Pathology of Non-Neoplastic Liver Disease

Positive hepatitis B surface antigen is the correct answer. The patient had jaundice in the past indicative of hepatitis and now has reactivation. The pattern rules out Hepatitis A. No risk factors for hepatitis C is given, and the biopsy histologic appearance is more consistent with Hepatitis B.

A 44-year-old man, an emergency medical technician, has felt fatigued for the past 4 months. He experienced an episode of jaundice 10 years ago, which spontaneously resolved. On physical examination there are no remarkable findings. Laboratory studies show: haemoglobin-14 g/dl, normal serum electrolytes, total protein 5.4 g/dl, albumin 2.9 g/dl, ALT 132 U/L, AST 113 U/L, total bilirubin 1.3 mg/dl and direct bilirubin 0.8 mg/dl. A liver biopsy is performed with histologic findings of ground-glass hepatocytes containing large, pale, finely granular cytoplasmic inclusions (attached image). Which of the following laboratory test findings would be most characteristic for his disease? pathology_of_nonneoplastic_liver_1.png Elevated serum ferritin Decreased serum ceruloplasmin Decreased serum alpha-1-antitrypsin Positive antimitochondrial antibody Positive hepatitis B surface antigen

Right-sided heart failure is the correct answer. These are findings of passive congestion of the liver, which can follow from right-sided heart failure as a consequence of lung disease, in her case most likely emphysema.

Question 10 1 / 1 pts A 63-year-old woman has a 70-pack-year history of smoking. She also has a 15-year history of chronic arthritis for which she has used analgesics. She dies from pneumonia. At autopsy her liver is slightly enlarged and grossly shows a "nutmeg" pattern on sectioning (attached image). On microscopic examination there is centrilobular congestion and necrosis, but no inflammation or fibrosis. Which of the following is the most likely cause of her hepatic pathologic findings? pathology_of_nonneoplastic_liver_10.png Uncontrolled diabetes mellitus Chronic hepatitis C Right-sided heart failure Acetaminophen ingestion Alpha-1-antritrypsin deficiency

Corneal Kayser-Fleischer rings The patient has Wilson's disease with decreased serum ceruloplasmin. The disease is characterized by Kayser-Fleischer rings.

Question 2 1 / 1 pts A 22-year-old woman with progressive malaise for the past year has become increasingly lethargic over the past week. On physical examination she is afebrile. Laboratory studies show: plasma ammonia-55 mmol/l, serum total bilirubin of 5.8 mg/dl, direct bilirubin 4.6 mg/dl, AST 110 U/L, ALT 135 U/L, serum ceruloplasmin is 12 mg/dl (low) and antimitochondrial antibody test is negative. Which of the following ocular findings is most likely to be present in this woman? Proliferative retinopathy Group of answer choices Bilateral papilledema Corneal Kayser-Fleischer rings Macular degeneration Crystalline lens cataract formation

Extensive necrosis is the correct answer. The patient has acetaminophen induced liver injury which is characterized by extensive hepatic necrosis.

Question 3 1 / 1 pts A 28-year-old woman with recent onset of a major depressive disorder ingests an entire bottle (100 capsules, 500 mg each) of a medication containing acetaminophen. She becomes progressively obtunded over the next 8 hours and jaundiced over the next three (3) days. Which of the following microscopic findings (as shown in the image) is most likely to be present in her liver 3 days following the ingestion? pathology_of_nonneoplastic_liver_3.jpg Portal chronic inflammation Steatosis Normal histology Intracanalicular cholestasis Extensive necrosis

Start regular phlebotomy is the correct answer. The patient has features of Hemochromatosis which is treated by regular phlebotomy.

Question 4 1 / 1 pts A 60-year-old postmenopausal woman on estrogen therapy presents to her family physician after development over the last five (5) months of worsening swelling of the feet; increasing breathlessness at night; and painful joints. Her skin has become tanned in the last 2 years without sun exposure. On physical examination there is no joint deformity. There is 2+ pitting edema up to the knees and crackles are heard in the lung bases on auscultation. A chest radiograph shows bilateral pleural effusions, pulmonary edema and cardiomegaly. Laboratory findings include a serum glucose of 196 mg/dl, creatinine 1.7 mg/dl, ferritin 9079 ng/ml, AST 25 U/L, ALT 38 U/L, alkaline phosphatase 49 U/L, total bilirubin 1.2 mg/dl, total protein 5.9 g/dl and albumin 3.3 g/dl. Which of the following therapeutic approaches is most appropriate for this patient? Stop estrogen therapy Give interferon therapy Thoracentesis Start regular phlebotomy Begin corticosteroid therapy

Stellate cell is the correct answer. Stellate cells (formerly Ito cells) may transform into myofibroblasts secreting collagen when hepatocytes are injured and elaborate free radicals and cytokines. This process takes years, but is potentially reversible to some degree if the injurious stimulus is removed. If sufficient functioning hepatic parenchyma remains, the cirrhosis may be well-compensated. The remaining cells listed do not produce collagen. The normal space of Disse contains only a small amount of type IV collagen.

Question 5 1 / 1 pts A pathologic study of hepatic cirrhosis is performed. There is collapse of reticulin with bridging fibrosis from deposition of collagen in the space of Disse to form fibrous septae. Which of the following cell types is activated under the influence of cytokines to give rise to collagen-producing cells? Stellate cell Endothelial cell Bile duct cell Hepatocyte Macrophage

Concentric "onion-skin" ductular fibrosis is the correct answer. The major targets in primary sclerosing cholangitis are intrahepatic bile ducts, and ulcerative colitis coexists in 70% of cases. Ducts undergo a destructive cholangitis that leads eventually to periductal fibrosis and cholestatic jaundice. Eventually, cirrhosis and liver failure can occur.

Question 6 1 / 1 pts A 43-year-old man has experienced progressive fatigue, pruritus, and icterus for 4 months. A colectomy was performed 5 years ago for treatment of ulcerative colitis. On physical examination, he now has generalized jaundice. The abdomen is not distended; on palpation, there is no abdominal pain and there are no masses. Laboratory studies show a serum alkaline phosphatase level of 285 U/L and an elevated titer of anti neutrophil cytoplasmic antibodies. Cholangiography shows widespread intrahepatic biliary tree obliteration and a beaded appearance in the remaining ducts. Which of the following morphologic features is most likely to be present in his liver? Portal bridging fibrosis Granulomatous bile duct destruction Concentric "onion-skin" ductular fibrosis Interface hepatitis Periportal PAS-positive globules Copper deposition in hepatocytes

Alcoholic hepatitis is the correct answer. The histologic and serologic findings are in keeping with alcoholic liver disease. The patient may have had some NAFLD as well given AST greater than 500. The AST:ALT ratio is more in keeping with alcoholic liver disease although AST is above 500.

Question 7 1 / 1 pts A 41-year-old man is presented to the Medical Emergency Department in a semi-comatose state. On admission, he is found to be icteric with a BMI of 30. His abdomen is distended and a fluid wave is demonstrated. Abdominal CT scan shows a massive peritoneal effusion and a uniformly enlarged liver that has decreased attenuation (decreased brightness). Laboratory studies show total protein 6.5 g/dl, albumin 2.8 g/dl, total bilirubin 4.8 mg/dl, AST 563 U/L, ALT 317 U/L, alkaline phosphatase 55 U/L, and ammonia 91 umol/l. A liver biopsy is performed and reported as showing histologic findings of abundant Mallory hyaline (see image), neutrophilic infiltrates, hepatocyte necrosis, portal fibrosis, and extensive macro-vesicular steatosis. Which of the following is the most likely diagnosis? pathology_of_nonneoplastic_liver_7.png Autoimmune hepatitis Non-alcoholic steato-hepatitis Hepatitis C virus infection Hepatitis B virus infection Alcoholic hepatitis

Splenomegaly is the correct answer. The patient has alcoholic liver cirrhosis which would be associated with impaired blood flow through the liver, portal hypertension and splenomegaly.

Question 8 1 / 1 pts A 42-year old female is brought to the emergency department by ambulance. She has a history of alcoholism and intravenous drug abuse. On physical examination she is noted to have a distended abdomen with a fluid wave; prominent, tortuous vasculature around the umbilicus, and a yellow hue to her skin. She dies within twenty-four (24) hours of hospitalization. Which of the following postmortem findings is most commonly seen with her illness? Splenomegaly Fungating colonic mass Diffusely thickened gastric wall Smooth, glistening liver capsule Edematous and erythematous gallbladder

Alcohol use disorder is the correct answer. The liver can remain cirrhotic even in those persons who have long since stopped drinking. The pattern is most often micronodular, with the nodules averaging <3 mm in size. The 'end stage' cirrhotic liver can be small and shrunken.

Question 9 1 / 1 pts An 84-year-old woman dies from hepatic encephalopathy. She is found at autopsy to have a 750 gm cirrhotic liver with nodules averaging 3 mm in diameter classified as micronodular cirrhosis (attached image). On microscopic examination the liver shows regenerative nodules with extensive fibrosis between portal regions along with scattered portal lymphocytes and bile duct proliferation. Which of the following is the most likely etiology for her liver disease? pathology_of_nonneoplastic_liver_9.png Veno-occlusive disease Hepatitis B infection Alpha-1-antitrypsin deficiency Biliary atresia Alcohol use disorder Wilson disease