Examqo › Examqo library › Pathology › Systemic pathology · IMLE
Patterns of injury on liver biopsy and hepatocellular tumours
A liver biopsy is read by pattern — hepatitic, cholestatic, steatotic, vascular or granulomatous — and by location in the lobule (periportal versus around the central vein), then activity is graded and fibrosis staged; in a liver mass, adenoma, FNH and hepatocellular carcinoma are distinguished by architecture and markers.
Why it matters in the exam
The bank asks where alcoholic injury begins, what characterises large bile duct obstruction and how tumours are distinguished. In hepatitis there is portal and lobular inflammation and "interface" hepatitis; in autoimmune hepatitis plasma cells are prominent, and in hepatitis C there are sometimes lymphoid follicles and fat. In fatty liver of metabolic or alcoholic origin, changes begin around the central vein (zone 3): large-droplet fat, "ballooned" hepatocytes, Mallory-Denk bodies and pericellular fibrosis. Fibrosis is produced by activated Ito (stellate) cells.
In large bile duct obstruction there is portal oedema, proliferation of bile ductules at the edge of the portal tract (ductular reaction) with neutrophils, bile plugs and finally "bile lakes" and bile infarcts. In primary biliary cholangitis there is destructive injury of small ducts with granulomas and antimitochondrial antibodies; in primary sclerosing cholangitis — "onion-skin" layered fibrosis around ducts, with an association with inflammatory bowel disease. In South-East Asia liver flukes such as Clonorchis are linked to cholangiocarcinoma.
In a liver mass in a non-cirrhotic liver: FNH shows a central scar and "map-like" glutamine synthetase staining; hepatocellular adenoma is classified into subtypes — HNF1A-inactivated (fatty, without significant malignant risk), inflammatory (bleeding risk), and β-catenin-activated (diffuse glutamine synthetase and nuclear β-catenin), which has the highest risk of malignant transformation. Hepatocellular carcinoma is characterised by trabeculae thicker than 3 cells, loss of the reticulin network and glypican-3 staining, and arises mainly in a cirrhotic liver.
Key points
- Patterns: hepatitic, cholestatic, steatotic, vascular, granulomatous.
- Alcohol and metabolic fat: zone 3, ballooning, Mallory-Denk.
- Large bile duct obstruction: portal oedema, ductular proliferation, neutrophils, bile lakes.
- FNH: central scar and map; β-catenin adenoma — malignant risk.
- Hepatocellular carcinoma: thick trabeculae, reticulin loss, glypican-3.
Summary table
| Pattern or lesion | Site or feature | Key finding | Example |
|---|---|---|---|
| Hepatitis | Portal and lobular, interface | Plasma cells in autoimmune | Viral, autoimmune |
| Steatotic | Zone 3 around the central vein | Fat, ballooning, Mallory-Denk | Alcohol, metabolic |
| Large bile duct obstruction | Portal tract | Oedema, ductular proliferation, neutrophils, bile lakes | Stone, tumour |
| β-catenin-activated adenoma | Mass in non-cirrhotic liver | Diffuse glutamine synthetase | Highest malignant risk |
| Hepatocellular carcinoma | Mostly in cirrhotic liver | Thick trabeculae, reticulin loss, glypican-3 | — |
Free exam questions
למטופל בן 67 בוצעה האבחנה ההיסטולוגית, בביופסיית מחט, של of angiosarcoma the liver . חשיפה לאיזה מבין החומרים הבאים מהווה גורם סיכון להתפתחות גידול זה? (the question as examined, in Hebrew)
- א. Vinyl chloride
- ב. Aflatoxin
- ג. Aldehydes
- ד. Naphthalene
מוטציות בגנים 1 JAG או 2 NOTCH , הגורמות לתסמונת ,Alagille קשורות לאיזו מהאנומליות הלבביות הבאות? (the question as examined, in Hebrew)
- א. טטרלוגיה על שם פאלו
- ב. פגם במחיצה הבין- .חדרית
- ג. צינור עורקי פתוח
- ד. לב שמאלי היפופלסטי
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Diagnostic pathology, Internal medicine, Medical licensing exam (IMLE).
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- MacSween's Pathology of the Liver, 8th edition (2023) — Patterns of liver injury; hepatocellular tumours
- WHO Classification of Tumours: Digestive System Tumours, 5th edition (2019) — Hepatocellular adenoma subtypes and hepatocellular carcinoma
- Robbins and Cotran Pathologic Basis of Disease, 10th edition (2021) — Liver and gallbladder
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.