Cirrhosis: Pathology review

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Cirrhosis: Pathology review


Peritoneum and peritoneal cavity disorders




Cirrhosis: Pathology review

USMLE® Step 1 questions

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USMLE® Step 1 style questions USMLE

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A 67-year-old man comes to the clinic due to worsening fatigue and abdominal distension. The patient has lost 11 pounds in the last 2 months with minimal change in appetite. Past medical history is notable for chronic liver disease due to hepatitis B infection that was diagnosed 15 years ago. His most recent colonoscopy 1 year ago showed no abnormalities. His temperature is 37.0°C (98.6°F), pulse is 85/min, and blood pressure is 154/89 mm Hg. Physical examination reveals temporal wasting and scleral icterus. Palmar erythema and multiple spider angiomas are present. The abdomen is distended with shifting dullness to percussion. There is 2+ pitting edema of the lower extremities. Ultrasound shows a single homogenous liver mass with irregular borders. Which of the following best describes the tumor marker that is likely elevated in this patient?


At the family medicine clinic, a 52- year- old male immigrant from Africa, named Jamar, came in for a checkup for the first time in a decade. On questioning, he admits to an extensive history of alcohol abuse. Physical examination reveals gynecomastia, palmar erythema and spider angiomata, as well as a palpable spleen.

Next, a 70- year- old Caucasian female, named Eleanor, with a history of chronic hepatitis C infection, is brought to the emergency department by paramedics due to altered mental status. She is completely disoriented and unable to provide an adequate history. Neurologic examination also reveals asterixis.

Lab tests of both show increased aspartate aminotransferase, or AST, and alanine aminotransferase or ALT. There’s also decreased albumin and increased prothrombin time. The difference is that Jamar has an AST level twice as high as ALT, in contrast with Eleanor, who has an ALT higher than AST. Eleanor, in particular, also has high serum levels of ammonia.

Both Jamar and Eleanor have cirrhosis. This is when chronic inflammation damages the liver causing it to become fibrotic. Normally, the liver is highly regenerative but scar tissue can replace liver cells which prevents regeneration and when this goes on for too long, it reaches the point where the damage is no longer reversible. If enough of the liver is replaced by scar tissue in advanced cirrhosis, a liver transplant might be needed. . Now, if we zoom into a hepatic lobule, we can see that it’s made of sheets of hepatocytes with sinusoids between them. The sinusoids are made of branches of the portal vein and hepatic artery, and together with the bile duct, form the portal triad which runs towards the central vein.

Now, there’s a space around each sinusoid, called the perisinusoidal space which contains stellate cells. When the hepatocytes are injured, they cluster together and form regenerative nodules. Here, they secrete paracrine factors that activate the stellate cells, which then proliferate, and start secreting transforming growth factor beta1, or TGF-beta. This causes them to produce collagen. The collagen builds up around the nodules and helps form scar tissue, leading to fibrosis.


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  3. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  4. "The Immunobiology and Pathophysiology of Primary Biliary Cirrhosis" Annual Review of Pathology: Mechanisms of Disease (2013)
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  8. "Oxidative Stress and Epigenetic Instability in Human Hepatocarcinogenesis" Digestive Diseases (2013)
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  10. "Hereditary Hemochromatosis — A New Look at an Old Disease" New England Journal of Medicine (2004)

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