Liver and Biliary Pathology Practice Questions

Q: A patient with symptomatic cholecystitis underwent a cholecystectomy. The following specimen was obtained. What is the diagnosis?

Gallbladder polyps. ***Gallbladder polyps*** - The image likely shows multiple, small, sessile or pedunculated lesions projecting from the gallbladder mucosa, which are characteristic features of **gallbladder polyps**. - These polyps are often discovered incidentally during cholecystectomy for symptomatic cholecystitis [1][2], as they can sometimes cause symptoms or are found alongside other gallbladder pathologies. *Gallbladder cancer* - **Gallbladder cancer** typically presents as a single, large, irregular mass that infiltrates the gallbladder wall, often with evidence of invasion into surrounding tissues [3]. - While it can be associated with cholecystitis, the image described (multiple, small lesions) is not typical for advanced gallbladder carcinoma [3]. *Cholesterolosis* - **Cholesterolosis**, also known as "strawberry gallbladder," is characterized by the accumulation of cholesterol esters in the macrophages within the lamina propria, giving the mucosa a yellow, speckled appearance. - It does not typically present as distinct, projecting polyps but rather as diffuse mucosal changes. *Strawberry bladder* - **Strawberry bladder** is a colloquial term for **cholesterolosis** of the gallbladder, referring to its speckled, yellow-red appearance due to cholesterol deposits. - This condition involves diffuse mucosal changes rather than discrete polypoid lesions. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 883-886. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 883-884. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 886.

Q: All are true about this liver specimen except:

Siderofibrotic nodules. ***Siderofibrotic nodules*** - **Siderofibrotic nodules** (also known as **Gamna-Gandy bodies**) are typically found in the **spleen** due to chronic venous congestion, not the liver. - Their presence in a liver specimen would be an unusual finding, making this the incorrect statement about a typical liver specimen with the described changes. *Centrilobular hemorrhagic necrosis* - This is a common finding in conditions causing **hypoxia** or **venous congestion** in the liver, such as **right-sided heart failure** or **Budd-Chiari syndrome** [1]. - The centrilobular zone (Zone 3) is most susceptible to ischemic injury due to its distance from the hepatic artery [2]. *Fatty change* - **Fatty change** (steatosis) is a very common finding in the liver, associated with conditions like **alcohol abuse**, **obesity**, **diabetes**, and **metabolic syndrome** [3]. - It involves the accumulation of **triglycerides** within hepatocytes. *Centrilobular fibrosis* - **Centrilobular fibrosis** can occur as a consequence of chronic injury, particularly in conditions like **alcoholic liver disease** or **chronic passive congestion** [1]. - It represents the deposition of **collagen** around the central veins. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 869-870. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 828. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 388-389.

Q: The following liver specimen shows:

Nutmeg liver. ***Nutmeg liver*** - **Nutmeg liver** is a gross pathological appearance of the liver due to **chronic passive congestion**, often seen in **right-sided heart failure** [1]. - The variegated appearance resembles a nutmeg due to alternating areas of **congested centrilobular veins** (darker) and **unaffected periportal areas** (lighter) [1][2]. *Post necrotic cirrhosis* - **Post necrotic cirrhosis** is characterized by broad fibrous bands and large regenerative nodules, often following massive hepatic necrosis. - The gross appearance would typically show a **shrunken, nodular liver** with extensive fibrosis, not the specific variegated pattern of nutmeg liver. *Dubin-Johnson syndrome* - **Dubin-Johnson syndrome** is a hereditary disorder causing conjugated hyperbilirubinemia due to impaired bilirubin excretion. - The liver is typically **macroscopically black** due to the accumulation of a dark pigment (epinephrine metabolites) within hepatocytes, which is distinct from the nutmeg appearance. *Miliary TB* - **Miliary tuberculosis** of the liver presents with numerous small, scattered **granulomas** (tubercles) throughout the liver parenchyma [3]. - Grossly, this would appear as **multiple tiny, pale nodules** resembling millet seeds, not the characteristic congested pattern of nutmeg liver. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, p. 126. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 870-872. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 401-402.

Q: The liver specimen is diagnostic of:

Nutmeg liver. ***Nutmeg liver*** - This term describes the gross appearance of a liver affected by **chronic passive congestion**, often due to right-sided heart failure [1][3]. - The mottled appearance resembles a cut nutmeg, with dark, congested central veins and paler, fatty peripheral zones [1][2][3]. *Post necrotic cirrhosis* - This is a type of **cirrhosis** resulting from massive or submassive hepatic necrosis, often due to viral hepatitis or drug toxicity. - Histologically, it shows broad bands of fibrosis with regenerating nodules, not the characteristic congestion pattern of nutmeg liver. *Chronic venous congestion of liver* - While "nutmeg liver" is the gross appearance of chronic venous congestion, this option is less specific [2]. - The term "nutmeg liver" specifically refers to the **macroscopic appearance** caused by this congestion [1][3]. *Dubin-Johnson syndrome* - This is a rare, benign, inherited disorder causing **direct hyperbilirubinemia** due to a defect in bilirubin excretion. - The liver appears **black** grossly due to the accumulation of a dark pigment in hepatocytes, which is distinct from the nutmeg appearance. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, p. 126. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 401-402. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 870-872.

Q: All are true about the marking X in histopathological specimen from a patient of fatty liver except:

Intranuclear inclusions. ***Best visualized with masson trichrome*** - The marking 'X' refers to **Mallory bodies** (also known as Mallory's hyaline or alcoholic hyaline) [1]. - Mallory bodies are **eosinophilic cytoplasmic inclusions** and are best visualized with **hematoxylin and eosin (H&E) stain**, not Masson trichrome. Masson trichrome is used to highlight **collagen** (fibrosis) [2]. *Eosinophilic aggregates of prekeratin* - Mallory bodies are indeed **eosinophilic aggregates** composed primarily of **intermediate filaments**, including **prekeratin** (cytokeratin 8 and 18) [3]. - This description accurately characterizes the composition and staining properties of Mallory bodies. *Intranuclear inclusions* - Mallory bodies are **cytoplasmic inclusions**, not intranuclear [1][3]. - Intranuclear inclusions are typically associated with viral infections (e.g., CMV, herpes) or certain genetic disorders. *Also seen in Indian childhood cirrhosis* - Mallory bodies are a characteristic feature of **alcoholic liver disease** but can also be found in other conditions, including **non-alcoholic steatohepatitis (NASH)**, **Wilson's disease**, **cholestasis**, and **Indian childhood cirrhosis** [1]. - Their presence in Indian childhood cirrhosis is a known histopathological finding. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 388-389. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 848-850. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 852.

Q: The marking X in a histopathological specimen from a patient of fatty liver shows:

Mallory hyaline body. ***Mallory hyaline body*** - **Mallory hyaline bodies** (also known as Mallory-Denk bodies) are characteristic eosinophilic cytoplasmic inclusions found in hepatocytes, often seen in **alcoholic fatty liver disease** and other forms of liver injury [1]. - They are composed of tangled intermediate filaments, primarily **keratin 8 and 18**, and indicate hepatocyte damage [1]. *Councilman body* - **Councilman bodies** are apoptotic hepatocytes, appearing as intensely eosinophilic, shrunken cells with condensed nuclei. - They are typically seen in conditions with widespread hepatocyte apoptosis, such as **viral hepatitis** or **yellow fever**, not specifically fatty liver. *Russell body* - **Russell bodies** are eosinophilic, spherical inclusions found within the cytoplasm of **plasma cells**. - They represent an accumulation of **immunoglobulins** within the endoplasmic reticulum and are associated with chronic inflammation or plasma cell dyscrasias, not liver pathology. *Normal Kupffer cell* - **Kupffer cells** are resident macrophages of the liver, located in the sinusoids. - While they are normal components of liver histology, they do not appear as specific "bodies" or inclusions indicative of fatty liver disease; rather, they are involved in phagocytosis and immune responses. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 852-854. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 388-389.

Q: A 30-year-old shepherd presents with painless hepatomegaly. Peripheral blood work shows eosinophilia. The histopathological slide of surgically removed cyst shows a marking X. This denotes:

Hydatid sand. ***Hydatid sand*** - The clinical presentation of painless hepatomegaly in a shepherd with eosinophilia is highly suggestive of **hydatid cyst (Echinococcosis)**. - **Hydatid sand** refers to the granular material found in hydatid cysts, consisting of **protoscolices**, hooklets, and calcareous corpuscles, which are diagnostic on histopathology [1]. *Blood capsule* - This term is not typically used in the context of hydatid cysts or their histopathology. - It does not describe a specific component of a hydatid cyst. *Endocyst* - The **endocyst** (or germinal layer) is the inner, nucleated layer of the hydatid cyst that produces the protoscolices and hydatid fluid [1]. - While part of the cyst, it is a layer, not the granular material referred to as "marking X" in the context of diagnostic findings. *Ectocyst* - The **ectocyst** (or laminated layer) is the acellular, chitinous, and elastic outer layer of the hydatid cyst, surrounding the endocyst [1]. - It is a structural component of the cyst wall, not the diagnostic granular material found within the cyst fluid. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, pp. 404-405.

Q: A 20-year-old college student presents with 7 day history of nausea and feeling feverish. He has tenderness in right upper quadrant and admits to high risk sexual behavior. The liver biopsy marking $X$ shows:

Councilman body. ***Councilman body*** - The clinical presentation (nausea, fever, RUQ tenderness, high-risk sexual behavior) is highly suggestive of **acute viral hepatitis**, likely **Hepatitis B** given the risk factors. - **Councilman bodies** (also known as **apoptotic bodies**) are characteristic findings in acute viral hepatitis, representing **apoptotic hepatocytes** [1]. *Mallory hyaline body* - **Mallory bodies** (or **Mallory-Denk bodies**) are typically seen in **alcoholic hepatitis** and other forms of **chronic liver injury**, not acute viral hepatitis [2]. - They are composed of **intermediate filaments** (cytokeratins) and other proteins, indicating hepatocyte damage. *Russell body* - **Russell bodies** are **eosinophilic inclusions** found within the cytoplasm of **plasma cells**, representing **accumulations of immunoglobulins**. - They are associated with conditions involving plasma cell proliferation, such as **multiple myeloma**, and are not a feature of acute viral hepatitis. *Normal kupffer cell* - **Kupffer cells** are **resident macrophages** of the liver and are normally present in the sinusoids. - While they play a role in inflammation, their presence alone as "normal" does not represent the specific pathological change expected in acute viral hepatitis, which is hepatocyte apoptosis [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 386-387. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 389-390.

Q: A 54-year-old chronic alcoholic died due to a liver disease. His pathological specimen is provided in the image below. The most likely diagnosis is:

Cirrhosis. ***Cirrhosis*** - The image of the liver from a chronic alcoholic, showing a **nodular, shrunken appearance**, is highly characteristic of **cirrhosis** [1][2]. - **Cirrhosis** is the end-stage of chronic liver disease, marked by widespread **fibrosis** and the formation of **regenerative nodules**, leading to impaired liver function [1][2]. *Focal nodular hyperplasia* - This is a **benign liver lesion** typically characterized by a **central stellate scar** and radiating fibrous septa, which is not consistent with the generalized nodularity seen in the image of a cirrhotic liver. - It usually occurs in otherwise healthy livers and is not directly linked to chronic alcoholism or diffuse liver failure. *Alcoholic fatty liver* - **Alcoholic fatty liver** (steatosis) is an early, usually reversible, stage of alcoholic liver disease characterized by **lipid accumulation** in hepatocytes, making the liver enlarged and greasy, but not typically shrunken and nodular [3]. - While it can progress to more severe forms, the image depicts the advanced, fibrotic changes of cirrhosis rather than simple steatosis [3]. *Hemangioma* - A **hemangioma** is a **benign vascular tumor** of the liver, appearing as a well-circumscribed, often dark red, spongy mass composed of blood vessels. - It presents as a focal lesion and does not cause the diffuse, nodular, and shrunken appearance of the entire liver seen in the image, which is indicative of widespread parenchymal damage. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 850. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 395-396. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 848.

Q: A 14-year-old male child presents with right upper quadrant pain, his pathological presentation is given in the image. Which one of the following statements is false?

This is radio-opaque in nature. ***This is radio-opaque in nature*** - **Pigment stones**, specifically **black pigment stones**, are typically **radio-lucent** or only faintly radio-opaque, making this statement false [1]. - Their radio-opacity is due to calcium content, but it's usually insufficient to be clearly visible on plain X-rays. *Composed of calcium bilirubinate* - **Black pigment stones** are primarily composed of **calcium bilirubinate** and small amounts of calcium phosphate and calcium carbonate [2][3]. - They form when there is an excess of unconjugated bilirubin in the bile, often due to hemolytic conditions [1]. *This is associated with hemolytic disorders* - **Black pigment stones** are strongly associated with conditions causing **chronic hemolysis**, such as **hereditary spherocytosis** or **sickle cell anemia** [1]. - Increased breakdown of red blood cells leads to elevated unconjugated bilirubin, which then precipitates in the gallbladder [1]. *Soft and crumble easily* - **Black pigment stones** are typically **small, multiple, and brittle**, often described as soft and crumbling easily. - This characteristic texture distinguishes them from cholesterol stones, which are usually harder. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 882-883. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 862. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 882.

Question 1

A patient with symptomatic cholecystitis underwent a cholecystectomy. The following specimen was obtained. What is the diagnosis?

Accepted Answer

Gallbladder polyps

Answer

Gallbladder cancer

Answer

Cholesterolosis

Answer

Adenomyomatosis

Question 2

All are true about this liver specimen except:

Accepted Answer

Siderofibrotic nodules

Answer

Centrilobular hemorrhagic necrosis

Answer

Fatty change

Answer

Centrilobular fibrosis

Question 3

The following liver specimen shows:

Accepted Answer

Nutmeg liver

Answer

Post necrotic cirrhosis

Answer

Dubin-Johnson syndrome

Answer

Miliary TB

Question 4

The liver specimen is diagnostic of:

Accepted Answer

Nutmeg liver

Answer

Post necrotic cirrhosis

Answer

Chronic venous congestion of liver

Answer

Dubin-Johnson syndrome

Question 5

All are true about the marking X in histopathological specimen from a patient of fatty liver except:

Accepted Answer

Intranuclear inclusions

Answer

Eosinophilic aggregates of prekeratin

Answer

Best visualized with masson trichrome

Answer

Also seen in Indian childhood cirrhosis

Question 6

The marking X in a histopathological specimen from a patient of fatty liver shows:

Accepted Answer

Mallory hyaline body

Answer

Councilman body

Answer

Russell body

Answer

Normal Kupffer cell

Question 7

A 30-year-old shepherd presents with painless hepatomegaly. Peripheral blood work shows eosinophilia. The histopathological slide of surgically removed cyst shows a marking X. This denotes:

Accepted Answer

Hydatid sand

Answer

Endocyst

Answer

Ectocyst

Answer

Brood capsule

Question 8

A 20-year-old college student presents with 7 day history of nausea and feeling feverish. He has tenderness in right upper quadrant and admits to high risk sexual behavior. The liver biopsy marking $X$ shows:

Accepted Answer

Councilman body

Answer

Mallory hyaline body

Answer

Russell body

Answer

Normal kupffer cell

Question 9

A 54-year-old chronic alcoholic died due to a liver disease. His pathological specimen is provided in the image below. The most likely diagnosis is:

Accepted Answer

Cirrhosis

Answer

Hemangioma

Answer

Focal nodular hyperplasia

Answer

Alcoholic fatty liver

Question 10

A 14-year-old male child presents with right upper quadrant pain, his pathological presentation is given in the image. Which one of the following statements is false?

Accepted Answer

This is radio-opaque in nature

Answer

Composed of calcium bilirubinate

Answer

This is associated with hemolytic disorders

Answer

Soft and crumble easily

Liver and Biliary Pathology — MCQs

Liver and Biliary Pathology — MCQs

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