LIVER AND BILIARY DISEASE
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

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Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!

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More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
Inflammation
Fluids
Genes
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Autoimmunity
Other Immune
HIV infections
The Anti-Immunization Activists
Infancy and Childhood
Aging
Infections
Nutrition
Environmental Lung Disease
Violence, Accidents, Poisoning
Heart
Vessels
Respiratory
Red Cells
White Cells
Coagulation
Oral Cavity
GI Tract
Liver
Pancreas (including Diabetes)
Kidney
Bladder
Men
Women
Breast
Pituitary
Thyroid
Adrenal and Thymus
Bones
Joints
Muscles
Skin
Nervous System
Eye
Ear
Autopsy
Lab Profiling
Blood Component Therapy
Serum Proteins
Renal Function Tests
Adrenal Testing
Arthritis Labs
Glucose Testing
Liver Testing
Porphyria
Urinalysis
Spinal Fluid
Lab Problem
Quackery
Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

LEARNING OBJECTIVES

KCUMB Students
"Big Robbins" -- Liver / Biliary
Lectures follow Textbook

QUIZBANK: Liver and biliary (all)

Liver / Pancreas
Taiwanese pathology site
Good place to go to practice

Liver and Biliary Tract
Photo Library of Pathology
U. of Tokushima

Liver Pathology
Photomicrograph collection
In Portuguese

Hepatobiliary
Iowa Virtual Microscopy
Have fun

Hepatobiliary Diseases

Chaing Mi, Thailand

Pathology of liver/pancreas infections
Great site
Yutaka Tsutsumi MD

Hepatobiliary
Brown Digital Pathology
Some nice cases

Gross Liver Photos
U. of Pittsburgh
Great pictures

Liver
Photos, explanations, and quiz
Indiana U.

Liver
Webpath
University of Utah

Hepatitis-Like Lesions
Histopathology and essay
For pathologists

Liver Exhibit
Virtual Pathology Museum
University of Connecticut

Liver Transplant Pictures
Great site
Transplant Pathology Internet Services

Lacerated liver
Car wreck
WebPath Photo

Liver in place
Autopsy photo
WebPath

PARTIAL GLOSSARY

{12220}    jaundice

Cholestasis of liver
Bile accumulation
WebPath

Intrahepatic lithiasis
Intrahepatic bile duct obstruction
WebPath

Bile plugs
Cholestasis
WebPath Photo

Cirrhosis
WebPath

Cirrhosis of the Liver
Australian Pathology Museum
High-tech gross photos

Hepatic cirrhosis
Trichrome stain
KU Collection

Liver Cirrhosis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

{12220}    jaundice

Jaundice

WebPath Photo

Liver
Gross photo
WebPath

Liver
normal histology
WebPath

INTRODUCTION

Is life worth living? It depends on the liver!

WHEN THE LIVER FAILS

{01383}    Alzheimer II glia in hepatic encephalopathy (best one is in the center of the field; it appears as a swollen, pale nucleus)

CIRRHOSIS

{00005}    cirrhosis
{08846}    cirrhosis, trichrome stain (fibrous tissue is blue, of course); micronodular
{39710}    cirrhosis after hepatitis, gross photo showing uneven involvement of the liver lobules. Just recognize cirrhosis.

{08285}    micronodular cirrhosis (this happens to have been a case of primary biliary cirrhosis); liver on left is normal

Micronodular cirrhosis
Urbana Atlas of Pathology

Micronodular cirrhosis
Chronic alcoholism
WebPath

MRI photo, cirrhosis
small nodular liver
WebPath

Micronodular cirrhosis and fatty change
Alcoholism
WebPath

CT scan with contrast
Small liver with cirrhosis
WebPath

Micronodular cirrhosis
Fatty change
WebPath

Micronodular cirrhosis
Fatty change
WebPath

Micronodular cirrhosis
Urbana Atlas of Pathology

Cirrhosis I
From Chile
In Spanish

Cirrhosis II
From Chile
In Spanish

{08441}    macronodular cirrhosis

Macronodular cirrhosis
Necrosis and fibrosis
WebPath

Macronodular cirrhosis
WebPath

{25659}    macronodular cirrhosis (some big scars show progression to postnecrotic cirrhosis)

CIRCULATORY PROBLEMS

    CONGESTION of the liver receives excessive attention. There's no mystery; if the right side of the heart isn't pumping well enough, blood pools in the liver.

      Except in the most sudden violent deaths, the central areas of the liver will be more or less congested. (If you're at an autopsy and someone asks, "Is that a nutmeg liver?", you can safely guess "Yes!")

      Clinicians enjoy showing the hepatojugular reflux of those with congested livers, especially behind failing right ventricles. Pathologists enjoy exhibiting their cut nutmegs, which have light-and-dark areas that resemble congested liver.

      * If you want to get fancy... instead of demonstrating hepatojugular reflux, you can now use a high-tech device to assess the "stiffness" of the liver, which is of course increased in the living when they have congestive heart failure in the absence of co-existing cirrhosis (Radiology 257: 872, 2010).

{03949}    nutmeg liver
{31889}    nutmeg, real

Nutmeg and nutmeg liver
Someone really had fun
making this photo!

Congested liver
Great labels
Romanian Pathology Atlas

Congested liver, live cells in zone 1
Slide from Andrea McCollum MD
Cuyahoga County Coroner's Office

Congested liver, dead cells in zone 3
Slide from Andrea McCollum MD
Cuyahoga County Coroner's Office

Chronic passive congestion
Nutmeg liver
WebPath

Chronic passive congestion
WebPath

Chronic passive congestion
"Cardiac cirrhosis"
WebPath

Infarcted liver
WebPath

{49262}    Budd-Chiari; liver is engorged with blood and you can see the clots;

{07020}    carbon tetrachloride, gross; note the necrosis (yellow, of course)
{07022}    carbon tetrachloride, microscopic

Necrosis with acetaminophen overdose
"Limp liver"
WebPath

{07023}    liver showing phosphorus poisoning; note periportal necrosis

INFECTIONS

{05961}    acute viral hepatitis with Councilman body
{08834}    acute viral hepatitis; sinusoids are not visible, lots of inflammatory cells
{11787}    acute viral hepatitis, great bile plugging
{12764}    acute viral hepatitis
{12758}    acute viral hepatitis
{12767}    acute viral hepatitis
{12770}    acute viral hepatitis (do you see a Councilman body?)
{12773}    acute viral hepatitis
{12776}    acute viral hepatitis

Hepatitis I
From Chile
In Spanish

Hepatitis II
From Chile
In Spanish

Hepatitis III
From Chile
In Spanish

Hepatitis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Viral hepatitis
WebPath

Viral hepatitis
Necrosis and lobular collapse
WebPath

Viral hepatitis B
Low power
WebPath

Viral hepatitis B
High power
WebPath

Viral hepatitis C
Low power
WebPath

Viral hepatitis C
High power
WebPath

Viral hepatitis with collapse
Trichrome stain
WebPath

{13320}    massive necrosis after hepatitis, gross (nothing left but the reticulin and endothelial framework!)
{13321}    massive necrosis after hepatitis, histology
{13322}    massive necrosis after hepatitis, histology

Fulminant hepatitis
Bridging
Pittsburgh Pathology Cases

{12779}    mild chronic hepatitis, story
{12785}    mild chronic hepatitis, H&E (not a very good case, since lymphocytes are very few, and a portal area is not even shown; indistinguishable from mild acute hepatitis)
{12788}    mild chronic hepatitis, reticulin stain (see the limiting plate intact); you don't need to tell this isn't normal liver;
{12791}    mild chronic hepatitis, trichrome (again, see the limiting plate intact); again, you can't tell this isn't normal liver;

{12800}    severe chronic hepatitis, piecemeal necrosis
{12803}    severe chronic hepatitis; subtle
{20328}    severe chronic hepatitis; almost to cirrhosis (the nodules are not yet completely separate)
{40279}    severe chronic hepatitis, note the necrotic cells
{20183}    severe chronic hepatitis with good bridging necrosis; the hepatocytes are stained orange and the bridge is an area of lytic necrosis

"Moderate" chronic hepatitis
Great labels
Romanian Pathology Atlas

Hepatitis C
Joel K. Greenson MD
U. of Michigan


{00444}    hepatitis A virus
{08173}    hepatitis A virus

{00445}    hepatitis B virus
{08175}    hepatitis B virus
{10532}    hepatitis B, * orcein stain (stains the virus)
{11708}    hepatitis B, core antigen stained in nuclei

Cirrhosis from hepatitis C
Pittsburgh Illustrated Case

CHRONIC HEPATITIS NOT CAUSED BY VIRUSES

{24568}    primary biliary cirrhosis, early; cirrhosis has not really developed yet, but portal areas are inflamed; you could not tell at this magnification that this is primary biliary cirrhosis
{24569}    primary biliary cirrhosis, histology (i.e., the bile duct is gone)

Secondary biliary cirrhosis
Great labels
Romanian Pathology Atlas

Primary biliary cirrhosis
Joel K. Greenson MD
U. of Michigan


Primary biliary cirrhosis
Chronic inflammatory infiltrate
WebPath

Anti-mitochondrial antibody
Immunofluorescence
WebPath

CHOLANGITIS

Amebic Liver Abscess
CDC
Wikimedia Commons

Amebic liver abscess

Yutaka Tsutsumi MD

Chronic ductopenic rejection
No inflammation, just no ducts
Joel K. Greenson MD, U. of Michigan


Primary sclerosing cholangitis
Onion-skinning around bile duct
KU Collection

Sclerosing cholangitis
Trichrome stain
WebPath

Sclerosing cholangitis
WebPath

{19381}    ascites
{05952}    ascites in a known cirrhotic
{05953}    ascites in a known cirrhotic

Caput medusae
Caused by cirrhosis
WebPath

Esophageal varices
Dilated submucosal veins
WebPath

Splenomegaly with portal hypertension
(Ignore the "hyaline perisplenitis")
WebPath

ALCOHOLIC LIVER DISEASE (Lancet 345: 227, 1995; Mayo Clin. Proc. 76: 1021, 2001)    

Fatty change, liver
Great labels
Romanian Pathology Atlas

Fatty metamorphosis
H & E stain
WebPath

Fatty metamorphosis
Cross section
WebPath

Fatty liver
Double normal weight
KU Collection

Fatty liver

KU Collection

Fatty metamorphosis
Lipid vacuoles
WebPath

Fatty liver

WebPath Photo

Mallory's hyaline
"Alcoholic" hyaline
WebPath

Acute alcoholic hepatitis
"Binge" drinkers
WebPath

Mallory's alcoholic hyaline

WebPath Photo

Cirrhosis

WebPath Photo

Alcoholic liver disease
Joel K. Greenson MD
U. of Michigan


Fatty liver
Alcohol vs. NASH
Wikimedia Commons

Microvesicular steatosis
Substance abuser
KCUMB Team

Woe to those who demand strong drink as soon as they rise in the morning, and linger into the night while wine inflames them!

Sir, I have known more old drunkards than old doctors.

Wine god's procession
"The Wine God's Procession"

{49271}    fatty cirrhotic liver vs. normal

{39929}    alcoholic hepatitis, good Mallory's hyaline
{26702}    alcoholic hepatitis, good Mallory's hyaline
{08832}    alcoholic hepatitis with fibrosis; there is no good hyaline; cells are becoming entrapped in the fibrous tissue
{21056}    "alcoholic hepatitis", looks like early cirrhosis to me
{26693}    "alcoholic hepatitis", looks like early cirrhosis to me

Alcoholic hepatitis
Alabama
Wikimedia Commons

{10538}    alcoholic cirrhosis, gross
{10844}    alcoholic cirrhosis, gross
{18795}    alcoholic cirrhosis, gross
{20163}    alcoholic cirrhosis, histology; trichrome stain
{08835}    alcoholic cirrhosis
{40412}    alcoholic cirrhosis
{10535}    "alcoholic cirrhosis" closeup of a lobule; note the Mallory's hyaline and the neutrophils attacking it. There may be fibrosis elsewhere, but this merely looks like alcoholic hepatitis.
{39593}    alcoholic cirrhosis; lots of bile duct proliferation (as is usual in alcoholic cirrhosis); edge of a nodule on each side of the screen

    * During the early 1990's, liver transplants for alcoholic liver disease got discussed as showcasing problems with our "no-guilt" / "you have a right" ideas. "Unconstitutional discrimination and a violation of the Americans with Disabilities Act" or not (the story of Mr. Bush's 1992 policy change is now history), good used livers and other resources are (as always) in limited supply. See Gastroent. 102: 1806, 1992 (the now-famous Pittsburgh study), JAMA 265: 1295, 1991; JAMA 266: 213, 1991; Br. Med. J. 299: 693, 1989. Half of alcoholics who receive liver transplants return to problem drinking within one year (Gut 43: 140, 1998), but the good news is that they seldom wreck their new livers in doing so (Gut 45: 421, 1999). In the late 20th century, a few philosophers continued to maintain that alcoholics "may justifiably be given lower priority than others in receiving these [limited] resources" (J. Med. Philos. 23: 31, 1998). However, the most recent article I could find was in Transplant International 14: 170, 2001 (essentially, lifelong alcoholics are no more responsible for their ruined livers than are babies with biliary atresia). Uh, sure. The "ethical debate" seems to be over and alcoholics are competing on an equal basis for liver transplants with the dying babies. The third-party payers now require six months of abstinence from alcohol, which is unverifiable and unenforcable (J. Med. Ethics 32: 263, 2006) -- and a large percentage return to alcohol abuse when they get their new liver. Update from the ethicists NEJM 365: 1836, 2011. ("We only transplant alcoholics who are sobered up, have a strong support network, and no major psychopathology.") Of course, an alcoholic might get some slight sympathy if someone who ruined their liver doing intravenous drugs or sexual promiscuity or taking medicines with suicidal intent (Liver Trans 17: 1111, 2011) gets priority. Especially if we continue to make it difficult to obtain organs for transplantation, this will eventually start getting media attention -- the truth is that I'm surprised it hasn't already. Strangely, having been a marijuana smoker absolutely disqualifies people from receiving a liver transplant in most jurisdictions (Curr. Op. Org. Transpl. 15: 249, 2010) although there is evidence that this does not have any negative impact on people before or after transplant. Tobacco smokers may or may not be barred from receiving a liver; they do worse than non-smokers. Nowadays, anyone with enough money can go to China and come back with a new liver from an executed prisoner (Clin. Transp. 23: 831, 2009); a few "moral high ground" ethicists say it's immoral for US physicians to treat people who have done this (Am. J. Bioethics 10: 3, 2010) -- what do you think?

NON-ALCOHOLIC FATTY LIVER DISEASE -- non-alcoholic steatohepatitis, NASH, non-alcoholic fatty liver diseae, NAFLD (Am. Fam. Phys. 73: 1961, 2006; pathologists see Am. J. Clin. Path. 128: 837, 2007; J. Clin. Path. 60: 1384, 2007; Gastroent. 134: 1682, 2008; NEJM 363: 1341, 2010); BMJ 343: d3897, 2011; Gut 60: 1152, 2011 -- "what's new under the microscope")

IRON OVERLOAD (update NEJM 350: 2383, 2004; Gastroenterology 139: 393, 2010; NEJM 366: 348, 2012; Dig. Dis. Sci. 57: 2988, 2012)

{49253}    hemochromatosis causing cirrhosis (Prussian Blue stain, of course)

Pathology of Iron Metabolism
WebPath Tutorial

Hemochromatosis
Liver, H&E stain
KU Collection

Hemosiderosis of liver
WebPath

Hemochromatosis of liver
WebPath

Hereditary hemochromatosis
Cirrhosis
WebPath

Hemosiderosis of liver
Prussian blue stain
WebPath

Hemochromatosis
Joel K. Greenson MD
U. of Michigan


Hemochromatosis
Pittsburgh Pathology Cases

Pathology of Iron Metabolism
WebPath Tutorial

Hemochromatosis
Pittsburgh Illustrated Case

WILSON'S DISEASE ("hepatolenticular degeneration"; Mayo Clin. Proc. 78: 1126, 2003; Gastroent. 125: 1868, 2003; Lancet 369: 379, 2007)

{00018}    Wilson's

Wilson's disease
Joel K. Greenson MD
U. of Michigan


HEPATIC AMYLOIDOSIS: We cover this in "immuno". Amyloid accumulates in the vessels and space of Disse, and can eventually give a large, very firm liver that usually still functions acceptably. Past concerns about biopsying the liver in suspected amyloidosis seem to be groundless (Medicine 82: 291, 2003).

{53548}    amyloid in the liver

Amyloidosis of the liver
Joel K. Greenson MD
U. of Michigan


LIVER POISONS

{24392}    "Halothane hepatitis" case; simply massive necrosis

REYE'S SYNDROME (Am. Fam. Phys. 50(7): 1491, 1994; NEJM 340: 1423, 1999; NEJM 340: 1377, 1999)

Reye's Liver
CDC
Wikimedia Commons

PEDIATRIC LIVER DISEASE

Biliary atresia
WebPath

Biliary atresia
Hepatic fibrosis
WebPath

{38758}    neonatal hepatitis, gross
{38761}    neonatal hepatitis, microscopic; with giant cells and bile stasis

Neonatal giant cell hepatitis
Idiopathic or viral
WebPath

{46222}    herpes simplex hepatitis, gross; trust me; all that you can appreciate is severe injury
{46223}    herpes simples hepatitis, microscopic (note the cell with two nuclei and herpes intranuclear inclusions)

{20137}    cirrhosis, galactosemia (* future pathologists: Note the "flowers" formed by hepatocytes in this condition)
{13301}    cirrhosis, alpha-1 antitrypsin deficiency (trust me)
{13302}    cirrhosis, alpha-1 antitrypsin deficiency (trust me)
{13304}    cirrhosis, alpha-1 antitrypsin deficiency; PAS stain shows alpha-1 antitrypsin granules well

Alpha-1-antitrypsin deficiency
PAS stain
WebPath

LIVER TRANSPLANT PATHOLOGY (update J. Clin. Path. 63: 47, 2010)

BENIGN LIVER MASSES

Liver Tumors I
From Chile
In Spanish

Liver Tumors II
From Chile
In Spanish

Liver hemangioma
Pittsburgh Pathology Cases

Polycystic changes in the liver
Transverse CT scan
WebPath

Dominant polycystic kidney disease
with polycystic liver
WebPath

Liver adenoma
Photo is too poor to r/h FHN
WebPath Photo

Hepatic adenoma
WebPath

Hepatic adenoma
Cut surface
WebPath

Hepatic adenoma
WebPath

PRIMARY CANCERS OF THE LIVER (i.e., the hepatocytes, the intrahepatic bile ducts, and the sinusoidal lining cells)

    HEPATOCELLULAR CARCINOMA ("hepatoma", "Mickey Mantle's disease"): A deadly disease, killing at least half a million people yearly around the world, clearly caused, in the large majority of cases, by longstanding infestation with hepatitis B and/or C viruses and/or iron overload. Reviews: Lancet 362: 1907, 2003; NEJM 365: 1118, 2011.
Mickey Mantle
Mickey Mantle

{18799}    hepatocellular carcinoma in macronodular cirrhosis; hepatocellular carcinomas are white
{24571}    hepatocellular carcinoma in cirrhosis
{39624}    hepatocellular carcinoma in cirrhosis
{39708}    hepatocellular carcinoma in cirrhosis
{40330}    hepatocellular carcinoma in cirrhosis
{40331}    hepatocellular carcinoma histology (one of many variants)

Hepatocellular carcinoma
in lymphatic vessels
KCUMB Team

Hepatocellular carcinoma
Anaplasia, no sinusoids; hep C
KCUMB Team

Hepatocellular carcinoma with
admixture of cholaniocarcinoma
KCUMB Team

Hepatocellular carcinoma
Great labels
Romanian Pathology Atlas

Hepatocellular carcinoma
Arising in post-necrotic cirrhosis
KU Collection

Hepatocellular carcinoma
Bizarre hepatocytes
KU Collection

Hepatocellular carcinoma
Satellite nodules
WebPath

Hepatocellular carcinoma
WebPath

Hepatocellular carcinoma
WebPath

Hepatocellular carcinoma
WebPath

Hepatocellular carcinoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Hepatocellular carcinoma
H&E, nice bile production
Wikimedia Commons

Hepatocellular carcinoma
Joel K. Greenson MD
U. of Michigan


Hepatocellular carcinoma
Ed Uthman MD
Wikimedia Commons

Hepatocellular carcinoma
Ed Uthman MD
Wikimedia Commons

Hepatocellular carcinoma
H&E
Wikimedia Commons

Biliary Tumors
From Chile
In Spanish

Cholangiocarcinoma
WebPath

Liver Metastases
Tom Demark's Site

Metastatic adenocarcinoma
WebPath

Metastatic adenocarcinoma
CT scan without contrast
WebPath

Metastatic adenocarcinoma
WebPath

Metastatic adenocarcinoma
CT scan with contrast
WebPath

Metastatic adenocarcinoma
Infiltrating ductal carcinoma
WebPath

Primary lymphoma of the liver
Pittsburgh Pathology Cases

Liver metastases
Oat cell
X-ray from NEJM

Metastases to Liver
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Liver metastases, renal cell carcinoma
AFIP
Wikimedia Commons

Liver metastases
Primary was pancreas
Wikimedia Commons

FOR FUTURE LIVER PATHOLOGISTS AND EXAM-TAKERS:

Centrilobular necrosis
Lipofuscin
WebPath

Lipofuscin pigment in liver
WebPath

Hepatocellular carcinoma
Chronic alcoholism and viral hepatitis
WebPath

Yolk sac carcinoma
Liver
Pittsburgh Pathology Cases

BILE DRAINAGE SYSTEM

Gall Bladder Images
University of Washington
Pictures and comments

{15774}    normal gallbladder, from the outside
{15775}    normal gallbladder, opened up to show mucosa
{08820}    "normal gallbladder" with Rokitansky-Aschoff sinuses; lumen and mucosa on right
{15287}    normal gallbladder

{00041}    faceted, mostly-cholesterol stones; despite the black bilirubinate coating, the large size and smooth faceted surfaces say "cholesterol" is their major component
{08425}    gallstone city!
{17591}    gallstone city!

Gallstones
From Chile
In Spanish

{18772}    bilirubin stones

{10544}    common duct stone
{49247}    common duct stones; common bile duct has been opened. Liver at top

{49181}    gallstone ileus
{49182}    gallstone ileus

{49242}    cholecystitis, acute-on-chronic

Cholecystitis
From Chile
In Spanish

{08822}    chronic cholecystitis, histology

Acute-On-Chronic Cholecystitis
Australian Pathology Museum
High-tech gross photos

{13362}    strawberry gallbladder ("cholesterolosis"), gross
{08108}    strawberry gallbladder, histology; foam cells (phagocytic macrophages) contain cholesterol

{38827}    hydrops ("mucocele") of the gallbladder

{26327}    adenocarcinoma of the gallbladder, gross
{26330}    adenocarcinoma of the gallbladder
{26333}    adenocarcinoma of the gallbladder
{49249}    adenocarcinoma of the gallbladder
{38821}    adenocarcinoma of the gallbladder, with stones
{38824}    adenocarcinoma of the gallbladder, no stones

*  *  * 

Future surgeons: COURVOISIER'S LAW!

Explanation:

To date, there is no established role for "alternative and complementary medicines" in the treatment of any liver disease, though it's possible some of the herbal remedies might have some effect. A famous and elaborate protocol by a naturopath for treatment of chronic hepatitis C, which centers around a very special recipe for breakfast museli, led to drops in transaminase levels but he made no effort to control for the fact that he also made his patients stop drinking alcohol. This invites an obvious conclusion. Plus, the risk of hepatotoxicity from herbal concoctions is well-known. See Liver Int. 23: 213, 2003; Lancet 361: 101, 2003; Med. J. Aust. 178: 442, 2003; Clin. Liver Dis. 7: 453, 2003; Clin. Tox. 46: 819, 2008 (from Hong Kong, where the problem is horrible.) In Korea, use of "alternative medicine" seems to be the most common cause of elevated liver enzymes in breast cancer patients (J. Kor. Med. Sci. 19: 397, 2004). In Oregon, "complementary herbal remedies" are now THE cause of massive hepatic necrosis requiring transplantation, exceeding even acetaminophen overdoses and all the viruses combined. (Arch. Surg. 138: 852, 2003). Even the much-touted "milk thistle" (silibindin; review Am. Fam. Phys. 72: 1285, 2005), though non-toxic, hasn't shown any robust evidence of working (Am. J. Med. 113: 506, 2002). There is a recent positive report for hepatitis C (Gastroent. 135: 1561, 2008) and another for NASH (Dig. Dis. Sci. 2387, 2007); both are small overseas studies. The pediatric oncologists at Columbia tried it for controlling the hepatotoxicity of chemotherapy; the milk-thistle group seemed to show a barely-significant benefit by measuring liver enzymes (Cancer 116: 506, 2010) -- milk thistle supposedly competes with other toxins for uptake by hepatocytes, so perhaps this is why the benefit (Eur. J. Emerg. Med. 17: 17, 2010.) Another failure, this time for hepatitis C under treatment: JAMA 308: 274, 2012.

* SLICE OF LIFE REVIEW

{08820}    gall bladder, normal
{08826}    liver, normal
{11798}    liver, normal
{11807}    liver, normal
{14874}    liver, porcine
{14875}    liver human, normal
{14875}    liver human, normal
{14876}    liver human, normal, central vein
{14876}    liver human, normal
{14877}    liver (sinusoids), normal
{14877}    liver (sinusoids), normal
{14878}    liver (sinusoids), normal, space of Disse
{14878}    liver (sinusoids), normal
{14879}    liver, portal triad
{14880}    liver, portal triad; a=vein, b=duct
{14883}    gallbladder, normal
{14885}    gallbladder (epithelium), normal
{15104}    liver
{15105}    liver
{15106}    liver
{15107}    liver, pig
{15281}    liver, normal
{15281}    liver, normal
{15282}    liver, normal
{15282}    liver, normal
{15283}    liver, normal
{15283}    liver, normal; a=vein, b=artery, c=duct
{15284}    liver, pig
{15285}    liver, pig
{15286}    gall bladder, normal
{15286}    gall bladder, normal
{15287}    gall bladder, normal
{15287}    gall bladder, normal
{15288}    gall bladder, normal
{15288}    gall bladder, normal
{15773}    gall bladder, normal
{15774}    gall bladder, normal
{15775}    gall bladder, normal
{15776}    liver, normal
{15778}    liver, normal
{16043}    liver, normal in fetus
{16074}    necrosis, liver junct.; normal
{17592}    gallbladder, normal
{19721}    gall bladder, normal
{20888}    liver, portal triad
{20889}    liver, portal vein
{20890}    liver, hepatic artery
{20891}    liver, bile duce
{20892}    liver, hepatocyte plate
{20893}    liver, central vein
{20894}    liver, central vein
{20895}    liver, portal triad
{20896}    liver, portal triad and central vein
{20897}    gall bladder
{26039}    liver, normal
{26042}    hepatocytes, normal aspirate
{26045}    hepatocytes, normal aspirate
{39498}    liver, normal
{39764}    liver, normal

I hate liver, liver makes me quiver,
liver makes me curl right up and die, makes me cry...
it gives you hives, gives you scurvy, turns my stomach topsy turvy,
liver just simply ain't my bag, makes me gag, makes me want to throw up...
Now liver is neither solid or liquid, but merely an amorphous, viscous colloid of putrid protein...
It is located between the 7th and the 10th dorsal vertebrae,
JUST south of the diaphragm, "lounging like a worm on a pillow of fat."
Now did you ever look at the word liver?
Is it any coincidence that there are 5 letters in the word liver?
The same number of letters as in the word death? the word drugs? the word hippy?...

Well, maybe you just haven't had it cooked right...

Naaah, I've had that stuff sauteed, I've had it breaded and broiled and broasted and braised,
I've had it diced and sliced and riced and sunnyside up over easy fried, and it still comes out, LIVER....
I hate liver, liver makes me quiver, liver makes me curl right up and die, (makes me cry)...
Why, first time I had it, I didn't like it at all...

Well, what happened?

Well, I was about 9 months..my mammy gave me a hunk of that Gerber's baby food.
Well, I rolled it around, looked at her eyeballs, spit it out and uttered my first words...

At nine months, what'd you say?

I said... I hate liver, liver makes me quiver,
liver makes me curl right up and die, makes me cry...
it gives you hives, gives you scurvy, turns my stomach topsy turvy,
liver just simply ain't my bag.

BIBLIOGRAPHY / FURTHER READING

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