U6 - Liver

The Liver
1. Anatomy and histology of the liver.
Topography
Large intraperitoneal organ found deep into the 7th to 11th ribs it's superior to the duodenum
and near to the stomach.
Anatomy
It's divided in two areas separated by a falciform ligament.
Left lobe
Right Lobe
→ Caudate lobe (superior)
→ Quadrate lobe (inferior)

The "surfaces" of the liver are two
The upper part of the liver is the diaphragmatic surface. (smooth, round)
● The posterior área of the diaphragmatic surface has a bare area (the rest is surrounded
by a serous membrane) that is in contact with the diaphragm.
● It’s surrounded by the coronary ligament and it forms the right triangular ligament and
the left one.
The lower part of the liver is the visceral surface. (sharper)
They're two sagittal fissures, left and right → The right one contains a fossa for a gallbladder.
Liver Circulation System → Porta hepatis
Portal vein
● Large vein that collects blood from various abdominal organs (stomach, pancreas,
intestine) not directly from the heart.
Hepatic Artery
● It supplies the liver with oxygen-rich blood.

● The majority of the blood supply (75%) comes from the portal vein.
Common bile duct.
● Is a duct that carries bile from the liver to the gallbladder, where it will be stored.
Inside hepatic lobules.
The hepatic parenchyma is composed of numerous hexagonal or pyramidal classical lobules.
The liver lobules are the structural and functional units of the liver. The lobule is surrounded
by 6 portal tracts and centered on the centrolobular vein, which is a terminal twig of the
hepatic vein.
The liver parenchymal cell (hepatocyte) is a polygonal cell with a central nucleus.
Hepatocytes are arranged in plates one cell thick with a sinusoid on either side, with a radial
arrangement in the center of the lobule.
The portal tracts at the lobulary periphery are composed of connective tissue, ensheathing
branches of the hepatic artery, portal vein, bile duct, and lymphatics.
The blood flows from the periphery (triada porter) to the sinusoid to the central vein
● The central vein faints (fusionarse) in to collectin veins that will end draining
(drenaje) in to the inferior vena cava.
● Bile is secreted in the canaliculi and then pooled into the biles ductules into the
gallbladder.
What are sinusoids?
● They're capillaries with fenestrated endothelium and NO basement membrane that

allows the hepatocyte to be submerged in plasma and exchanges substances.
Kupffer cells
● They're specializated cells of the mononuclear phagocyte system. They're situated on

the luminal (inner) side of hepatic sinusoids.
○ Their function is to remove foreign (rare) particles, bacteria and cellular debris
located on the sinusoids.
Hepatic stellate cells / Ito cells
● They're located in the space of Disse (area between the sinusoids and the hepatocytes)
○ Stellate cells have various functions
■ Store vitamine A
■ Regulation of the liver's extracellular matrix
■ Play role in liver fibrosis.
● Pit cells
○ They're kind of lymphocytes and their function is related with natural killer
(NK) cells.
2. Fine needle aspiration (FNA)
Fine needle aspiration (FNA) is used mainly for the diagnosis of focal lesions of the liver.
Biopsy with a large-core needle is preferred for diagnosing diuse liver diseases (such as
hepatitis and cirrhosis), for which architectural details are important.
Sensitivity of cytology is higher than the one of histology, whereas histology is more specific.
The combination of both techniques allows a higher sensitivity and a more precise definition
of the lesion.
FNA is usually performed percutaneously under the guidance of computed tomography (CT),
magnetic resonance imaging (MRI) or ultrasonography.
It is a very sensitive and specific method in diagnosing malignancies. False positive results
are very rare.
FNA cannot differentiate hepatic adenoma, focal nodular hyperplasia and regenerative
nodules in cirrhosis, but it is useful in these cases for excluding a malignancy.
P
Complications of FNA are rare, including hemorrhage, bile peritonitis, tumor seeding,
anaphylactic shock (aer aspiration of an echinococcal cyst) (WE CANNOT ASPIRED
QUISTS).
3. Normal cells
Hepatocytes - cytologic features
1. Large polygonal cells Isolated cells.

2. Centrally placed, round to oval nuclei, binucleation, nuclear pseudoinclusions.
3. Abundant granular cytoplasm.
4. Pigment
- Lipofuscin (a normal pigment related to cellular aging) – golden with the
Papanicolaou stain and green-brown with a Romanowsky-type stain.
- Hemosiderin – dark brown with the Papanicolaou stain and blue with a
Romanowsky-type stain. Hemosiderin appears when we have
hemochromatosis it appears when we have an excess of iron in the
body/blood.
- Bile (in cholestasis) – dark green with both Papanicolaou and Romanowsky
stains (si se ve mucho) - There must be bile pigment but not in excess because
that would mean that there is some type of obstruction in the bile ducts that go
to the bile glands and therefore bile accumulates in the liver.
Bile Duct epithelium y kupffer cells? → Hemosidin en las kupffer cells porque se comen el
hierro pero no lopuden disimular
Hemosiderin que se comen el hierro y por eso se tiñen de ese color pero al no poder digerirlo
pues de se queda de ese color
4. Infections
4.1 Hepatic Abscess

Hepatic abscesses can be bacterial, fungal or amebic). Bacterial abscesses result from
ascending cholangitis and sepsis. Fungal abscesses (such as those due to Candida species) are
most common in immunocompromised patients.
Cytomorphology of bacterial and fungal abscesses:
○ leukocytes and necrotic debris (sistema inmunitario).

○ may see bacteria and fungi in routine stains.
4.2 Echinococcal Cyst (Hydatid Cyst)
The larval form of Echinococcus granulosus, a dog tape-worm, causes infection in a variety
of organs in humans, principally the liver.
Inside the cyst there are the head of the worm (echinococcus) ; the heads are also called
scolex. The PAAF is not indicated because of the risk of anaphylactic shock. If we aspirate
this quist we will see the scolex and a lot of inflammatory cells, necrotic background-debris.
Some hepatocytes may change their nuclear features or characteristics (the nucleus is bigger).
Fragments of the laminated membrane of this organism appear as parallel, acellular striations
and are diagnostic (hematoxylin-eosin [H & E]-stained cell block).
Inset: Some cysts contain mostly acellular debris without scolices. A diligent search uncovers
the pale dagger-like hook- lets, which do not stain with the Papanicolaou stain (Papanicolaou
stain).
5. Benign lesions
5.1 Cirrhosis
The cirrosis is caused by a progresis fibrosis of the hepatic pharemchima that leads to a
cellular necrosis. They can progressed to a hepatocellular carcinoma
There are 3 signs of cirrhosis:

1. Necrosis
2. Fibrotic processes
3. Regenerative noduls ; inside these nodules we have reactive hepatocytes.When we
perform a FNA we are making sure that the hepatocytes aren’t malignant→
carcinoma hepatocellular(si los nodulos son cancerosos).
Cytologic diagnostic features
- Normal-appearing hepatocytes, sometimes with steatosis (accumulation of fat)
- Focal atypia in some cases (marked variation in nuclear size, prominent nucleoli
(hipercromatina), binucleation)
6. Malignant tumors
6.1 Hepatocellular carcinoma (HCC)
Hepatocellular carcinoma (HCC) accounts for 90% of all primary cancers of the liver.
In Asia and Africa it is more common that this is caused by hepatitis B and C, while in the
West it is due to cirrhosis/alcoholism.
We cannot differentiate the cancer cells and the cirrhotic cells.
The cancer makes different nodules (FNA cirrhotic).
Cytologic diagnostic features (well-differentiated HCC)
1. Spindle-shaped endothelial cells.

2. Increased N/C ratio
3. Granular cytoplasm with bile or hyaline globules. (red papanicolau)
4. Large round nuclei, prominent nucleoli.
5. Large naked nuclei

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The Liver

1. Anatomy and histology of the liver.

It's divided in two areas separated by a falciform ligament.

→ Caudate lobe (superior)

→ Quadrate lobe (inferior)

The lower part of the liver is the visceral surface. (sharper)

Liver Circulation System → Porta hepatis

● It supplies the liver with oxygen-rich blood.

Common bile duct.

Inside hepatic lobules.

The hepatic parenchyma is composed of numerous hexagonal or pyramidal classical lobules.

What are sinusoids?

● They're capillaries with fenestrated endothelium and NO basement membrane that

● They're specializated cells of the mononuclear phagocyte system. They're situated on

Hepatic stellate cells / Ito cells

2. Fine needle aspiration (FNA)

Hepatocytes - cytologic features

1. Large polygonal cells Isolated cells.

4.1 Hepatic Abscess

Cytomorphology of bacterial and fungal abscesses:

○ leukocytes and necrotic debris (sistema inmunitario).

4.2 Echinococcal Cyst (Hydatid Cyst)

There are 3 signs of cirrhosis:

Cytologic diagnostic features

- Normal-appearing hepatocytes, sometimes with steatosis (accumulation of fat)

6.1 Hepatocellular carcinoma (HCC)

We cannot differentiate the cancer cells and the cirrhotic cells.

The cancer makes different nodules (FNA cirrhotic).

Cytologic diagnostic features (well-differentiated HCC)

1. Spindle-shaped endothelial cells.

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