Liver and Biliary Pathology Practice Questions

Q: A 32-year-old male with a history of klebsiella infection presents with right upper quadrant pain and on performing cholecystectomy the following stones were seen. All the following statements are true regarding this condition except: (Recent NEET Pattern 2016-17)

It is composed of calcium palmitate. ***It is composed of calcium palmitate*** - The gallstones formed in the context of **Klebsiella infection** and **beta-glucuronidase** activity are typically **pigment stones**, specifically **brown pigment stones** [1]. - Brown pigment stones are primarily composed of **calcium bilirubinate** and not calcium palmitate . *This condition is a resultant of secretion of beta glucuronidase* - **Bacterial infection**, particularly with *Klebsiella*, can lead to the production of **beta-glucuronidase** [1]. - This enzyme deconjugates **bilirubin glucuronide** in bile, making it insoluble and promoting the formation of **calcium bilirubinate stones** [1]. *Initiating factor could be ascaris worm* - **Parasitic infections**, such as those by **Ascaris lumbricoides**, can act as a nidus for stone formation in the biliary tree. - The presence of the worm or its eggs can lead to **biliary stasis** and recurrent infections, contributing to pigment stone formation. *This is radiolucent in nature* - **Pigment gallstones**, including brown pigment stones, are generally **radiolucent** on plain X-rays. - This is because they contain little to no calcium carbonate, which is required for radiopacity. **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. 882.

Q: What type of gallstones are shown in the image from a patient with history of acute cholecystitis?

Cholesterol stones. ***Cholesterol stones*** - The image distinctly shows multiple, **yellowish, translucent stones** within the gallbladder, which are characteristic macroscopic features of **cholesterol gallstones**. - These stones are formed due to an imbalance in bile composition, specifically **supersaturation of cholesterol**, and are the most common type of gallstone associated with acute cholecystitis. *Black pigment stones* - These stones are typically **small, rigid, and dark** (black to dark brown) in color, often resembling gravel. - They are composed primarily of **unconjugated bilirubin polymer** and calcium salts, and are commonly seen in conditions like **hemolytic anemias** or cirrhosis. *Strawberry gallbladder* - This is a condition called **cholesterolosis**, where cholesterol deposits accumulate within the gallbladder mucosa, giving it a **strawberry-like appearance** due to prominent yellow flecks against a red background. - While it involves cholesterol, it refers to the mucosal changes, not the presence of discrete, large stones in the lumen. *Brown pigmented stones* - Brown pigment stones are soft, greasy, and tend to be **laminated**. They are primarily composed of **calcium bilirubinate** and fatty acid calcium salts. - They are typically associated with **biliary tract infections** and stasis, and are often seen in the bile ducts rather than solely in the gallbladder.

Q: All are true about the sectioned slice of liver except:

Changes are irreversible. ***Changes are irreversible*** - **Fatty change** (steatosis) in the liver, which is the most likely condition described by the other options, is generally considered a **reversible** process if the underlying cause is removed [1][2]. - Irreversible changes typically refer to processes leading to **cell death** or **fibrosis/cirrhosis**, which are not directly implied by the description of a sectioned slice with fat accumulation. *Occurs due to intracellular accumulation of triglycerides* - **Fatty liver** (steatosis) is indeed characterized by the **intracellular accumulation of triglycerides** within hepatocytes [2][3]. - This accumulation can be due to various causes, including alcohol, obesity, and metabolic syndrome. *H and E stain results in non-staining vacuoles* - In **fatty liver**, the accumulated lipids are dissolved during tissue processing for H&E staining, leaving behind **empty, clear vacuoles** within the hepatocytes [1][2]. - These vacuoles appear **non-staining** because the lipid content is lost. *Tense glistening capsule with rounded margins* - A liver with significant **fatty change** often appears **enlarged**, with a **tense, glistening capsule** and **rounded margins** due to the increased volume from lipid accumulation [2]. - This macroscopic appearance is characteristic of a steatotic liver. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Cellular Responses to Stress and Toxic Insults: Adaptation, Injury, and Death, pp. 51-53. [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: Identify the stain shown in the liver section.

Gordon and Sweet's reticulin stain. ***Gordon and Sweet's reticulin stain*** - The image shows **reticular fibers** in the liver, which appear as a delicate, branching network stained in **black**. This pattern is characteristic of a reticulin stain. - Reticulin stains are used to evaluate the **hepatic architecture** and detect its disruption in various liver diseases like cirrhosis. *Warthin starry* - The **Warthin-Starry stain** is primarily used to detect **spirochetes** (e.g., *Treponema pallidum* for syphilis) and certain bacteria like *Helicobacter pylori*. - It would show these organisms as black or brown, usually in a tissue section, but not the widespread network of reticular fibers seen here. *Steiner silver stain* - The **Steiner silver stain** is another type of silver impregnation stain used to detect **spirochetes** and other microorganisms, similar to Warthin-Starry. - It would not highlight the reticular fiber network of the liver in this specific pattern. *Grimelius silver stain* - The **Grimelius silver stain** is used to identify **neuroendocrine cells** and their granules, especially in tumors like carcinoids. - It stains the argyrophilic granules within these cells dark brown or black, which is distinct from the reticular network observed in the image.

Q: Which of the following is NOT correct for ‘strawberry gall bladder’?

It is a malignant condition of gall bladder. ***It is a malignant condition of gall bladder*** - **Strawberry gallbladder**, also known as **cholesterolosis**, is a **benign** condition where cholesterol esters accumulate in the macrophages within the lamina propria of the gallbladder wall. - It is **not cancerous** and does not lead to malignancy. *It may be associated with cholesterol Stones* - **Cholesterolosis** is often associated with a higher incidence of **cholesterol gallstones (cholelithiasis)**, as both conditions involve abnormal cholesterol metabolism [1]. - The accumulation of cholesterol in the gallbladder wall can sometimes precede or coincide with the formation of cholesterol stones within the lumen [1]. *Simple cholecystectomy is the treatment of choice* - For symptomatic **cholesterolosis**, especially when associated with pain or recurrent biliary colic, **cholecystectomy** (surgical removal of the gallbladder) is the standard and effective treatment. - Asymptomatic cases generally do not require treatment. *It has submucous aggregation of cholesterol crystals* - The characteristic appearance of **"strawberry gallbladder"** is due to the macroscopic visualization of yellow, lipid-laden macrophages aggregated within the **lamina propria** (a layer beneath the mucous membrane), appearing as tiny yellow flecks against a red mucosal background. - These aggregates contain **cholesterol esters**, which can crystallize. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 882.

Q: Which of the following statements regarding hepatic adenomas are correct? 1. They are almost exclusively seen in females aged 25-50 years 2. They are associated with the use of oral contraceptive pills 3. They do not have any malignant potential 4. Majority are detected incidentally on imaging

1, 2 and 4. ***1, 2 and 4*** - **Hepatic adenomas** are indeed almost exclusively seen in **females aged 25-50 years**, primarily due to their association with hormonal factors. - They are strongly associated with the use of **oral contraceptive pills** (OCPs) and other exogenous estrogens [1]. - The majority of hepatic adenomas are detected **incidentally on imaging** performed for other reasons, as they are often asymptomatic unless complications arise. - While most hepatic adenomas are benign, they do carry a **risk of malignant transformation**, particularly larger lesions or certain subtypes [1]. *2, 3 and 4* - This option incorrectly states that hepatic adenomas **do not have any malignant potential**; however, certain subtypes and larger adenomas can undergo malignant transformation [1]. - The other statements regarding association with OCPs and incidental detection are correct. *1, 3 and 4* - This choice incorrectly claims that hepatic adenomas **do not have any malignant potential**, which is false as there is a recognized risk of transformation to **hepatocellular carcinoma** [1]. - It also omits the correct statement about their association with OCPs. *1, 2 and 3* - This option incorrectly asserts that hepatic adenomas **do not have any malignant potential**, which contradicts current medical understanding as they can transform into **hepatocellular carcinoma** [1]. - It also omits the common finding that they are often detected incidentally. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 874-875.

Q: A chronic alcoholic patient presents with increasing abdominal girth. A liver biopsy reveals reddish inclusions within the hepatocytes. What are these inclusions composed of?

Intermediate filaments. ***Intermediate filaments*** - In chronic alcoholic patients, reddish inclusions within hepatocytes are characteristic of **Mallory bodies** (also known as alcoholic hyaline) [1]. - Mallory bodies are aggregates of **intermediate filaments**, specifically **cytokeratin filaments**, that have been damaged. *Hemosiderin* - **Hemosiderin** is an iron-storage complex and appears as **golden-brown granules** within cells [1]. - While iron overload can occur in alcoholic liver disease, hemosiderin is not the primary component of the reddish inclusions described as Mallory bodies. *Triglycerides* - **Triglycerides** accumulate in hepatocytes in **fatty liver disease** (steatosis), which is common in alcoholics [1]. - These appear as clear lipid vacuoles rather than reddish inclusions. *Glycogen* - **Glycogen** is a branched polysaccharide of glucose, found in the cytoplasm, and appears as clear vacuoles or small, periodic acid-Schiff (PAS)-positive granules. - Hepatic glycogen accumulation is not described as reddish inclusions in the context of alcoholic liver disease. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 388-390.

Question 1

A 32-year-old male with a history of klebsiella infection presents with right upper quadrant pain and on performing cholecystectomy the following stones were seen. All the following statements are true regarding this condition except: (Recent NEET Pattern 2016-17)

Accepted Answer

It is composed of calcium palmitate

Answer

This condition is a resultant of secretion of beta glucuronidase

Answer

Initiating factor could be ascaris worm

Answer

This is radiolucent in nature

Question 2

What type of gallstones are shown in the image from a patient with history of acute cholecystitis?

Accepted Answer

Cholesterol stones

Answer

Black pigment stones

Answer

Strawberry gallbladder

Answer

Brown pigmented stones

Question 3

A liver biopsy reveals following findings. What is true about this condition?

Accepted Answer

Nutmeg liver with dark areas of perivenular dead hepatocytes and grey areas of periportal viable hepatocytes

Answer

Nodular regenerative hyperplasia of liver induced due to OCPs

Answer

Nutmeg liver with pale areas of necrosis and dark congested areas of perivenular viable hepatocytes

Answer

Cirrhotic liver with fibrotic nodules

Question 4

All are true about the sectioned slice of liver except:

Accepted Answer

Changes are irreversible

Answer

Occurs due to intracellular accumulation of triglycerides

Answer

H and E stain results in non-staining vacuoles

Answer

Tense glistening capsule with rounded margins

Question 5

Identify the stain shown in the liver section.

Accepted Answer

Gordon and Sweet's reticulin stain

Answer

Warthin starry

Answer

Steiner silver stain

Answer

Grimelius silver stain

Question 6

Consider the following:

1. Cholesterolosis
2. Adenomyomatosis
3. Polyposis
4. Cholelithiasis

To which of the above does cholecystoses refer to?

Accepted Answer

1 and 2 only

Answer

1 and 3 only

Answer

1, 2 and 3

Answer

2, 3 and 4

Question 7

Which of the following is NOT correct for ‘strawberry gall bladder’?

Accepted Answer

It is a malignant condition of gall bladder

Answer

It may be associated with cholesterol Stones

Answer

Simple cholecystectomy is the treatment of choice

Answer

It has submucous aggregation of cholesterol crystals

Question 8

Which of the following statements regarding hepatic adenomas are correct?

1. They are almost exclusively seen in females aged 25-50 years

2. They are associated with the use of oral contraceptive pills

3. They do not have any malignant potential

4. Majority are detected incidentally on imaging

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 3

Question 9

A chronic alcoholic patient presents with increasing abdominal girth. A liver biopsy reveals reddish inclusions within the hepatocytes. What are these inclusions composed of?

Accepted Answer

Intermediate filaments

Answer

Hemosiderin

Answer

Triglycerides

Answer

Glycogen

Question 10

A 65-year-old man comes to the clinic complaining of abdominal pain for the past 2 months. He describes the pain as a dull, aching, 6/10 pain that is diffuse but worse in the right upper quadrant (RUQ). His past medical history is significant for diabetes controlled with metformin and a cholecystectomy 10 years ago. He reports fatigue and a 10-lb weight loss over the past month that he attributes to poor appetite; he denies fever, nausea/vomiting, palpitations, chest pain, or bowel changes. Physical examination is significant for mild scleral icterus and tenderness at the RUQ. Further workup reveals a high-grade malignant vascular neoplasm of the liver. What relevant detail would you expect to find in this patient’s history?

Accepted Answer

Prior occupation in a chemical plastics manufacturing facility

Answer

Chronic alcohol abuse

Answer

Heavy ingestion of acetaminophen

Answer

Infection with the hepatitis B virus

Answer

Obesity

Liver and Biliary Pathology — MCQs

Liver and Biliary Pathology — MCQs

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