1. Liver and pancreas SYLLABUS: RBP(Robbins Basic Pathology) Chapters: The Liver and the Biliary Tract The Pancreas

2. Liver and pancreas 182aChronic cholecystitis 228Gall bladder carcinoma 249Metastatic carcinoma of the liver (small cell carcinoma) 230Metastatic carcinoma of the liver (mucinous carcinoma) 254Chronic hepatitis 253Liver cirrhosis (H&A, Masson) 252 Miliary tuberculosis (liver) 250Hepatocarcinoma 250a Cholangiocarcinoma 246Acute pancreatitis

3. Liver and pancreas 3 Acute hepatic congestion 5 Chronic passive congestion of the liver 17 Liver steatosis (H&E) 18 Liver steatosis (Sudan III) 43Balser necrosis (enzymatic fat necrosis) 186 Insuloma flashback

4. Acute hepatic congestion flashback

5. Chronic passive congestion of the liver flashback

6. Liver steatosis (H&E) flashback

7. Liver steatosis (Sudan III) flashback

8. Chronic hepatitis Chronic persistent hepatitis (CPH) pattern: - lymphocyte-predominant inflammation without: - loss of hepatocytes immediately surrounding the portal region ("piecemeal necrosis") - more than slight fibrosis Chronic active hepatitis (CAH) pattern: - portal lymphocyte-predominant inflammation - piecemeal necrosis - inflammation extending outward beyond limiting plate of portal triad to involve periportal hepatocytes - some hepatocytes are simply entrapped by inflammation while others drop out (liquefaction necrosis) - acidophil cells (apoptotic) possible - eventually: bridging fibrosis and/or cirrhosis

9. Chronic hepatitis

12. Liver cirrhosis - bridging fibrous septae in the form of delicate bands or broad scars linking portal tracts with one another and portal tracts with terminal hepatic veins - parenchymal nodules containing proliferating hepatocytes encircled by fibrosis, with diameters varying from very small (<3 mm, micronodules) to large (several centimeters, macronodules) - disruption of the architecture of the entire liver Active cirrhosis: - piecemeal necrosis - extra-portal inflammation Specific cause can sometimes be determined, (eg for viral infection, hemochromatosis, Wilson's disease, alpha-1- antitrypsin deficiency, and alcohol, if alcoholic hepatitis present)

13. Liver cirrhosis

14. Liver cirrhosis (Masson stain)

15. Liver cirrhosis

16. Hepatocarcinoma - range of appearances from hepatocytes with little atypia forming sinusoidal, trabecular, or possibly tubular structures (well-differentiated)... -... to highly atypical hepatocytes in sheets (poorly differentiated) - complete loss of bile ducts and Kupffer cells - little sclerosis

17. Hepatocarcinoma

19. Cholangiocarcinoma - glands with cuboidal to columnar atypical and pleomorphic cells - typical perineural and periductal growth pattern - often desmoplastic stroma - may contain signet cells

20. Cholangiocarcinoma

22. Metastatic carcinoma of the liver microscopic features depend on the type of the primary tumor: eg: - small cell carinoma (lung) - mucinous carcinoma (GI)

23. Metastatic carcinoma of the liver (small cell carcinoma)

25. Metastatic carcinoma of the liver (mucinous carcinoma)

27. Miliary tuberculosis (liver) numerous small TB granulomas

28. Miliary tuberculosis (liver)

30. Chronic cholecystitis (some use this diagnosis whenever gallstones are identified, whether chronic inflammation is seen or not, others require chronic inflammation) - chronic inflammatory infiltration features - Rokitansky's-Aschoff sinuses (diverticula with increased smooth muscle, related to chronic increase in lumenal pressure) usually present and may have associated bile granulomas - possibly endarteritis obliterans - „follicular cholecystitis”: same lesion with germinal centers in wall of gallbladder

31. Chronic cholecystitis

33. Gall bladder carcinoma - neoplastic glands lined by highly atypical cuboidal cells - desmoplastic stroma often forms concentric surrounding fibrosis

34. Gall bladder carcinoma

36. Acute pancreatitis Depending on the phase and severity: - acute inflammation - edema - fat necrosis - small vessel thrombosis - necrosis of acini - hemorrhages - extensive necrosis of both fat and parenchyma

37. Acute pancreatitis

39. Balser necrosis (enzymatic fat necrosis) flashback

40. Insuloma flashback