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JCU MB4 Term 2 Week 3 (Liver)

1

Viral serology interpretation: HBsAg +ve, HBcAb +ve, HBcAb IgM -ve, HBeAg +ve


  Acute viral hepatitis

  Immunised against Hep B

  Chronic hepatitis B

  Hepatitis B carrier stage

  Fulminant hepatitis B


Results consistent with current infection, lack of IgM indicates that this is chronic rather than acute.

2

51yo male, alcohol. Picture of abdomen shown - what is the pathogenesis of the indicated feature?

Cirrhosis - Ascites


  Porta-systemic shunt

  Hyperoestrogenaemia

  Portal hypertension

  Hypoalbuminaemia

  Decreates vitamin K


Arrow points to abdominal ascites, the main cause of which is portal hypertension.

3

The pathogenesis pathway shown in the illustration is typical of which virus?

Pathogenesis - Hepatitis


  HAV

  HBV

  HCV

  HDV

  Non-specific


Permissive cells are typically seen in Hepatitis B (sometimes in hepatitis C)

4

42yo male, alcoholic, fatigue. Liver biopsy is shown. What is the likely diagnosis?

Liver Biopsy - Chronic Hepatitis


  Acute hepatitis

  Chronic hepatitis

  Chronic lymphocytic leukaemia

  Fulminant hepatitis

  Cirrhosis


Inflammation surrounding the portal triad with extension into parenchyma is characteristic of chronic hepatitis.

5

A 42yo travelling salesman has routine medical test for insurance. Following initial testing he was advised a liver biopsy. The biopsy image is shown. What is the most likely diagnosis?

Liver Biopsy - Acute Hepatitis


  Acute viral hepatitis

  Alcoholic hepatitis

  Chronic viral hepatitis

  Post-viral cirrhosis

  Alcoholic cirrhosis


More diffuse foci of inflammation with swollen hepatocytes is more characteristic of acute hepatitis. Portal inflammation is visible, which while more characteristic of chronic heptatis can also be seen in acute cases.

6

Viral serology interpretation: HBsAg -ve, HBcAb -ve, HBsAb +ve


  Acute viral hepatitis

  Immunised against Hep B

  Past hepatitis B

  Hepatitis B carrier stage

  Fulminant hepatitis B


Negative HBsAg negative indicates no current infection. Positive immunity to HBsAg without HBcAg indicates immunisation rather than past infection.

7

Viral serology interpretation: HBsAg negative, HBsAb +ve, HBcAb +ve, HBcAb IgM -ve.


  Acute viral Hep B

  Immunised against Hep B

  Past Hep B

  Hep B carrier stage

  Carrier state of Hep B


No current infection with immune reaction to HBcAg indicates previous resolved infection rather than immunisation.

8

Lab investigation interpretation:

  • Protein (Total): 59g/L
  • Albumin: 30g/L
  • Globulin: 29g/L
  • Bilirubin (Total): 27µmol/L
  • ALP: 71U/L
  • GGT: 523U/L
  • ALT: 79U/L
  • AST: 151U/L


  Alcoholic liver disease

  Acute viral hepatitis

  Past Hepatitis B

  Hepatitis B carrier stage

  Carrier state of Hepatitis B


Isolated markedly raised GGT is relatively specific for alcoholic damage to the liver. Normal ratio between Alb/Glo should be 2:1.

9

Lab investigation interpretation:

  • Urea: 5.8mmol/L
  • Creatinine: 80µmol/L
  • Protein (Total): 66g/L
  • Albumin: 35g/L
  • Globulin: 31g/L
  • Bilirubin (total): 192µmol/L
  • Bilirubin (conjugated): 130µmol/L
  • ALP: 203U/L
  • GGT: 470U/L
  • ALT: 6055U/L
  • AST: 4860U/L


  Alcoholic liver disease

  Past Hepatitis B

  Acute viral hepatitis

  Hepatitis B carrier stage

  Carrier state of Hepatitis B


Markedly raised ALT/AST is characteristic of acute parenchymal liver injury. Conjugated bilirubin levels indicate that there is some biliary damage also.

10

28yo male, alcoholic, homosexual, icterus and fever. Liver biopsy is shown. What is the diagnosis?

Liver Biopsy - Acute Hepatitis


  Acute viral hepatitis

  Haemolytic anaemia

  Chronic persistent hepatitis

  Alcoholic fatty liver

  Alcoholic hepatitis


Large tracts of lymphocytic inflammation not confined to the portal triad suggests acute viral hepatitis. Alcoholic hepatitis would show fatty change with predominantly neutrophil infiltration. Suggestion that this shows 'interface hepatitis' which would be more characteristic of chronic hepatitis. In this case either would be correct.

11

69yo female, chronic bronchitis. Died following chronic cardiac failure. Liver specimen shown. What is the likely diagnosis?

Liver - Nutmeg Liver


  Alcoholic hepatitis

  Dubin-Johnson Syndrome

  Alcoholic cirrhosis

  Nutmeg liver

  Metastatic deposits


Cardiac failure is likely due to cor pulmonale 2° to COPD. This typically produces venous congestion of the liver resulting in a 'nutmeg' appearance.

12

62yo male, malaise, lethargy for 2 years. Mild hepatomegaly, no jaundice. Liver function tests are normal. Liver biopsy shown. What is the most likely diagnosis?

Liver Biopsy - Fatty Liver


  Alcoholic fatty liver

  Acute viral hepatitis

  Fulminant hepatitis

  Chronic viral hepatitis

  Alcoholic cirrhosis


Fatty infiltration obvious. May also be NASH given a lack of EtOH history.

13

22yo male, alcoholic, 3 weeks of fatigue, icterus and fever. Liver biopsy shown. What is the structure identified by the arrow?

Liver Biopsy - Necrosis


  Mallory hyaline

  Apoptotic cell

  Viral inclusion

  Hepatocyte necrosis

  Inflammatory cell


Often seen in acute viral hepatitis.

14

34yo male, icterus and fever. Liver biopsy shown. What is the likely diagnosis?

Liver Biopsy - Acute Hepatitis


  Acute hepatitis

  Chronic persistent hepatitis

  Chronic active hepatitis

  Fulminant hepatitis

  Cirrhosis


Characteristic Councilman body observed (cell swelling).

15

51yo male, alcohol. Picture of abdomen shown - what is the pathogenesis of the indicated feature?

Cirrhosis - Gynecomastia


  Porta-systemic shunt

  Hyperoestrogenaemia

  Portal hypertension

  Hypoalbuminaemia

  Decreased vitamin K


Gynecomastia shown, a common complication of cirrhotic liver disease.

16

56yo chronic alcoholic, 2 days fever, abdomen distended, tender, tap yielded cloudy yellow fluid with 98% neutrophils. Blood culture grows E. coli. Patient dies 3 days later. Liver image shown. What is the likely diagnosis?

Liver - Cirrhosis


  α1-antitrypsin deficiency

  HEV infection

  Hereditary haemochromatosis

  Primary sclerosing cholangitis

  Alcoholic cirrhosis


Patients with cirrhosis, and alcoholics especially, have a tendency to develop spontaneous bacterial peritonitis.

17

58yo male, alcoholic, distended abdomen and icterus. Liver biopsy shown. What is the likely diagnosis?

Liver Biopsy - Cirrhosis


  Chronic active hepatitis

  Chronic persistent hepatitis

  Hepatocellular carcinoma

  Cirrhosis

  Chronic alcoholic hepatitis


Characteristic bands of fibrosis and inflammation surrounding surviving nodules.

18

51yo male, alcoholic, history of surgery for pigmented skin lesion. Liver specimen shown. What is the likely diagnosis?

Liver - Metastatic Melanoma


  Amoebic liver abscesses

  Multiple liver infarcts

  Alcoholic hepatitis

  Macronodular cirrhosis

  Metastatic deposits


Isolated pigmented lesions consistent with metastasised melanoma.

19

59yo male, alcoholic, presents with fatigue, anorexia. Normal liver function tests. Liver specimen shown. What is the likely diagnosis?

Liver - Fatty Liver


  Dubin-Johnson Syndrome

  Alcoholic cirrhosis

  Alcoholic hepatitis

  Fatty liver

  Metastatic deposits


Parenchyma is pale.

20

22yo male, alcoholic, 3 weeks of fatigue, icterus and fever. Liver biopsy is shown. Identify the structure indicated.

Liver Biopsy - Mallor Hyaline


  Mallory hyaline

  Apoptotic cell

  Viral inclusion

  Hepatocyte necrosis

  Inflammatory cell


Characteristic of alcoholic hepatitis.

21

28yo male, 3 weeks after visiting east timor presents with malaise, fatigue, loss of appetite. Mild icterus. AST and ALT mild elevation. Total bilirubin 3.9mg/dL (direct 2.8). Which of the following would be positive?


  HBsAb

  Anti-HDV IgM

  Anti-HCV

  Anti-HAV IgM

  HBcAb


Symptoms of recent and current acute viral hepatitis. Incubation period is too short for HBV or HCV. HDV requires HBV.

22

41yo female, increasing malaise, 10kg weight loss since last year. Developed coma and died. Liver specimen shown. What is the most likely etiologic agent?

Liver - HCC


  Aspirin abuse

  Ferrous sulphate

  Acetaminophen

  Alfatoxins

  Raw oysters


Alfatoxins, produced by Aspergillus, is a known liver carcinogen. Raw oysters can also cause cancer (typically cholangiocarcinoma) by harbouring the parasite Clonorchis sinensis (also found in fish).

23

A 48yo male is referred following high ALT in health screening. HCV immunoassay positive. Past history of appendicectomy 10 years ago. Examination is normal. Which of the following tests would determine if he has chronic HCV infection?


  Repeat EIA for anti-HCV Ab

  Recombinant immunoblot assay (RIBA)

  Alpha-fetoprotein levels

  HCV RNA

  Direct, indirect and total bilirubin assay


Demonstrating the DNA/RNA of a virus is the most definitive method of establishing its presence in the host.