Surgical Pathology: Liver, Biliary Tree and Pancreas. Lecture by NCS done Sept. 24/14 - AUF SOM, 3rd year medicine

1. Surgical Pathology of LIVER,
BILIARY TREE and PANCREAS
BY: NOEL C. SANTOS, MD

2. LEARNING OBJECTIVES
• Know the indications of doing biopsy, types of biopsy
• Familiarize with the conditions that needed a biopsy for definitive
diagnosis and predict the clinical outcome
• Familiarize with the terms used in the assessment of various
conditions
• Know the approach in diagnosing masses

3. LIVER
• Involved in wide variety of non-neoplastic and neoplastic conditions
• Indications for doing biopsy
• Assess severity of liver disease - medical
• Assess the nature of space occupying lesion - surgical
• Evaluate prior to transplantation
• Types of biopsy
• NEEDLE BIOPSY (Fine or Core), usually guided biopsy
• TISSUE BIOPSY – during laparotomy

4. MEDICAL LIVER DISEASES
• Grading and Staging in Chronic Viral Hepatitis, Cirrhosis
• Metabolic Disorders: Hemochromatosis, Wilson, Reye’s syndrome,
Acute Fatty Liver of Pregnancy, Alpha 1-Antitrypsin deficiency
• Obstructive Jaundice

5. Viral hepatitis, liver, gross
• Grossly, there are areas of necrosis and collapse of liver lobules seen here as
ill-defined areas that are pale yellow. Such necrosis occurs with hepatitis.

6. Viral hepatitis, liver, gross
• The necrosis and lobular collapse is seen here as areas of hemorrhage
and irregular furrows and granularity on the cut surface of the liver.

7. Viral hepatitis B, liver, low power microscopic
• Viral hepatitis leads to liver cell destruction. A mononuclear inflammatory cell infiltrate
extends from portal areas and disrupts the limiting plate of hepatocytes which are
undergoing necrosis, the so-called "piecemeal" necrosis of chronic active hepatitis.

8. Viral hepatitis B, liver, high power microscopic
• Individual hepatocytes are affected by viral hepatitis. A large pink cell
undergoing "ballooning degeneration" is seen below the right arrow. At a
later stage, a dying hepatocyte is seen shrinking down to form an eosinophilic
"councilman body" below the arrow on the left.

9. Viral hepatitis C, liver, high power microscopic
• The extent of chronic hepatitis can be graded by the degree of activity (necrosis and inflammation) and
staged by the degree of fibrosis. In this case, necrosis and inflammation are prominent, and there is some
steatosis. Regardless of the grade or stage, the etiology of the hepatitis must be sought, for the treatment
may depend upon knowing the cause, and chronic liver diseases of different etiologies may appear
microscopically and grossly similar.

10. Viral hepatitis C, liver, low power microscopic
• A case of viral hepatitis which is at a high stage with extensive
fibrosis and progression to macronodular cirrhosis.

11. Alpha-1-antitrypsin deficiency, liver, PAS stain, microscopic
• The periportal red hyaline globules seen here with periodic acid-Schiff (PAS) stain are
characteristic for alpha-1-antitrypsin (AAT) deficiency. The globules are collections of
alpha-1-antitrypsin not being excreted from hepatocytes. This may eventually lead to
chronic hepatitis and cirrhosis.

12. MRI Cirrhosis

13. Micronodular cirrhosis

14. Micronodular cirrhosis:

15. Macronodular Cirrhosis

16. Hemochromatosis of liver, gross
• The dark brown color of the liver, as well as the pancreas (bottom center) and lymph nodes
(bottom right) on sectioning is due to extensive iron deposition in a middle-aged man with
hereditary hemochromatosis (HHC).

18. Hemochromatosis Prussian blue stain for Iron

19. Alcoholic Fatty Liver

20. Alcoholic Fatty Liver

21. SURGICAL LIVER DISEASES
• Space occupying lesions
• Primary Tumors
• Metastatic Lesions
Examples:
- Focal Nodular Hyperplasia (FNH)
- Adenoma
- Hepatocellular Carcinoma
- Cholangiocarcinoma
- Metastatic Carcinoma/Sarcoma
- Pediatric Tumors: Hepatoblastoma
- Bile Duct Hamartomas and Adenomas

38. GALL BLADDER
• Commonly removed with Cholelithiasis
• Acute obstruction, distention, perforation/rupture
• Tumors – uncommon
• benign (polyps)
• malignant (cholangiocarcinoma)
• Documentation: legal, insurance

43. Pancreas pseudocyst
Local accumulation of pancreatic juice - occur after
pancreatitis
Pancreas - abscess
Occur after pancreatitis,
Cause : colliquation necrosis
Sterile, in case, no secondary infection occurs

45. Tumors of the pancreas
Benign
Malignant
Causative agents
smoking
alcohol
high energy diet

46. Benign tumors of the pancreas
Serous cystadenoma
Cystic teratoma
Lymphangioma
Insuloma
Mesenchymal tumors

47. Pancreas carcinoma – symptoms
(head-tail)
Jaundice - Curvoisier sign
Weight loss
Pain
Passage disturbances
Migrating thrombophlebitis (Trousseau)
Pancreatitis
Metastasis

48. Pancreatic Carcinoma
• Incidence has increased since 1950s
• Smoking tobacco is the strongest associated feature;
weak alcohol effect
• Coffee is not shown to increase risk
• Genetics: BRCA and hereditary pancreatitis
• Survival: 1 year – 10%; 5 years – 2.5%

49. HEAD
~70%
BODY
5-10%
TAIL
10-15%

50. Pancreatic Carcinoma

53. Islet cell tumors
Hormone production in 50% of the cases
Uncertain biological behaviour
Round, well circumscribed lesions
Insulinoma
Glucagonoma
VIP-oma
Gastrinoma
Somatostatinoma