The Liver and The Biliary

Tract
 Viral Hepatitis

An alterative inflammation of
the liver caused by hepatitis
virus.
Pathogenesis
Pathological characteristics of
viral hepatitis:
diffuse inflammation of liver,
degeneration and necrosis of
hepatocytes in different forms
and degrees.
Degeneration of hepatocytes:
Cytoplasmic swelling and
ballooning degeneration.
Acidophilic degeneration
Ballooning Degeneration
Ballooning Degeneration
Necrosis of hepatocytes:
Cytolysis: the necrotic cells appear to
have “dropped out”.
Spotty necrosis, Piecemeal necrosis,
Bridging necrosis, Massive necrosis
Apoptosis (Acidophilic necrosis):
apoptotic hepatocytes shrink, become
intensely eosinophilic, and have
fragmented nuclei.
Spotty Necrosis
Piecemeal Necrosis
Piecemeal Necrosis
 Clinical Pathological varieties

Virus-carrier status
Acute viral hepatitis: icteric or
anicteric
Chronic viral hepatitis: mild,
moderate, severe
Fulminant viral hepatitis:
submassive to massive hepatic
necrosis
 Carrier State
A “carrier” is an individual without
manifest symptoms who harbors and
therefore can transmit an organism.
Pathogen of viral hepatitis (+),
normal liver function
Histopathology: normal or very mild
damage of hepatocytes- “ground-
glass” hepatocyte
Ground-Glass Degeneration
Ground-Glass and Hydropic Degeneration
Histoimmunochemical Stain of HBsAg
Histoimmunochemical Stain of HBcAg
Specific Stain of HBV
 Acute Viral Hepatitis
Acute hepatitis: anicteric or
icteric
(1) An incubation period
(2) A symptomatic preicteric phase
(3) A symptomctic icteric phase
(4) convalescence
Diffuse degeneration and mild necrosis of
hepatocytes (spotty necrosis), non-specific
for pathogen
Clinical manifestations: fever, fatigue,
nausea, vomiting, loss of appetite, tender
hepatomegaly, elevated serum
transaminase, jaundice
Most cases-recovered, 10% chronic (HB,
HC), neither HA nor HE develops to CVH
Ballooning Degeneration and Spotty Necrosis
Ballooning Degeneration with Cholestasis
Acidophilic Degeneration
 Chronic Viral Hepatitis
Chronic viral hepatitis is defined as
symptomatic, biochemical, or serologic
evidence of continuing or relapsing
hepatic disease for more than 6
months, with histologically
documented inflammation and
necrosis. HCV and HBV are the two
major pathogens that cause chronic
hepatitis.
Clinical manifestations: fatigue, loss
of appetite, mild jaundice
Physical findings: spider angiomas,
palmar erythema, mild hepatomegaly,
hepatic tenderness, and mild
splenomegaly
Degeneration and necrosis of
hepatocytes, fibrosis of liver in
different degrees
Mild CVH: spotty necrosis, piecemeal
necrosis, intact lobular architecture
Moderate CVH: spotty necrosis,
piecemeal necrosis, bridging necrosis,
impaired lobular architecture
Severe CVH: spotty necrosis,
piecemeal necrosis, bridging necrosis,
massive necrosis, disturbed lobular
architecture, early cirrhosis in a sense
Piecemeal Necrosis of hepatocytes
Piecemeal Necrosis of Hepatocytes
Piecemeal Necrosis of Hepatocytes
 Acute Fulminant hepatitis
Massive necrosis of hepatocytes, the
remaining hepatocytes scatter in
periphery of lobules, no obvious
regeneration, a collapsed reticulin
framework and preserved portal tracts
Liver “atrophy”, yellow or red
High mortality, due to hepatic failure,
survivals may transform into subacute
fulminant hepatitis
Acute Red Atrophy of the Liver
Acute diffuse necrosis: liver
Massive Hepatic Necrosis
Subacute Fulminant Hepatitis

Submassive necrosis and

nodular proliferation of
hepatocytes
Die of hepatic failure,
transform into cirrhosis
Massive necrosis of the liver
Submassive Hepatic Necrosis
 Cirrhosis
Continued loss of hepatocytes and
fibrosis results in cirrhosis, with
fibrous septa and hepatocyte
regeneration nodules.
(1) Nodular regeneration of hepatocytes-
pseudolobule formation
(2) Fibrosis
(3) Reconstruction of vasculature
Liver is deformed and
hardened
Impairment of liver function
Portal hypertension
 Pseudolobule
Regenerative nodular hepatocytes
following necrosis of large number of
hepatocyte, fibrous tissue around the
nodule
Inside the nodule: central vein-absent,
eccentric, multiple, or in portal area
Hepatic cord disarrangement
Pseudolobule Formation
Classification of Cirrhosis
Portal cirrhosis
Postnecrotic cirrhosis
Biliary cirrhosis
Cardiac (congestive) cirrhosis
Parasitic cirrhosis
Pigmentary cirrhosis
 Portal Cirrhosis

Etiology:
(1) Viral hepatitis: HB, HC, HD
(2) Alcoholism
(3) Malnutrition
(4) toxin
 Morphology

Nodule size: 1-5mm, <1.0cm

Fibrous tissue between
nodules: thin, even
Micronodular cirrhosis: liver
 Postnecrotic Cirrhosis

Etiology: similar to those of portal

cirrhosis
Morphology
(1) Nodule size: 1-3cm, up to 6cm
(2) Fibrous tissue: thick, uneven
Macronodular cirrhosis
 Biliary Cirrhosis
Etiology
(1) Obstruction of biliary tract by
different causes, resulting in bile
stasis and destruction of hepatocytes
and biliary canals
(2) Primary: autoimmune to biliary
canals (rare)
(3) Secondary: gallstone, infection,
congenital obstruction (common)
 Morphology: enlarged, deep green
colored liver with fine nodularity
Clinical feature
(1) Heavy jaundice
(2) Dysfunction of liver and portal
hypertension (mild)
Biliary cirrhosis of liver
 Clinical Pathological correlation

Portal hypertension
(1) Increased resistance to portal flow at the
level of the sinusoids and compression
of central veins by perivenular fibrosis
and expansile parenchymal nodules
(2) Anastomoses of intrahepatic blood
vessels between branches of hepatic
artery and portal vein, between branches
of hepatic artery and sublobular vein
 Manifestations of portal
hypertension
(1) Ascites
(2) The formation of portosystemic
venous shunts
(3) Congestive splenomegaly
(4) Congestion of gastrointestinal tract
 Portosystemic shunts
(1) Veins around and within the rectum:
hemorrhoids
(2) The cardioesophageal junction:
esophagogastric varices
(3) The retroperitoneum, and the falciform
ligament of the liver involving
periumbilical and abdominal wall
collaterals: dilated subcutaneous veins
extending from the umbilicus toward the
rib margins (caput medusae)
 Hepatic insufficiency
(1) Spider angiomas (spider naevus),
palmar erythema
(2) Hepatic encephalopathy (hepatic
coma)
(3) Bleeding tendency
 The causes of death in patients
with cirrhosis
(1) Breakthrough bleeding of
esophageal varices
(2) Secondary infection
(3) Complicated with hepatic
carcinoma
Primary Carcinoma of the liver

Primary carcinomas arise from

hepatocytes or epithelium of
intrahepatic bile duct
(1) Hepatocellular carcinoma, HCC
(2) Cholangiocellular carcinoma
(3) A mixture of the two cell types
 Gross:
1. Minute hepatocarcinoma: 1 or 2
nodules, <3cm
2. Advanced carcinoma of liver:
 massive type
 nodule type
 diffusely infiltrative type
 Cut surface of the tumor
Yellowish – HCC, with
cirrhosis
Gray – cholangiocellular
carcinoma, no cirrhosis
 Histological types
1. HCC: 95% AFP (+)
Trabecular type
Acinar type
2. Cholangiocellular carcinoma, AFP (-)
3. Mixed liver cell and bile duct
epithelium carcinomas, AFP (+) or (-)
Carcinoma of common bile duct: liver
 Etiology
(1) Viral hepatitis HBV and HCV
(2) Cirrhosis
(3) Aflatoxin, nitrosamine
(4) Infection of clonorchiasis