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Liver Cirrhosis & Complications

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Liver Cirrhosis & Complications ھذه اﻟﻣﺣﺎﺿرة ھﻲ ﺗﻛرﯾم ﻟﻛل ﻣن ﯾﻌﻣل وﻻ ﯾﻛرّم،ﻟﻛل ﻣن ﯾﻌﻣل ﺑﺎﻟﺧﻔﺎء،ﻟﻛل اﯾﺎدي ﺗدﻓﻌﻧﺎ ﻣن ظﮭورﻧﺎ ﻻ ﻧرى وﺟوه اﺻﺣﺎﺑﮭﺎ Liver cirrhosis & Complications Content Explanation Notes Important Objectives from Dr slides Define Cirrhosis Recognize the types of cirrhosis Recognize the causes and the pathogenic Mechanisms leading to cirrhosis. Describe the pathological findings in cirrhotic livers. Recognize the major complications of cirrhosis Understand the pathogenetic mechanisms underlying the occurrence of the complications Recognize the clinical features inherent to the above mentioned complications Describe the pathological findings of the different complications Liver anatomy and physiology by osmosis Define liver Cirrhosis and types Cirrhosis by Osmosis liver Cirrhosis ● Cirrhosis refers to the diffuse transformation of the liver into regenerative parenchymal nodules surrounded by fibrous bands no Cirrhosis triad and no portal vein. ● it is among the top 10 causes of death in the Western world. ● It is the end-stage of chronic liver disease only if the patient survive to this stage Robbins: majority of cases of cryptogenic cirrhosis, without These two are the clear etiology, are now recognized as “burned-out” NASH most common Other causes include: Main I. alcohol abuse most III. biliary disease Worldwide common cause in western Causes countries. IV. iron overload hemochromatosis and II. viral hepatitis most wilson’s disease common cause in ksa 1)Fibrosis bridges of fibres tissue in the form of delicate bands or broad scars/septae Cirrhosis is defined by 3 2)Nodules characteristics containing regenerating hepatocytes encircled by fibrosis, with diameters varying from very small (<3 mm, micronodules) to large (several centimeters, macronodules) 3)Disruption of the architecture of the entire liver by the parenchymal damage and scarring, with the formation of abnormal Vascular architecture interconnections between vascular inflow is reorganized and hepatic vein outflow channels Bridges collaterals ﺑﯾﺻﯾر ﻋﻧدﻧﺎ ﺗﻔرﻋﺎت Features of cirrhosis Once cirrhosis has developed, reversal is thought to be rare Fibrosis is the key اﻟﻠﻲ ﺑﺎﻟﻮردي ھﻮ اﻟﮭﯿﺒﺎﺗﻮﺳﺎﯾﺘﺲ. او ﺑﺎﻷﺻﺢ ﻣﺎﺗﺒﻘﻰ ﻣﻨﮭﺎ feature of progressive Regenerative nodules damage to the liver. With bridges of fibres tissue Define liver Cirrhosis and types liver Cirrhosis ﻋﻧدﻧﺎ ﻧوﻋﯾن ﻣن اﻟﻛﻼﺳﻔﯾﻛﯾﺷن اﻣﺎ اﻻﯾﺗﯾوﻟوﺟﻲ او ﺣﺟم اﻟﻧودﯾوﻟز ● ﻟﻛن اﻻھم ھو اﻟﺗﻘﺳﯾم ﻋن طرﯾق اﻻﺗﯾوﻟوﺟﻲ .The classification is based on the underlying etiology ● Many forms of cirrhosis (particularly alcoholic cirrhosis) are initially micronodular, but there is a tendency for nodules to increase in size with time. ﻏﺎﻟﺑﺎ ﻣﺎﺗﺗﻌدا اﻟﺛﻼﺛﺔ ذول وھم اﻻﻛﺛر اﻧﺗﺷﺎرا Alcoholic liver disease 60% to 70% Viral hepatitis B&C 10% Biliary diseases 5% to 10% Based on causes Primary hemochromatosis 5% Wilson disease Rare Accumulation of copper α1-Antitrypsin deficiency Rare Cryptogenic cirrhosis 10% to 15% I. The cirrhosis developing in infants and children with galactosemia and tyrosinosis II. Drug-induced cirrhosis (methotrexate, enalapril, Almost all drugs can affect the function of the liver,but vitamin A). especially paracetamol can be very toxic and leads to fibrosis Other infrequent III. Severe fibrosis can occur in the setting of cardiac Classification of Cirrhosis Classification types of cirrhosis : disease; called "cardiac cirrhosis" IV. In some cases there is no cause and these are referred to as cryptogenic cirrhosis Once cirrhosis is established, it is usually impossible to establish an etiologic diagnosis on morphologic grounds alone Define liver Cirrhosis and types Robbins: Three processes are central to the pathogenesis of cirrhosis: death of hepatocytes, extracellular matrix deposition, and vascular reorganization. ● The pathogenic processes in cirrhosis are progressive fibrosis and reorganization of the vascular microarchitecture of the liver ● In the normal liver, interstitial collagens (types I and III) are concentrated in portal tracts and around central veins. The type IV collagen(reticulin) is in the space of Disse. ● In cirrhosis, types I and III collagen are deposited in the lobule, creating delicate or broad septal tracts ● There is loss of fenestrations in the sinusoidal endothelial cells Due to the fibrosis (capillarization of sinusoids, that is the sinusoidal space comes to resemble a capillary rather than a channel for exchange of solutes between hepatocytes and plasma) ● The major source of excess collagen in cirrhosis is the perisinusoidal stellate cells ( Ito cells), which lie in Pathogenesis of Cirrhosis the space of Disse. ● Although Ito cells normally function is a vitamin A fat- storing cells, during the development of cirrhosis they become activated and transform into myofibroblast-like cells. Lay down collagen due to injury of hepatocytes Collagen synthesis is stimulated by: 1) Chronic inflammation, with production of inflammatory cytokines. 2) Cytokine production by activated endogenous cells (Kupffer cells, endothelial cells, hepatocytes, and bile duct epithelial cells). 3) Disruption of the normal extracellular matrix. 4) Direct stimulation of stellate cells by toxin Describe the pathological findings in cirrhotic livers. Morphology : Gross features Macronodular Micronodular The nodules seen here are larger than 3 Micronodular cirrhosis : The mm maybe reach to 2-3 cm and, hence, regenerative nodules are quite small, this is an example of "macronodular" averaging less than 3 mm in size. The cirrhosis. In radiology more than 2 cm can be most common cause for this is chronic cancer so biopsy is required. alcoholism. Microscopically Regenerative nodules of hepatocytes are surrounded by fibrous connective tissue contains large amount of collagen that bridges between portal tracts. Within this collagenous tissue are scattered lymphocytes as well as a proliferation of bile ducts: Cirrhosis is a chronic progressive mechanism Clinical Features : All forms of cirrhosis may be clinically silent. When symptomatic they lead to nonspecific clinical manifestations: anorexia, weight loss, weakness, osteoporosis and in advanced disease,frank debilitation,jaundice*, Incipient or overt hepatic failure may develop. At first the liver function is so there’s no symptoms (ﻣﻤﻜﻦ أﺷﯿﻞ ﻧﺺ اﻟﻜﺒﺪ وﻣﺎ ﯾﺼﯿﺮ ﻋﻨﺪي ﺗﺄﺛﯿﺮ ,compensated (capacity of liver is huge until it reach uncompensated stage. (*) it will appear because the liver can’t deal with bilirubin which produced from broken RBC’s. The ultimate mechanism of most cirrhotic deaths is: 1. Progressive liver failure so become uncompensated liver disease 2. A complication related to portal hypertension maybe the patient will have bleeding from esophageal varices 3. The development of hepatocellular carcinoma He will have only a risk factor Recognize the causes and the pathogenic . Mechanisms leading to cirrhosis •Chronic Viral Hepatitis (hepatitis B and C virus) •Autoimmune hepatitis Causes of Liver •Biliary Cirrhosis Secondary biliary cirrhosis Cirrhosis Primary biliary cirrhosis In our country this Primary sclerosing cholangitis arrangement of causes is •Alcoholic liver disease more common. Chronic Hepatitis Morphology Some changes are shared with acute hepatitis. ● Hepatocyte injury, necrosis, and regeneration . ● Sinusoidal cell reactive changes. ● Portal tract Inflammation: (by lymphocytes) ○ Confined to portal tracts or ○ Spillover into adjacent parenchyma, with necrosis of hepatocytes ("interface hepatitis") or ← Is a feature of active ○ Bridging inflammation and necrosis chronic hepatitis. ● Fibrosis: Continued loss of hepatocytes results in fibrous septa formation which ultimately leads to cirrhosis HBV: "ground-glass" hepatocytes, "sanded" nuclei Not very important because we can diagnose the patient basically by blood test for HB B HCV: bile duct damage, lymphoid aggregate formation Notes the bile ducts and Stage 1: ● Cirrhosis: The end-stage outcome lymphocytes passes Increase fibrous tissue in portal tract. through the other side stage 2: parenchyma Ground glass appearance This fibrosis and Bridging fibrosis and later on these bridging lymphocytes will reach fibrosis will complete from area to other ﻣﻣﺳوح ﻛﺄﻧﮫ ﻗزاز (Inclusion of viral particles in the cytoplasm) the bile duct. area until the liver will be cirrhotic. Ground Glass Dilated vein Piecemeal necrosis in HBsAg +ve Because of chronic hepatitis lymphocytes Spillover into adjacent it’s chronic parenchyma, with inflammation necrosis of hepatocytes Lymphoid "interface hepatitis" aggregate Viral hepatitis C which is at a high stage with extensive fibrosis and progression to macronodular cirrhosis, as evidenced by the large regenerative nodule at the center right. Recognize the causes and the pathogenic . Mechanisms leading to cirrhosis ● is a chronic hepatitis with histologic features like that of chronic viral hepatitis. There’re portal inflammation, interface hepatitis and fibrosis. ● This disease may run an indolent or severe course. From the name itself the patient has autoantibodies against the liver. Two primary types of autoimmune hepatitis: Type 1 autoimmune hepatitis is most often seen in middle-age women and is characteristically associated with anti-nuclear and anti–smooth muscle antibodies. Type 2 autoimmune hepatitis is most often seen in children or teenagers and is associated with anti–liver kidney microsomal autoantibodies. very rare. ● Absence of viral serologic markers ● γ Elevated serum IgG and -globulin levels (>1.5 times normal) ● High serum titres of autoantibodies in 80% of cases, including antinuclear (ANA), antismooth muscle (SMA) and anti-mitochondrial
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