcinoma

23. Liver tissue containing a pale and yellowish nodular hepatic mass with areas of hemorrhage and necrosis.

24. This example of well-differentiated HCC shows a trabecular pattern with intervening sinusoids.

25. [HEPATOCELLULAR CARCINOMA]
[HEPATOCELLULAR CARCINOMA]. The key to the identification of HCC is its resemblance to hepatocytes, the presence of more than 2-3 cell-thick hepatocellular plates/cords, nuclear atypia, and absence of portal tracts. Note the hepatic plates are separated from each other by sinusoids.
Well differentiated hepatocellular carcinoma showing: Distorted hepatic architecture, thick hepatic trabeculae , with mildly atypical hepatocytes showing large nuclei and prominent nucleoli.

27. [HEPATOCELLULAR CARCINOMA]
[HEPATOCELLULAR CARCINOMA]. Anaplastic tumor giant cells can be seen in poorly differentiated HCC (arrow)
The malignant liver cells are pleomorphic, binucleated or forming giant cells with hyperchromatic nuclei. Mitoses are numerous. g

28. Hepatocellular carcinoma: Section show tumour consisting of:
Thick cords, trabeculae and nests of malignant liver cells separated by sinusoidal spaces.
Malignant liver cells are atypical hepatocytes showing large nuclei and prominent nucleoli.
Patients with Hepatitis B and C have a risk to develop hepatic carcinoma, (Serology for hepatitis B and C status).
Tumor marker: Alpha-fetoprotein.

29. Chronic cholecystitis with stones

31. CHRONIC CHOLECYSTITIS

32. Cholecystitis, Chronic • The surface epithelium has lost its normal delicate papillary appearance(green arrow) with an increase in fibrous tissue and mild chronic inflammation in the lamina propria
• Rokitansky-Aschoff sinuses are seen in the muscularis(black arrow)
• The degree of chronic inflammation is quite variable and as in this case surprisingly mild

33. Chronic cholecystitis: Section of gallbladder wall shows:
Irregular mucosal folds and foci of ulceration in mucosa.
Wall is penetrated by mucosal glands which are present in muscle coat ( Rokitansky- Aschoff sinuses).
All layers show chronic inflammatory cells infiltration and fibrosis.

34. Drug toxicity

35. Hepatocellular necrosis due to paracetamol (acetaminophen). 
Confluent necrosis with little inflammation is seen in a perivenular area.

36. Drug Toxicity Liver injury due to medications or other toxic agents.
Can resemble any liver process; clinical correlation essential in diagnosis.
Histopathology: Changes that can be seen are:
Cholestasis
Steatosis
Granulomas
Hepatocellular Necrosis