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DISEASES OF LIVER Assistant of professor Nechiporenko G.V.

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Presentation on theme: "DISEASES OF LIVER Assistant of professor Nechiporenko G.V."— Presentation transcript:

1 DISEASES OF LIVER Assistant of professor Nechiporenko G.V.

2 The Major Causes of Liver Diseases Injury from metabolic disturbances Injury from metabolic disturbances Injury from toxins and poisons Injury from toxins and poisons Lesions of the biliary tract Lesions of the biliary tract Certain virus infections Certain virus infections Hypoxia Hypoxia Starvation Starvation Late pregnancy Late pregnancy Diabetes mellitus Diabetes mellitus

3 Fatty Change in Liver

4 Hepatic fatty change. The lipids accumulate in the hepatocytes as vacuoles. These vacuoles have a clear appearance with H&E staining.

5 Steatosis of Liver ( with Sudan III). Steatosis of Liver ( with Sudan III).

6 Toxic Dystrophy of Liver 1-centrolobular necrosis of hepatocytes 1-centrolobular necrosis of hepatocytes 2-peripheral fatty change of hepatocytes 2-peripheral fatty change of hepatocytes

7 Toxic Dystrophy of Liver (with Sudan III). Toxic Dystrophy of Liver (with Sudan III).

8 V I R A L H E P A T I T I S Hepatitis A virus (HAV), causing a fecally-spread self-limiting disease; Hepatitis A virus (HAV), causing a fecally-spread self-limiting disease; Hepatitis B virus (HBV), causing a parenterally transmitted disease that may become chronic; Hepatitis B virus (HBV), causing a parenterally transmitted disease that may become chronic; Hepatitis C virus (HCV), causing chiefly transfusion-related disease; Hepatitis C virus (HCV), causing chiefly transfusion-related disease; Hepatitis D virus (HDV) is associated as superinfection with hepatitis B virus; Hepatitis D virus (HDV) is associated as superinfection with hepatitis B virus; Hepatitis E virus (HEV), causing water-borne infection; Hepatitis E virus (HEV), causing water-borne infection; Hepatitis G virus (HGV), has recently been discovered. Hepatitis G virus (HGV), has recently been discovered.

9 The pathological changes in the liver in acute viral hepatitis. The liver is slightly enlarged and bile stained. The liver is slightly enlarged and bile stained. Hydropic (ballooning) swelling of the hepatocytes. Hydropic (ballooning) swelling of the hepatocytes. Centri- zonal and focal necrosis of the hepatocytes with formation of Councilman bodies. Centri- zonal and focal necrosis of the hepatocytes with formation of Councilman bodies. Necrotic areas and bile tracts infiltrated by lymphocytes, macrophages, eosinophils and plasma cells. Necrotic areas and bile tracts infiltrated by lymphocytes, macrophages, eosinophils and plasma cells. Cholestasis in hepatocytes and bile canaliculi. Cholestasis in hepatocytes and bile canaliculi. Kupffer cells show hyperplasia, hypertrophy and phagocytosis. Kupffer cells show hyperplasia, hypertrophy and phagocytosis. Intact reticulum frame work. Intact reticulum frame work. Regenerating liver cells. Regenerating liver cells.

10 Liver, acute viral B hepatitis Liver, acute viral B hepatitis A cellular infiltrate throughout the hepatic lobule obscures the normal- appearing hepatic architecture. A cellular infiltrate throughout the hepatic lobule obscures the normal- appearing hepatic architecture.

11 Liver, acute viral B hepatitis Councilman, or acidophilic, bodies are individually necrotic or apoptotic hepatocytes. They appear as small cells with eosinophilic cytoplasm and, at times, a dark, degenerative, pyknotic nucleus. Councilman, or acidophilic, bodies are individually necrotic or apoptotic hepatocytes. They appear as small cells with eosinophilic cytoplasm and, at times, a dark, degenerative, pyknotic nucleus.

12 Fulminant hepatitis Grossly, there are pale yellow areas of necrosis and collapse of liver lobules.

13 Liver, fulminant hepatitis There is massive necrosis of hepatocytes throughout the lobules in fulminant hepatitis. There is massive necrosis of hepatocytes throughout the lobules in fulminant hepatitis.

14 V iral hepatitis C with prominent necrosis, inflammation and some steatosis.

15 Chronic Viral Hepatitis It develops predominantly in HVC and HVB cases with progression to cirrhosis. It develops predominantly in HVC and HVB cases with progression to cirrhosis. 1.Chronic persistant hepatitis 1.Chronic persistant hepatitis 2.Chronic active (agressive) hepatitis 2.Chronic active (agressive) hepatitis 3.Chronic lobular hepatitis 3.Chronic lobular hepatitis

16 Liver, chronic persistant viral B hepatitis A chronic inflammatory infiltrate is limited to the portal area. It does not extend into the adjacent lobule. A chronic inflammatory infiltrate is limited to the portal area. It does not extend into the adjacent lobule.

17 Liver, chronic agressive viral B hepatitis There is a chronic inflammatory infiltrate in the portal areas of the liver that extends beyond the portal area into the adjacent lobule, where it encircles hepatocytes, many of which are undergoing degeneration and necrosis. There is a chronic inflammatory infiltrate in the portal areas of the liver that extends beyond the portal area into the adjacent lobule, where it encircles hepatocytes, many of which are undergoing degeneration and necrosis.

18 Liver, viral B hepatitis This is an immunohistoche mical stain for HBsAg in a section of liver. The "ground- glass" hepatocytes, which are laden with HBsAg, stain dark red. This is an immunohistoche mical stain for HBsAg in a section of liver. The "ground- glass" hepatocytes, which are laden with HBsAg, stain dark red.

19 Chronic Active C Hepatitis of Liver The portal-based inflammatory infiltrate develops. Enough hepatocytes have been lost and replaced by fibrous connective tissue so that the pattern of bridging necrosis with fibrosis is evident. The portal-based inflammatory infiltrate develops. Enough hepatocytes have been lost and replaced by fibrous connective tissue so that the pattern of bridging necrosis with fibrosis is evident.

20 Chronic Active C Hepatitis of Liver This is the same area shown in the previous image, stained to highlight collagen fibrosis (blue) This is the same area shown in the previous image, stained to highlight collagen fibrosis (blue)

21 CAUSES of CIRRHOSIS Alcoholism Alcoholism Viral hepatitis (HBV,HCV,HDV) Viral hepatitis (HBV,HCV,HDV) Hereditary metabolic diseases (Alpha-1 - antitrypsin deficiency, Wilson's disease, Hemochromatosis) Hereditary metabolic diseases (Alpha-1 - antitrypsin deficiency, Wilson's disease, Hemochromatosis) Drugs and toxins Drugs and toxins Biliary disease (primary biliary cirrhosis, primary sclerosing cholangitis, cholelithiasis and bacterial cholangitis) Biliary disease (primary biliary cirrhosis, primary sclerosing cholangitis, cholelithiasis and bacterial cholangitis) Parasites (schistostoma, clonorchis) Parasites (schistostoma, clonorchis) Venous outflow obstruction ( Budd-Chiari syndrome, veno-occlusive disease) Venous outflow obstruction ( Budd-Chiari syndrome, veno-occlusive disease) Idiopathic (15-20%) Idiopathic (15-20%)

22 ETIOLOGICAL TYPES of LIVER'S CIRRHOSIS Postinfectious (viral hepatitis, syphilis) Postinfectious (viral hepatitis, syphilis) Toxic and Toxic-Allergic (alcohol, poisons, drugs) Toxic and Toxic-Allergic (alcohol, poisons, drugs) Biliary (cholangitis, cholestasis) Biliary (cholangitis, cholestasis) Metabolic and Alimentary (deficiency of proteins, vitamines, lipotropic factors) Metabolic and Alimentary (deficiency of proteins, vitamines, lipotropic factors) Circulatory (chronic congestion in the liver) Circulatory (chronic congestion in the liver) Cryptogenic Cryptogenic

23 PATHOGENIC TYPES of LIVER'S CIRRHOSIS 1. Postnecrotic (macronodular) 2. Portal or Septal (micronodular or mixed) 3. Biliary (primary and secondary) According to the size of the regenerating nodules cirrhosis is classified into: According to the size of the regenerating nodules cirrhosis is classified into: -Micronodular cirrhosis: Nodules l-3mm in diameter. -Micronodular cirrhosis: Nodules l-3mm in diameter. -Macronodular cirrhosis: Nodules from 3mm to several cm. -Macronodular cirrhosis: Nodules from 3mm to several cm. -Mixed micro-macronodular cirrhosis. -Mixed micro-macronodular cirrhosis.

24 MORPHOLOGICAL CHANGES of the LIVER'S TISSUE in CIRRHOSIS Degeneration and necrosis of hepatocytes Degeneration and necrosis of hepatocytes Nodular regeneration of hepatocytes Nodular regeneration of hepatocytes Diffuse sclerosis Diffuse sclerosis Diffuse restoration of lobular and vascular structure of the liver Diffuse restoration of lobular and vascular structure of the liver Deformation of the liver Deformation of the liver

25 Macronodular Cirrhosis of Liver The nodules are larger than 3 mm Macronodular Cirrhosis of Liver The nodules are larger than 3 mm

26 Macronodular cirrhosis Viral hepatitis (B or C) is the most common cause for macronodular cirrhosis

27 Liver, postnecrotic cirrhosis The regenerating liver cells are separated by depressed scar tissue, grey bands of fibrosis. The regenerating liver cells are separated by depressed scar tissue, grey bands of fibrosis.

28 Micronodular cirrhosis The regenerative nodules are quite small, averaging less than 3 mm in size.

29 Micronodular Cirrhosis of Liver The regenerative nodules of hepatocytes are surrounded by fibrous connective tissue that bridges between portal tracts. Within this collagenous tissue are scattered lymphocytes as well as a proliferation of bile ducts.

30 Posthepatitic Cirrhosis of Liver, trichrome stain Note the blue-stained dense collagen fibrosis.

31 Cardiac cirrhosis

32 Primary biliary cirrhosis

33 Primary biliary cirrhosis, a rare autoimmune disease (mostly of middle-aged women) that is characterized by destruction of bile ductules within the triads of the liver. Seen here in a portal tract is an intense chronic inflammatory infiltrate with loss of bile ductules.

34 Liver, primary biliary cirrhosis The chronic inflammation in the portal areas is associated with bile duct destruction by the inflammatory infiltrate. These are the hallmarks of the florid duct lesions in primary biliary cirrhosis. The chronic inflammation in the portal areas is associated with bile duct destruction by the inflammatory infiltrate. These are the hallmarks of the florid duct lesions in primary biliary cirrhosis.

35 Liver, secondary biliary cirrhosis The cut surface is dark green, due to marked cholestasis within the liver. Regenerative nodules of liver parenchyma are separated by tan bands of fibrous tissue. The cut surface is dark green, due to marked cholestasis within the liver. Regenerative nodules of liver parenchyma are separated by tan bands of fibrous tissue.

36 Secondary micrinodular biliary cirrhosis after congenital atresia of the biliary tract, cholestasis

37 Biliary atresia Biliary atresia, a common cause of neonatal cholestasis, results from progressive destruction of the hepatic and common bile ducts. This leads to the development of cirrhosis in the first year of life. It is the most common cause of referral for liver transplantation in children. Biliary atresia, a common cause of neonatal cholestasis, results from progressive destruction of the hepatic and common bile ducts. This leads to the development of cirrhosis in the first year of life. It is the most common cause of referral for liver transplantation in children.

38 The gross picture of the liver in different types of cirrhosis NUTRITIONAL POST- HEPATITIC POST- NECROTIC BILIARY Size:DecreasedDecreasedDecreasedIncreased Color:YellowYellowYellowGreen Regener ative nodules: 2-3mm10-15mml-6cm2-5mm Normal areas: AbsentAbsentPresentAbsent

39 The Effects of Cirrhosis: 1. Portal hypertension. 1. Portal hypertension. It is caused by obstruction to the blood flow through the liver, pressure of the regeneration nodules on the hepatic veins; development of anastomosis between the branches of the hepatic artery and portal vein. The higher arterial pressure is transmitted to the portal veins. It is caused by obstruction to the blood flow through the liver, pressure of the regeneration nodules on the hepatic veins; development of anastomosis between the branches of the hepatic artery and portal vein. The higher arterial pressure is transmitted to the portal veins.

40 Portal hypertension leads to the following effects: Chronic venous congestion in the portal area. Chronic venous congestion in the portal area. Splenomegaly. Splenomegaly. Ascites. Ascites. Varices of the anastomotic veins between the portal and systemic circulations: Varices of the anastomotic veins between the portal and systemic circulations: - At the lower end of the esophagus i.e. esophageal varices. - At the lower end of the esophagus i.e. esophageal varices. - At the lower end of the rectum i.e. piles. - At the lower end of the rectum i.e. piles. - Around the umbilicus i.e. “caput medusae”. - Around the umbilicus i.e. “caput medusae”.

41 2. Ascites: Occurs lately and is caused by: Portal hypertension. Portal hypertension. Hypoproteinemia. Hypoproteinemia. Sodium and water retention due to hyperaldosteronism. Sodium and water retention due to hyperaldosteronism. 3. Hypersplenism: 3. Hypersplenism: Causes anemia, leucopenia and thrombocytopenia. Causes anemia, leucopenia and thrombocytopenia.

42 4. Pathological Effects of Disturbed Hepatic Function Hepatocellular failure Hepatocellular failure It results from loss of a large number of liver cells from various causes and/or from impaired their function, especially in hepatic cirrhosis. It results from loss of a large number of liver cells from various causes and/or from impaired their function, especially in hepatic cirrhosis. A) changes in nitrogen metabolism causing hepatic encephalopathy B) failure to remove bilirubin from the blood, to conjugate it and excrete it in the bile

43 C) failure to produce plasma proteins in normal amounts, particulary, albumin, fibrinogen, prothrombin and other clotting factors, hypoproteinemia D) diminished vitamin A formation E) circulatory disturbances with cyanosis and hypervolemic circulation F) Hormonal disturbances with hepatic metabolism of steroids

44 Decrease estrogen inactivation by the liver results in: Decrease estrogen inactivation by the liver results in: Gynecomastia: enlargement of the male breast. Gynecomastia: enlargement of the male breast. Atrophy of the testis. Atrophy of the testis. Palmer erythema. Palmer erythema. Decrease pubic and axillary hair. Decrease pubic and axillary hair. Arterial spider: dilated vessels on the face, neck and arms. Arterial spider: dilated vessels on the face, neck and arms. 5. Malignancy especially in macronodular cirrhosis. 5. Malignancy especially in macronodular cirrhosis.

45 “Caput medusae"

46 S plenomegaly

47 Esophageal varices have appeared here as a result of portal hypertension from cirrhosis of the liver

48 Hepatocellular carcinoma

49

50 Liver, alcoholic hepatic steatosis (fatty liver) Liver, alcoholic hepatic steatosis (fatty liver)

51 Liver, alcoholic hepatic steatosis (fatty liver) In alcoholic fatty liver, lipid accumulates within the cytoplasm of hepatocytes, creating large clear vacuoles within cells. The nuclei in such cells are compressed to the periphery of the cell. In alcoholic fatty liver, lipid accumulates within the cytoplasm of hepatocytes, creating large clear vacuoles within cells. The nuclei in such cells are compressed to the periphery of the cell.

52 Liver, alcoholic hepatitis Hepatic steatosis is noted, especially in centrilobular regions, in this case of alcoholic hepatitis. There is both a chronic and an acute inflammatory infiltrate within hepatic lobules. Sinusoidal, perivenular, and portal fibrosis shows up as blue-stained areas. Hepatic steatosis is noted, especially in centrilobular regions, in this case of alcoholic hepatitis. There is both a chronic and an acute inflammatory infiltrate within hepatic lobules. Sinusoidal, perivenular, and portal fibrosis shows up as blue-stained areas.

53 .This is Mallory's hyaline, also known as "alcoholic" hyaline. The globules are aggregates of intermediate filaments in the cytoplasm resulting from hepatocyte injury.

54 Liver, alcoholic cirrhosis This liver contains numerous, fairly uniform, small nodules of regenerative hepatocytes separated by depressed areas of fibrous scar tissue. This liver contains numerous, fairly uniform, small nodules of regenerative hepatocytes separated by depressed areas of fibrous scar tissue.

55 Liver, alcoholic cirrhosis. In a cut section, the uniform small nodules of regenerating hepatocytes are more obvious.

56 Liver, alcoholic cirrhosis Nodules of regenerating hepatocytes consist of disordered cords of cells of irregular thickness, many of which are two or more cell layers thick. Note the lack of central veins in these regenerative nodules. The nodules are surrounded by fibrous tissue containing variable amounts of chronic inflammatory cells and areas of bile ductular proliferation. Nodules of regenerating hepatocytes consist of disordered cords of cells of irregular thickness, many of which are two or more cell layers thick. Note the lack of central veins in these regenerative nodules. The nodules are surrounded by fibrous tissue containing variable amounts of chronic inflammatory cells and areas of bile ductular proliferation.

57 Alcoholic cirrhosis and intraintestinal bleeding


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