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Hepatitis

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Hepatocellular carcinoma. Normal Liver Micronodular cirrhosis Macronodular Cirrhosis Normal Liver Histology CV PT Liver Biopsy Cirrhosis Liver Biopsy ... – PowerPoint PPT presentation

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Title: Hepatitis


1
Hepatitis Cirrhosis
  • Dr. Gehan Mohamed Dr. Abdelaty Shawky

2
Learning objectives
  • Understand the normal Liver Functions so can
    predict what is the clinical picture when liver
    failure occur.
  • Recognize definition of hepatitis and discuss its
    types(Acute, Chronic, Fulminant).
  • List different Causes and Patterns of hepatitis
    .
  • - Understand the differences between different
    types of viral hepatitis regarding Transmisson,
    Carrier state, Chronicity.
  • List the cellular changes in both Acute and
    chronic Hepatitis.

3
Learning objectives
  • Understand difference between chronic hepatitis
    and fulminant hepatitis.
  • Discuss definition ,etiology of cirrhosis and its
    variable gross pictures.
  • discuss the Pathogenesis of Hepatic
    Encephalopathy.

4
Hepatitis
  • Definition
  • Hepatitis is necro-inflammatory liver disease
    characterized by the presence of inflammatory
    cells in in the portal tracts then spillover to
    neighboring parynchmatous liver cells .

5
Normal liver
6
Hepatitis
7
Causes of hepatitis
  • 1. Viral hepatotropic (A, B, C, D.) and
    non-hepatotropic (cytomegalovirus and Epstein bar
    virus).
  • 2. Alcoholic.
  • 3. immune mediated autoimmune hepatitis.
  • 4. Drug induced.
  • 5. Metabolic disorders Hemochromatosis (due to
    iron accumulation) and Wilsons disease (copper
    accumulation) can cause liver inflammation and
    necrosis.

8
  • 6. Other causes
  • Biliary obstruction by gall stones .
  • ischemic hepatitis associating shock.
  • giant cell hepatitis ,common in children may be
    due to viral infection.

9
Virus Hep-A Hep-B Hep-C
agent RNA DNA RNA
Transmisson. Feco-oral Parenteral -maternal to fetal -sexual -drug abusers - Parenteral maternal to fetal Sexual drug abusers
Carrier state None 0.1-1.0 0.2-1.0
Chronic Hepatitis None 5-10 gt50
10
Patterns of hepatitis
  • Carrier state is an individual who harbor and
    can transmit the virus but has no manifest
    symptoms.
  • Acute hepatitis hepatitis is considered acute
    if its manifestation persist for period less than
    six months.
  • Chronic hepatitis hepatitis is considered
    chronic if there is clinical or seriological
    evidence of liver pathology persistent for more
    than six consequent months.
  • Fulminant hepatitis hepatitis is considered
    fulminant if massive hepatic cell necrosis
    happened within few weeks leading to acute
    hepatic failure and hepatic encephalopathy.

11
Acute Viral Hepatitis
12
Diagnosis of acute hepatitis
  • 1. Clinical picture.
  • 2. Laboratory investigations.
  • 3. Histopathologic diagnosis of liver biopsy.

13
1. Clinical picture of acute viral hepatitis
(AVH)
  • AVH is more likely to be asymptomatic in younger
    people.
  • If AVH is symptomatic, it may be either non
    specific or specific symptoms.
  • Initial features are of nonspecific flu-like
    symptoms include malaise, muscle and joint aches,
    fever, nausea or vomiting, diarrhea, loss of
    appetite, and headache.
  • More specific symptoms and signs are yellow
    color of the eyes and skin (i.e., jaundice) and
    abdominal discomfort from hepatomegaly (swelling
    of the liver).

14
jaundice
15
2. Laboratory investigations of AVH
  • 1. Ultrasound examination to detect any biliary
    stones, hepatomegaly.
  • 2. Serologic examination to detect
  • a- Elevated hepatic enzymes as
  • - aspartate aminotransferase(AST)
  • - alanine aminotransferase(ALT).
  • b- Viral hepatitis markers as HBV sAg, HCV
    Antigen and Antibody
  • c- Autoantibodies as in case of autoimmune
    hepatitis.
  • d- Polymerase chain reaction(PCR) to identify
    the virus.

16
3. Histopathology of AVH
  • The normal liver architecture is usually
    preserved.
  • Inflammatory cellular infiltrate (plasma cells,
    lymphocytes and neutrophils) inside portal tracts
    and around foci of necrosis.
  • The hepatocytes show
  • Apoptosis the cells appear acidophilic
    (Councilman bodies).
  • Hydropic degeneration.
  • Cholestasis means accumulation of bile in liver
    cells even canalicular bile plugs can be formed
    in cases of hepatitis caused by biliary
    obstruction by stones.
  • Hepatocyte regeneration.

17
Acute - Hepatitis - Chronic
18
Liver Biopsy Chronic Hepatitis the
inflammatory cells are present in portal tract
and in periportal areas
19
Councilman bodies are eosinophilic dead apoptotic
liver cells
20
Cholestasis accumlation of bile inside
hepatocytes
21
Chronic hepatitis
22
Clinical picture of Chronic hepatitis
  • Often no symptoms at all.
  • It is commonly identified on blood tests
    performed either for screening or to evaluate
    nonspecific symptoms.
  • nonspecific symptoms such as malaise, tiredness
    and weakness.
  • The occurrence of jaundice indicates advanced
    liver damage.
  • On physical examination there may be enlargement
    of the liver

23
Histopathology for chronic hepatitis
  • I. Portal tracts show
  • a. Piece meal necrosis necrosis of the
    hepatocytes at the limiting plate.
  • b. Portal tract inflammation
  • mononuclear inflammatory cells lymphocytes,
    macrophages with occasional plasma cells.
  • Lymphoid follicle formation (with HCV).
  • Bile duct inflammation (with HCV).

24
  • II. The hepatic lobules show
  • Degeneration Fatty change (with HCV).
  • Necrosis
  • Focal (spotty) necrosis surrounded by
    inflammatory cells.
  • Confluent necrosis and bridging necrosis with
    progressive hepatitis.
  • Dysplasia of hepatocytes (precancerous).
  • Von Kupffer cell hyperplasia.

25
  • Specific diagnostic lesions
  • Ground glass appearance of hepatocytes (with
    HBV).
  • Presence of cupper particles inside the
    hepatocytes (with Wilson disease).
  • Rosseting occasional arrangement of a group of
    hepatocytes around a central bile canaliculus.
    Characteristic of auto-immune hepatitis.
  • III. Fibrosis Cirrhosis.

26
  • Grading of chronic hepatitis by assessing the
    degree of activity this is done by examining 4
    parameters portal inflammation, piece meal
    necrosis, focal (spotty) necrosis and confluent
    necrosis. The degree of activity is graded as
    mild, moderate and marked according to the score
    of these parameters.
  • Staging of chronic hepatitis by assessment of the
    degree of fibrosis

27
chronic hepatitis with piece meal necrosis
28
Histopathology show ground glass hepatocytes,
which are seen in chronic hepatitis B infections
represent accumulations of viral antigen in the
endoplasmic reticulum. HE
29
Histopathology show lymphoid aggregates and
fatty change of the hepatocytes, which are
characteristically seen in chronic hepatitis C
infections
30
Liver cirrhosis
31
Definition
  • Chronic Diffuse, irreversible disorder of the
    liver characterized by
  • Liver cell degeneration and necrosis.
  • Replaced by extensive fibrosis .
  • Compensatory hyperplasia of the remaining healthy
    liver cells leading to the formation of the
    Regenerating parenchymal nodules.
  • Complete loss of normal architecture.

32
Etiological classification of Cirrhosis
  • A. Congenital cirrhosis
  • Congenital syphilis.
  • Hemochromatosis.
  • Glycogen storage disease.
  • Wilson disease.
  • a1 antitrypsin deficiency.

33
  • B. Acquired cirrhosis
  • 1. Post-hepatitic (viral).
  • 2. Alcoholic.
  • 3. Biliary cirrhosis.
  • 4. Cirrhosis caused by circulatory disorders e.g.
    chronic right sided heart failure.

34
Complications of Cirrhosis
  • 1. Liver cell Failure
  • 2. Portal hypertension
  • 3. Hepatocellular carcinoma.

35
Normal Liver
36
Micronodular cirrhosis
37
Macronodular Cirrhosis
38
Normal Liver Histology
CV
PT
39
Liver Biopsy Cirrhosis
40
Liver Biopsy Cirrhosis
41
Liver cell failure
42
Normal Liver Functions
  • Metabolism Carbohydrate, Fat Protein.
  • Secretory bile, Bile acids, salts.
  • Excretory Bilirubin, drugs, toxins.
  • Synthesis Albumin, coagulation factors.
  • Storage Vitamins, carbohydrates etc.
  • Detoxification toxins, ammonia, etc.

43
Manifestations of liver cell failure
  • 1. Jaundice yellow colour of skin ,mucosa due to
    hyperbilirubinemia as liver became unable to
    conjugate bilirubin so it not secreted in urine
    and so it is reabsorbed by blood and precipitate
    in tissues.
  • 2. Coagulopathy? bleeding tendency
  • 3. Hypoproteinemia specially albumin ? decrease
    osmotic pressure of blood ? generalized edema
  • .

44
  • 4. Hepatic Encephalopathy caused by the
    inability of the liver to detoxify amonia which
    produced by effect of intestinal bacteria on food
    so this amonia can affect brain causing coma.
  • 5. Hyperestrogenemia due to decrease estrogen
    degradation by the diseased liver leading to
    gynaecomastia and testicular atrophy in males

45
Gynaecomastia in cirrhosis i.e. enlargement of
male breast due to failure of degradation of
estrogen by the diseased liver.
46
Portal hypertension
47
  • Portal hypertension leading to
  • 1. Varices esophageal varices, piles.
  • 2. Splenomegaly due to splenic congestion.
  • 3. Ascites which is accumulation of transudate
    in the peritoneal cavity.

48
Ascitis in Cirrhosis
49
CirrhosisClinical Features
50
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