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OBJECTIVES

1. List 8 major functions of the liver (Table 27-1, p. 371).

2. Describe cirrhosis of the liver. Name the single most important cause of cirrhosis, describe the consequences of cirrhosis including : jaundice, portal hypertension, ascites, esophageal varices, hepatic coma. (pp. 385-391)

3. Define and briefly describe the following conditions : hepatitis, cholelithiasis, cholecystitis, pancreatitis. (pp. 378-384, 391-396)

4. Name three common components of gall stones (p. 392).

5. Know all underlined terms and * questions, including case study questions.

Development of Cirrhosis of the Liver - Normal Liver (PH 8145), Fatty Metamorphosis (PH 1525) and Cirrhosis of the Liver (PH 1520) (pp. 35-36, Fig. 3-3, p. 385) Click here 

First study the slide of normal liver. Notice the size and shape of the liver cells, the purple nuclei and pink cytoplasm. Notice the sinusoids (specialized capillaries) situated between strands of liver cells.

            1. Normal liver in situ, gross
            2. Normal liver, external, gross
            3. Normal liver, cut surface, gross
            4. Normal liver zones, microscopic*

On the slide of fatty metamorphosis, you will note large clear bubbles or vacuoles within the liver cells. Notice how these vacuoles occupy a large proportion of the cell's volume and push the cytoplasm up against the cell membrane, forming "signet ring cells". These vacuoles contain fat which has accumulated due to abnormal biochemical reactions within the cell. These changes occur with various types of injury to the liver, including the early stages of cirrhosis. (Fig. 3-3, p. 36.)

            7. Fatty metamorphosis of liver, microscopic*
            8. Fatty metamorphosis of liver, microscopic*

* Is fatty degeneration a reversible or irreversible change? (pp. 385)

With continued assault to liver cells, cells will die and be replaced by scar tissue. In the slide of cirrhosis of the liver, notice bands of fibrous scar tissue which extend through the liver and separate lobules of functioning liver cells. (See also the photograph of Liver/Cirrhosis).

                16. Cirrhosis of liver, microscopic*
                17. Micronodular cirrhosis and fatty change of liver, microscopic*
                18. Mallory's hyaline, liver, microscopic*
                29. Cholestasis of liver, microscopic*  - from blocked ducts
                30. Cholestasis of liver, microscopic* - from blocked ducts
                53. Viral hepatitis C, liver, low power microscopic* - from hepatitis
                54. Viral hepatitis with collapse, liver, Trichrome stain, microscopic* - from hepatitis

* What is a common cause of cirrhosis? (p. 385)

* Is cirrhosis reversible or irreversible? (p. 388)

Fatty Degeneration - Plastic Mount

Compare the texture of the normal and fatty liver. Notice that the normal liver has many open channels for blood passage. The very small lumps, each of which has a small depression (vessel) in the center, are the lobules. Notice that in the fatty liver most of the vessels are not visible. They have been compressed by the swollen liver cells filled with fatty degeneration or cirrhosis.
            1. Normal liver in situ, gross
            2. Normal liver, external, gross
            3. Normal liver, cut surface, gross
            5. Fatty metamorphosis of liver, gross
            6. Fatty metamorphosis of liver, gross

* Why do liver cells accumulate fat when they are being damaged by chemicals or microorganisms? (pp. 35-36, 385)

* How is the fatty degeneration detected? (p. 385)

Normal Liver and Cirrhotic Liver - Specimens in plastic bag. (pp. 35-36, 57)

Compare the color of the two liver specimens. The paler color of the cirrhotic liver is due to the accumulation of fat within the liver cells. Look closely at the cirrhotic liver to observe the bands of scar tissue which extend throughout the specimen separating small lobules of liver cells. Compare the edge of the two liver specimens; the edge of the normal liver is smooth, whereas that of the diseased liver is lumpy.

                12. Micronodular cirrhosis of liver, gross [MRI]  - from alcoholism
                13. Micronodular cirrhosis and fatty change of liver, gross [CT]  - from alcoholism
                14. Micronodular cirrhosis and fatty change of liver, gross  - from alcoholism
                15. Micronodular cirrhosis and fatty change of liver, gross  - from alcoholism
                9. Macronodular cirrhosis of liver, gross - from hepatitis
                10. Macronodular cirrhosis of liver, gross - from hepatitis
                11. Macronodular cirrhosis of liver, gross - from hepatitis

* What is responsible for the lumpy edge of the cirrhotic liver? (pp. 56, 385)

Metastatic Cancer - Liver with Metastatic Colonic Cancer (Fig. 8-8, p. 114)

Note the many large lobules scattered within the normal liver tissue. These are metastases from a primary cancer of the colon. The liver is a common site for metastases from various types of cancer, including cancer of the GI tract, breast, pancreas and lung.

44. Metastatic adenocarcinoma, liver, gross [CT]
45. Metastatic adenocarcinoma, liver, gross
46. Metastatic adenocarcinoma, liver, gross [CT]
47. Metastatic adenocarcinoma, liver, microscopic*

* What are 3 possible routes cancer cells may follow when they metastasize to distant organs? (pp. 112-113)

* Which route do you think the colon cancer cells followed to arrive in this liver? (p. 370, Fig. 27-2)

Gall Stones - Dried gall stones - (pp. 40-41, Fig. 3-10)

There are several different types of gall stones from different people. Notice the different sizes, shapes, colors and textures of the various gall stones. These differences are due in part to the different causes for formation of stones and the different materials contained in the stones. (Fig. 3-10, p. 40.)

            1. Normal gallbladder, gross
            12. Normal common bile duct, gross
            5. Cholelithiasis, gallbladder, gross [CT]
            6. Cholelithiasis, gallbladder, gross
            7. Cholelithiasis with chronic cholecystitis, gallbladder, gross
            8. Porcelain gallbladder, gross
            13. Biliary tract lithiasis, diagram
            19. GIF animation showing complications of biliary tract lithiasis
            18. Intrahepatic lithiasis, liver, gross
            16. Cholestasis of liver, microscopic*
            15. Obstructive jaundice, medium power, microscopic*

* What are 3 different substances found in gall stones? (p. 391)

* Name the 2 most common complications caused by gall stones. (p. 392)

* What is the technical name for having gall stones in the gall bladder? (p. 391)

* What is the relationship between gall stones and pancreatitis? (p. 392-393)

Cirrhosis of the Liver (pp. 368-372, 385-391)

Gloria is a 35 year old housewife admitted with hepatic coma. She has had numerous hospitalizations since age 19, usually for psychosomatic and nervous disorders. She has 3 children and her husband is an executive of a large corporation. Although she admits to drinking socially, she denies alcoholism and denies drinking more than 3 oz alcohol per day.

Review of old records reveals progressive weakness, weight loss, anorexia, jaundice, edema, ascites and mental disorientation. In the past four years, she has refused treatment except in crises.

On admission, Gloria is stuporous, hypotensive, has twitching and a flapping tremor. She is a thin, malnourished female who looks more than her stated age. Signs and symptoms noted included : marked edema of the lower extremities, ascites, jaundice, spider angiomas, bruising throughout the body, and palpable spleen and liver.

Previous liver biopsies indicated:

At age 29 : fatty liver
At age 31 : cirrhosis

Present Laboratory Values: Gloria's Values Normal values

Total Bilirubin : 11 mg/100 ml 0.1-1.0 mg/100 ml
Serum enzymes:
SGOT 180 U/ml 5-40 U/ml
SGPT 525 U/ml 5-35 U/ml
LDH 450 U/ml 90-200 U/ml
Serum ammonia: 220 mg/100 ml 50-170 mg/100 ml

Discussion Questions

*1. What are possible causes of cirrhosis? What type of cirrhosis does Gloria have? (pp. 385-386).

*2. What correlations exist between malnutrition and alcoholism? (p. 385).

*3. Describe the pathophysiological changes that occur in the liver as cirrhosis develops and explain the results of her two liver biopsies. (p. 385).

*4. List the signs and symptoms of liver failure apparent in Gloria. For each, explain the pathophysiological basis. (pp. 386-388).

*5. Explain the significance of the results of her laboratory values. (pp. 372-375, Table 27-2).

*6. What is the etiology of hepatic coma? (pp. 372-375, Fig. 27-9).

*7. Gloria was being closely observed for the possibility of gastrointestinal bleeding. Why would this be considered as a possible complication? (pp. 388-389, Fig. 27-7).

*8. In the early stages of cirrhosis, what can be done to control the disease? (p. 385).