{"id":63,"date":"2019-03-19T20:33:12","date_gmt":"2019-03-19T20:33:12","guid":{"rendered":"https:\/\/blogs.imperial.ac.uk\/my-path\/?p=63"},"modified":"2019-03-19T20:33:13","modified_gmt":"2019-03-19T20:33:13","slug":"medical-liver-biopsies-for-trainees","status":"publish","type":"post","link":"https:\/\/blogs.imperial.ac.uk\/my-path\/2019\/03\/19\/medical-liver-biopsies-for-trainees\/","title":{"rendered":"Medical Liver Biopsies for Trainees."},"content":{"rendered":"

Acute Hepatitis<\/strong><\/p>\n

Distinguish acute and chronic hepatitis.<\/p>\n

Liver disease lasting less (acute) or more (chronic) 6 months.<\/p>\n

Describe the natural history of hepatitis.<\/p>\n

Acute hepatitis > chronic hepatitis > cirrhosis<\/p>\n

Name the 2 commonest causes of acute hepatitis.<\/p>\n

    \n
  1. Drugs<\/li>\n
  2. Viruses<\/li>\n<\/ol>\n

    Name 5 viruses which cause acute hepatitis.<\/p>\n

    HAV, HBV, HCV, HDV and HEV<\/p>\n

    Name one drug that causes an acute hepatitis.<\/p>\n

    Paracetamol<\/p>\n

    Describe the characteristic histological features of an acute hepatitis.<\/p>\n

    Spotty (lobular) hepatocyte necrosis and inflammation<\/p>\n

     <\/p>\n

    Chronic Hepatitis<\/strong><\/p>\n

    Name the 3 causes of a chronic hepatitis<\/p>\n

      \n
    1. Viruses<\/li>\n
    2. Drugs<\/li>\n
    3. Autoimmune<\/li>\n<\/ol>\n

      Define grade with reference to chronic hepatitis.<\/p>\n

      The activity of the inflammation (portal, interface and lobular).<\/p>\n

      Define stage with reference to chronic hepatitis.<\/p>\n

      The degree of fibrosis ranging from portal tract expansion through bridging fibrosis to nodule formation (= cirrhosis).<\/p>\n

      Name the scoring system for grading and staging chronic hepatitis that you use in your hospital.<\/p>\n

      Modified HAI (Ishak) \/ METAVIR<\/p>\n

       <\/p>\n

      Viral Hepatitis<\/strong><\/p>\n

      Name 3 viruses which cause chronic hepatitis.<\/p>\n

      HBV, HCV and HDV (causes co-infection \/ superinfection with HBV).<\/p>\n

      Describe the characteristic histological feature of chronic hepatitis B.<\/p>\n

      Ground glass cells, immunopathic hepatocyte damage<\/p>\n

      Describe the 3 characteristic histological features of chronic hepatitis C.<\/p>\n

      Inflammatory bile duct damage, lymphoid follicle formation, fatty change (Genotype 3).<\/p>\n

      Describe the characteristic histological feature of hepatitis D.<\/p>\n

      Cytopathic hepatocyte damage<\/p>\n

       <\/p>\n

      Auto-immune Hepatitis<\/strong><\/p>\n

      List the main clinical features.<\/p>\n

      Younger women, often associated with other autoimmune diseases<\/p>\n

      Classify auto-immune hepatitis.<\/p>\n

      Type 1 Associated with smooth muscle actin antibodies in adults (and the commonest one we see).<\/p>\n

      Type 2 associated with liver-kidney microsomal antibodies, commoner in children<\/p>\n

      Describe the 2 characteristic histological features of auto-immune hepatitis.<\/p>\n

      Marked, especially interface, inflammation and prominent plasma cells.<\/p>\n

      Be aware of the existence of overlap syndromes.<\/p>\n

      With PBC and PSC.<\/p>\n

       <\/p>\n

      Drug induced hepatitis \u00a0<\/strong><\/p>\n

      and Drug Induced Liver Injury (DILI)<\/strong><\/p>\n

      Describe the range of liver diseases that can be caused by a drug.<\/p>\n

      \u2018Any kind of liver disease can be caused by a drug\u201d.<\/p>\n

      Describe 5 characteristic histological features of a drug-induced hepatitis.<\/p>\n

      Fatty change, eosinophils, granulomas, cholestasis, dropout<\/p>\n

      Name one drug which causes a chronic hepatitis.<\/p>\n

      Isoniazid<\/p>\n

       <\/p>\n

      Fatty Liver Disease:<\/strong><\/p>\n

       <\/p>\n

      Describe the natural history of fatty liver hepatitis.<\/p>\n

      Fatty change> fatty liver hepatitis > cirrhosis<\/p>\n

      Describe the 2 morphological types of fatty change.<\/p>\n

      Small droplet (microvesicular) and large droplet (macrovesicular)<\/p>\n

      List the 2 common causes of each type of fatty change.<\/p>\n

      Small droplet: Drugs (e.g. sodium valproate) and pregnancy.<\/p>\n

      Large droplet: Alcohol and Diabetes (insulin resistance).<\/p>\n

      List 4 other causes of large droplet fatty change.<\/p>\n

      Drugs (e.g. steroids), viruses (HCV), starvation and other metabolic diseases (e.g. Wilson\u2019s Disease).<\/p>\n

      Describe the 4 key histological features of a fatty liver hepatitis.<\/p>\n

      All changes most marked in Zone 3: ballooning (with or without Mallory-Denk bodies), inflammation (lymphocytic and \/ neutrophilic, pericellular fibrosis.<\/p>\n

      Know which histological feature may help distinguish alcoholic from non-alcoholic fatty change.<\/p>\n

      Nuclear vacuolation which is associated with insulin resistance.<\/p>\n

      Know the associations of nuclear vacuolation.<\/p>\n

      Physiological:<\/em> childhood and young adults.<\/p>\n

      Pathological:\u00a0 <\/em>\u00a0insulin resistance, Wilson\u2019s Disease and glycogen storage diseases.<\/p>\n

      Name the 2 commonest causes of a fatty liver hepatitis.<\/p>\n

      Alcohol and Diabetes \/ insulin resistance (= N<\/strong>on-A<\/strong>lcoholic S<\/strong>teato-H<\/strong>epatitis)<\/p>\n

      These 3 stages may co-exist<\/p>\n

      Name one drug that causes a fatty liver hepatitis.<\/p>\n

      Tamoxifen<\/p>\n

      Name the scoring system for grading and staging chronic hepatitis that you use in your hospital.<\/p>\n

      Nash Activity Score (NAS) and Stage<\/p>\n

       <\/p>\n

       <\/p>\n

      Primary biliary cholangitis (PBC)<\/strong><\/p>\n

      List the main clinical features.<\/p>\n

      Middle aged, females<\/p>\n

      The presence of anti-mitochondrial antibodies is the key diagnostic test.<\/p>\n

      Describe the key histological feature.<\/p>\n

      Inflammatory destruction of bile ducts often associated with granulomas.<\/p>\n

      General features of chronic cholestatic liver disease (see below).<\/p>\n

      Progressive portal fibrosis but less than half are cirrhotic at presentation<\/p>\n

       <\/p>\n

      Primary sclerosing cholangitis (PSC) <\/strong><\/p>\n

      List the key clinical features.<\/p>\n

      Younger men<\/p>\n

      Associated with ulcerative colitis.<\/p>\n

      Increased risk of cholangiocarcinoma.<\/p>\n

      Imaging is the key diagnostic test,<\/p>\n

      Describe the key histological feature.<\/p>\n

      Fibrotic destruction of bile ducts.<\/p>\n

      Progressive portal fibrosis.<\/p>\n

      Involves mainly the extrahepatic bile ducts.<\/p>\n

       <\/p>\n

      List the diseases that cause bile duct loss.<\/p>\n

        \n
      1. PBC<\/li>\n
      2. PSC<\/li>\n
      3. Drug-induced liver disease e.g. ketamine<\/li>\n
      4. Chronic liver transplant rejection<\/li>\n
      5. Graft versus Host Disease etc.<\/li>\n<\/ol>\n

         <\/p>\n

        Know the general features of chronic cholestatic liver disease and which special stains are needed to demonstrate them.<\/p>\n

          \n
        1. Bile duct loss<\/li>\n
        2. Proliferation of intermediate-type hepatocyte progenitor cells.<\/li>\n
        3. Accumulation of copper and copper associated protein in periportal hepatocytes.<\/li>\n
        4. Ballooning degeneration of periportal hepatocytes (with or without Mallory-Denk bodies).<\/li>\n<\/ol>\n

          1 and 2 confirmed on CK7 staining.<\/p>\n

          Copper-associated protein: metallothionine<\/p>\n

          Copper: rubeanic acid<\/p>\n

           <\/p>\n

          List the features which assess the active damage of biliary tract disease.<\/p>\n

            \n
          1. bile duct inflammation<\/li>\n
          2. interface hepatitis<\/li>\n<\/ol>\n

             <\/p>\n

            List the features which assess the chronic damage of biliary tract disease.<\/p>\n

              \n
            1. portal fibrosis<\/li>\n
            2. interlobular bile duct loss<\/li>\n
            3. deposition of copper associated protein.<\/li>\n<\/ol>\n

               <\/p>\n

              Wilson \u2019s disease<\/strong><\/p>\n

              List the main clinical features.<\/p>\n

              Associated with neurological problems (\u201chepato-lenticular degeneration\u201d) and eye involvement (Kayser-Fleisher rings).<\/p>\n

              Should always be considered in younger patients with unexplained liver disease.<\/p>\n

              Describe the underlying pathophysiology<\/p>\n

              Autosomal recessive with no dominant mutation.<\/p>\n

              Failure of copper excretion by hepatocytes into the biliary system due the failure to express a transporter protein<\/p>\n

              Describe the range of histological features.<\/p>\n

              From fatty liver hepatitis to chronic hepatitis.<\/p>\n

              Increased copper or copper associated protein can only be demonstrated, histologically, in half of cases:<\/p>\n

              The gold standard is liver copper measurement.<\/p>\n

              NB Copper also increased in chronic biliary tract diseases but not the same extent.<\/p>\n

               <\/p>\n

              Haemochromatosis<\/strong><\/p>\n

              List the main clinical features<\/p>\n

              Presents in adults but in men earlier than in women.<\/p>\n

              Describe the underlying pathophysiology<\/p>\n

              Autosomal recessive with a single dominant mutation (HFe)<\/p>\n

              Increased iron absorption from the gut. NB There is no method for excreting iron<\/p>\n

              Describe the key histological features.<\/p>\n

              Iron deposition in hepatocytes starting in the periportal hepatocytes and then spreading to the rest of the lobule.<\/p>\n

              Progressive portal fibrosis.<\/p>\n

              Be able to distinguish this from other causes of iron overload.<\/p>\n

              Chronic anaemia, also, leads to increased iron absorption from the gut and deposition in hepatocytes.<\/p>\n

              Blood transfusion leads to iron deposition in Kupffer cells and does not, usually, lead to fibrosis.<\/p>\n

               <\/p>\n

              Alpha-1 antitrypsin deficiency<\/strong><\/p>\n

              List the key clinical features<\/p>\n

              Associated with emphysema<\/p>\n

              Describe the key histological feature.<\/p>\n

              dPAS positive globules in periportal hepatocytes.<\/p>\n

               <\/p>\n

              IgG Related Disease (IgG4)<\/strong><\/p>\n

              List the main clinical features<\/p>\n

              Often part of systemic disorder<\/p>\n

              Often involves the hepato-biliary (and pancreatic) system producing, e.g.:<\/p>\n

                \n
              1. A mass lesion in the liver<\/li>\n
              2. A PSC like disease<\/li>\n<\/ol>\n

                List the 3 key histological features.<\/p>\n

                  \n
                1. Increased numbers of IgG4 expressing plasma cells.<\/li>\n
                2. Storiform fibrosis<\/li>\n
                3. Vasculo-obliterative lesions<\/li>\n<\/ol>\n

                  \u00a0<\/strong><\/p>\n

                  Granulomas<\/strong><\/p>\n

                  Know a classification of granulomas in the liver:<\/p>\n

                    \n
                  1. Aetiolgical<\/li>\n
                  2. Practical<\/li>\n
                  3. Where you know the cause:<\/em><\/li>\n<\/ol>\n

                    e.g. see a schistosome egg or acid-fast bacilli<\/p>\n

                      \n
                    1. Where you can have an educated guess:<\/em><\/li>\n<\/ol>\n

                      e.g. Associated with bile duct damage (PBC) or portal based, fibrotic granuloma with little associated inflammation (Sarcoid) or associated with other features suggesting DILI.<\/p>\n

                        \n
                      1. The rest!<\/em><\/li>\n<\/ol>\n

                         <\/p>\n

                        Vascular Diseases of the Liver<\/strong><\/p>\n

                        Describe the clinical associations and key histological features of the main vascular diseases of the liver.<\/strong><\/p>\n

                          \n
                        1. Budd Chiari Syndrome<\/em><\/li>\n<\/ol>\n

                          Thromboses of hepatic vein \/ branches etc.<\/p>\n

                          Associated with pro-thrombotic states<\/p>\n

                          Marked congestion, with extravasation of red cells onto hepatocytes, and patent central veins.<\/p>\n

                            \n
                          1. Veno-occlusive disease<\/em><\/li>\n<\/ol>\n

                            Fibrotic obliteration of portal vein branches.<\/p>\n

                            Associated with azathioprine, radiation and Jamaican bush tea<\/p>\n

                              \n
                            1. Sinusoidal obstruction syndrome.<\/em><\/li>\n<\/ol>\n

                              Sinusoidal damage with congestion and haemorrhage,<\/p>\n

                              Associated with chemotherapy,<\/p>\n

                                \n
                              1. Primary portal hypertension. <\/em><\/li>\n<\/ol>\n

                                Obliteration of hepatic vein branches and sinusoidal herniation.<\/p>\n

                                  \n
                                1. Nodular regenerative hyperplasia.<\/li>\n<\/ol>\n

                                  Regenerative nodules but no fibrosis.<\/p>\n

                                  Associated with systemic diseases<\/p>\n

                                  \u00a0<\/strong><\/p>\n

                                  \u00a0<\/strong><\/p>\n

                                  Cirrhosis<\/strong><\/p>\n

                                  \u00a0<\/strong><\/p>\n

                                  Define cirrhosis.<\/p>\n

                                  End stage liver disease:<\/p>\n

                                    \n
                                  1. involving the whole liver,<\/li>\n
                                  2. associated with fibrosis,<\/li>\n
                                  3. nodules of regenerating hepatocytes and<\/li>\n
                                  4. shunting of blood (intrahepatic and extrahepatic)<\/li>\n<\/ol>\n

                                    List the 3 commonest causes of cirrhosis<\/p>\n

                                      \n
                                    1. Viral hepatitis<\/li>\n
                                    2. Alcoholic liver disease<\/li>\n
                                    3. Non- alcoholic fatty liver disease (NAFLD)<\/li>\n<\/ol>\n

                                      List 4 other causes of cirrhosis.<\/p>\n

                                        \n
                                      1. PBC<\/li>\n
                                      2. PSC<\/li>\n
                                      3. DILI<\/li>\n
                                      4. Hemochromatosis<\/li>\n<\/ol>\n

                                        Know how to classify cirrhosis.<\/p>\n

                                          \n
                                        1. According to the aetiology<\/li>\n
                                        2. According to the sizes of the nodules<\/li>\n<\/ol>\n

                                          Micronodular (smaller than a normal liver lobule) \u2013 alcohol<\/p>\n

                                          Macronodular (bigger than a normal liver lobule) \u2013 viral hepatitis<\/p>\n

                                          Mixed<\/p>\n

                                           <\/p>\n

                                          List 3 complications of cirrhosis.<\/p>\n

                                            \n
                                          1. Portal hypertension.<\/li>\n
                                          2. Liver failure<\/li>\n
                                          3. Liver cell cancer<\/li>\n<\/ol>\n

                                             <\/p>\n","protected":false},"excerpt":{"rendered":"

                                            Acute Hepatitis Distinguish acute and chronic hepatitis. Liver disease lasting less (acute) or more (chronic) 6 months. Describe the natural history of hepatitis. Acute hepatitis > chronic hepatitis > cirrhosis Name the 2 commonest causes of acute hepatitis. Drugs Viruses Name 5 viruses which cause acute hepatitis. HAV, HBV, HCV, HDV and HEV Name one […]<\/p>\n","protected":false},"author":1119,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-63","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"\nMedical Liver Biopsies for Trainees. - My Path<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.imperial.ac.uk\/my-path\/2019\/03\/19\/medical-liver-biopsies-for-trainees\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Medical Liver Biopsies for Trainees. - My Path\" \/>\n<meta property=\"og:description\" content=\"Acute Hepatitis Distinguish acute and chronic hepatitis. 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