Never offer the devil (desire) a ride,

He always want to be in the driving seat!

-- BK

CPC 4.2.3 2013 yellow eyes

CASE STUDY 1

Mr. T.D. 50 year old, presents to his GP. My stomach appears big
and my wife has noticed a yellow tinge in my eyes.
Presenting Symptoms:
Abd distension, fatigue, yellow discoloration of eyes for 1 week

Liver failure
Fatigue / Anorexia..?
Liver failure
Nausea, Vomiting..?
Portal Hypertension
Haematemesis ?
Obstructive jaundice.
Itching..?
Hepatitis.
Fever..?
Abdominal distension slow..? Cirrhosis.
Vit-K deficiency.
Bleeding / Bruising..?
Differential
Diagnosis:
Alcoholic hepatitis.
10 stubbies/day
/more..?
Hepatitis: Alcoholic/Infective/Malignant/Drug/Toxins
Viral Hepatitis (B/C)
Many Tattoos..?
Acute / Chronic? Primary/Secondary?
Anorexia / Obesity
BMI if low / High..?
HBV / HCV, CMV, Lepto,
Dengue, Melioidosis.
steatosis.

Case2: Mr.GG, 48y, fatigue & yellow

Abdominal distension, fatigue, yellow
sclera 6 weeks.
Hardware business, Alcohol 40units / wk.
Travel: Thailand, had tattoo / surgery /
transfusion.. *
PE: abdomen nil sig. mild RUQ
tenderness. No organomegaly.
AST = 1320 U/l
ALT = 1780 U/l
Differential: Acute hepatitis.

CMV, Lepto, Hep A,B,C..

Hepatitis - Alcohol
Chronic hepatitis.
Drugs, toxins,

Alk. Phos. = 133 U/l

GGT = 192 U/l
Hep B Serology
Hep B sAg +ive
Hep B sAb <10
Hep B cAb IgM +ive
Hep B e Ag +ive
Hep B eAb ive 3

CPC 4.2.2 - 2010

George, 62 year old farmer from Tully, presents to
his GP with fatigue. His wife has asked him to
consult you as his eyes look a bit yellow'.
Fatigue: Progressing 2wk. Unable to get out.
nausea : no
vomiting/haematemesis : no
Anorexia, wt loss: yes thinks lost a bit of weight.
bowel habit : constipated, stool pale, no blood.
2 x episodes fatigue last 2 years preceded by 2
weeks of fever. Lab: liver not working so well'.
then felt better and has not been to see GP since.
Banana farmer from Greece - 26 years ago.
4

Laboratory Investigations:
FBC: Hb 13.8 g/dl, PCV 45%; WBC 7000/mm3, 70% N,
25% L; Platelets 200,000/mm3
Blood film: Normocytic, normochromic cells
Bilirubin: Total serum Bilirubin = 98 mol/l, (Direct 67)
Liver enzymes:
Aspartate amino transferase (AST) = 182 U/l
Alanine amino transferase (ALT) = 55 U/l
Alkaline Phosphatase = 190 U/I
Serum Protein: Total protein = 59 g/l, Albumin = 20 g/l,
HepPositive
B sAg +ive
Hepatitis B Surface Antigen (HbsAg):
Hep B sAb <10
Hep B cAb IgM +ive
Hep B e Ag +ive
Hep B eAb ive
5

Differential Diagnosis:
Viral fever -?
Yellow fever, Relapsing fever, Dengue, Ebola,
Leptospirosis (common in Tully) - ?

Hepatitis Acute / Chronic - ?

Chronic Hepatitis B why chronic?
History & presentation in Hep. A & C ?
Other causes of Jaundice?
Alcoholic liver disease ?
Toxins, chemical, Reyes syndrome?
Hemolytic / Anemia - ?
Malignancy - ?

CPC23: HBS Hepatitis & Cirrhosis

Pathology Major CLI:

Acute & Chronic Liver injury.

Pathophysiology of Jaundice, Clinical & Pathological types.
Alcoholic Liver disease Pathophysiology, types & complications.
Hepatitis Causes, types, Pathology (Alcohol, viral, Drug)
Pathology of cirrhosis Types, morphology & Clinical.

Pathology Minor CLI:

Primary Biliary cirrhosis & Primary Sclerosing Cholangitis.

Wilson's disease, 1-Antitrypsin (AAT) deficiency.
Hemosiderosis, Hemochromatosis, Wilsons disease.
Liver tumours adenoma, hyperplasia & cancer.
Cysts: Amoebic liver abscess & Hydatid disease of liver.
Congenital: Gilberts sy, Childhood cirrhosis
Dengue, Ebola virus, Reyes sy,
Liver blood supply disorders: Budd-Chiari Sy.

"When you speak, speak the truth;

perform when you promise;
discharge your trust... Withhold your
hands from striking, and from taking
that which is unlawful and bad..."
-- From Wings of Fire, book by Dr. APJ Abdul Kalam, Foremer President of India.

Pathology of

Common Liver Disorders

Dr. Venkatesh M. Shashidhar.
Assoc.Prof & Head of Pathology

Normal
1.5 kg, wedge shape
4 lobes, Right, left,
(Caudate, Quadrate)
Double blood supply
Hepatic arteries
Portal Venous blood

10

Normal Liver - Infant

Much larger, both lobes big, palpable below costal margin

CT Upper abdomen - Normal

Liver
Stomach
Aorta

Spleen
Lu
ng

Lung

12

Normal Liver Microscopy

Acinus showing zones 1, 2 & 3.
Central Vein

o
Blo

low
F
d

Portal Triad

13

Structure of Liver Lobule

Heart
IVC

Portal Triad: Art, Vein, BD

Metab, s
ynthe

GIT Venous bl.

sis, detox
ification..
.

Liver failure in
Cirrhosis?

14

Acinus

Lobule

Functional

Anatomic
Toxins

Toxins

Ischemia

Zone 1 Toxin damage.

Ischemia

Zone 3 Ischemic damage

15

Liver Function Tests: Interpretation

Synthesis / Function.
Total protein & albumin low, PT prolonged why? (vit K..)

Hepatocyte Injury.
ALT, AST, LDH - high. why?
Alk Phos moderately increased. why?

Bile Duct Damage:

Alk Phos increased why?

Other:

GGT

Alcohol (centrilobular)

IgG

Autoimmune hepatitis

IgM

Primary biliary cirrhosis

Alcoholic cirrhosis

+ve

Hep. Cell. Carcinoma

Antimitochondrial
antibody

+ve

Primary biliary cirrhosis

Anti-smooth
muscle, & ANA

+ve

Autoimmune hepatitis

GGT increased with alcohol use. why?

IgA
Viral serology Auto-Antibody panel.
AFP

16

Jaundice Types:
Overproduction
(Hemolytic Unconjugated)
Impaired uptake
(Hepatitis - mixed)
Block in metabolism
(Congenital)
Impaired transport.
(Hepatitis, toxins)
Intrahepatic Obst.
(Hepatitis)
17

Jaundice Clinical Types:

Stool

Urine

Ser. chem.

Diagnosis

Dark

Normal

Un.Conj / ID

Hemolysis.

Pale

Dark

Conj./D + ALP

Cholestasis

Pale

Dark

ID+D ALT/AST

Hepatitis.

Variable

Variable

Variable

Cong. Syndr.

18

A wise man watches his faults more

closely than his virtues; others
reverse the order.
--Napoleon Hill

Pathology of Viral Hepatitis

Dr. Venkatesh M. Shashidhar.
Assoc.Prof & Head of Pathology

20

Viral Hepatitis: Introduction

Viral Hepatitis:
Specific Heptitis B, C, D (serum), A, E
Non-Specific - Many viruses CMV, EBV, etc.
Acute, Chronic (CPH, CAH), Fulminant.

Specific viral hepatitis important cause of

morbidity & mortality.
Horizontal transmission Blood.. Sex.
Vertical transmission Mother to fetus.
Hepatitis Cirrhosis Hepatic Ca. (not in A/E)

21

Hepatitis A

'faecal-oral' spread, Travel / exposure.

Relatively short incubation period (2-6wk)
Epidemics common, may be sporadic.
Direct cytopathic virus (immune in B & C)
No carrier state prolonged immunity.
Usually mild illness, full recovery usual.
Rarely severe or fulminant.
IgM Ab is diagnostic. (no IgG tests).
22

Viral Hepatitis A: Serology

23

History Hep B Virus:

In 1965 - Dr. Blumberg who was
studying haemophilia, found an
antibody in two patients which reacted
against an antigen from an Australian
Aborigine. Later the antigen was found
in patients with serum type hepatitis
and was initially designated "Australia
Antigen". Later proved to be hepatitis B
virus surface antigen (HBsAg). Dr.
Blumberg was awarded the Nobel Prize
in 1976.
24

Hepatitis B

Spread by blood, Sex & birth (serum hepatitis..)

Relatively long incubation period (4-26wk)
liver damage by antiviral immune reaction
Carrier & Chronic state exist.
Relatively serious infection chronic
Complications: cirrhosis, carcinoma.
anti-HAV
Acute Hepatitis A
Diagnosis: Viral serology (HBs, IgM
HBc
&
HBe)
antibody
HBsAg

Hepatitis B or
carrier exp./inf.

HBeAg

Active hepatitis B
infection

Anti-HCV antibody

Hepatitis C virus
exposure

HCV RNA

Active hepatitis C
infection
25

Viral Hepatitis B: Serology

Sequence of serologic markers for hepatitis B viral hepatitis demonstrating (A)

acute infection with resolution and (B) progression to chronic infection.

26

Pathogenesis of Hepatitis A & B:

27

Pathogenesis:
Ingestion / inoculation
Replication - Viremia
Liver major site replication.
Cellular immune response.
Apoptosis, necrosis of hepatocytes.
Inflammation - Hepatitis
Bridging Hepatocyte necrosis (Central vein,
portal triad)
Fibrosis patchy/bridging
Cirrhosis extensive fibrosis with loss of
archetecture & regenerating nodules.
Liver Failure, Coma, Carcinoma..

28

Pattern of Liver Damage

Zonal Toxin/Hypoxia
Bridging Viral & severe
Interface CAH, Immune
Apoptotic Acute Viral

29

Clinical Viral Hepatitis: (A,B,C, D & E)

Carrier state / Asymptomatic phase

Hepatic dysfunction:
Acute hepatitis fever, icterus.
Chronic Hepatitis non specific.
Chronic Persistent Hepatitis (CPH)
Chronic Active Hepatitis (CAH)

Fulminant hepatitis massive necrosis

Cirrhosis total fibrosis.
Hepatocellular Carcinoma
30

Viral Hepatitis: Microbiology

Virus

Hep-A

Hep-B

Hep-C

Hep-E

agent

ssRNA

dsDNA

ssRNA

ssRNA

Incubation

2-6 wk

4-26 wk

2-6 wk

4-6 wk

Transm.

Faeco-oral Parenteral

Parenteral

Faeco-oral

Carrier

None

5-10%

Rare/None None

Chronic
Cirrhosis

None
None

4-10%
1-3%

80%
50%

Other

Young Mild /
fulminant,
travel.

Long incubat. Steatosis

~ 120d
Severe.

None
None
Severe in
Pregnant
31

Acute viral Hepatitis: Swelling & Apoptotic cells.

Diffuse Inflammation.
Necrosis & Apoptosis.
Liver enzymes raised.

32

Liver Biopsy CPH:

Inflammation

Portal Inflammation.
No Necrosis
Liver enzymes normal

33

Chronic Active Hepatitis(CAH):

Portal & Diffuse Inflammation.

Necrosis & Apoptosis.
Liver enzymes abnormal.

34

Viral Steatosis - Alcoholic

Microvesicular (viral)

Macrovesicular (alcoholic)
35

Fulminant Hepatitis:

Hepatic failure with in 2-3 weeks.

Reactivation of chronic or acute hepatitis
Massive necrosis, shrinkage, wrinkled
Collapsed reticulin network
Only portal tracts visible
Little or massive inflammation time
More than a week regenerative activity
Complete recovery or - cirrhosis.
36

Fulminant Hepatitis:

37

Clinical Spectrum of HBV inf:

38

Failure is a blessing when it pushes

one out of a cushioned seat of selfsatisfaction and forces him to do
something useful.
--Napoleon Hill

Laboratory Diagnosis
Viral Hepatitis

Viral Hepatitis C: Serology

41

Hepatitis B Lab result interpret

Learn from the mistakes

of others. You can't live
long enough to make
them all yourself!

61% of
of 55thth year
year students
students exceeded
exceeded sensible
sensible limits
limits
61%
Drugs and
and alcohol
alcohol were
were taken
taken mainly
mainly for
for pleasure
pleasure and
and were
were
Drugs
perceived as
as aa normal
normal part
part of
of life
life for
for many
many students
students
perceived
Capability of
of advising
advising patients?
patients?
Capability
http://www.lycaeum.org/research/researchpdfs/1996_webb_1.pdf
http://www.lycaeum.org/research/researchpdfs/1996_webb_1.pdf

43

"The past, the present and the

future are really one: they are
today!"
-Harriet Beecher Stowe

The past has gone and future you cannot see. The present, when you can do something, that is the
Gift (Present) with which you can make your future & past memorable.
- Sai Baba

Other Hepatitis

45

Drug Induced Zonal Hepatitis:

Autopsy specimen in a case of
acetaminophen (paracetamol /
NSAID) overdose.
Prominent hemorrhagic necrosis
of the centrilobular zones of all
liver lobules.
greater activity of drugmetabolizing enzymes in the
central zones.
Other agents that produce such
injury are carbon tetrachloride,
toxins of the mushroom Amanita
phalloides.
Patients either die in acute
hepatic failure or recover without
sequelae.
46

Autoimmune Hepatitis:
Clinical & pathology similar
to Chronic hepatitis.
Female predominance
(70%)
Elevated serum IgG
High titers of
autoantibodies.
Autoimmune diseases.

47

Reye Syndrome:
Acute disease of children
Following a febrile illness,
commonly influenza or
varicella infection with use
of aspirin.
Microvesicular steatosis,
hepatic failure, and
encephalopathy.
Cerebral edema and fat
accumulation in the brain.
Pathogenesis remains
unknown (Aspirin..)
Uncommon.

Fat stain (oil-red o)

48

Toxemia of Pregnancy:
Abnormal LFT in 3-5% of preg.
Acute Fatty Liver of Pregnancy
Intrahepatic Cholestasis of Preg.
Hypertension, proteinuria, edema
and coagulation abnormalities
(pre-eclampsia) with convulsions
& coma (eclampsia).
HELLP syndrome (hemolysis,
elevated liver enz. & low plt).
Patchy hemorrhages over
capsule, DIC
Fibrin thrombi in portal vessels.
Hepatocellular necrosis.
49

Self Study: brief

Primary Biliary cirrhosis & Primary Sclerosing Cholangitis
(differences, Male, female, associated conditions etc).
Wilson's disease & 1-Antitrypsin (AAT) deficiency.
Hemosiderosis, Hemochromatosis differences.
Liver tumours adenoma, hyperplasia & cancer.
Cysts: Congenital, Amoebic & Hydatid.
Congenital: Gilberts sy, Childhood cirrhosis
Hepatitis in Dengue & Leptospirosis
Reyes syndrome.
Budd-Chiari Syndrome.

50

Pathology of Cirrhosis

51

Cirrhosis
End stage of many
diffuse liver damages.
Resulting in scaring &
regenerating nodules
(liver failure due to
loss of archetecture)
Normal

Shrunken

Nodular

Cirrhosis
52

Clinical Features - Pathogenesis

Hypoalbuminemia/edema
Hypoalbuminemia/edema
Hyperammonemia/CNS coma.
Hyperammonemia/CNS coma.
Hypoglycemia
Hypoglycemia
Palmar erythema
Palmar erythema
Spider angiomas
Spider angiomas
Hypogonadism
Hypogonadism
Gynecomastia
Gynecomastia
Weight loss
Weight loss
Muscle wasting
Muscle wasting
Ascites
Ascites
Splenomegaly
Splenomegaly
Esophageal varices
Esophageal varices
Hemorrhoids
Hemorrhoids
Caput medusae-abdominal skin
Caput medusae-abdominal skin
Coagulopathy
Coagulopathy
Hepatic encephalopathy
Hepatic encephalopathy
Hepatorenal syndrome
Hepatorenal syndrome

Decreased Albumin synthesis

Decreased Albumin synthesis
Hepatorenal syndrome
Hepatorenal syndrome
Glycogen metabolism.
Glycogen metabolism.
Excess Oestrogens
Excess Oestrogens
Excess Oestrogens
Excess Oestrogens
Excess Oestrogens
Excess Oestrogens
Excess Oestrogens
Excess Oestrogens
Decreased metabolism.
Decreased metabolism.
Decreased metabolism
Decreased metabolism
Portal Hypertension
Portal Hypertension
Portal Hypertension
Portal Hypertension
Portal Hypertension
Portal Hypertension
Portal Hypertension
Portal Hypertension
Portal Hypertension
Portal Hypertension
Coag factory synthesis.
Coag factory synthesis.
Detoxification.
Detoxification.
? Renal ischemia
? Renal ischemia

53

MRI Cirrhosis

Shrunken

Nodular

54

Liver Biopsy Cirrhosis

Fibrous septa

Reg. nodule

55

Liver Biopsy Cirrhosis

Fibrous septa

Reg. nodule

56

Liver Needle Biopsy Cirrhosis:

(Blue collagen stain)

Fibrous septa
Reg. nodule

57

Etiology of Cirrhosis

Alcoholic liver disease 60-70%

Viral hepatitis
10%
Biliary disease
5-10%
Primary hemochromatosis 5%
Cryptogenic cirrhosis
10-15%
Wilsons, 1AT def
rare

58

Pathogenesis:
Hepatocyte injury leading to necrosis.
Alcohol, virus, drugs, toxins, genetic etc..

Chronic inflammation - (hepatitis).

Bridging fibrosis.
Regeneration of remaining hepatocytes
Proliferate as round nodules.
Loss of vascular arrangement results in
regenerating hepatocytes ineffective.
59

Cirrhosis Portal hypertension

Cirrhosisobstruction
Portal
hypertension
Splenomegaly
transudation Ascites

60

Hepatic encephalopathy

Clinical
Features

61

Gynaecomastia in Cirrhosis

62

Palmar erythema & Spider nevi

? Pathogenesis
63

Primary Biliary Cirrhosis

Autoimmune.
Females 6:1.
Pruritis, jaundice,
hepatosplenomegaly (initial).
Intrahepatic Bile duct inflammation
Cholestasis (bile stained liver)

64

Neonatal cholestasis / Cirrhosis

Infections;
CMV, Syphilis, Septicemia.

Extrahepatic biliary atresia.

Drugs & Toxins
Nutrition, drugs.

1-Antitrypsin deficiency
Protease inhibitor (inflam).
Mild hepatitis cirrhosis.

Cystic fibrosis.
Idiopathic
Indian child hood cirrhosis.
65

Normal / Cirrhosis Liver

66

Hepatocellular Carcinoma

Normal - Carcinoma

67

Hepatic Adenoma: rare

adenoma

adenoma

68

Nutmeg Liver:
Chronic Passive
Congestion Heart failure.
Central zone (Zone-3)
congestion and necrosis.
Hemorrhage RBCs in
zone-3 - Mottled
appearance (nutmeg).
Symptoms similar to
chronic hepatitis, Ascites,
distended abdomen, ankle
edema, Hepatic
encephalopathy, confusion.
69

Liver Metastasis:
Multiple
Clear
demarcation
Hemorrhage /
Central necrosis
(+/-)
Microscopy
depends on type.

70

Learn from the mistakes

of others. You can't live
long enough to make
them all yourself!

61% of
of 55thth year
year students
students exceeded
exceeded sensible
sensible limits
limits
61%
Drugs and
and alcohol
alcohol were
were taken
taken mainly
mainly for
for pleasure
pleasure and
and were
were
Drugs
perceived as
as aa normal
normal part
part of
of life
life for
for many
many students
students
perceived
Capability of
of advising
advising patients?
patients?
Capability
http://www.lycaeum.org/research/researchpdfs/1996_webb_1.pdf
http://www.lycaeum.org/research/researchpdfs/1996_webb_1.pdf

71

Alcoholic
Liver Disease

Incidence is increasing!

73

Chronic Alcoholism:
Clinical Features:

74

Alcoholic Liver Injury:

Ethyl alcohol : Common cause of
acute/Chronic liver disease
Alcoholic Liver disease - Patterns
Fatty change,
Acute hepatitis (Mallory Hyalin)
Chronic hepatitis with Portal fibrosis
Chronic Liver failure
Cirrhosis

All reversible except cirrhosis stage.

75

Alcoholic Liver Injury: Pathogenesis

Acetaldehyde metabolite hepatotoxic
Diversion of metabolism to alcohol
Fat storage fatty change. Cell swelling..
Rupture Fat necrosis severe
inflammation fibrosis.
Alcohol stimulates collagen synthesis
Inflammation, Portal bridging fibrosis
Micronodular cirrhosis.

76

Alcoholic Liver Injury: Pathogenesis

Diversion of fat metabolism
to alcohol fat storage.
Acetaldehyde hepatotoxic
denatures Proteins
Increased peripheral release
of fatty acids.
Alcohol stimulates collagen
synthesis
Mutant ALDH2 gene with low
activity enzyme is observed
in Caucasians but is found in
some 40% of Orientals
(autosomal dominant).

Acetaldehyde

77

Alcoholic Liver Damage

Ito Cells

78

Safe drinking
High Risk

Intermediate

Low Risk

79

Risk of Alcohol injury

80

1 Unit = 10ml = 8gm

Alcohol Toxicity:
Liver

Fatty change

Toxicity

Acute hepatitis
Alcoholic cirrhosis
Nervous system

Wernicke syndrome

Thiamine deficiency

Korsakoff syndrome

Toxicity and thiamine deficiency

Cerebellar degeneration

Nutritional deficiency

Peripheral neuropathy

Thiamine deficiency

Cardiomyopathy

Toxicity

Hypertension

Vasopressor

Gastritis

Toxicity

Pancreatitis

Toxicity

Skeletal muscle

Rhabdomyolysis

Toxicity

Reproductive system

Testicular atrophy

Spontaneous abortion

Growth retardation

Toxicity

Cardiovascular system
Gastrointestinal tract

Fetal alcohol syndrome

Mental retardation, Birth

defects.

81

Alcoholic Liver Damage

82

Alcoholic Hepatitis:

Centrilobular necrosis. Ballooned degenerating hepatocytes (BC) Mallory bodies

(MB) Many Neutrophils, few lymphocytes & Macrophages.
The central vein(or terminal hepatic venule (THV), is encased in connective
tissue (C) (central sclerosis). Fat-laden hepatocytes (F) are evident in the lobule.
83
The portal tract displays moderate chronic inflammation.

Alcoholic Hepatits - Mallory's hyalin

84

Alcoholic hepatitis & Mallory Hyalin:

85

Alcoholic Fatty Liver

86

Alcoholic Fatty Liver

87

Alcoholic Fatty Liver

88

Diffuse fatty liver - un-enhanced CT.

Normal

Hamer O W et al. Radiographics 2006;26:1637-1653

2006 by Radiological Society of North America

Alcoholic Fatty Liver - CT

90

Alcoholic Fatty Liver - CT

91

Alcoholic Fatty liver:

92

Alcoholic Fatty Liver - collagen stain

93

Alcoholic Cirrhosis:

94

Alcoholic Fatty Liver - collagen stain

95

Alcoholic Liver Injury: Complications

Pancreatitis Acute or Chronic. Due to
ischemic damage to pancreas.
Alcoholic hepatitis similar to viral
hepatitis.
Fulminant hepatitis
Alcoholic Cirrhosis Micronodular.

Alcohol & Medical students

http://www.m-c-a.org.uk/about_us/about_mca

96

Miscellaneous Conditions

97

Primary Biliary Cirrhosis

Autoimmune, Chronic, progressive
Destruction of intrahepatic bile ducts, portal
inflammation & scarring cholestasis.
Leading to cirrhosis and liver failure.
Females common (6:1)
Insidious onset of Pruritis & cholestatic jaundice.
Markedly high ALP, +ve antimitochondrial Ab.
Histopathology: Portal inflammation, bile stasis,
bile plugs & lakes, Later stages cirrhosis Firm
fibrotic, nodular, greenish, Shrunken.

Macronodular Cirrhosis - PBC

PBC Microscopy:

Bile Lakes

Bile Plugs

Cholestasis: Bile plugs,

Bile lakes

Biliary Atresia in a 3m child.

Dark bile stained liver tissue, cirrhosis & death before 2 years of age.

Hepatosplenic schistosomiasis:
Schistosoma Mansoni /
haematobium
Granulomas in the liver.
Fibrotic reaction around egg
Pipe stem Portal Fibrosis
Cirrhosis, spleenomegaly,
ascitis.

103

Hepatosplenic schistosomiasis:
Schistosoma Mansoni /
haematobium
Granulomas in the liver.
Fibrotic reaction around egg
Pipe stem Portal Fibrosis
Cirrhosis, spleenomegaly,
ascitis.

104

"It's not the will to win, but the will

to prepare to win that makes the
difference."
- - Bear Bryant 1913-1983, Football Coach

CPC-2.2 Major Pathology CLI:

Pathology of Acute & Chronic Liver injury.
Hepatitis Causes, Types, Pathophysiology, Gross &
Microscopic Pathology. Complications.
Common types: Viral (Specific & Non specific), Alcoholic
& Drug induced.
Pathophysiology of Jaundice, Clinical & Pathological
types.
Pathology of cirrhosis Classification, morphology &
Complications.
Pathology of Alcoholic Liver disease Pathophysiology,
types & complications.

106

CPC-2.2 Minor Pathology CLI:

Hemosiderosis & Hemochromatosis.

Pathogenesis of Hepatic coma, Liver failure.
Primary Biliary cirrhosis.
Hepatocellular carcinoma.
Liver cysts & tumours adenoma, hyperplasia & cancer.
Amoebic liver abscess & Hydatid disease of liver.
Congenital liver disorders enzyme disorders.

107

Clinical Case Study

108

Case # 2 - ? Diagnosis
60yr Male, 8 month slowly developing weakness,
mild icterus.
PE: Mild Abdominal tenderness, No
organomegaly. Mild Scleral icterus.

ALT: 52 (N= 8-33 U/L)

AST: 58 (N= 4-36 U/L)
Alk Phos: 150 (N= 20-130 u/L)
Bilirubin 3.9 (N= 0.1-1.2 mg/dL) (direct 1.8)
T Protein 4.8 (N= 6.0-7.8 g/dL)
Albumin 2.5 (N= 3.2-4.5 g/dl)
PT = 16 sec (N= 11-14.7 sec )
Differential diagnosis?
What further investigations?
Labs:

109

Diagnosis pathway:
Jaundice?

ALT: 52
AST: 58
Alk Phos: 150
Bilirubin 3.9 (direct 1.8)

Mild increase, Mixed (combined)

Synthesis?
Total protein, albumin Low & PT abnormal.

Obstruction & Bilirubin Clearance ?

Alk Phos is up a bit but not high some obstruction.

Hepatocyte Direct Injury:

ALT & AST are up a bit, but not dramatically.

Discussion:
Chronic Mild compromise - chronic Active
hepatitis. (In CPH LFT will be normal)
110

 28y Male, 3 weeks after visiting east Timor,

presents with malaise, fatigue, loss of
appetite. Mild icterus. AST & ALT mild
elevation. Total bil 3.9mg/dl (Direct 2.8).
Which of the following would be positive?

111

Alcohol Metabolism:

112

Chronic Hepatitis:
Passive CPH

Active CAH

Limited Periportal
inflammation.
Mild Periportal fibrosis
No hepatocyte
Necrosis.
LFT normal or mild
change.
Late cirrhosis

Extensive
Inflammation
More fibrosis.
Necrosis of
hepatocytes.
LFT abnormal.
Early cirrhosis & other
complication.

113

Nearly all men can stand adversity,

but if you want to test a man's
character, give him power!
Abraham Lincoln