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Normal structure of liver. Normal function of liver Metabolic (glucose homeostasis…) Metabolic (glucose homeostasis…) Synthetic (albumin, coagulation.

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Presentation on theme: "Normal structure of liver. Normal function of liver Metabolic (glucose homeostasis…) Metabolic (glucose homeostasis…) Synthetic (albumin, coagulation."— Presentation transcript:

1 Normal structure of liver

2 Normal function of liver Metabolic (glucose homeostasis…) Metabolic (glucose homeostasis…) Synthetic (albumin, coagulation factors) Synthetic (albumin, coagulation factors) Storage (glycogen, triglycerides, Fe, Cu, vitamins soluble in fat) Storage (glycogen, triglycerides, Fe, Cu, vitamins soluble in fat) Catabolic (endogenous substances – hormones…, exogenous substances – drugs, alcohol…) Catabolic (endogenous substances – hormones…, exogenous substances – drugs, alcohol…) Excretoric (bile) Excretoric (bile)

3 Histologic examination Necropsy Necropsy Excision during laparotomy Excision during laparotomy Fine needle punction Fine needle punction Percutaneous punction biopsy Percutaneous punction biopsy unguidedunguided laparoscopiclaparoscopic guided (Sono, CT)guided (Sono, CT) transjugulartransjugular

4 Liver biopsy Representativeness Quality Clinical dataDiagnosis Reproducibility

5 Representativeness Biopsy represents approx. 1/ of organ Biopsy represents approx. 1/ of organ Ideal biopsy (Scheuer, MacSween) Ideal biopsy (Scheuer, MacSween) 2 cm length2 cm length more than 4 (8) portal tractsmore than 4 (8) portal tracts Borderline representativeness Borderline representativeness contact CLINICIAN!!contact CLINICIAN!! Non-representative Non-representative

6 Quality Clinical data Clear and sufficient Clear and sufficient clinical outcome, historyclinical outcome, history etiologyetiology biochemical findings, other markers (oncomarkers, markers of autoimmunity…)biochemical findings, other markers (oncomarkers, markers of autoimmunity…) treatmenttreatment previous histologyprevious histology preliminary diagnosis!preliminary diagnosis! Unclear Unclear contact CLINICIAN!!contact CLINICIAN!! Insufficient and confusing Insufficient and confusing

7 Quality Diagnosis Diagnosis Diagnosis recent diagnostic praxis (grading and staging of chronic hepatitis…)recent diagnostic praxis (grading and staging of chronic hepatitis…) recent diagnostic textbooks - contact CLINICIAN!!recent diagnostic textbooks - contact CLINICIAN!! Methods Methods biopsy - contact CLINICIAN!!biopsy - contact CLINICIAN!! immunohistochemistry, ELMI -contact CLINICIAN!!immunohistochemistry, ELMI - contact CLINICIAN!! experimentalexperimental

8 Recently used diagnostic textbooks

9 Histologic examination – special stains and methods Haematoxylin/eosin Haematoxylin/eosin Fouchet – bile (green), collagen (red) Fouchet – bile (green), collagen (red) Fe, Cu – Fe pigment, Cu pigment Fe, Cu – Fe pigment, Cu pigment Gömori – reticulin mesh Gömori – reticulin mesh Orcein – HBsAg Orcein – HBsAg PAS, Müller – mucopolysaccharides PAS, Müller – mucopolysaccharides Immunohistochemistry (HBsAg, HBcAg,  1 fetoprotein, CEA, hepatocytes – OCH1E5) Immunohistochemistry (HBsAg, HBcAg,  1 fetoprotein, CEA, hepatocytes – OCH1E5) ELMI (metabolic diseases) ELMI (metabolic diseases) PCR (HBV DNA, HCV RNA,…) PCR (HBV DNA, HCV RNA,…)

10 Damage of hepatocytes Type (ischemic-coagulation necrosis, piecemal necrosis, apoptosis) Type (ischemic-coagulation necrosis, piecemal necrosis, apoptosis) Extent (monocellular, focal, submassive, massive, bridging: C-C; C-P) Extent (monocellular, focal, submassive, massive, bridging: C-C; C-P) Localization (centrolobular, periportal, midzonal) Localization (centrolobular, periportal, midzonal) Course Course regeneration, healing ad integrumregeneration, healing ad integrum regeneration + fibrosis: cirrhosisregeneration + fibrosis: cirrhosis acute liver failure: coma and deathacute liver failure: coma and death

11 Liver failure Jaundice Jaundice Hypoalbuminemia Hypoalbuminemia Coagulopathy Coagulopathy Hyperamonemia Hyperamonemia Increase of levels of cytosolic enzymes Increase of levels of cytosolic enzymes Endocrine complications Endocrine complications Hepatoencephalopathy Hepatoencephalopathy Hepatorenal syndrome Hepatorenal syndrome Coma Coma

12 Necrosis of liver: damage of hepatocytes

13 Cirrhosis Nodular rearrangement Nodular rearrangement Morphology Morphology micronodularmicronodular macronodularmacronodular

14 Cirrhosis: etiology Alcohol (60-70%) Alcohol (60-70%) Chronic hepatitis (10%) Chronic hepatitis (10%) Cryptogenic (10-15%) Cryptogenic (10-15%) Biliary (primary, secondary) Biliary (primary, secondary) Haemochromatosis (primary, secondary) Haemochromatosis (primary, secondary) Metabolic diseases (tyrosinemia, galactosemia) -very rare Metabolic diseases (tyrosinemia, galactosemia) -very rare

15 Cirrhosis: complications Portal hypertension Portal hypertension Liver failure Liver failure Hepatocellular carcinoma Hepatocellular carcinoma

16 Portal hypertension Prehepatic (tumor, infection, pancreatitis, pregnancy, peroral contraceptives) Prehepatic (tumor, infection, pancreatitis, pregnancy, peroral contraceptives) Intrahepatic – most frequent (cirrhosis, fibrosis) Intrahepatic – most frequent (cirrhosis, fibrosis) Posthepatic (congestive cardiac failure, Budd-Chiari syndrome, venoocclusive disease) Posthepatic (congestive cardiac failure, Budd-Chiari syndrome, venoocclusive disease) Signs: Signs: portosystemic shuntsportosystemic shunts splenomegalysplenomegaly ascitesascites

17 Cirrhosis

18 Cirrhosis

19 Cirrhosis

20 Cirrhosis + hepatocellular carcinoma

21 Cirrhosis: Masson staining

22 Cirrhosis: Fouchet staining

23 Cirrhosis

24 Cirrhosis: active

25 Cirrhosis: biliary

26 Dysplasia

27 Dysplasia

28 Hepatitis: etiology Infectious (acute, chronic) Infectious (acute, chronic) viruses (most often)viruses (most often) bacteria (TBC, malaria, salmonelosis, leptospirosis,…)bacteria (TBC, malaria, salmonelosis, leptospirosis,…) parazites (ecchinococcus)parazites (ecchinococcus) protozoal (amebiasis)protozoal (amebiasis) Non-infectious (acute, chronic) Non-infectious (acute, chronic) autoimmuneautoimmune metabolicmetabolic drug induceddrug induced cryptogeniccryptogenic

29 Viral hepatitis HAVRNAPikornavirus HBVDNAHepadnavirus HDVRNADefektní virus Non A Non B HCVRNAFlavivirus HEVRNAKalicivirus HFVRNATogavirus HGVRNAFlavivirus

30 Viral hepatitis: HBV+HDV

31 Viral hepatitis: HBsAg, ground glass

32 Viral hepatitis: HBsAg, Orcein staining

33 Viral hepatitis: HBcAg, immunohistochemistry

34 Viral hepatitis: HBcAg, electron microscopy

35 Viral hepatitis: course Acute (HAV, HBV, HCV, HDV, HEV) Acute (HAV, HBV, HCV, HDV, HEV) Chronic (HBV, HBV + HDV, HCV) Chronic (HBV, HBV + HDV, HCV) risk of cirrhosis developmentrisk of cirrhosis development risk of hepatocellular carcinoma developmentrisk of hepatocellular carcinoma development Fulminant (HBV, HCV) Fulminant (HBV, HCV)

36 Acute hepatitis Gross finding – oedematous, red liver Gross finding – oedematous, red liver Microscopic finding Microscopic finding focal necrosisfocal necrosis bridging necrosisbridging necrosis panacinar/multiacinar necrosispanacinar/multiacinar necrosis periportal necrosisperiportal necrosis Hepatocytes Hepatocytes polymorphismpolymorphism balooning degenerationbalooning degeneration

37 Acute hepatitis Inflammation Inflammation polynuclear/mononuclear infiltrationpolynuclear/mononuclear infiltration activation of Kupfer’s cellsactivation of Kupfer’s cells Other changes Other changes cholestasischolestasis damage of bile ductsdamage of bile ducts Regeneration Regeneration

38 Fulminant hepatitis Gross finding - soft consistency Gross finding - soft consistency Microscopic finding – complete necrosis of parenchyma Microscopic finding – complete necrosis of parenchyma Course Course liver failure - coma - deathliver failure - coma - death regeneration – postnecrotic cirrhosisregeneration – postnecrotic cirrhosis

39 Acute hepatitis: HBV

40 Acute hepatitis

41

42

43 Acute hepatitis: regeneration

44 Fulminant hepatitis: HBV

45 Fulminant hepatitis: HBsAg, Orcein staining

46 Chronic hepatitis: etiology HBV, HBV+HDV, HCV HBV, HBV+HDV, HCV Autoimmune Autoimmune Drug induced Drug induced Wilson’s disease Wilson’s disease  1 anti-trypsin deficiency  1 anti-trypsin deficiency Cryptogenic Cryptogenic

47 Chronic hepatitis: clinical definition Clinical symptoms of hepatitis more than: 6 months 6 months 12 months in HCV 12 months in HCV

48 Chronic hepatitis: morphology Inflammation Inflammation portal portal periportalperiportal lobularlobular Necrosis/apoptosis Necrosis/apoptosis piecemalpiecemal bridgingbridging focalfocal Fibrosis Fibrosis Deposits (Cu, PAS globules,…) Deposits (Cu, PAS globules,…)

49 Chronic hepatitis - portal + steatosis, HCV

50 Chronic hepatitis: portal

51 Chronic hepatitis: periportal

52

53 Chronic hepatitis: HCV, transition into the cirrhosis

54 Autoimmune chronic hepatitis Females, young/middle age Females, young/middle age Autoantibodies – ANA, AMA Autoantibodies – ANA, AMA Autoimmune „overlap“ syndromes Autoimmune „overlap“ syndromes lupus erythematodeslupus erythematodes arthritisarthritis

55 Autoimmune chronic hepatitis - ANA

56 Autoimmune chronic hepatitis - AMA

57 NASH: non-alcoholic steatohepatitis Hepatomegaly Hepatomegaly Increase of aminotransferases Increase of aminotransferases Histological picture – similar to alcoholic hepatitis without alcohol consumption Histological picture – similar to alcoholic hepatitis without alcohol consumption macrovesicular steatosismacrovesicular steatosis lobular hepatitis and necrosislobular hepatitis and necrosis balooning of hepatocytesbalooning of hepatocytes fibrosisfibrosis

58 NASH: non-alcoholic steatohepatitis Epidemiologic signs of NASH Females Females Obesity Obesity DM of II type, hyperglycaemia DM of II type, hyperglycaemia

59 NASH: non-alcoholic steatohepatitis Diseases related to NASH Acquired metabolic diseases (obesity, DM, hyperlipidemia, parenteral nutrition) Acquired metabolic diseases (obesity, DM, hyperlipidemia, parenteral nutrition) Inherited metabolic diseases (Wilson’s disease, abetalipoproteinaemia, tyrosinaemia) Inherited metabolic diseases (Wilson’s disease, abetalipoproteinaemia, tyrosinaemia) Surgery (jejunoileal bypass, extensive resections of small intestine...) Surgery (jejunoileal bypass, extensive resections of small intestine...) Drugs, toxins (amiodarone, glucocorticoids, tamoxifen, synthetic estrogens…) Drugs, toxins (amiodarone, glucocorticoids, tamoxifen, synthetic estrogens…)

60 Toxic and drug induced liver damage Anorganic substances Anorganic substances Organic substances Organic substances Industrial and plant substances Industrial and plant substances Poisons/venoms Poisons/venoms Drugs Drugs Alcohol Alcohol

61 Toxic and drug induced liver damage: effect Expectable Expectable Non-expectable (idiosyncratic) Non-expectable (idiosyncratic)

62 Toxic and drug induced liver damage : forms Necrosis Necrosis Steatosis Steatosis macrovesicular (alcohol, corticoids)macrovesicular (alcohol, corticoids) microvesicular (tetracyklin, aspirine)microvesicular (tetracyklin, aspirine) Cholestasis (steroids-anabolic, contraceptives) Cholestasis (steroids-anabolic, contraceptives) Hepatitis mild (aspirin, synthetic penicilines) Hepatitis mild (aspirin, synthetic penicilines) Hepatitis serious (halotan) Hepatitis serious (halotan) Chronic periportal hepatitis (sulphonamides) Chronic periportal hepatitis (sulphonamides)

63 Toxic and drug induced liver damage : forms Granulomatous hepatitis (phenylbutazone) Granulomatous hepatitis (phenylbutazone) Vascular lesions (contraceptives, cytostatics) Vascular lesions (contraceptives, cytostatics) Hyperplasia, neoplasia (contraceptives) Hyperplasia, neoplasia (contraceptives)

64 Alcoholic Liver Disease (ALD) Steatosis (90%) Steatosis (90%) Fibrosis (perivenular, pericellular) Fibrosis (perivenular, pericellular) Steatofibrosis Steatofibrosis Alcoholic hepatitis Alcoholic hepatitis Alcoholic cirrhosis Alcoholic cirrhosis Mallory hyaline Mallory hyaline Cholestasis Cholestasis Siderosis Siderosis Hepatocellular carcinoma Hepatocellular carcinoma Dif.dg: NASH Dif.dg: NASH

65 Alcoholic Liver Disease (ALD) : steatosis

66

67 Alcoholic Liver Disease (ALD) : steatofibrosis

68 Alcoholic Liver Disease (ALD) : cholestasis

69 Alcoholic Liver Disease (ALD) : Mallory hyaline

70

71 Alcoholic Liver Disease (ALD) : steatohepatitis

72

73 Alcoholic Liver Disease (ALD) : steatohepatitis, cholestasis, Mallory hyaline

74 Metabolic liver disease Haemochromatosis Haemochromatosis Wilson’s disease Wilson’s disease  1 anti-trypsin deficiency  1 anti-trypsin deficiency Glycogenoses Glycogenoses

75 Haemochromatosis Excessive accumulation of iron in parenchymatous organs Excessive accumulation of iron in parenchymatous organs Primary (idiopatic), secondary Primary (idiopatic), secondary Cirrhosis, diabetes mellitus, pigmentation of skin Cirrhosis, diabetes mellitus, pigmentation of skin Dif.dg. of brown pigment within the liver Dif.dg. of brown pigment within the liver Fe (haemochromatosis)Fe (haemochromatosis) Cu (Wilson’s disease)Cu (Wilson’s disease) lipopigment (brown atrophy of liver, lipopigment dystrophy)lipopigment (brown atrophy of liver, lipopigment dystrophy)

76 Haemochromatosis

77

78

79 Brown atrophy of liver: dif.dg.

80 Wilson’s disease Hepatolenticular degeneration Hepatolenticular degeneration Low levels of ceruloplasmin Low levels of ceruloplasmin Increase of Cu in liver and urine Increase of Cu in liver and urine Morphology Morphology steatosissteatosis acute hepatitisacute hepatitis chronic hepatitischronic hepatitis glycogen nucleus (also typical in DM)glycogen nucleus (also typical in DM) increased amount of Cu pigmentincreased amount of Cu pigment

81 Wilson’s disease : Cu pigment

82 Wilson’s disease/DM: glycogen nucleus

83

84  1 anti-trypsin deficiency Low levels of  1AT (inhibitor of proteases) Low levels of  1AT (inhibitor of proteases) Emphysema of lungs Emphysema of lungs Liver changes (cholestasis, cirrhosis) Liver changes (cholestasis, cirrhosis) PAS positive acidophilic globular inclusions in the cytoplasmPAS positive acidophilic globular inclusions in the cytoplasm ELMI – complementary diagnosisELMI – complementary diagnosis

85 Circulatory disorders of the liver Disorders of arterial system Disorders of arterial system Disorders of portal system Disorders of portal system Disorders of venous system Disorders of venous system Disorders of lobular system Disorders of lobular system

86 Disorders of arterial system Infarct of the liver Rare Rare Thrombosis, compression, obliteration of a. hepatis branch (polyarteritis nodosa,…) Thrombosis, compression, obliteration of a. hepatis branch (polyarteritis nodosa,…) Pale Pale Dif.dg.: Dif.dg.: Zahn infarct (occlusion of intrahepatic branch of v. portae): no necrosis, local congestion of sinusoids and secondary atrophyZahn infarct (occlusion of intrahepatic branch of v. portae): no necrosis, local congestion of sinusoids and secondary atrophy

87 Liver infarct

88 Disorders of portal system Thrombosis and occlusion of v.portae Extrahepatal (phlebitis, pancreatitis, surgery, trauma) Extrahepatal (phlebitis, pancreatitis, surgery, trauma) Intrahepatal (invasion of tumor) Intrahepatal (invasion of tumor)

89 Thrombosis of v.portae

90 Disorders of venous system Thrombosis of hepatic veins (Budd-Chiari syndrome) Thrombosis of hepatic veins (Budd-Chiari syndrome) causes: polycytemia vera, pregnancy, contraceptives, intraabdominal malignant tumors, hepatocellular carcinomacauses: polycytemia vera, pregnancy, contraceptives, intraabdominal malignant tumors, hepatocellular carcinoma centrilobular necrosis and congestion, fibrosiscentrilobular necrosis and congestion, fibrosis Venoocclusive disorder Venoocclusive disorder complication of bone marrow transplantation (5-25%) – chemotherapy, radiotherapycomplication of bone marrow transplantation (5-25%) – chemotherapy, radiotherapy Bush-tea (pyrrolizidine alcaloids)Bush-tea (pyrrolizidine alcaloids) obliteration of hepatic veins – subendothelial accumulation of colagen and reticulin, perivenular fibrosis, perivenular hemosiderinobliteration of hepatic veins – subendothelial accumulation of colagen and reticulin, perivenular fibrosis, perivenular hemosiderin

91 Budd-Chiari

92 Disorders of lobular system Occlusion of sinuses Occlusion of sinuses eclampsyeclampsy Sickle cell anaemiaSickle cell anaemia Systemic circulation Systemic circulation passive congestionpassive congestion centrilobular necrosiscentrilobular necrosis nutmeg liver (venostasis/steatosis)nutmeg liver (venostasis/steatosis)

93 Congestion

94 Pathology of intrahepatal bile ducts Secondary biliary cirrhosis (SBC) Secondary biliary cirrhosis (SBC) Primary biliary cirrhosis (PBC) Primary biliary cirrhosis (PBC) Primary sclerosing cholangitis (PSC) Primary sclerosing cholangitis (PSC)

95 SBC Obstruction of extrahepatal bile ducts: atresia, lithiasis, tumor, iatrogenic Obstruction of extrahepatal bile ducts: atresia, lithiasis, tumor, iatrogenic Striking cholestasis Striking cholestasis

96 PBC Autoimmune (AMA), Autoimmune (AMA), Majority of females Majority of females Coincidency: Sjögren sy., arthritis, thyreoiditis, vasculitis,.. Coincidency: Sjögren sy., arthritis, thyreoiditis, vasculitis,.. Hepatomegaly, Hepatomegaly, 4 stages 4 stages I - granulomatous destruction of ductsI - granulomatous destruction of ducts II - ductular proliferation and periportal hepatitisII - ductular proliferation and periportal hepatitis III - scarring, necrosis, septal fibrosisIII - scarring, necrosis, septal fibrosis IV - cirrhosisIV - cirrhosis

97 PSC Autoimmune (ANA) Autoimmune (ANA) Inflammation and obliterative fibrosis of bile ducts Inflammation and obliterative fibrosis of bile ducts Coincidency: IBD (Inflammatory Bowel Disease – ulcerative colitis, m.Crohn) Coincidency: IBD (Inflammatory Bowel Disease – ulcerative colitis, m.Crohn)

98 PBC: I.stage

99

100 PBC: II.stage

101 PBC: III.stage

102 Patology of liver during pregnancy Preeclampsy/eclampsy Preeclampsy/eclampsy HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low PlateletsHELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets fibrin within the sinusoidsfibrin within the sinusoids hematomas (fatal rupture of liver)hematomas (fatal rupture of liver) Acute microvesicular steatosis during pregnacy (third trimester) Acute microvesicular steatosis during pregnacy (third trimester) Cholestasis during pregnancy (third trimester) Cholestasis during pregnancy (third trimester)

103 Transplantation Liver disorders related to bone marrow transplantation Liver disorders related to bone marrow transplantation Liver disorders related to liver transplantation Liver disorders related to liver transplantation

104 Liver disorders related to bone marrow transplantation TimeCause Before transplantation Viral hepatitis Tumor infiltration Day 0-25 Drug related damage Venoocclusive disease Day Acute GVHD (destruction of bile ducts, endothelitis, necrosis of hepatocytes) Opportune infections Day 100- Chronic GVHD (involvement of portal tracts, destruction of bile ducts, endothelitis) Viral hepatitis Fulminant hepatitis („rebound“ phenomenona)

105 Liver disorders related to liver transplantation TimeCause 1. week Acute rejection (necrosis, inflammation) Technical complication (vascular anastomoses…) Non-functionality (primary) 2. week-2. month Opportune infections Acute rejection Drug related damage 2. month - Chronic vascular rejection (vasculitis) Vanishing bile ducts syndrome Viral hepatitis

106 Tumors of liver Tumor-like lesion Tumor-like lesion Benign tumors Benign tumors Malignant tumor Malignant tumor

107 Tumor-like lesions Focal nodular hyperplasia Focal nodular hyperplasia Nodular regeneratory hyperplasia (lack of fibrosis) Nodular regeneratory hyperplasia (lack of fibrosis) Cysts Cysts Hamartoma (von Meyenburg complex) Hamartoma (von Meyenburg complex) Inflammatory pseudotumor Inflammatory pseudotumor

108 Nodular regeneratory hyperplasia

109 Benign tumors Adenoma Adenoma hepatocellular (lack of portal tracts!)hepatocellular (lack of portal tracts!) cholangiogenic (lack of bile production, less than 1cm, subcapsular)cholangiogenic (lack of bile production, less than 1cm, subcapsular) Haemangioma Haemangioma subcapsularsubcapsular cavernouscavernous bleeding risk during punction!bleeding risk during punction!

110 Cavernous haemangioma

111 Malignant tumors Hepatocellular carcinoma (HCC) Hepatocellular carcinoma (HCC) subvariant – fibrolamelar carcinomasubvariant – fibrolamelar carcinoma Cholangiogenic carcinoma (lack of bile production) Cholangiogenic carcinoma (lack of bile production) peripherialperipherial extrahepatal -Klatskin tumorextrahepatal -Klatskin tumor Hepatoblastoma (embryonal, teratoid,…) Hepatoblastoma (embryonal, teratoid,…) Angiosarcoma, malignant haemangioendothelioma Angiosarcoma, malignant haemangioendothelioma Metastases (most often) Metastases (most often) GIT, lung, kidneyGIT, lung, kidney

112 HCC

113 HCC

114 HCC

115 HCC

116 Cholangiogenic carcinoma

117 Biliary system: cholelithiasis 10-20% of population 10-20% of population Cholesterol concrements (females, obesity, steroids, hyperlipidemia) Cholesterol concrements (females, obesity, steroids, hyperlipidemia) Pigmented/bilirubine concrements (biliary infection, haemolysis) Pigmented/bilirubine concrements (biliary infection, haemolysis) Blockage of bile ducts (acute cholangoitis, sepsis, biliary cirrhosis, pancreatitis) Blockage of bile ducts (acute cholangoitis, sepsis, biliary cirrhosis, pancreatitis) Irritation of gallbladder (cholecystitis, carcinoma) Irritation of gallbladder (cholecystitis, carcinoma) Valve-like blockage (hydrops) Valve-like blockage (hydrops) Perforation, fistula Perforation, fistula

118 Cholecystolithiasis

119

120 Cholecystitis Acute Acute empyema of gallbladderempyema of gallbladder gangrenous cholecystitisgangrenous cholecystitis acalculous cholecystitis (postoperative, trauma, burns, sepsis,…)acalculous cholecystitis (postoperative, trauma, burns, sepsis,…) Chronic Chronic fibroproduction (thickening of the wall, adhesion)fibroproduction (thickening of the wall, adhesion) chronic inflammmationchronic inflammmation dystrophic calcification (risk of carcinoma development)dystrophic calcification (risk of carcinoma development) hydropshydrops

121 Chronic cholecystitis

122 Carcinoma of gallbladder Adenocarcinoma Infiltrating Infiltrating Exophytic Exophytic Early invasion into the liver – poor prognosis! Early invasion into the liver – poor prognosis!

123 Carcinoma of gallbladder

124 Other disorders of biliary system Atresia of bile ducts (rapid progression, uncelar etiopathogenesis, cirrhosis) Atresia of bile ducts (rapid progression, uncelar etiopathogenesis, cirrhosis) Cholesterolosis (strawberry gallbladder) Cholesterolosis (strawberry gallbladder) Choledocholithiasis (risk of ascendent cholangoitis, intrahepatic abscess and sepsis, risk of biliary cirrhosis) Choledocholithiasis (risk of ascendent cholangoitis, intrahepatic abscess and sepsis, risk of biliary cirrhosis) Tumors of papilla Vateri (ampuloma, periampular carcinoma – difficult diagnosis) Tumors of papilla Vateri (ampuloma, periampular carcinoma – difficult diagnosis)

125 Exocrine pancreas: acute pancreatitis Causes Causes cholelithiasis, alcohol, surgery, trauma,cholelithiasis, alcohol, surgery, trauma, idiopathicidiopathic Most serious form Most serious form acute haemorrhagic necrotizing pancreatitisacute haemorrhagic necrotizing pancreatitis Morphology Morphology nekrosis of pancreasnekrosis of pancreas nekrosis of fat tissue (steatocytonecrosis, Balzer’s necrosis)nekrosis of fat tissue (steatocytonecrosis, Balzer’s necrosis) haemorrhagyhaemorrhagy Complication, healing Complication, healing abscessesabscesses pseudocystspseudocysts duodenal obstructionduodenal obstruction multiorgan failuremultiorgan failure

126 Pancreatonecrosis

127

128 Steatocytonecrosis: omentum

129

130 Exocrine pancreas: chronic pancreatitis Causes Causes alcohol, hyperlipidemia, hypercalcemia, hereditaryalcohol, hyperlipidemia, hypercalcemia, hereditary Morphology Morphology fibrosisfibrosis reduction of acinesreduction of acines obstruction of ductsobstruction of ducts chronic inflammatory infiltration (lymphocytes, plasmocytes)chronic inflammatory infiltration (lymphocytes, plasmocytes) Complications Complications calcifications, pseudocysts, thrombosis v. lienaliscalcifications, pseudocysts, thrombosis v. lienalis diabetesdiabetes steatorrheasteatorrhea jaundicejaundice

131 Chronic pancreatitis

132 Exocrine pancreas: tumors Cystic tumors (5%) Cystic tumors (5%) mucinous cystadenomamucinous cystadenoma mucinous cystadenocarcinomamucinous cystadenocarcinoma Carcinoma of pancreas Carcinoma of pancreas Adenocarcinoma, various degree of differentiationAdenocarcinoma, various degree of differentiation Head (early diagnosis - jaundice), body, tail (difficult diagnosis, late detection)Head (early diagnosis - jaundice), body, tail (difficult diagnosis, late detection) Often - fibroproduction (dif.dg. chron.pancreatitis)Often - fibroproduction (dif.dg. chron.pancreatitis) Trosseau syndrome – migratory thrombophlebitis in 10%Trosseau syndrome – migratory thrombophlebitis in 10%

133 Carcinoma of pancreas

134

135


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