LEARNER OBJECTIVES
At the completion of this chapter, the learner will be able to:
Section 1: Liver Structure and Function
1.1 Describe the normal anatomic structure of the liver.
1.2 Explain hepatobiliary function, including metabolism, drug disposition, and bile
formation.
Section 2: Approach to the Patient with Liver Disease
2.1 List the major clinical manifestations of liver disease.
2.2 Define jaundice.
2.3 Describe pathophysiologic mechanisms of jaundice.
2.4 Discuss the laboratory, radiologic, and histologic tests used to evaluate for the
presence of liver disease.
2.5 List indications for liver biopsy.
2.6 Explain the clinical approach to diagnosing liver disease.
Section 3: Congenital Hyperbilirubinemia
3.1 Discuss unconjugated hyperbilirubinemia, including Gilbert's syndrome and
Crigler-Najjar syndrome.
3.2 Describe two conditions characterized by conjugated hyperbilirubinemia: the
Dubin-Johnson syndrome and Rotor's syndrome.
Section 4: Acute Viral Hepatitis
4.1 Define hepatitis.
4.2 Discuss the causes of acute hepatitis.
4.3 Explain the clinical manifestations of hepatitis A, B, and C.
4.4 Describe the diagnostic tests for acute viral hepatitis.
4.5 Discuss complications associated with acute viral hepatitis.
4.6 Explain the indications for hepatitis A and B vaccination.
Section 5: Chronic Hepatitis
5.1 Define chronic hepatitis.
5.2 List the causes of chronic hepatitis.
5.3 Describe the histologic features of mild, moderate, and severe chronic hepatitis.
5.4 Differentiate between chronic viral hepatitis B and C with respect to
presentation, diagnosis, treatment, and prognosis.
5.5 Differentiate between viral and alcoholic hepatitis, including history, diagnosis,
and treatment.
5.6 Describe autoimmune hepatitis.
Section 6: Alcoholic Liver Disease
6.1 Discuss the spectrum of alcoholic liver disease.
6.2 Explain alcoholic hepatitis, including clinical presentation, diagnostic findings,
and prognosis.
6.3 Discuss alcoholic cirrhosis, including clinical presentation, histological
findings, prognosis, and management.
Section 7: Drug-Induced Liver Disease
7.1 Discuss the different types and pathogenesis of drug-induced liver disease.
7.2 Explain acute hepatocellular injury, including toxic necrosis and acute hepatitis.
7.3 Discuss two forms of cholestasis: inflammatory type and pure non-inflammatory
type.
Section 8: Inherited Liver Disease
8.1 Define the following, including definition, histology, presenting symptoms,
diagnostic procedures, and treatment:
a. Hemochromatosis
b. Alpha1-antitrypsin deficiency
c. Wilson's disease
Section 9: Cholestasis
9.1 Define cholestasis.
9.2 List the main causes of cholestasis.
9.3 Define primary biliary cirrhosis (PBC), including diagnosis and management.
9.4 Explain secondary biliary cirrhosis.
9.5 Discuss the clinical approach to the patient with cholestasis.
Section 10: Cirrhosis of the Liver
10.1 Define cirrhosis of the liver.
10.2 List the causes of cirrhosis.
10.3 Discuss the clinical features of cirrhosis.
10.4 Explain Child-Pugh classification.
10.5 Discuss the treatment of cirrhosis.
Section 11: Portal Hypertension
11.1 Define portal hypertension.
11.2 List the causes of portal hypertension.
11.3 Discuss the pathophysiology, diagnosis, and management of portal
hypertension.
Section 12: Ascites
12.1 Define ascites.
12.2 Discuss the pathogenesis of ascites.
12.3 Discuss the differential diagnosis of ascites.
12.4 Discuss the physical exam techniques used to detect ascites.
12.5 Discuss how paracentesis may help distinguish the various causes of ascites.
12.6 Explain the treatment of ascites.
12.7 Discuss complications associated with ascites.
Section 13: Hepatic Encephalopathy
13.1 Describe the grading system for hepatic encephalopathy.
13.2 List the precipitating factors for hepatic encephalopathy.
13.3 Describe the factors of importance in the pathogenesis of encephalopathy.
13.4 Discuss management of hepatic encephalopathy.
Section 14: Hepatorenal Syndrome
14.1 Define what is meant by the hepatorenal syndrome.
14.2 Discuss the diagnosis and treatment of hepatorenal syndrome.
Section 15: Liver Transplantation
15.1 List indications for liver transplantation.
15.2 Describe the criteria for referral of patients for transplantation.
15.3 Discuss the contraindications for liver transplantation.
15.4 Explain postoperative management of a patient with a liver transplant.
15.5 Discuss the immunosuppressive agents currently used in liver
transplantations.
15.6 Discuss early and late postoperative complications associated with liver
transplants.
Section 16: Neoplasms of the Liver
16.1 Discuss benign tumors of the liver, including clinical features, diagnostic tests,
and treatment.
16.2 Define primary hepatocellular carcinoma, including clinical presentation,
diagnostic testing, and treatment.
Section 17: Liver Disease in Pregnancy
17.1 Discuss the effects of pregnancy on the liver.
17.2 Describe liver diseases unique to pregnancy.
Section 18: Vascular Disorders of the Liver
18.1 Discuss vascular disorders associated with the liver, including congestive
heart failure, hepatic vein thrombosis (Budd-Chiari syndrome), veno-occlusive
disease, and portal vein thrombosis.
LEARNER WORKBOOK
EXERCISE 1
1.0 Briefly describe the normal anatomic and histologic structure of the liver.
1.1 What is the liver's role in: a) carbohydrate, b) protein, and c) fat metabolism?
1.2 What is the purpose of bile?
EXERCISE 2
2.0 List six major clinical manifestations of liver disease.
2.1 What is the differential diagnosis of jaundice?
2.2 Why are the following tests useful in diagnosing liver disease?
2.3 List six indications for liver biopsy.
2.4 When faced with a patient with known or suspected liver disease, what key
questions should the physician attempt to answer? List five.
EXERCISE 3
3.0 What are a) Gilbert's syndrome, and b) Crigler-Najjar syndrome?
3.1 a. Name two conditions characterized by congenital conjugated hyperbilirubinemia.
b. Briefly describe each.
EXERCISE 4
4.0 What is hepatitis?
4.1 List eight causes of acute hepatitis and briefly describe each.
4.2 Briefly describe the clinical presentations of hepatitis A, B, and C.
4.3 When symptomatic, what are the symptoms of viral hepatitis? List five.
4.4 How is viral hepatitis diagnosed?
4.5 Briefly describe the following complications of viral hepatitis:
a. Fulminant hepatitis
b. Cholestasis
c. Immune complex disease
4.6 How can hepatitis A and B be prevented?
EXERCISE 5
5.0 What is chronic hepatitis?
5.1 What are the histologic characteristics of chronic hepatitis?
5.2 What are the differences between chronic viral hepatitis B and C with respect to:
a. Presentation
b. Diagnosis
c. Treatment
d. Prevention
5.3 Fill in the following table:
| Viral Hepatitis | Alcoholic Hepatitis |
| History |
| Physical exam |
| Laboratory exam |
| Liver biopsy |
5.4 What is autoimmune hepatitis?
EXERCISE 6
6.0 What is alcoholic fatty liver?
6.1 Fill in the blanks in the following table:
| Alcoholic Hepatitis | Alcoholic Cirrhosis |
| Clinical presentation |
| Diagnostic findings |
| Prognosis |
EXERCISE 7
7.0 Fill in the blanks in the following table:
| Drug-induced liver disease: |
| Type and Example | Pathogenesis |
Acute hepatocellular injury
-Toxic necrosis
-Hepatitis-like
|
Cholestasis
-Inflammatory
-Pure |
7.1 What are the differences between two forms of cholestasis: inflammatory and
pure (non-inflammatory)?
7.2 List examples of drugs which can cause the following chronic liver diseases:
a. Chronic hepatitis
b. Chronic cholestasis
c. Fibrosis/cirrhosis
d. Tumors
EXERCISE 8
8.0 Fill in the blanks in the following table:
Inherited liver disease:
| Hemochromatosis | Alpha1-
Antitrypsin Deficiency | Wilson's Disease |
| Definition |
| Histology |
| Presenting symptoms |
| Diagnostic procedures |
| Treatment |
EXERCISE 9
9.0 What does cholestasis mean?
9.1 List eight major causes of cholestasis.
9.2 How is PBC (primary biliary cirrhosis) diagnosed and treated?
9.3 What is secondary biliary cirrhosis?
9.4 What is clinical approach to the patient with cholestasis?
EXERCISE 10
10.0 What is cirrhosis of the liver?
10.1 List six causes of cirrhosis.
10.2 What is the difference between micronodular and macronodular cirrhosis?
10.3 Briefly describe the clinical features of cirrhosis.
10.4 Fill in the following table:
Criteria for Child-Pugh classification:
| Group Designation | A | B | C |
| Serum bilirubin |
| Serum albumin |
| Ascites |
| Neurological disorder |
| Nutrition |
10.5 How is cirrhosis treated?
EXERCISE 11
11.0 What is portal hypertension?
11.1 List three primary causes of portal hypertension.
11.2 Fill in the following table:
Common sites of portal-systemic collateral formation:
| Location | Portal
Circulation | Systemic Circulation | Clinical Consequence |
Proximal stomach and distal
esophagus |
| Anterior abdominal wall |
| Retroperitoneal |
| Anorectal |
11.3 How is portal pressure measured?
11.4 List three complications of portal hypertension.
EXERCISE 12
12.0 What is ascites?
12.1 What is the presumed pathogenesis of ascites?
12.3 What are the differences between secondary and spontaneous bacterial
peritonitis?
EXERCISE 13
13.0 Fill in the following table:
Grading of hepatic encephalopathy:
| Grade | Level of Consciousness | Intellectual Function | Neurological Findings | EEG |
|
| 1 |
| 2 |
| 3 |
| 4 |
13.1 List four precipitating factors for hepatic encephalopathy.
13.2 How is hepatic encephalopathy managed?
EXERCISE 14
14.0 What is the hepatorenal syndrome?
14.1 How is the hepatorenal syndrome treated?
EXERCISE 15
15.0 Briefly discuss four indications for a liver transplant.
15.1 What are the criteria for referral of patients for transplantation?
15.2 What are the contraindications for liver transplantation?
15.3 Briefly discuss the postoperative management of a patient with a liver
transplant.
15.4 Briefly describe the following immunosuppressive agents currently used in liver
transplantation:
a. Cyclosporine
b. Corticosteroids
15.5 What potential postoperative complications are associated with liver
transplants?
EXERCISE 16
16.0 Describe three benign tumors of the liver.
16.1 What is primary hepatocellular carcinoma?
16.2 How is primary hepatocellular carcinoma diagnosed and treated?
EXERCISE 17
17.0 What are the effects of pregnancy on the liver?
17.1 Describe three liver diseases unique to pregnancy.
EXERCISE 18
18.0 What is the most frequent abnormality of circulation to affect the liver?
18.1 What is the Budd-Chiari syndrome?
18.2 What can portal vein thrombosis result from?
