"It's not the will to win, but the will to prepare to win that makes the

difference."

Bear Bryant1913-1983, Football Coach

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Pathology of Common Liver Disorders

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

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Viral serology interpretation:HBsAg Positive, Anti HBcAg PositiveAnti HBcAg IGM NegativeAnti HBsAg Negative

1 2 3 4 5

41%

7%

0%

26%26%

A. Acute Viral HepatitisB. Immunised against Hep. BC. Chronic Hepatitis BD. Hepatitis B carrier stageE. Fulminant hepatitis B

IgM anti-HAV antibody

Acute Hepatitis A

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

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?

A. B. C. D. E.

20% 20% 20%20%20%A. Chronic Passive Hepatitis BB. Chronic Viral Hepatitis AC. Hepatitis CD. Alcoholic Hepatitis.E. Transfusion Haemochromatosis.

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51y M, Alcoholic: Look at Arrow ? Pathogenesis.

1 2 3 4 5

0% 0% 0%

13%

88%

A. Porta-systemic shuntB. Hyper-oestrogenemiaC. Portal hypertensionD. Hypo-albuminemiaE. Decreased vit-K

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?

1 2 3 4 5

18%

29%

12%

29%

12%

1. Acute Alcoholic hepatitis.2. Drug induced Hepatitis.3. Fulminant Hepatitis.4. Nutmeg liver (venous congestion)5. Budd Chiari Syndrome.

42y M, alcoholic, recurrent fatigue 3 years. Liver biopsy. ? Diagnosis

1 2 3 4 5

0% 0%6%

0%

94%

A. Acute HepatitisB. Chronic Active hepatitis.C. Chronic Persistant hepatitis.D. Fulminant Hepatitis.E. Cirrhosis.

8

?

1 2 3 4 5

65%

0% 0%

29%

6%

1. Acute Alcoholic hepatitis.2. Drug induced Hepatitis.3. Fulminant Hepatitis.4. Acute Viral hepatitis5. Budd Chiari Syndrome.

Pathogenesis - typical of which virus?

1 2 3 4 5

100%

0% 0%0%0%

1. HAV2. HBV3. HCV4. HDV5. Non Specific

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?

1 2 3 4 5

59%

6%

0%0%

35%

1. Hepatic failure – cirrhosis.2. Hepatic encephalopathy.3. Hepatorenal syndrome.4. Chronic renal failure.5. Budd Chiari Syndrome.

A 42year travelling salesperson has routine medical test for insurance. Following initial testing he was advised liver biopsy. This is a image of his Liver Biopsy. What is the most likely diagnosis?

A. B. C. D. E.

31%

0% 0%

19%

50%

A. Acute Viral HepatitisB. Alcoholic hepatitis.C. Chronic viral Hepatitis. D. Post viral cirrhosis.E. Alcoholic Cirrhosis.

69y Female, Chronic bronchitis. Died following chronic Cardiac failure. Liver specimen. Likely diagnosis?

1 2 3 4 5

0%7%

14%

79%

0%

A. Alcoholic Hepatitis B. Dubin-Johnson SyndromeC. Alcoholic cirrhosisD. Nutmeg liverE. Metastatic deposits

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Viral serology interpretation:HBsAg Negative, Anti HBcAg Ab NegativeAnti HBcAg IGM NegativeAnti HBsAg Ab PositiveA. Acute Viral Hepatitis

B. Immunised against Hep. BC. Past Hepatitis BD. Hepatitis B carrier stageE. Fulminant hepatitis B

28y M, alcoholic, homosexual icterus and fever. Liver biopsy. ? diagnosis

A. B. C. D. E.

80%

0%

10%

0%

10%

A. Acute viral hepatitisB. Hemolytic anemiaC. Chronic persistent hepatitisD. Alcoholic fatty liver.E. Alcoholic Hepatits.

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Viral serology interpretation:

1 2 3 4 5

0% 0% 0%

50%50%

HBsAg Negative, Anti HBsAg Ab PositiveAnti HBcAg Ab PositiveAnti HBcAg IGM NegativeA. Acute Viral Hepatitis B

B. Immunised against Hep. BC. Past Hepatitis BD. Hepatitis B carrier stageE. Carrier state of Hepatitis B

58y M, alcoholic, distended abdomen & icterus. Liver biopsy. ? diagnosis

1 2 3 4 5

0% 0%

50%

0%

50%

A. Chronic active hepatitis.B. Chronic Persistant hepatitis.C. Hepatocellular carcinoma.D. CirrhosisE. Chronic alcoholic hepatitis.

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Lab Investigations interpretation:

A. B. C. D. E.

57%

14%

0%

14%14%

Protein (Total) 59 g/LAlbumin 30 g/LGlobulin 29 g/LBilirubin (Total) 27 μmol/LALP 71 U/LGGT 523 U/LALT 79 U/LAST 151 U/L

A. Alcoholic Liver diseaseB. Acute Viral Hepatitis.C. Past Hepatitis BD. Hepatitis B carrier stageE. Carrier state of Hepatitis B

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51y M, Alcoholic: Look at Arrow ? Pathogenesis.

1 2 3 4 5

0%

81%

0%

13%6%

A. Porta-systemic shuntB. Hyper-oestrogenemiaC. Portal hypertensionD. Hypo-albuminemiaE. Decreased vit-K

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Lab Investigations interpretation:

A. B. C. D. E.

33% 33% 33%

0%0%

Urea 5.8 mmol/LCreatinine 80 μmol/LProtein (Total) 66 g/LAlbumin 35 g/LGlobulin 31 g/LBilirubin (Total) 192 μmol/LBilirubin (Conj.) 130 μmol/LALP 203 U/LGGT 470 U/LALT 6055 U/LAST 4860 U/L

A. Alcoholic Fatty liverB. Past Hepatitis B C. Acute Viral Hepatitis.D. Hepatitis B carrier stageE. Chronic Hepatitis

62 year Male, malaise, lethargy since 2 years. Liver mildly enlarged. No jaundice. Liver function tests normal. Image from liver biopsy. Most likely diagnosis?

A. B. C. D. E.

33%

67%

0%0%0%

A. Alcoholic fatty liver. B. Acute viral hepatitis.C. Fulminant hepatitis.D. Chronic viral hepatitis.E. Alcoholic Cirrhosis.

MG, 29 year old man presents with arthritis, darkening of skin and fatigue since 3 years. He has also recently developed congestive cardiac failure. His Hb A1c is 11.2%. Image shows his liver biopsy stained with Prussian blue stain for iron. Most likely diagnosis?

A. B. C. D. E.

0% 0% 0%0%0%

A. Cirrhosis of liver. B. Hemosiderosis.C. Hemochromatosis.D. Wilson’s disease.E. Chronic pancreatitis.

22y M, alcoholic, 3wk fatigue, icterus & fever. Liver biopsy. ? Identify the structure

1 2 3 4 5

0%

33% 33%33%

0%

A. Mallory hyalineB. Apoptotic cellC. Viral inclusionD. Hepatocyte necrosisE. Inflammatory cell

34y M, icterus and fever. Liver biopsy. ? diagnosis

1 2 3 4 5

0%

100%

0%0%0%

A. Acute HepatitisB. Chronic Persistent Hepatitis.C. Chronic active HepatitisD. Fulminant HepatitisE. Cirrhosis

56y chronic alcoholic, 2 days fever, abdomen distended, tender, tap yielded cloudy yellow fluid with 98% neutrophils, Blood culture E.coli. Patient dies 3 days later. Image shows his liver.

1 2 3 4 5

0% 0% 0%0%0%

A. A1 antitrypsin deficiencyB. HEV infectionC. Hereditary hemochromatosisD. Primary sclerosing cholangitisE. Alcoholic cirrhosis

22y M, alcoholic, 3wk fatigue, icterus & fever. Liver biopsy. ? Identify the structure

1 2 3 4 5

0% 0% 0%0%0%

A. Mallory hyalineB. Apoptotic cellC. Viral inclusionD. Hepatocyte necrosisE. Inflammatory cell

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Learn from the mistakes of others. You can't live long enough to make them all yourself…!

61% of 5th year students exceeded ‘sensible’ limitsDrugs and alcohol were taken mainly for pleasure and were perceived as a normal part of life for many students… Capability of advising patients…?

http://www.lycaeum.org/research/researchpdfs/1996_webb_1.pdf

51y M, Alcoholic, surgery for pigmented skin lesion: Liver specimen. Likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

A. Amoebic Liver abscessesB. Multiple Liver InfarctsC. Alcoholic HepatitisD. Macronodular cirrhosisE. Metastatic deposits

59y Male, Alcoholic, presents with fatigue, anorexia. Normal liver function tests. Liver specimen. Likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

A. Dubin-Johnson SyndromeB. Alcoholic cirrhosisC. Alcoholic HepatitisD. Fatty LiverE. Metastatic deposits

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?

1 2 3 4 5

0% 0% 0%0%0%

1. Anti HBs2. IgM anti-HDV3. Anti HCV4. IgM anti HAV5. Anti HBc

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?

1 2 3 4 5

0% 0% 0%0%0%

1. Anti HBs2. IgM anti-HDV3. Anti HCV4. IgM anti HAV5. Anti HBc

41y Female, increasing malaise, 10kg weight loss since last year. Developed coma and died. Specimen of her Liver. Most likely etiologic agent?

1 2 3 4 5

0% 0% 0%0%0%

1. Aspirin abuse2. Ferrous sulphate3. Acetaminophen4. Aflatoxins5. Raw Oysters.

A 48y man referred following high ALT in health screening. HCV immunoassay +ve. Past h/o appendectomy 10 years ago. Examination is normal. Which of the following tests would determine if he has Chronic HCV infection?

1 2 3 4 5

0% 0% 0%0%0%

1. Repeat EIA for anti HCV Ab.2. Recombinant immunoblot assay (RIBA)3. Alpha-fetoprotein levels.4. HCV RNA test.5. Direct, indirect & total bilirubin assay.

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Alcohol Metabolism: