Liver and Biliary Pathology Practice Questions

Q: A 58-year-old male with history of multiple sexual partners presented with anorexia and jaundice. The biopsy shows ground-glass opacity in the cells. What is the most probable diagnosis?

Hepatitis B. ***Hepatitis B***- The biopsy finding of **ground-glass opacity** in hepatocytes is pathognomonic for chronic **Hepatitis B Virus (HBV)** infection, caused by the accumulation of **Hepatitis B surface antigen (HBsAg)** in the endoplasmic reticulum [1].- The patient's presentation of jaundice and anorexia, combined with the risk factor of **multiple sexual partners**, is highly suggestive of HBV transmission [3].*Hepatitis A*- Hepatitis A is transmitted via the **fecal-oral route** and rarely leads to chronic liver disease, making it unlikely given the patient's risk profile and chronic signs [2].- Histologically, it causes predominantly **acute panlobular hepatitis** without the distinguishing ground-glass inclusions.*Hepatitis C*- Histologic evaluation of Hepatitis C often reveals **lymphoid aggregates** within the portal tracts and prominent **steatosis** (fatty change), rather than ground-glass inclusions [1].- While transmitted parenterally and potentially sexually, the absence of the characteristic HCV histological features makes this diagnosis less likely.*Hepatitis D*- Hepatitis D is a **defective virus** requiring co-infection or superinfection with **Hepatitis B** for replication.- Although often co-existing with HBV, the specific **ground-glass appearance** results from the accumulation of **HBsAg**, the protein produced primarily by the Hepatitis B virus [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 843-844. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 844-845. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 838.

Q: Comment on the diagnosis of the gallbladder specimen provided: (Recent NEET Pattern 2016-17)

Cholesterolosis. ***Cholesterolosis*** - This condition is characterized by the accumulation of **cholesterol esters** within the macrophages in the lamina propria of the gallbladder wall. - Grossly, it appears as **yellow specks or streaks** on the mucosal surface, often described as a "strawberry gallbladder" due to the resemblance to strawberry seeds. *Cholesterol polyposis* - While cholesterolosis involves diffuse mucosal changes, **cholesterol polyps** are discrete, sessile or pedunculated lesions composed of cholesterol-laden macrophages. - These are typically single or few, rather than the widespread "strawberry" appearance seen in cholesterolosis. *Cholecystitis glandularis proliferans* - This is a rare, benign proliferative lesion of the gallbladder characterized by **hyperplasia of the mucosal glands** and muscularis, often forming intramural diverticula (Rokitansky-Aschoff sinuses) [1]. - It does not primarily involve cholesterol deposition and has a different macroscopic appearance. *Diverticulosis of gallbladder* - Diverticulosis of the gallbladder refers to the presence of **multiple outpouchings or diverticula** from the gallbladder wall. - These are typically **Rokitansky-Aschoff sinuses** [1], which are invaginations of the mucosa through the muscular layer, and are not primarily characterized by cholesterol deposition. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 404-405.

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.

Question 1

Vinyl chloride exposure is associated with which of the following malignancies?

Accepted Answer

Angiosarcoma of the liver

Answer

Angiofibroma of the nose

Answer

Hepatocellular carcinoma

Answer

Transitional cell carcinoma of the bladder

Question 2

A 58-year-old male with history of multiple sexual partners presented with anorexia and jaundice. The biopsy shows ground-glass opacity in the cells. What is the most probable diagnosis?

Accepted Answer

Hepatitis B

Answer

Hepatitis D

Answer

Hepatitis A

Answer

Hepatitis C

Question 3

A liver biopsy shows ballooning degeneration of hepatocytes, Mallory-Denk bodies, and neutrophilic infiltration. The patient has a history of chronic alcohol abuse. What is the most likely diagnosis?

Accepted Answer

Alcoholic hepatitis

Answer

Viral hepatitis B

Answer

Primary biliary cholangitis

Answer

Non-alcoholic steatohepatitis (NASH)

Question 4

Comment on the diagnosis of the gallbladder specimen provided: (Recent NEET Pattern 2016-17)

Accepted Answer

Cholesterolosis

Answer

Cholesterol polyposis

Answer

Cholecystitis glandularis proliferans

Answer

Diverticulosis of gallbladder

Question 5

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 6

All are true about this liver specimen except:

Accepted Answer

Siderofibrotic nodules

Answer

Centrilobular hemorrhagic necrosis

Answer

Fatty change

Answer

Centrilobular fibrosis

Question 7

The following liver specimen shows:

Accepted Answer

Nutmeg liver

Answer

Post necrotic cirrhosis

Answer

Dubin-Johnson syndrome

Answer

Miliary TB

Question 8

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 9

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 10

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

Liver and Biliary Pathology — MCQs

Liver and Biliary Pathology — MCQs

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