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Home > Student Cases > Cirrhosis of the liver

Cirrhosis of the liver

cirrhosis specimen

Inferior surface of the liver.

cirrhosis specimen

Cut surface of the liver.

Clinical data

  • This patient was a 31 year old man with a 3 month history of abdominal swelling, epigastric pain, weight loss and jaundice.
  • He drank 3 bottles of wine a day.
  • On examination he had gross ascites and hepatomegaly.
  • A week after admission he had an episode of haematemesis and gastroscopy showed that he was bleeding from oesophageal varices.
  • Despite sclerotherapy he had repeated episodes of bleeding and developed signs of liver and respiratory failure.

Some laboratory investigations

  • Chemistry
    • albumin ↓
    • AST and ALP ↑
    • Total and conjugated bilirubin ↑
    • Alpha-foeto protein ↑↑
  • Virology
    • Hepatitis B surface antigen positive

Pathology

  • At autopsy the liver weighed 2530g (normal ± 1500g).
  • It is diffusely riddled with nodules, compatible with cirrhosis.

Pathology of cirrhosis liver

 

  • On the cut surface it can be seen that the nodules are mostly >3mm and up to 1cm in size, so this is predominantly a macronodular cirrhosis.

 

  • A close up of an area in the right lobe shows that quite a few nodules have a suspicious fleshy appearance.

nodules


Histology

  • Microscopy confirmed the macroscopic appearance of cirrhosis.
  • In addition there was extensive replacement by poorly differentiated hepatocellular carcinoma.

A few notes on cirrhosis

  • Cirrhosis is a response to diffuse injury of the liver parenchyma.
  • It is characterised by two main processes 
    • constrictive fibrous scarring (fibrosis) and 
    • regenerative activity 

which together result in the nodularity.

  • The architecture of the entire liver and its vasculature is disrupted.

liver biopsy

  • This fragment of cirrhotic liver was sampled by liver biopsy.
  • Fibrous septae (staining red) surround regenerative nodules of liver cells.

  • The normal liver lobule structure is distorted. 
  • Portal tracts have largely been obliterated by the fibrosis. 
    • the obstructed portal circulation leads to portal hypertension.
  • The central venule of each liver lobule has disappeared.
    • the disrupted lobular circulation leads to hepatic dysfunction.

A few notes on hepatocellular carcinoma (HCC)

liver specimen

  • HCC often presents as a single large liver mass

liver specimen

  • or may have a multifocal origin, as in this case.
  • It often but not always arises in a cirrhotic liver.
  • Accumulation of DNA mutations during repeated cycles of regenerative cell division is an important factor in the pathogenesis of HCC. 

Aetiology and local epidemiology

  • The most important causes of both cirrhosis and HCC are alcohol and chronic viral hepatitis (B & C).
  • Sub-Saharan Africa has historically had a high prevalence of hepatitis B (± 10%) and consequently a high incidence of HCC (29 per 100 000 in South Africa, 113 per 100 000 in Moçambique). 
  • In this context HCC presents in young adults (20 - 40 years, more often male) who have acquired hepatitis B in childhood or even in utero.
  • The inclusion of the hepatitis B vaccine in the childhood immunisation programme in South Africa since 1995 will almost certainly reduce viral cirrhosis and HCC over time.

Related specimens in the collection

XVIII:viii:39
A typical fatty liver from a patient with high alcohol intake. Early changes of cirrhosis were seen on microscopy.

fatty liver


XVIII:viii:34 
Predominantly micronodular cirrhosis typical of alcoholic liver disease.
micronodular cirrhosis

XVIII:ix:4 
Hepatocellular carcinoma occurring as a single large nodule with a few daughter nodules.

Hepatocellular carcinoma


References & links

  • Kew, MC. Progress towards the comprehensive control of hepatitis B in Africa: a view from South Africa. Gut, 1996; 38 (Suppl 2):S31-S36
  • To reinforce what you have learned here, look at the first 19 images of the section on Hepatic Pathology in WebPath      http://library.med.utah.edu/WebPath/LIVEHTML/LIVERIDX.html#1
 

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