Hepatobiliary & Pancreas

PATHOLOGY OF HEPATOBILIARY SYSTEM AND PANCREAS Case 1: hepatitis B infection → A 30 year old nurse complained of anorexia, low grade fever, yellow sclerae, dark urine & light stools. Her serum transaminases are elevated. With the persistence of symptoms for 6 months, liver biopsy was done → Which of the following is compatible with the patient’s disease? → Signs  Jaundice & serum transaminases: Means there is hepatocytic injury  Light stools: Possibly obstructive jaundice → A & A1: Chronic Passive Congestion  Gross (A)  Smooth contour  Blackish spaces: Hemorrhages??  Microscopic (A1): hepatic lobule  Normally, hepatic lobule must be arranged radially, but in this slide it is in disarray  Narrowing of spaces: Physiologic hyperplasia: Regeneration  Dilated sinusoids: Congestion  Bile in the space of disse, biliary tract & sinusoids: hepatic congestion  Congestive heart failure: Right heart failure  Hemorrhagic central vein necrosis  Cardiac cirrhosis  Bile accumulation → B & B1: Alcoholic Hepatitis  Gross  Yellow, enlarged (Must produce abdominal pain, which is absent in our patient)  Presence of fibrosis & fatty liver  Microscopic: Fatty change  Fatty change: Means there is hepatic injury  Cirrhosis? No: because there must be hepatocyte necrosis  regeneration  Fibrosis  Presence of lymphocytes → C, C1, C1a, C1b: Viral Hepatitis  C  Lymphoid aggregates  Inflammation: From central vein to portal tract distribution, involving the full thickness of the lobules  C1a  Diffuse presence of mononuclear  Hepatocyte ballooning degeneration with central nuclei  Necrosis with destruction of hepatocyte  bile will escape  jaundice  Coagulation necrosis:  acidophilia of cytoplasm, accentuated glassy homogenous appearance  C1: Chronic active hepatitis: HBV  Inflammation of portal region  Spillage of inflammatory cells into the lobule  Piecemeal necrosis → D & D1  D1  Bile pigments within space & cell  Extensive bile accumulation  Not the case: since the patient has obstructive jaundice, expected findings is an overflow “Bumabaha” of bile which is not present in the picture → Interpret this profile: HBsAG positive, HBeAg positive, HBeAb negative: The patient has no protection → Discuss prevention, diagnosis & outcome  Possible outcome: Resolution in greater than 90% of cases, hepatocellular carcinoma, cirrhosis, hepatic failure, chronic hepatitis, fulminant hepatitis Case II

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A 55 year old bank manager was admitted because of ascites associated with difficulty of breathing. He is a known alcoholic for the past 20 years. Pertinent physical examination showed gynecomastia, distended abdomen, caput medusae & bipedal edema Signs Edema:  hydrostatic pressure or  oncotic pressure Gynecomastia:  Estrogen Discuss the morphologic findings & correlate with portal hypertension D1: Nodular fibrosis  Fibrous capsule  Alcoholic hepatitis D3: Cirrhosis  Fatty change  Necrosis  regeneration (Crowded, not linearly arranged): Hyperplasia D4: Viral hepatitis  Swelling  Post necrotic hepatitis E2: Hepatocellular carcinoma  mitosis  Atypia: pleomorphism of nucleus & cytoplasm  Nuclear changes: hyperchromasia, irregularity, chromatin clumping Differentiate a primary liver malignancy from metastatic malignancy Primary  Parenchymal cholangiocarcinoma: hepatocyte or biliary tracts: adenocarcinoma  α feto protein: Hepatocellular carcinoma Metastatic  More common  Squamous cell carcinoma or adenocarcinoma (Metastasis from GI, GU)  Multiple nodules  Central necrosis (umbilication)

Case III: Pancreatitis → A 29 year old lawyer complained of severe abdominal pain after bouts of beer drinking in a class reunion. The pain was described to be severe, referring to the back & was slightly relieved by doubling up. Pertinent physical examination showed board like rigidity of his abdomen. Serum amylase & serum lipase were high while serum calcium was low. He was rushed to the hospital where he went into coma & expired few hours later → Signs  Determine whether the patient was suffering from an acute medical abdomen (pancreatitis) or an acute surgical abdomen → Post mortem examination showed which of these processes → A & A1: Acute hemorrhagic pancreatitis  High serum amylase & lipase  Reflux theory: reflux of enzymes  Gross  Hemorrhage, inflammation  Chalky white fatty necrosis  Microscopic  Cloudy, fatty necrosis  Hemorrhage  Presence of inflammatory cells: neutrophils → B & B1: Chronic Pancreatitis  Fibrosis  Pancreas hardens on chronic pancreatitis → C, C1, C2, C3  C: Gross  Large, circular mass at the head of the pancreas  C1: Adenocarcinoma  Neoplastic glands replacing the normal serous glands

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C2: Islet cell tumor C3: Undifferentiated carcinoma

Case IV → A 45 year old obese cook complained of severe right upper quadrant abdominal pain noted after eating fatty food in a fiesta. The persistence of the symptoms thru the night necessitated the admission to the hospital. Subsequent work up & cholecystectomy was done. Which of the following characterize her condition → Signs  Exacerbated by fatty food: Fatty food will induce contraction of gallbladder which will produce pain because of inflammation  Acute surgical abdomen: if it ruptures will produce peritonitis (Bile is sterile but is irritating) → A: Acute hemorrhagic Cholecystitis  Hemorrhage, granular, inflammation in the mucosa → B & B1: Chronic Cholecystitis  Lipid laden macrophages  Cholesterol stones → C: Adenocarcinoma of the gallbladder  Well differentiated  Couvousier: dilated with tumor CHRABI 