Pathology of Hepatitis

1. Pathology of Hepatitis Never offer the devil a ride.<br />He will always want to be in the driving seat…!<br />BK<br />

2. 2<br />CPC 4.2.2<br />George, 62 year old farmer from Tully, presents to his GP with fatigue. His wife has asked him to consult you as his eyes look a bit yellow'. <br />Fatigue: Progressing 2wk. Unable to get out. <br />nausea : no <br />vomiting/haematemesis : no <br />Anorexia, wt loss: yes thinks lost a bit of weight. <br />bowel habit : constipated, stool pale, no blood.<br /> 2<br />CPC 4.2.2<br />George, 62 year old farmer from Tully, presents to his GP with fatigue. His wife has asked him to consult you as his eyes look a bit yellow'. <br />Fatigue: Progressing 2wk. Unable to get out. <br />nausea : no <br />vomiting/haematemesis : no <br />Anorexia, wt loss: yes thinks lost a bit of weight. <br />bowel habit : constipated, stool pale, no blood.<br />

3. 3<br />CPC 4.2.2<br />Fever: no <br />Bleeding/bruising : no <br />cough/dyspnoea : no<br />previous episodes : 2 x episodes fatigue last 2 years; first attack preceeded by 2 weeks of fever. saw GP - blood tests : 'showed liver not working so well'. then felt better and has not been to see GP since. This time he feels much worse. <br />other PMH of note? 'never sees doc'; has never been in hospital; no regular medication <br />no OTC/herbal remedies <br />SH : married; 3 adult children. Moved to Australia from Greece 26 years ago. Banana farmer <br /> 3<br />CPC 4.2.2<br />Fever: no <br />Bleeding/bruising : no <br />cough/dyspnoea : no<br />previous episodes : 2 x episodes fatigue last 2 years; first attack preceeded by 2 weeks of fever. saw GP - blood tests : 'showed liver not working so well'. then felt better and has not been to see GP since. This time he feels much worse. <br />other PMH of note? 'never sees doc'; has never been in hospital; no regular medication <br />no OTC/herbal remedies <br />SH : married; 3 adult children. Moved to Australia from Greece 26 years ago. Banana farmer <br />

4. 4<br />Laboratory Investigations:<br />FBC: Hb 13.8 g/dl, PCV 45%; WBC 7000/mm3, 70% N, 25% L; Platelets 200,000/mm3 <br />Blood film: Normocytic, normochromic cells <br />Bilirubin: Total serum Bilirubin = 98 μmol/l, (Direct 67)<br />Liver enzymes: <br />Aspartate amino transferase (AST) = 62 U/l <br />Alanine amino transferase (ALT) = 110 U/l <br />Alkaline Phosphatase = 116 U/I <br />Serum Protein: Total protein = 61 g/l, Albumin = 20 g/l, <br />Hepatitis B Surface Antigen (HbsAg): Positive <br /> 4<br />Laboratory Investigations:<br />FBC: Hb 13.8 g/dl, PCV 45%; WBC 7000/mm3, 70% N, 25% L; Platelets 200,000/mm3 <br />Blood film: Normocytic, normochromic cells <br />Bilirubin: Total serum Bilirubin = 98 μmol/l, (Direct 67)<br />Liver enzymes: <br />Aspartate amino transferase (AST) = 62 U/l <br />Alanine amino transferase (ALT) = 110 U/l <br />Alkaline Phosphatase = 116 U/I <br />Serum Protein: Total protein = 61 g/l, Albumin = 20 g/l, <br />Hepatitis B Surface Antigen (HbsAg): Positive <br />

5. 5<br />Differential Diagnosis:<br />Viral fever -? <br />Yellow fever, Relapsing fever, Dengue, Ebola, <br />Leptospirosis (common in Tully) - ?<br />Hepatitis – Acute / Chronic - ?<br />Chronic Hepatitis B – why chronic?<br />History & presentation in Hep. A & C ?<br />Other causes of Jaundice?<br />Alcoholic liver disease ?<br />Toxins, chemical, Reyes syndrome?<br />Anemia - ?<br />Malignancy - ?<br /> 5<br />Differential Diagnosis:<br />Viral fever -? <br />Yellow fever, Relapsing fever, Dengue, Ebola, <br />Leptospirosis (common in Tully) - ?<br />Hepatitis – Acute / Chronic - ?<br />Chronic Hepatitis B – why chronic?<br />History & presentation in Hep. A & C ?<br />Other causes of Jaundice?<br />Alcoholic liver disease ?<br />Toxins, chemical, Reyes syndrome?<br />Anemia - ?<br />Malignancy - ?<br />

6. 6<br />Jaundice Clinical Diagnosis<br />

7. 7<br />Pathology of HepatitisViral & Alcoholic<br />Dr. Venkatesh M. Shashidhar.<br />Assoc.Prof & Head of Pathology<br /> 7<br />Pathology of HepatitisViral & Alcoholic<br />Dr. Venkatesh M. Shashidhar.<br />Assoc.Prof & Head of Pathology<br />

8. 8<br />1.5 kg, wedge shape<br />4 lobes, Right, left, (Caudate, Quadrate)<br />Double blood supply<br />Hepatic arteries<br />Portal – Venous blood<br />Normal<br /> 8<br />1.5 kg, wedge shape<br />4 lobes, Right, left, (Caudate, Quadrate)<br />Double blood supply<br />Hepatic arteries<br />Portal – Venous blood<br />Normal<br />

9. 9<br />CT Upper abdomen - Normal<br />Liver<br />Stomach<br />Aorta<br />Spleen<br />Lung<br />Lung<br /> 9<br />CT Upper abdomen - Normal<br />Liver<br />Stomach<br />Aorta<br />Spleen<br />Lung<br />Lung<br />

10. . Normal Liver - Infant<br />Much larger, both lobes, below costal margin – palpable*<br />

11. . 11<br />Normal Liver<br />

12. . 12<br />Normal Liver – MicroscopyAcinus – showing zones 1, 2 & 3.<br />Central Vein<br />Blood Flow<br />Portal Triad<br />

13. . 13<br />Structure of Liver Lobule<br />Portal Triad: Art, Vein, BD<br />

14. . 14<br />Acinus LobuleFunctional Anatomic<br />3<br />Zone 1 – Toxin damage. Zone 3 – Ischemic damage<br />

15. . Jaundice<br />15<br /><ul><li>Overproduction of bilirubin

16. . Impaired bilirubin uptake.

17. . Block in metabolism

18. . Impaired transport.

19. . Obstruction to bile excretion.</li></li></ul><li>16<br />Liver Function Tests: Interpretation<br />Synthesis / function defect.<br />Total protein & albumin low, PT prolonged why?<br />Bile Obstruction.<br />Alk Phos – markedly increased – why?<br />Hepatocyte Injury.<br />ALT, AST - high. – why?<br />Alk Phos – moderately increased. – why?<br />Other:<br />GGT – increased with alcohol use. – why?<br />Viral serology - <br />Auto-Antibody panel. <br />Clinical Features<br /><ul><li>Fever

20. . Fatigue

21. . Indigestion

22. . Fat intolerance

23. . urine/stool*

24. . Jaundice

25. . Bleeding

26. . Edema

27. . Abd. Distension

28. . Confusion

29. . Coma</li></li></ul><li>17<br />Clinical Features - Pathogenesis<br /><ul><li>Hypoalbuminemia

30. . Hyperammonemia

31. . Hypoglycemia

32. . Palmarerythema

33. . Spider angiomas

34. . Hypogonadism

35. . Gynecomastia

36. . Weight loss

37. . Muscle wasting

38. . Ascites

39. . Splenomegaly

40. . Esophagealvarices

41. . Hemorrhoids

42. . Caput medusae-abdominal skin

43. . Complications of Hepatic Failure

44. . Coagulopathy

45. . Hepatic encephalopathy

46. . Hepatorenal syndrome</li></ul>Decreased Albumin synthesis<br />Hepatorenal syndrome<br />

47. . Jaundice in liver failure<br />18<br />

48. . 19<br />Diseases of Liver:<br />Hepatitis: Inflammation of Liver<br />Viral, Alcohol, immune, Drugs, Toxins, parasites<br />Acute, Chronic & Fulminant – types.<br />Billiary obstruction – gall stones.<br />Cirrhosis – diffuse scarring & regeneration.<br />Carcinoma - Hepatocellular & Bile duct.<br />Congenital: metabolic, cysts, tumors.<br />

49. . Viral Hepatitis:<br />

50. . 21<br />Viral Hepatitis: Introduction<br />Viral Hepatitis:<br />Specific – Heptitis B, C, D (serum),A, E<br />Non-Specific - Many viruses CMV, EBV, etc.<br />Acute, Chronic (CPH, CAH), Fulminant.<br />Specific viral hepatitis important cause of morbidity & mortality.<br />Horizontal transmission – Blood.. Sex.<br />Vertical transmission – Mother to fetus.<br />Hepatitis  Cirrhosis  Hepatic Ca. (not in A/E)<br />