‫‪Pathoogy | Chapter ‬‬

‫‪LIVER DISEASES‬‬

‫اﻟـ‪ pathologist‬ﺑﺘﻮع ﻛﻠﻴﺔ ﻃﺐ ﺟﺎﻣﻌﺔ اﻟﻘﺎﻫﺮة ‪ are pioneers‬ﻲﻓ اﻟـ‪liver diseases‬؛‬

‫ﻷن إﺣﻨﺎ ﻋ� ﻣﺪى ‪ ٢٥‬ﺳﻨﺔ ﻛﺎن ﻋﻨﺪﻧﺎ أﺳﺘﺎذ ﻲﻓ ﻗﺴﻢ اﻟﺒﺎﺛﻮﻟﻮﺟﻲ ﻛﻞ ﺳﻨﺔ ﻳﺒﻘﻰ ﻫﻮ رﺋﻴﺲ‬
‫اﻟـ‪،association of hepatology and hepatologist‬إﺣﻨﺎ ﻲﻓ اﻟﻌﺎﻟﻢ رؤﺳﺎء‬
‫اﻟـ‪ association‬ﺑﺘﺎع أﻣﺮاض اﻟﻜﺒﺪ وﻲﻓ آﺧﺮ ﻣﺆﺗﻤﺮ ﻟﻠﻜﺒﺪ ﻛﺎﻧﻮا ﺑﻴﻘﻮﻟﻮا إن اﻟـ‪bilharziasis‬‬
‫ﻳﻨﺤﺴﺮ وإن اﻟـ‪ hepatitis‬ﻳﻨﺘﺸﺮ‪.‬‬

‫اﻟـ‪ liver‬ﻋﺸﺎن ﺗﻔﻬﻤﻮه ﻣﺤﺘﺎج اﺷﺮﺣﻠﻜﻮا اﻷﻧﺎﺗﻮﻣﻲ واﻟﻔﺴﻴﻮﻟﻮﺟﻲ واﻟﻬﺴﺘﻮﻟﻮﺟﻲ ﺑﺘﺎع اﻟﻜﺒﺪ‪،‬‬
‫اﻟ� أﻧﺎ ﻋﺎرف اﻧﺘﻮا ﻣﺘﻌﺮﻓﻮﻫﻮش‪.‬‬

‫ـ‪ :Anatomy‬ﻫﻮ ‪ ،largest solid organ in your body‬أﻛﺮﺒ ‪ solid organ‬ﻲﻓ‬

‫ﺟﺴﻤﻚ ﻫﻮ اﻟﻜﺒﺪ‪ ،‬أُﻣﺎل إﻳﻪ؟ ‪ the largest organ in your body‬اﻟـ‪ ،skin‬اﻟـ ‪skin is‬‬
‫‪.the largest organ but not largest solid organ‬‬
‫‪ anatomically‬اﻟـ‪ liver‬ﻛﺎم ‪lobe‬؟ اﻟ� ﻣﻴﻌﺮﻓﻮش ﺣﺎﺟﺔ ﺑﻴﻘﻮﻟﻮا ‪ ،٢‬وﻟﻜﻦ‬
‫ـ‪ anatomically‬اﻟﻜﺒﺪ ‪4 lobes‬‬
‫‪anatomically; left, right, caudate & quadrate‬‬
‫‪ surgical‬ﻛﺎم ‪lobe‬؟ ‪ ، ٨‬وﳌﺎ ﺑﻨﻴﺠﻲ ﻧﺰرع ﻛﺒﺪ ﻣﺶ ﺑﻨﺰرع ‪ anatomical lobe‬ﺑﻨﺰرع‬
‫‪ surgical lobe‬ﻋﺸﺎن ﻣﻨﻌﻮرش اﻟـ‪ framework‬ﻓﺎﻟـ‪ lobe‬اﻟ� ﻫﻨﺎﺧﺪه ﻣﻦ اﻟـ‪ ٨‬ﻫﻴﻌﻤﻞ ﻲﻓ‬
‫اﻟـ‪ recipient‬ﻛﺒﺪ ﻛﺎﻣﻞ واﻟ� ﻳﺘﺎﺧﺪ ﻣﻨﻪ ﻫﻴﻨﻤﻮ و�ﺒﻘﻰ اﻟﻜﺒﺪ ﺑﺘﺎﻋﻪ ﻛﺎﻣﻞ‪.‬‬

‫وﻟﻜﻦ اﻟ� ﻳﻬﻤﻨﺎ أﻛﺮﺘ اﻟـ‪what’s the structural and functional unit ،Histology‬‬
‫‪of the liver‬؟ اﻟـ‪ classic hepatic lobule‬آدي اﻟ� ﻗﺪاﻣﻜﻮا دي ‪classic hepatic‬‬
‫‪ lobule‬أول ﻣﺮة ﺗﺸﻮﻓﻮﻫﺎ ﺑﻬﺬﻫﺎﻟﻄﺮ�ﻘﺔ ﺻﺢ؟ آه ﺷﻮﻓﺘﻮا اﻟﺼﻮره دي ﻗﺒﻞ ﻛﺪه؟ ﻻ ﻷن أﻧﺘﻮا‬
‫ﺑﺘﺸﻮﻓﻮه ﻣﻦ ﻓﻮق اﻟـ‪ section‬ﻛﺪه ﻟﻜﻦ أﻧﺎ ﺟﺎﻳﺒﻠﻜﻮا ‪ 3D diagram‬ﻛﺪه ودا ﺑﻴﺒ� ﻟﻜﻮا‬
‫ﻣﺪى ﺗﻌﻘﻴﺪ اﻟـ‪ ،classic hepatic lobule‬ﻧﺮﺟﻊ ﻟﻠﺼﻮرة اﻟ� أﻧﺘﻢ ﺗﻌﺮﻓﻮﻫﺎ‪this is ،‬‬
‫‪ classic hepatic lobule‬إﻳﻪ ده؟ ﻣﺶ دي اﻟﺼﻮرة اﻟ� إﺣﻨﺎ ﻧﻌﺮﻓﻬﺎ؟ وأﻧﺘﻮا ﻲﻓ ﺳﻨﺔ ﺗﺎﻧﻴﺔ‬
‫ﻣﺶ أﺧﺪﺗﻮا ﺷﻜﻞ اﻟـ‪classic hepatic lobule‬؟ أﺧﺪﺗﻮا إن ﻫﻮ ﺑﻴﺒﻘﻰ ‪hexagonal‬‬
‫ﺳﺪاﻲﺳ اﻷﺿﻼع‪ ،‬اﻟ� ﻗﺪاﻣﻜﻮا ده أﻧﺘﻮا ﺷﺎﻳﻔ� أﺿﻼع أﺳﺎﺳﺎ؟! دا اﻟـ ‪normal liver of‬‬
‫‪ human‬ﻷن اﻟ� اﻧﺘﻮا ﺑﺼﻴﺘﻮا ﻋﻠﻴﻪ ﻲﻓ ﺳﻨﺔ ﺗﺎﻧﻴﺔ ﻛﺎن ‪ ،liver pig‬ﻣﺎﻟﻔﺮق ﺑ� ﻛﺒﺪ اﻹﻧﺴﺎن‬
‫وﻛﺒﺪ اﻟﺨﻨﺰ�ﺮ؟ ﻲﻓ اﻟﺒﻨﻲ آدﻣﻴ� اﻟـ‪ framework‬ﺑﻴﺒﻘﻰ ﻣﻌﻤﻮل ‪mainly by reticulin‬‬
‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫‪ and elastic fibres‬ودي ﻣﺶ ﺑﺘﺘﺼﺒﻎ ﺑﺎﻟـ‪ H&E‬ﻓﻌﺸﺎن ﻛﺪه ﻣﺒﻨﺸﻮﻓﺶ ﺷﻜﻞ ﺳﺪاﻲﺳ‪،‬‬
‫ﻟﻜﻦ ﻲﻓ اﻟـ‪ pigs‬ﻣﻌﻤﻮل ﻣﻦ ‪ fibrous tissue‬ﻓﺒﻴﺘﺼﺒﻎ ﺑﺎﻟـ‪ H&E‬ﻓﺒﻨﺸﻮف اﻟﺸﻜﻞ‬
‫اﻟﺴﺪاﻲﺳ‪ ،‬ﻣﻤﻜﻦ ﺗﺸﻮف ‪ liver‬ﺑﻨﻲ آدم ﺷﻜﻞ ﺳﺪاﻲﺳ؟ آه ﻟﻮ ﺻﺒﻐﺘﻪ ﺑﺎﻟـ ‪trichrome‬‬
‫‪ elastic stain‬ﺳﺎﻋﺘﻬﺎ ﻫﻴﺒﺎن اﻟﺸﻜﻞ اﻟﺴﺪاﻲﺳ‪ ،‬اﺗﻔﻘﻨﺎ؟ ده ﻫﺴﺘﻮﻟﻮﺟﻲ‪ ،‬ﻳﻬﻤﻨﻲ؟ ﻻ‬
‫ﺍﻟﻠﻲ ﺑﻌﺪﻩ‪:‬‬
‫ﻣﻦ ﺣﻴﺚ اﻟﻬﺴﺘﻮﻟﻮﺟﻲ ﻳﻘﺴﻤﻮا اﻟـ‪ classic hepatic lobule‬ﻣﻦ ﺑﺮة ﻟﺠﻮة ‪according‬‬
‫‪ ،to the blood supply‬ﻓﺒﻴﻘﻮﻟﻮا إن اﻟـ‪ hepatocytes‬ﺣﻮاﻟ� اﻟـ‪ central vein‬ﺑﻴﺴﻤﻮﻫﺎ‬
‫‪ central zone‬واﻟ� ﻲﻓ اﻟﻨﺺ ﺑﻴﺴﻤﻮﻫﺎ ‪ mid zone‬واﻟ� ﺑﺮة ﺑﻴﺴﻤﻮﻫﺎ ‪peripheral‬‬
‫‪.zone‬‬
‫إﺣﻨﺎ ﻫﻨﻤﻲﺸ ﺑﺎﻟﺘﻘﺴﻴﻤﺔ دي وﻣﺶ ﻫﻨﻤﻲﺸ ﺑﺘﻘﺴﻴﻤﺘﻬﻢ‪ ،‬ﺑﺘﻮع اﻟﻬﺴﺘﻮﻟﻮﺟﻲ ﻗﺴﻤﻮه ﻣﻦ‬
‫ﺑﺮه ﻟﺠﻮه ‪ central, mid and peripheral 1, 2, 3‬ﻟﻴﻪ؟ ﻷن ﺑﺎﻟﻬﺴﺘﻮﻟﻮﺟﻲ اﻟـ ‪blood‬‬
‫‪ supply‬ﻟﻠـ‪ classic hepatic lobule‬ﺑﻴﺒﻘﻰ ‪ from portal to central‬ﻓﺒﺎﻟﺘﺎﻲﻟ ﻣ�‬
‫اﻟـ‪ zone‬اﻟ� ﺗﺘﺄﺛﺮ أﻛﺮﺘ ﺑﺎﻟـ‪ ischemia‬أو ﺑﺎﻟـ‪hypoxia‬؟ اﻟـ‪ central‬ﻷن ﻫﻲ ﻣﺒﻴﻮﺻﻠﻬﺎش‬
‫أﻛﺴﺠ� ﻛﺘ�‪ ،‬ﻟﻜﻦ ﻣ� ﻳﺘﺄﺛﺮ أﻛﺮﺘ ﺑﺎﻟـ‪toxin‬؟ اﻟـ‪ peripheral‬ﻷن اﻟﺪم ﺑﻴﺠﻴﻠﻬﺎ ﻲﻓ اﻷول‪،‬‬
‫اﺗﻔﻘﻨﺎ ﻋ� اﻟﻜﻼم ده؟‬

‫آدي اﻟ� ﻗﺪاﻣﻜﻮا ده ‪ portal tract‬وآدي ا ﻟ� ﻗﺪاﻣﻜﻮا ﻫﻨﺎك ‪ central vein‬ﻳﺒﻘﻰ ده‬
‫‪ ،classic hepatic lobule‬اﻟﺨﻼﻳﺎ اﻟ� ﺣﻮاﻟ� اﻟـ‪ central vein‬ﺑﻨﺴﻤﻴﻬﺎ ‪central‬‬
‫‪ zone‬وﻲﻓ اﻟﻨﺺ ‪ mid zone‬وﺑﺮه ‪ ،peripheral‬دي اﻟـ‪ ،mid zone‬ﻓﻴﻪ ﺣﺎﺟﺔ اﺳﻤﻬﺎ اﻟـ‬
‫‪ portal lobule‬وﻫﻮ اﻟـ‪ portal triad‬ﻳﺎﺧﺪ اﺗﻨ� ‪.hepatic classic lobules‬‬
‫اﻟ� ﻳﻬﻤﻨﺎ ﺑﻘﻰ أول ﺣﺎﺟﺔ ﻫﻨﺎﺧﺪﻫﺎ ﻲﻓ اﻟـ‪ ،diseases of the liver‬ﻣﺶ ‪ disease‬وﻟﻜﻦ‬
‫ﻫﻮ ﺣﺎﺟﺔ ﺑﻨﺴﻤﻴﻬﺎ ‪.liver necrosis‬‬

‫‪LIVER NECROSIS‬‬

‫ﻟﻮ ﺳﻤﺤﺘﻮا اﻛﺘﺒﻮا ﻋ� اﻟـ‪ ،category A ⟵ liver necrosis‬ﻧﻈﺮي ﻟﻔﻬﻢ أﻣﺮاض اﻟﻜﺒﺪ‪.‬‬

‫ﻣﻴﻨﻔﻌﺶ أروح ﻋﻨﺪ دﻛﺘﻮر ‪ hepatology‬و�ﺸﺨﺼﻨﻲ إ� ﻋﻨﺪي ‪liver ،liver necrosis‬‬

‫‪ ،necrosis is not a disease‬اﻟـ‪ liver necrosis‬ده ‪commonly found in many‬‬
‫‪ ،liver diseases‬دي ﺣﺎﺟﺔ ﺑﻨﺸﻮﻓﻬﺎ ﻛﺘ� ﻲﻓ أﻣﺮاض اﻟﻜﺒﺪ وﻟﻜﻦ أﺷﻬﺮ ﺣﺎﺟﺔ ﺗﻬﻤﻨﺎ ﻲﻓ‬
‫ﻣﺼﺮ ﺑﻨﺸﻮﻓﻬﺎ ﻲﻓ ﺣﺎﻻت اﻟـ‪ hepatitis‬ﻟﻴﻪ؟! ﻻﺯﻡ ﻧﻌﻠﻤﻜﻮﺍ ﺍﻟـ ‪ liver necrosis‬ﻷﻧﻪ‬
‫ﺑﻴـ‪ ،correlate with severity of hepatitis‬ﻳﻌﻨﻲ إﻳﻪ؟ ﻛﻞ أﻣﺎ أﻻﻗﻲ اﻟـ‪necrosis‬‬
‫ﻋﻨﻴﻒ ﻛﻞ أﻣﺎ أﻋﺮف ﻣﺼ� ﻋﻴﺎن اﻟـ‪ hepatitis‬ﻷن ده ﺑﻴـ‪.correlate with severity‬‬

‫اﻟـ‪ liver necrosis‬ﻣﺶ ﻣﺮض‪ ،‬اﻟـ‪ liver necrosis is a finding‬ﺑﻨﺸﻮﻓﻪ ﻲﻓ ﻣﻌﻈﻢ‬

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Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis

.hepatitis‫أﻣﺮاض اﻟـ‬
:‫ ﻣﺠﻤﻮﻋﺎت‬٣‫ ﻟـ‬liver necrosis‫ﻋﻠﻤﺎء اﻟﻬﺴﺘﻮﺑﺎﺛﻮﻟﻮﺟﻲ ﻲﻓ اﻟﻌﺎﻟﻢ ﺑﻴﻘﺴﻤﻮا اﻟـ‬

Mild Liver Necrosis:

�‫؟ اﻟ‬liver human or liver pig ‫ ﺑﺼﻮا ﻋ� اﻟﺼﻮرة اﻟ� ﻗﺪاﻣﻜﻮا دي‬،‫أول ﻣﺠﻤﻮﻋﺔ‬
liver ‫ ﻟﻴﻪ؟! ﻣﻠﻴﺶ دﻋﻮة أﻧﺎ ﺑﺎﻟﺨﻨﺎز�ﺮ وأﺟﻴﺒﻪ ﻣﻨ�؟! دا‬pig ‫ ﻫﺠﻴﺒﻠﻜﻮا‬human ‫ﻗﺪاﻣﻜﻮا ده‬
‫؟! ﻷن‬classic hepatic lobule‫ إزاي وأﻧﺎ ﺷﺎﻳﻒ اﻟـ‬human ‫ ﻳﺎ ﻧﻬﺎر أﺳﻮد‬،of human
‫ ﻋﻠﺸﺎن ﻛﺪه ﺑﻴﻨﺖ‬trichrome elastic stain‫ دي‬H&E ‫اﻟﺼﺒﻐﺔ اﻟ� ﻗﺪاﻣﻜﻮا دي ﻣﺶ‬
.‫ﻟﻴﻨﺎ اﳌﻨﻈﺮ اﻟﺴﺪاﻲﺳ‬

mild liver ‫ ﺣﺎﺟﺔ ﺑﻨﺴﻤﻴﻬﺎ‬finding ‫ اﻟ� ﻫﻮ ﻣﺶ ﻣﺮض دا‬necrosis‫أول ﻧﻮع ﻣﻦ أﻧﻮاع اﻟـ‬
‫؟ ﻛﺎم ﻛﻴﻠﻮ؟ ﻛﺎم ﺳﻢ؟ ﻛﺎم ﻧﻴﻮﺗﻦ؟ ﻛﺎم وات؟‬mild ‫ ﻳﻌﻨﻲ إﻳﻪ‬necrosis
‫ ﻳﺒﻘﻰ اﻟﻌﻴﺎن ﻣﺶ ﻋﻨﺪه أﻋﺮاض و‬that not disturb liver function ‫ ﺗﻌﻨﻲ‬mild ‫ﻛﻠﻤﺔ‬
‫ وﻫﻮ ده ﺗﻌﺮ�ﻒ ﻛﻠﻤﺔ‬cirrhosis ‫ ﻳﻌﻨﻲ ﺑﺎﻟﺘﺎﻲﻟ ﻣﻴﻘﻠﺒﺶ‬not disturb the framework
.mild
mild → doesn’t disrupt liver function and doesn’t impair framework
mild‫ اﻟـ‬،toxin ‫ أوﺑﻨﺸﻮﻓﻪ ﺑﺴﺒﺐ‬acute viral hepatitis ‫ﻲﻓ ﻣﻌﻈﻢ اﻷﺣﻴﺎن ﺑﻨﺸﻮﻓﻪ ﻲﻓ‬
:�‫ﺑﻴﻘﺴﻤﻮه ﻟﻨﻮﻋ‬

Unicellular Necrosis:

‫ ﻫﻨﺎ ﻲﻓ‬،mid‫ ﻫﻨﺎ ﻲﻓ اﻟـ‬،central zone‫ ﺧﻠﻴﺔ ﻫﻨﺎ ﻲﻓ اﻟـ‬،‫ واﺣﺪة‬scattered cell ‫ﻳﺈﻣﺎ ﺗﻼﻗﻲ‬
‫ دا‬classic hepatic lobule‫ ﻣﻴﺘﻪ ﻲﻓ اﻟـ‬whatever scattered cells ،peripheral‫اﻟـ‬
‫ وﻟﻜﻦ ﻲﻓ ﻋﻠﻤﺎء ﻛﺘ� ﺑﻴﻌﺮﺘﺿﻮا ﻋ� ﻫﺬه‬،mild ‫ ودا‬unicellular necrosis ‫ﺑﻴﺴﻤﻮه‬
necrosis‫؛ ﻷن إﻳﻪ ﺗﻌﺮ�ﻒ اﻟـ‬unicellular necrosis ‫اﻟﺘﺴﻤﻴﺔ و�ﻘﻮﻟﻮا ﻣﻴﻨﻔﻌﺶ ﻧﺴﻤﻴﻪ‬
necrobiosis ‫ ﻓﺴﻤﻮه‬death of a group of cells ‫زي ﻣﺎ أﺧﺪﺗﻮه اﻟﺮﺘم اﻷول؟ ﻫﻮ‬
‫ ﺗﻌﺮﻓﻮا ﻳﻌﻨﻲ إﻳﻪ‬،necrobiosis ‫ ﺗﺴﻤﻴﺔ ﺧﺎﻃﺌﻪ واﺳﻤﻪ اﻟﺼﺢ‬unicellular necrosis‫اﻟـ‬
‫ زﻣﺎن ﻛﺎﻧﻮا ﺑﻴﺴﻤﻮا‬،apoptosis‫ دا اﻻﺳﻢ اﻟﻘﺪﻳﻢ ﺑﺘﺎع اﻟـ‬necrobiosis‫؟ اﻟـ‬necrobiosis
.necrobiosis ⟵ apoptosis‫اﻟـ‬
‫ واﻟﻨﺎس ﺑﺘﻌﺮﺘض ﻋ� اﻟﺘﺴﻤﻴﺔ ﻓﺒﻨﺴﻤﻴﻪ‬unicellular ‫ اﺳﻤﻪ‬mild‫ﻳﺒﻘﻲ أول ﻧﻮع ﻣﻦ اﻟـ‬
.necrobiosis

Focal Necrosis:

‫ ﺑﺘﺒﻘﻰ ﻣﻴﺘﺔ ﻲﻓ ﻛﻞ‬scattered few cells ‫؟‬focal ‫ ﻳﻌﻨﻲ إﻳﻪ‬،focal ‫ﻓﻴﻪ ﻧﻮع ﺗﺎ� ﺑﻴﺴﻤﻮه‬
.classic hepatic lobule‫اﻟـ‬
:mild ‫ ﻷن اﻷﻫﻢ ﻣﻨﻪ ﻣﺶ‬mild ‫ﺑﺮﺿﻮ ده‬

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Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis

Zonal Necrosis:
‫؟ ﻳﻌﻨﻲ‬zonal necrosis ‫ ﻳﻌﻨﻲ إﻳﻪ‬،zonal necrosis ‫ اﺳﻤﻪ‬mild‫اﻟﻨﻮع اﻟﺘﺎ� ﺑﻌﺪ اﻟـ‬
‫ ﻲﻓ‬central zone for example ‫؟‬particular zone ‫ ﻳﻌﻨﻲ إﻳﻪ‬،particular zone
peripheral‫ أو اﻟـ‬mid‫ ﺑﺘﺒﻘﻰ ﺧﻼﻳﺎﻫﺎ ﻣﻴﺘﺔ أو اﻟـ‬classic hepatic lobule‫ﻛﻞ اﻟـ‬
.particular cells affected in each hepatic lobule ‫ ﻫﻮ‬zonal necrosis‫اﻟـ‬

disturbance of liver ‫ ﻳﻌﻨﻲ اﻟﻌﻴﺎن ﺑﻴﺒﻘﻰ ﻋﻨﺪه‬mild‫ ده ﻓﻮق اﻟـ‬zonal necrosis‫اﻟـ‬

‫ ﻲﻓ ﻣﻌﻈﻢ اﻷﺣﻴﺎن‬no ‫؟‬cirrhosis ‫ ﻟﻜﻦ ﻫﻞ ﻳﻘﻠﺐ‬،presents jaundice ‫ و‬function
‫ ﻳﻘﻠﺐ ﺑﺲ ﻟﻮ ﻛﺎن‬،framework‫ ﺑﻌﻴﺪه ﻋﻦ اﻟـ‬mid zone‫ واﻟـ‬central zone‫ ﻷن اﻟـ‬no
.example‫ وﻫﻔﻬﻤﻜﻮا أﻛﺮﺘ ﻲﻓ اﻟـ‬peripheral zone ‫اﻟﻨﻮع اﻟ� اﺳﻤﻪ‬

Central Zonal Necrosis:

classic hepatic lobule‫ إﻳﻪ اﻟ� ﻳﻌﻤﻠﻪ؟ إﻳﻪ اﻟ� ﻳﺨ� اﻟـ‬central zonal necrosis‫اﻟـ‬
‫ ﻣﻀﺮوﺑﺔ؟‬central zone ‫ﻲﻓ ﻛﻞ اﻟـ‬
‫؛ ﻷن ﻲﻓ‬chronic venous congestion ‫؟‬CVC ‫ ﺗﻌﺮﻓﻮا ﻳﻌﻨﻲ إﻳﻪ‬،CVC ‫أﺷﻬﺮ ﺳﺒﺐ‬
‫ وﻻ‬from central to portal ‫ واﻟﺪم ﺑﻴﻤﻲﺸ ﻲﻓ اﻟﻜﺒﺪ‬،hypoxia ‫ ﺑﻴﺒﻘﻰ ﻓﻴﻪ‬CVC‫اﻟـ‬
‫ أﻣﺎ ﻳﻮﺻﻞ اﻟﺪم اﻟ� اﻷﻛﺴﺠ� ﻓﻴﻪ‬،portal to central ‫؟‬from portal to central
‫ ﻫﻴﺤﺼﻠﻬﺎ‬central zone‫ ﻫﻴﻜﻮن اﻷﻛﺴﺠ� ﻓﻴﻪ راح ﻓﺴﺎﻋﺘﻬﺎ اﻟـ‬central zone‫ﻗﻠﻴﻞ اﻟـ‬
steatosis ‫ ﺑﻴﺒﻘﻰ ﻓﻴﻬﺎ‬peripheral zone‫ اﻟـ‬،‫ إﺣﻨﺎ ﻗﻮﻟﻨﺎ اﻟﻜﻼم ده ﻗﺒﻞ ﻛﺪه‬،necrosis
.necrosis ‫ ﻓﻴﻬﺎ‬Central zone‫واﻟـ‬

acute viral ‫ ﻳﻠﻴﻬﺎ ﺑﻌﺪ ﻛﺪه اﻟـ‬CVC‫ ﻫﻮ اﻟـ‬central zonal necrosis �‫أﺷﻬﺮ ﺣﺎﺟﺔ ﺗﻌﻤ‬
‫ ﻫﻨﺎﺧﺪه اﻧﻬﺎرده اﻻﻟﺘﻬﺎب اﻟﻜﺒﺪي اﻟﻮﺑﺎﻲﺋ وده‬acute viral hepatitis‫ اﻟـ‬،hepatitis
virus is intracellular parasite‫ وﻟﻜﻦ اﻟـ‬،hepatocytes‫ ﻛﻞ اﻟـ‬affect‫ ﺑﻴـ‬virus
‫ ﻗﻠﻴﻞ؟‬already ‫ ﻓﻴﻬﺎ‬ATP‫ ﺑﺘﺎع اﻟﺨﻠﻴﺔ ﻓﺒﺎﻟﺘﺎﻲﻟ ﻣ� اﻟﺨﻠﻴﺔ اﻟ� اﻟـ‬ATP‫ﺑﻴﻌﺘﻤﺪ ﻋ� اﻟـ‬
‫؟ﻻن‬central zone‫ ﻃﻴﺐ اﺷﻤﻌﻨﻰ اﻟـ‬،central zone‫ﻓﺒﺎﻟﺘﺎﻲﻟ ﻫﻴﻮﺻﻞ ﻟﺼﻔﺮ وﺗﻤﻮت؟ اﻟـ‬
CVC or ‫ ﻲﻓ ﺣﺎﻟﺘ� ﻣﺎﻟﻬﻮﻣﺶ ﺛﺎﻟﺚ؟‬blood supply‫ اﺑﻌﺪ ﻣﺎ ﻳﻜﻮن ﻋﻦ اﻟـ‬ischemic ‫ﻫﻲ‬
.acute viral hepatitis

Mid Zonal Necrosis:

mid ‫ اﻟـ‬،‫ ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ﺧﺎﻟﺺ‬common ‫ ﻣﺶ‬mid zonal necrosis ‫اﻟﻨﻮع اﻟﺘﺎ� اﺳﻤﺔ‬
‫ ده‬yellow fever ‫ اﻟـ‬،yellow fever ‫ واﺣﺪ‬example �‫ ﻣﻠﻮش ﻏ‬zonal necrosis
‫ رﻏﻢ ان اﺳﻤﻬﺎ ﻋﺎﻳﺪة اﳌﺼﺮ�ﺔ وﻟﻜﻦ‬،Aedes Aegypti ‫ﻓ�وس ﺑﻴﻨﺘﻘﻞ ﺑﻨﺎﻣﻮﺳﻪ اﺳﻤﻬﺎ‬
‫ ﻃﺐ ﻟﻴﺔ ﺳﻤﻮﻫﺎ‬،‫ﻫﺬة اﻟﻨﺎﻣﻮﺳﺔ ﻣﺶ ﺑﺘﻌﻴﺶ ﻲﻓ ﻣﺼﺮ ﺑﺘﻌﻴﺶ ﻲﻓ اﳌﻨﺎﻃﻖ اﻻﺳﺘﻮاﺋﻴﺔ واﳌﺪار�ﺔ‬
‫ﻋﺎﻳﺪة اﳌﺼﺮ�ﺔ ؟ّ! ﺑﺘﺎع اﻟﺒﺎرا اﻟ� اﻛﺘﺸﻔﻬﺎ ﻛﺎن ﺑﻴﻼﻗﻴﻬﺎ ﺑﺘﻄ� وﺗﻘﻌﺪ ﺗﻠﻒ ﻛﺪا وﺗﻄ� وﺗﻘﻌﺪ‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﺗﻠﻒ ﻛﺪا وﻫﻮ ﻛﺎن ﺑﻴﺤﺐ اوﺑﺮا ﻋﺎﻳﺪة ﻓﺴﻤﺎﻫﺎ ﻋﺎﻳﺪة اﳌﺼﺮ�ﺔ ﻣﻊ إن ﻣﻮﻃﻨﻬﺎ اﻻﺻ� ﻣﺶ ﻣﺼﺮ‬
‫ﻃﻴﺐ اﺷﻤﻌﻨﺎ ﺗﻀﺮب اﻟـ‪mid zone‬؟ ﻷن ﻲﻓ ﺣﺎﺟﺔ اﺳﻤﻬﺎ ‪receptor tropism‬‬
‫اﻟـ‪ receptor‬ﺑﺘﺎع اﻟـ‪ virus‬ده ﻣﺶ ﻣﻮﺟﻮد إﻻ ﻲﻓ اﻟـ‪.mid zonal hepatocytes‬‬

‫‪Peripheral Zonal Necrosis:‬‬

‫آﺧﺮ ﻧﻮع اﺳﻤﻪ ‪ peripheral zonal necrosis‬ده اﻟ� ﺑﻨﺸﻮﻓﻪ ﻲﻓ ﻣﻌﻈﻢ اﻷﺣﻴﺎن ﺑﺴﺒﺐ‬
‫اﻟـ‪ chronic hepatitis‬اﺷﻤﻌﻨﻰ؟ ﻷن ﻲﻓ اﻟـ‪ chronic hepatitis‬اﻟـ‪ virus‬ﻣﺶ ﺑﻴﻤﻮّت‬
‫اﻟﺨﻼﻳﺎ أوي ﻟﻜﻦ ﺟﻬﺎز اﳌﻨﺎﻋﺔ ﺑﻴﻀﺮب اﻟﺨﻼﻳﺎ اﻟ� ﺟﻮاﻫﺎ اﻟﻔ�وس‪ ،‬وإﻳﻪ أﻗﺮب ﺣﺘﺔ اﻟﺪم‬
‫ﺑﻴﺠﻴﺐ ﻓﻴﻬﺎ ﺟﻬﺎز اﳌﻨﺎﻋﺔ؟ اﻟـ‪ ،peripheral zone‬وﻫﻮ ده اﻟﻨﻮع اﻟﻮﺣﺶ ﻲﻓ اﻟـ ‪zonal‬‬
‫‪ necrosis‬اﺷﻤﻌﻨﻰ ﻫﻮ ده اﻟﻨﻮع اﻟﻮﺣﺶ؟ ﻷﻧﻪ ﺑﻴـ‪ disturb the framework‬اﻟ�‬
‫ﻣﻮﺟﻮدة ‪ peripheral‬ﻓﺒﺎﻟﺘﺎﻲﻟ ﻳﻘﻠﺐ ‪.cirrhosis‬‬

‫‪Marked & Very Marked Necrosis:‬‬

‫آﺧﺮ ﻧﻮع ﻣﻦ أﻧﻮاع اﻟـ‪ necrosis‬ﺑﻴﺴﻤﻮه اﻟـ‪ marked‬واﻟـ‪،very marked necrosis‬‬
‫اﻟـ‪ marked‬واﻟـ‪ very marked necrosis‬ﻓﻴﻪ اﻟـ‪ hepatocytes‬ﻲﻓ ﻣﻌﻈﻢ أو ﻛﻞ‬
‫اﻟـ‪ classic hepatic lobule‬ﻣﻀﺮوﺑﺔ وده ﺑﻴﺸﻤﻞ أﻧﻮاع ﻫﻨﻘﻮﻟﻬﺎ دﻟﻮﻗﺘﻰ‪:‬‬

‫‪Bridging Necrosis:‬‬

‫ﻳﻌﻨﻲ إﻳﻪ ﻛﻠﻤﺔ ‪bridging‬؟ ﻳﻌﻨﻲ ﻧﻼﻗﻲ ﻓﻴﻪ ﺻﻒ ﻣﻦ اﻟـ‪ necrosis‬وﺻﻞ اﻟـ‪portal‬‬
‫ﺑﺎﻟـ‪ central‬ووﺻﻞ اﻟـ‪ central‬ﺑﺎﻟـ‪ central‬ﻓﻴﻬﻢ ﻛﻠﻬﻢ‪ ،‬ﻋﺪى ﻋ� اﻟـ‪ framework‬وﻻ‬
‫ﻣﻌﺪاش؟ ﻳﻌﻨﻲ ﻓﻴﻪ ‪ disturbance of liver function‬وﻻ ﻣﻔﻴﺶ؟ اه‪ ،‬ﻳﻌﻨﻲ ﻳـ‪heal‬‬
‫ﺑـ‪ cirrhosis‬ﻟﻮ اﻟﻌﻴﺎن ﻋﺎش وﻻ ﻣﺶ ﻫﻴـ‪heal‬؟ اﻳﻮة‪ ،‬اﺗﻔﻘﻨﺎ ﻋ� ﻫﺬا اﻟﻜﻼم؟‬

‫‪Severe (acute atrophy) Necrosis:‬‬

‫ﻓﻴﻪ ﻧﻮع اﺳﻤﻪ ‪ severe‬أو ‪ acute atrophy‬اﻟﻌﻴﺎن ﺑﻴﻤﻮت ﺧﻼل أﻳﺎم‪.‬‬

‫‪Subacute Necrosis:‬‬

‫ﻓﻴﻪ ﻧﻮع اﺳﻤﻪ ‪ subacute‬اﻟﻌﻴﺎن ﺑﻴﻤﻮت ﺧﻼل أﺳﺎﺑﻴﻊ‪.‬‬

‫‪ This is liver necrosis‬اﻟـ‪ liver necrosis‬ﻣﺶ ‪ disease‬اﻟـ ‪liver necrosis is the‬‬

‫‪ common finding in many liver diseases‬وﺧﺼﻮﺻﺎً اﻟـ‪.hepatitis‬‬

‫اﻟﺠﺪ ﻫﻴﺒﺪأ ﺑﻘﻰ‪ ،‬أول ﻣﻮﺿﻮع ﻫﻨﺎﺧﺪه اﻛﺘﺒﻮا ﻋﻠﻴﻪ ‪ ،category A‬ﻋﻠﺸﺎن ﺗﻔﻬﻤﻮا اﻟ�‬
‫ﻫﻘﻮﻟﻪ دﻟﻮﻗﺘﻲ أﻧﺎ ﺷﺮﺣﺖ اﻷﻧﺎﺗﻮﻣﻲ واﻟﻬﺴﺘﻮﻟﻮﺟﻲ واﻟﻔﺴﻴﻮﻟﻮﺟﻲ واﻟـ‪.necrosis‬‬

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‫‪VIRAL HEPATITIS‬‬

‫اﻟـ‪ acute viral hepatitis‬أو اﻟـ‪ viral hepatitis‬اﻛﺘﺒﻮا ﻋﻠﻴﻪ ‪category A‬‬
‫اﻟـ‪ viral hepatitis‬ﻲﻓ آﺧﺮ ﻣﺆﺗﻤﺮ ﻟﻠﻜﺒﺪ ﻛﺎﻧﻮا ﺑﻴﻘﻮﻟﻮا ﻛﺪه‪ :‬اﻟﻜﺒﺪ اﳌﺼﺮي ﻣﻮﺑﻮء ﻣﻨﺬ ﻣﺎ ﻗﺒﻞ‬
‫اﻟﺘﺎر�ﺦ ﻋﻤﻠﺖ إﺣﺼﺎﺋﻴﺔ ﻣﻊ رﺋﻴﺴﺔ اﻟﻘﺴﻢ اﻟﺴﺎﺑﻘﺔ اﺳﻤﻬﺎ دﻛﺘﻮرة ﺳﻬ�‪ ،‬ﺟﺒﻨﺎ ﺟﺎرات ﻲﻓ‬
‫اﳌﻮﻣﻴﺎت ﻟﻘﻴﻨﺎ اﻟـ‪ ova‬ﻣﻮﺟﻮده ﻲﻓ اﻟﺠﺎرات ده‪ ،‬ﻋﻨﺪﻣﺎ ﺗﺬﻛﺮ ﻣﺼﺮ ﻳﺬﻛﺮ اﻟـ‪،bilharziasis‬‬
‫وﻟﻜﻦ اﻧﺘﻮا ﻋﺎرﻓ� ﻲﻓ اﻟﻔﺮﺘة اﻷﺧ�ة اﻟـ‪ bilharziasis‬ﻣﺒﻘﺘﺶ ﻣﻬﻤﺔ‪ ،‬ﻟﻴﻪ؟ آه ﻷن اﻟـ‪snail‬‬
‫ﺑﻘﻰ ﺑﻴﻘﺮف ﻳﻌﻴﺶ‪ ،‬إﺣﻨﺎ اﻟﺪوﻟﺔ اﻟﻮﺣﻴﺪه اﻟ� ﻗﺪرﻧﺎ ﻧﻘﻲﻀ ﻋ� اﻟﺒﻠﻬﺎرﺳﻴﺎ ﺑﺎﻟﻘﺬارة‪ ،‬وﻛﺎﻧﻮا‬
‫ﺑﻴﻘﻮﻟﻮا ﻲﻓ آﺧﺮ ﻣﺆﺗﻤﺮ إن اﻟـ‪ bilharziasis‬ﺗﻨﺤﺴﺮ وإن اﻟـ‪ hepatitis‬ﻳﻨﺘﺸﺮ‪.‬‬

‫‪Aetiology:‬‬
‫ﻳﻌﻨﻲ إﻳﻪ ‪viral hepatitis‬؟‬
‫اﻟـ‪ viral hepatitis‬ﻫﻮ اﻟ� ﻣﻌﻤﻮل ﺑﺎﻟـ‪ ،hepatitis virus‬ﻣﺎﻫﻲ اﻟـ‪hepatitis viruses‬؟‬
‫ﻟﻮ ﺳﻤﺤﺘﻮا ﻫﺘﻼﻗﻮا ﻋﻨﺪﻛﻮا اﻟـ‪ aetiology‬ﺑﺘﺎﻋﻪ ﻛﺪه ﻲﻓ ﺑﺮاﺟﺮاف ﻛﺒ�‪ ،‬ﺳﻮف اﺳﺘﺒﺪل‬
‫ﻫﺬااﻟﺮﺒاﺟﺮاف ﺑﺠﺪول ﺻﻐ�‪ ،‬اﻟﺠﺪول اﻟ� ﻗﺪاﻣﻜﻮا ده‪ ،‬إﻳﻪ اﻟﺠﺪول اﻟ� ﻗﺪاﻣﻜﻮا ده؟ ﻃﺐ‬
‫ﻟﻴﻪ ﻧﻌﻤﻞ اﻟﺠﺪول ده؟ ﻷن اﻟـ‪ viruses‬دي اﺳﻄﻤﺒﺔ ﻫﻨﻜﺮرﻫﺎ ﺣﻀﺮاﺗﻜﻮا ﻲﻓ ﻫﺬه اﻟﺤﺼﺔ ‪٦‬‬
‫ﻣﺮات ﻓﻼزم ﺗﺒﻘﻰ ﺣﺎﻓﻈﻬﺎ ﻋﻦ ﻇﻬﺮ ﻗﻠﺐ‪ ،‬اﻟﻜﻼم ده ﻫﻨﺤﻮﻟﻪ ﻟﺠﺪول‪ ،‬إﻳﻪ اﻟﺠﺪول؟ اﻟﺠﺪول‬
‫ﻓﻴﻪ‪ ،‬اﻟﻔ�وﺳﺎت اﻟ� أﻧﺘﻮا ﻣﻄﺎﻟﺒ� ﺑﻴﻬﺎ ‪ A, B, C, D, E‬ﻲﻓ ﻛﻞ واﺣﺪ ﺗﻌﺮف اﺳﻤﻪ اﻟﻘﺪﻳﻢ‬
‫إﻳﻪ وﺑﻌﺪ ﻛﺪه اﻟـ‪ incubation period‬وﺑﻌﺪ ﻛﺪه اﻟـ‪ mode of transmission‬وﺑﻌﺪ ﻛﺪه‬
‫اﻟـ‪ ،effects‬اﻫﺪوا ﺑﻘﻰ ﻣﻌﺎﻳﺎ‪ ،‬ﻫﻤﺎ ﺧﻤﺴﺔ ﺑﻜﺎم ‪ point‬ﻫﺘﺘﻜﻠﻢ ﻋﻠﻴﻬﺎ؟ ارﺑﻌﺔ‪.‬‬

‫‪Virus‬‬ ‫‪Old name‬‬ ‫‪Incubation‬‬ ‫‪Mode of‬‬ ‫‪Effects‬‬

‫‪period‬‬ ‫‪trans.‬‬

‫‪A‬‬ ‫‪Infectious‬‬ ‫‪2-6 weeks‬‬ ‫‪Feco-oral‬‬ ‫‪Acute/‬‬

‫‪hepatitis‬‬ ‫‪fulminant‬‬

‫‪B‬‬ ‫‪Serum‬‬ ‫‪2-6 months‬‬ ‫‪Serum/‬‬ ‫‪Acute/‬‬

‫‪hepatitis‬‬ ‫‪sexual‬‬ ‫‪fulminant/‬‬
‫‪chronic/‬‬
‫‪cirrhosis/‬‬
‫‪carrier/‬‬
‫‪carcinoma‬‬

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‫‪C‬‬ ‫‪Non-A‬‬ ‫‪2-6 years‬‬ ‫‪Serum‬‬ ‫‪Acute/‬‬

‫‪Non-B‬‬ ‫‪fulminant/‬‬
‫‪chronic/‬‬
‫‪cirrhosis/‬‬
‫‪carrier/‬‬
‫‪carcinoma‬‬

‫‪D (Defective‬‬ ‫ــــــــــــــــــــ‬ ‫‪2-6 months‬‬ ‫‪Serum‬‬ ‫‪chronic/‬‬

‫)‪virus‬‬ ‫‪cirrhosis/‬‬
‫‪carrier/‬‬
‫‪carcinoma‬‬

‫‪E‬‬ ‫ــــــــــــــــــــ‬ ‫‪2-6 weeks‬‬ ‫‪Feco- oral‬‬ ‫‪Acute/‬‬

‫‪fulminant‬‬

‫‪Old Names:‬‬

‫أول ‪ virus‬اﻟ� ﺗﻢ اﻛﺘﺸﺎﻓﻪ ﻲﻓ اﻷول ده‪ ،‬ﻟﻘﻮا إﻧﻪ ﺑﻴﻨﺘﻘﻞ ﻋﻦ ﻃﺮ�ﻖ اﻟﺮﺒاز‪ ،‬أﻛﻞ ﻣﻠﻮث ﺑﺎﻟﺮﺒاز‬
‫‪ feco-oral‬ﻓﺰﻣﺎن ﻣﻜﺎﻧﻮش ﻣﺴﻤﻴﻴﻨﻪ ‪ A‬ﻛﺎﻧﻮا ﻣﺴﻤﻴﻨﻪ ‪،infectious hepatitis‬‬
‫‪ infectious‬ﻳﻌﻨﻲ إﻳﻪ؟ ﻳﻌﻨﻲ ﻣُ ﻌﺪي أو اﻟﻮﺑﺎﻲﺋ‪.‬‬
‫ﺑﻌﺪ ﻛﺪه اﻛﺘﺸﻔﻮا ‪ virus‬ﺗﺎ� وﻟﻜﻦ ﻳﻨﺘﻘﻞ ﻋﻦ ﻃﺮ�ﻖ اﻟـ‪ serum‬راﺣﻮا ﻣﺴﻤﻴﻴﻨﻪ ‪serum‬‬
‫‪ hepatitis‬ﻟﺴﻪ ﻣﺴﻤﻮش ‪ A‬وﻻ ‪ B‬وﻻأي ﺣﺎﺟﺔ‬
‫ﺑﻌﺪ ﻛﺪه اﻛﺘﺸﻔﻮا واﺣﺪ زي ﺑﺎﻟﻈﺒﻂ ﺑﺘﺎع اﻟـ‪ serum‬وﻟﻜﻦ ﻣﺶ ‪ B‬ﻓﺮاﺣﻮا ﻣﺴﻤﻴﻨﻪ ‪non-A‬‬
‫‪ non-B‬وده اﻻﺳﻢ اﻟﻘﺪﻳﻢ ﺑﺘﺎع اﻟـ‪ C‬ﻛﺎن اﺳﻤﻪ ‪.non-A non-B‬‬
‫ﺟﻢ ﺑﻌﺪ ﻛﺪه اﻛﺘﺸﻔﻮا ﻓ�وس ﺗﺎ� ﻣﻴﺠﻴﺶ ﻟﻮﺣﺪه ﻻزم ‪ on top of B‬ﻷﻧﻪ ‪defective‬‬
‫ﻓﻘﺎﻟﻮا ﻫﻨﺴﻤﻴﻪ ‪.D‬‬
‫ﻗﺎﻟﻮا ﺧﻼص ﻳﺒﻘﻰ اﻷول اﺳﻤﻪ ‪ A‬واﻟﺘﺎ� اﺳﻤﻪ ‪ B‬واﻟﺘﺎﻟﺖ اﺳﻤﻪ ‪ C‬واﻟﺮاﺑﻊ اﺳﻤﻪ ‪ D‬اﻟﺮاﺑﻊ‬
‫ﻣﻠﻮش أي اﺳﻢ ﻗﺪﻳﻢ‪.‬‬
‫اﻟـ‪ A‬اﺳﻤﻪ اﻟﻘﺪﻳﻢ ‪ ،infectious‬اﻟـ‪ B‬اﺳﻤﻪ اﻟﻘﺪﻳﻢ ‪ ،serum‬اﻟـ‪،non-A non-B⟵ C‬‬
‫اﻟـ‪ D‬ﻣﻠﻮش اﺳﻢ ﻗﺪﻳﻢ‪.‬‬
‫اﻛﺘﺸﻔﻮا ﺑﻌﺪ ﻛﺪه ﻲﻓ ﻗﺮ�ﺔ ﻲﻓ اﻟﻬﻨﺪ ﻓ�وس زي اﻟـ‪ A‬ﺑﻴﻔﺮق ﻲﻓ ﺣﺎﺟﺔ واﺣﺪه ﻫﻘﻮﻟﻬﺎ ﻓﻘﺎﻟﻮا‬
‫ﺧﻼص ﻫﻨﺴﻤﻴﻪ ‪ E‬ﻟﻴﻪ ﺑﻘﻰ ‪E‬؟ ﻷن اﻟـ‪ A‬واﻟـ‪ E‬ﺣﺮوف ﻋﻠﺔ ﻣﺶ اﻟـ‪ A‬واﻟـ‪ E‬دول ﺣﺮوف ﻋﻠﺔ؟‬
‫ﺑﻨﺤﻂ ﻗﺒﻠﻬﻢ ‪ an‬ﺣﺮوف ﻋﻠﺔ ﺣﻀﺮﺗﻚ ‪xD‬‬

‫ـ‪Incubation period:‬‬

‫اﻟـ‪ incubation period‬ﻓﻴﻬﻢ ﻛﻠﻬﻢ ﻣﻦ ‪ ٢‬ﻟـ‪ ٦‬وﻟﻜﻦ ﺑﺘﻔﺮق ﻲﻓ اﻟﻮﺣﺪه‪:‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫اﻟـ‪ A‬ﻣﻦ ‪.2-6 weeks‬‬

‫اﻟـ‪ B‬ﻣﻦ ‪.2-6 months‬‬
‫اﻟـ‪ C‬ﻣﻦ ‪.2-6 years‬‬
‫اﻟـ‪ D‬ﻣﻦ ‪ 2-6 months‬زي اﻟـ‪.B‬‬
‫اﻟـ‪ E‬ﻣﻦ ‪ 2-6 weeks‬زي اﻟـ‪.A‬‬

‫‪Mode of transmission:‬‬

‫اﻟـ‪ A‬ﺑﻴﻨﺘﻘﻞ إزاي؟ ‪ feco-oral‬ﻋﻠﺸﺎن ﻛﺪه ﺳﻤﻮه ‪.infectious‬‬

‫أُﻣﺎل اﻟـ‪B‬؟ اﺳﻤﻪ ‪ ،serum‬ﺑﻴﻨﺘﻘﻞ ﻋﻦ ﻃﺮ�ﻖ ‪ contaminated blood‬أو اﻟـ‪ serum‬أو‬
‫اﻟـ‪ blood component‬أو ‪ contaminated surgical equipment‬أو اﻟﻌﻴﺎﻧ� اﻟ�‬
‫ﻋ� ‪ renal haemodialysis‬أو ﻳﻨﺘﻘﻞ ﺑﺎﻟـ‪ razor‬اﻷﻣﻮاس ﻋﻨﺪ اﻟﺤﻼﻗ�‪،‬أو اﻟـ ‪dental‬‬
‫‪ ،instruments‬أي ﺣﺎﺟﺔ ﻓﻴﻬﺎ ‪ body secretion‬أو اﻟﺪم ﺑﺎﻟﺬات‪ ،‬وﺑﻴﻨﺘﻘﻞ ‪ sexual‬و‬
‫‪ trans-placental‬ﻳﻌﻨﻲ ﻛﻞ أﻧﻮاع اﻟﻄﺮق ﻷن ﻫﻮ ﻣﻮﺟﻮد ﻲﻓ اﻟـ‪.secretions‬‬

‫اﻟـ‪ C‬ز�ﻪ ﺑﺎﻟﻈﺒﻂ وﻟﻜﻦ ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ﻣﻨﻘﺪرش ﻧﻘﻮﻟﻪ إﻧﻪ ﻳﻨﺘﻘﻞ ‪ sexual‬ﻷن ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ‬
‫أﺷﻬﺮ ﻧﻮع ‪ virus‬ﻫﻮ اﻟـ‪ C‬واﻟـ‪ C‬ﺣﻀﺮﺗﻚ ﺑﻴـ‪ affect‬أﻛﺮﺘ ﻣﻦ ‪ 60%‬ﻣﻦ اﻟﺸﻌﺐ اﳌﺼﺮي‬
‫ﻓﺒﺎﻟﺘﺎﻲﻟ ﻟﻮ ﻗﻠﻨﺎ ﺑﻴﻨﺘﻘﻞ ‪ sexual‬ﻫﻨﺠﻴﺐ أي ﻧﺎس ﻣﻦ ﺑﺮه ﻧﻄﻠﻘﻬﻢ ﻷن أي واﺣﺪ اﺗﺠﻮز واﺣﺪه‬
‫ﻋﻨﺪﻫﺎ ‪ C‬ﻫﺘﺨﺎف ﺗﻌﺪﻳﻪ ﻓﻴﻄﻠﻘﻬﺎ‪ ،‬ﻓﺎﻫﻤ� ﺣﺎﺟﺔ؟ واﻟﻌﻜﺲ ﺑﺎﻟﻌﻜﺲ‪ ،‬ﻷﺳﺒﺎب ﺳﻴﺎﺳﻴﺔ‬
‫ﻓﻘﻂ ﻲﻓ ﻣﺼﺮ ﺑﻨﻘﻮل إن اﻟـ‪ C‬ﻣﺶ ﺑﻴﻨﺘﻘﻞ ‪ sexual‬أُﻣﺎل ﺑﻴﻨﺘﻘﻞ إﻳﻪ؟ ﺑﻴﻨﺘﻘﻞ ﺑﺎﻟـ‪serum‬‬
‫ﻓﺎﻫﻤ� وﻻ ﻣﺶ ﻓﺎﻫﻤ�؟ ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ﺑﺲ ﻟﻜﻦ ﻫﻮ ﺑﺎﻟﻈﺒﻂ زي اﻟـ‪.B‬‬

‫اﻟـ‪ D‬ﻣﻴﺠﻴﺶ ﻟﻮﺣﺪه‪ ،‬ﺑﻴﻴﺠﻰ زي اﻟـ‪ B‬ﻷﻧﻪ ﺑﻴﻴﺠﻲ ‪ ،on top of B‬ﻳﻌﻨﻲ ﻳﻴﺠﻲ ﺑﺮﺿﻮ ‪.serum‬‬
‫اﻟـ‪ E‬زي اﻟـ‪ ،A‬ﻣﺶ اﻻﺗﻨ� ﺣﺮوف ﻋﻠﺔ؟ ﺑﻴﻨﺘﻘﻞ ﺑﺈﻳﻪ؟ ‪.feco-oral‬‬

‫آﺧﺮ ﺣﺎﺟﺔ ﺍﻟـ‪:effects‬‬

‫رﻛﺰوا ﺑﻘﻰ‪ ،‬ﻓ�وﺳﺎت اﻟـ‪ hepatitis‬ﺑﺘﻌﻤﻞ ﻋﻨﺪﻧﺎ اﻷﻋﺮاض اﻵﺗﻴﺔ‪:‬‬

‫● ﻳﺎ إﻣﺎ ﺗﻌﻤﻞ ‪ acute‬ﺃﻭ ‪fulminant‬‬

‫‪acute ⟵ acute‬‬
‫‪ ⟵ fulminant‬ﻣﻠﻬﻠﺐ‬
‫ﻣ� ﻳﻌﻤﻞ اﻟـ‪ acute‬واﻟـ‪fulminant‬؟ ﻛﻠﻬﻢ ﻣﺎﻋﺪا اﻟـ‪ D‬ﻷن اﻟـ‪ D‬ﻻزم ﻳﺒﻘﻰ ‪ chronic‬ﻓﻜﻠﻪ‬
‫ﻳﻌﻤﻞ ‪ acute‬و ‪.fulminant‬‬

‫● ﻟﻜﻦ ﻣ� ﻓﻴﻬﻢ ﻳﻌﻤﻞ }‪ {C‬ﻳﻌﻨﻲ إﻳﻪ ﻳﻌﻤﻞ }‪{C‬؟ ﻳﻌﻨﻲ ﻳﻌﻤﻞ ‪Carrier/ Chronic/‬‬
‫‪ Cirrhosis/ Carcinoma‬اﻟـ‪ B‬واﻟـ‪ C‬ﺣﺪ ﻓﺎﻫﻢ ﺣﺎﺟﺔ؟!‬

‫اﻟـ‪ A‬واﻟـ‪ E‬ﻓﻴﻬﻢ ﺣﺮف ‪C‬؟ ﻓﻴﻌﻤﻠﻮا ‪ acute‬و ‪fulminant‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﻟﻜﻦ اﻟ� ﻓﻴﻬﻢ ‪ C‬ﻳﻌﻤﻠﻮا }‪ {C‬ﻣ� اﻟ� ﻓﻴﻬﻢ ‪C‬؟ اﻟـ‪ B‬واﻟـ‪ C‬أو اﻟـ‪ ،D on top of B‬ﻛﻞ دول‬
‫ﻳﻌﻤﻠﻮا ‪ chronic/ cirrhosis/ carrier/ carcinoma‬ﻣﺘﻔﻘ� ﻋ� ﻛﺪه؟‬

‫‪Clinico-Pathological Effects:‬‬
‫ﻷن ﻋﻨﺪﻧﺎ اﻟﻔ�وﺳﺎت اﻟﻜﺒﺪﻳﺔ ﻟﻮ دﺧﻠﺖ اﻟﻜﺒﺪ ﺗﻌﻤﻞ إﻳﻪ؟ ﺣﺎﺟﺔ اﺳﻤﻬﺎ ‪Clinico-‬‬
‫‪ Pathological Effect‬ﻷن ﻫﻲ دي اﳌﻮاﺿﻴﻊ اﻟ� ﻫﺸﺮﺣﻬﺎ‪:‬‬

‫أول ﺣﺎﺟﺔ ﺗﻌﻤﻞ ‪ ،acute‬ﻣ� اﻟ� ﻳﻌﻤﻞ ‪ acute‬ﻣﻦ اﻟﺠﺪول؟ ﻛﻠﻬﻢ ﻣﺎﻋﺪا اﻟـ‪ D‬ﻷن اﻟـ‪D‬‬
‫ﺑﻴﺠﻲ ‪ on top of B‬اﻟـ‪ D‬ﻓﺒﻴﻴﺠﻲ ‪.chronic‬‬
‫أﺻﻞ ﻟﻮ ﺟﺎﻟﻚ اﳌﻮﺿﻮع ﻻزم ﺗﻜﺘﺐ اﻟـ‪ etiology‬ﻣﻦ اﻟﺠﺪول‪ ،‬ﻓﺎﻫﻤ� ﺣﺎﺟﺔ؟ اﻟﺠﺪول ده‬
‫اﺳﻄﻤﺒﺔ ﻫﻨﻜﺮرﻫﺎ ﻲﻓ أي ﻣﻮﺿﻮع ‪.hepatitis‬‬
‫ﻣ� ﻳﻌﻤﻞ ‪fulminant‬؟ ﻛﻠﻬﻢ ﻳﻌﻤﻠﻮا ‪ fulminant‬ﻣﺎ ﻋﺪا ﻃﺒﻌﺎً اﻟـ‪ ،D‬ﺣﻠﻮ‪.‬‬
‫ﻣ� ﻓﻴﻬﻢ ﻳﻌﻤﻞ ‪ carrier‬واﻟـ‪chronic‬؟! ﻛﻠﻪ ﻣﺎﻋﺪا اﻟـ‪ A‬واﻟـ‪ E‬ﻷن اﻟـ‪ A‬واﻟـ‪ E‬ﻣﻔﻴﻬﻮﻣﺶ ‪.C‬‬

‫‪ACUTE VIRAL HEPATITIS‬‬

‫ﻫﻨﺒﺪأ اﻟﺸﺮح‪ ،‬ﺑﺼﻮا ﻣﻌﺎﻳﺎ‪ ،‬أول ﻣﺮض اﻛﺘﺒﻮا ﻋﻠﻴﻪ ‪ category A‬ﻧﻈﺮي وﺑﻴﺴﻤﻮه زﻣﺎن‬
‫‪ ،autumn hepatitis‬ﻛﺎﻧﻮا زﻣﺎن ﺑﻴﺴﻤﻮه ‪ autumn hepatitis‬أو اﻟﺘﻬﺎب اﻟﺨﺮ�ﻒ‬
‫وﻫﻨﻌﺮف ﻟﻴﻪ‪ ،‬اﻟـ‪ autumn hepatitis‬أو اﻟـ‪ acute viral hepatitis‬ﻣﺮض ﻛﻠﻜﻠﻮا أُﺻﻴﺒﺘﻮا‬
‫ﺑﻴﻪ وﺑﻴﺴﻤﻮه ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ﺻﻔﺮة اﻷﻃﻔﺎل‪ ،‬واﻟـ‪ autumn hepatitis‬أو اﻟـ ‪acute viral‬‬
‫‪ hepatitis‬ﻋﻼﺟﻪ ﺑﻴﺪوا اﻟﻌﻴﺎن ﻋﺴﻞ وﻣﺮﺑﻰ وﻣﻜﺮوﻧﺔ وﻣﻴﺎﻛﻠﻮش ﻟﺤﻤﺔ وﻻ ‪ ،fat‬واﻟﻌﺴﻞ‬
‫ﻳﺒﻘﻲ ﻋﺴﻞ أﺳﻮد‪.‬‬

‫‪Aetiology:‬‬
‫اﻟـ‪ ،acute viral hepatitis‬اﻟـ‪ aetiology‬ﻣ� ﻳﻌﻤﻞ اﻟـ‪acute‬؟ ﻛﻠﻬﻢ ﻣﺎﻋﺪا اﻟـ‪D‬‬
‫ﻳﻌﻨﻰ )‪ (A, B, C, E‬ﺻﺢ ﻛﺪا‪ ،‬ﺑﺲ ﻫﻨﻜﺘﺒﻬﺎ ﻛﺪه؟ اﻟﺠﺪول ﻳﺎ أﺧﻮ�ﺎ ﻷن ﻛﻞ واﺣﺪ ﻫﺘﻘﻮل‬
‫اﻟـ‪ mode of transmission‬و ‪ incubation period‬و ‪.........‬‬

‫وﻟﻜﻦ أﺷﻬﺮ ﺣﺎﺟﺔ ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ واﻟﻌﺎﻟﻢ ﺗﻌﻤﻞ ‪ acute‬ﻫﻮ اﻟـ‪ ،A‬اﻟـ‪ A‬ﻫﻮ اﻟ� ﺑﻴﻌﻤﻞ‬
‫اﻟـ‪ acute‬وده ﻣﻠﻮش أي ﻗﻴﻤﺔ زي ﻣﺎ ﻫﺘﺸﻮﻓﻮا‪.‬‬

‫ﺑﻌﺪ اﻟـ‪ aetiology‬اﻟﺠﺪول ﻳﺘﻜﺘﺐ ﻫﻨﺎ ﻓﺎﻫﻤ� ﺣﺎﺟﺔ؟ اﻟﺴﺆال ده ﻟﻮ ﻧﺰﻟﻚ اﻟـ‪aetiology‬‬
‫ﺑﺘﺎﻋﺔ ﺑﺲ ﺑﻴﻨﺰل ﻛﺪه‪ aetiology of acute viral hepatitis ،‬ﺑﻴﻨﺰﻟﻚ ﺑـ‪ ٥‬درﺟﺎت‪ ،‬ﻳﺒﻘﻲ‬
‫ﻲﻓ اﻟـ‪ aetiology‬ﻻزم ﺗﻜﺘﺐ ‪causative organism- mode of transmission-‬‬
‫‪ predisposing factors‬ودي اﻟ� ﻣﻜﺘﻮﺑﺔ ﻲﻓ اﻟﺠﺪول‪ ،‬ﻟﻜﻦ أﺷﻬﺮ ﺣﺎﺟﺔ اﻟـ‪.A‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫‪Pathology‬‬
‫‪Gross:‬‬

‫اﻟـ ‪ ،acute viral hepatitis‬دا ﺷﻜﻞ اﻟﻜﺒﺪ و اﻟﻜﺒﺪ ‪ grossly‬و ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب ﺑﻨﻌﺮﺒ‬
‫ﻋﻨﻪ ﺑﻜﻠﻤﺘ�‪ :‬ان ﻫﻮ ﻛﺒ� و أﺧﻀﺮ ‪.‬‬
‫‪ ،is enlarged and bile stained‬اﻟـ ‪ bile‬اﳌﻔﺮوض ﻳﺒﻘﻰ ‪ yellow‬ﺑﺲ ﻫﻨﺎ ‪brownish‬‬
‫ﺷﻮ�ﺔ ﻣﺶ ﻣﻬﻢ‪.‬‬
‫اﻟـ ‪ liver is enlarged and bile stained‬ﻛﺒ� و أﺧﻀﺮ ‪.‬‬
‫ﻣﻦ اﻟﻜﻠﻤﺘ� دول ﻫﻄﻠﻌﻠﻜﻮا اﳌﻴﻜﺮوﺳﻜﻮب رﻛﺰوا ﺑﻘﻰ ‪.‬‬

‫‪Microscopy:‬‬

‫آدى اﻟ� ﻗﺪاﻣﻜﻮا ده ﺣﺎﻟﺔ ‪ grossly ،acute viral hepatitis‬أﻧﺎ ﻗﻮﻟﺖ اﻧﻪ ﺑﻴﺒﻘﻰ ﻛﺒ� و‬
‫أﺧﻀﺮ ﻟﻴﻪ؟ ﻷن ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب ‪ ،‬إﻳﻪ اﻟ� اﻧﺘﻮا ﺷﺎﻳﻔﻴﻨﻬﺎ دى ؟ ‪ ، Hepatocyte‬إﻳﻪ‬
‫رأﻳﻜﻮا ﻓﻰ ﺣﺠﻤﻬﺎ ؟!‬
‫‪ Hepatocyte shows hydropic degeneration‬اﻟـ ‪ Hepatocyte‬ﻣﻨﻔﻮﺧﺔ ‪،H2O‬‬
‫ﺣﺪ ﻳﻌﺮف ﻟﻴﻪ ؟! اﻟﻔ�وس ﺑﻴﻌﻴﺶ ﻓ� ؟ ﻓﻰ اﻟﺨﻠﻴﺔ و ﺑﻴﺴﺘﻬﻠﻚ إﻳﻪ ؟ ‪ ATP‬ﻓﺒﺎﻟﺘﺎﻰﻟ‬
‫اﻟـ‪ Na+-ATP pump‬ﺗﻘﻞ ﻓﺎﻟﺼﻮدﻳﻮم ﻳﺪﺧﻞ و ﻳﺸﻔﻂ اﻟـ ‪.H2O‬‬
‫ﻓﻬﻨﺎ اﻟـ ‪ Hepatocyte show ballooning degeneration‬ودى أول ﺣﺎﺟﺔ ﺗﺴﺎﻋﺪ ان‬
‫اﻟﻜﺒﺪ ﻳﺒﻘﻰ ‪. enlarged‬‬

‫ﺗﺎ� ﺣﺎﺟﺔ‪ :‬اﻧﺘﻮا ﻟﻮ ﺟﻴﺘﻮا ﺗﺒﺼﻮا ﻫﺘﻼﻗﻮا إن ﻓﻴﻪ ‪ ،liver cell necrosis‬ﻓ� ﺑﻘﻰ؟ ﺗﺘﻮﻗﻌﻮا‬
‫ﺗﺸﻮﻓﻮا اﻟـ ‪ necrosis‬ﻓ� ؟!ﻓﻰ اﻟـ ‪ ،central zone‬ﻟﻴﻪ ﺑﻘﻰ؟ اﺷﻤﻌﻨﻰ؟ ﻷﻧﻬﺎ أﺑﻌﺪ ﻣﺎ ﻳﻜﻮن‬
‫ﻋﻦ اﻟـ ‪ ،O2‬ﻓﻜﻤﻴﺔ اﻟـ ‪ ATP‬اﻟ� ﻓﻴﻬﺎ ﻗﻠﻴﻠﺔ ﻓﺒﺎﻟﺘﺎﻰﻟ ﻫﻰ اﻟ� ﺗﻤﻮت ﻓﻰ اﻷول و دا ﺗﺎ� ﺳﺒﺐ‬
‫ﻳﺴﺎﻋﺪ ان اﻟﻜﺒﺪ ﻳﻜﺮﺒ ‪ ،‬ﻷن ﻋﻨﺪﻣﺖ ُﺗﻘﺘﻞ اﻟﺨﻠﻴﺔ ﺗﻜﺮﺒ و ﻻ ﺗﺼﻐﺮ ؟! ﺗﻜﺮﺒ ‪ .‬وﺗﺒﻘﻰ ‪ acidic‬و ﻻ‬
‫‪ alkaline‬؟! ‪.Alkaline‬‬
‫ﻛﺮﺒت‪ ،‬ﻓﺪه ﺑﻴﺴﺎﻋﺪ اﻟﻜﺒﺪ أﻛﺮﺘ ‪ ،‬ﻣﻤﻜﻦ ﻧﻼﻗﻴﻪ ‪ ،unicellular or focal‬ﻟﻜﻦ أﻫﻢ ﺣﺎﺟﺔ اﻟـ‬
‫‪ centrizonal necrosis‬ﻟﻘﻮا ﺑﻌﺾ اﻟـ ‪ hepatocyte‬ﺑﺘﺒﻘﻰ ‪ shrunken‬و ‪acidophilic‬‬
‫وﺳﺎﻋﺘﻬﺎ ﺳﻤﻮﻫﺎ ‪ Councilman bodies‬ﺧﺪﻧﺎﻫﺎ دى ﻗﺒﻞ ﻛﺪه ؟! آه ‪ ،‬اﻟـ ‪Councilman‬‬
‫‪ bodies‬ﻣﺎﻫﻰ إﻻ ‪ ،apoptosis‬ﺑﻌﺾ اﻟﺨﻼﻳﺎ ﻳﺤﺼﻞ ﻟﻬﺎ ‪ apoptosis‬ﻓﺘﺼﻐﺮ‪ ،‬ﻣﺶ‬
‫ﻣﺸﻜﻠﺔ‪.‬‬

‫ﺇﻳﻪ ﻛﻤﺎﻥ ؟!‬

‫ﻧﺮﺟﻊ ﻟﻠﺼﻮرة اﻷوﻻﻧﻴﺔ‪ ،‬ﻫﻮ دﻟﻮﻗﺘﻰ اﻟـ ‪ disease‬ده ﻓ�وس دﺧﻞ ﺟﻮا ﺧﻼﻳﺎ اﻟﻜﺒﺪ ﻓﺎﺳﺘﺜﺎر‬
‫اﻟـ ‪ immunity‬ﺻﺢ ﻛﺪا؟‬
‫ﻫﻨﻼﻗﻰ اﻟـ ‪ portal tract‬و اﻟـ ‪ hepatic lobule‬ﻓﻴﻬﺎ ‪ ، inflammation‬ﻣ� اﻟـ‬
‫‪ inflammatory cell‬اﻟ� ﺑﺘﻄﻠﻊ ﻓﻰ اﻟـ ‪acute viral infection‬؟‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫اﻟـ ‪neutrophil‬؟ ﻷ ﻃﺒﻌﺎ‪ ،‬ﻫﻨﺎ ﻫﺘﺒﻘﻲ ‪lymphocyte, plasma cell and‬‬

‫‪ macrophage‬و دول ﻟﻮ دﺧﻠﻮا ﺟﻮا اﻟﻜﺒﺪ ﻳﻌﻤﻠﻮا إﻳﻪ ﻓﻰ اﻟﺤﺠﻢ ؟ ﻳﺰودوه ‪.‬‬

‫ﻋﺮﻓﺘﻮا ﻛﻠﻤﺔ ﻛﺒ� ﺗﻔﺴ�ﻫﺎ ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب إﻳﻪ ؟‬

‫‪ -١‬اﻟـ ‪.Hydropic degeneration‬‬
‫‪ -٢‬اﻟـ ‪.necrosis‬‬
‫‪ -٣‬اﻟـ ‪ inflammation‬اﻟ� ﻣﻮﺟﻮد‪.‬‬
‫ﻣﻔﻬﻮﻣﺔ؟ ‪.ok‬‬

‫ﻃﻴﺐ ﻟﻴﻪ ﺃﺧﻀﺮ؟‬

‫أﺧﻀﺮ دى ﻋﻠﺸﻨﺎ ﻓﻰ ﺣﺎﺟﺔ ﻓﻰ اﻟﻬﺴﺘﻮﻟﺠﻰ أﻧﺘﻮا ﻣﺎﺗﻌﺮﻓﻮﻫﺎش‪ normally ،‬أﻧﺘﻮا ﻋﺎرﻓ�‬
‫اﻟـ ‪ space‬اﻟ� ﺑ� اﻟـ ‪ hepatocyte cords‬ﻛﺪه دا ﺑﻴﺴﻤﻮه ‪ ،sinusoid‬ﻟﻜﻦ اﻟ� ﺑ� اﻟـ‬
‫‪ hepatocyte‬واﻟ� ﺟﻨﺒﻬﺎ ﻲﻓ ﻧﻔﺲ اﻟـ‪ cord‬ده ﺑﻴﺴﻤﻮه ‪bile canaliculus‬؛ ﻻن ﺑﺘﻴﺠﻰ اﻟـ‬
‫‪ hepatocyte‬ﺗﻌﻤﻞ اﻟـ ‪ bile‬و ﺗﺮﻣﻴﻪ ﻓﻰ اﻟـ ‪ canaliculus‬اﻟ� ﺑﻌﺪ ﻛﺪا ﻳﻤﻰﺸ ﻓﻰ اﻟـ ‪bile‬‬
‫‪ canaliculi‬ﻳﺮوح ﻧﺎﺣﻴﺔ اﻟـ ‪ portal tract‬ﻋﻠﺸﺎن ﻳﺨﺮج ﻓﺎﻫﻤ� ﺣﺎﺟﺔ؟‬

‫ﻃﻴﺐ ﻣﺎ اﻧﺖ ﻗﺒﻞ ﻛﺪا ﺧﻼﻳﺎ اﻟﻜﺒﺪ ﺑﺴﺒﺐ اﻟـ ‪ hydropic degeneration‬ﺣﺼﻠﻬﺎ إﻳﻪ ؟ ﻛﺮﺒت‬
‫ﻳﺒﻘﻰ اﻟـ ‪ bile canaliculi‬ﻫﻴﺤﺼﻞ ﻟﻬﺎ اﻳﻪ ؟ ‪ ،obstruction‬ﻓﺎﻟﺒﺘﺎﻰﻟ اﻟـ ‪ bile‬ﻫﻴﻌﺮف ﻳﺨﺮج‬
‫؟! ﻷ ‪ ،‬ﻓﻴﺘﺤﻮش ﺟﻮه اﻟـ ‪ ،hepatocyte‬أدى دا اﻟـ ‪ ،bile‬ﺣﺪ ﺷﺎﻳﻒ ‪ pigment‬ﻟﻮﻧﻬﺎ ﺑﻨﻰ‬
‫ﻣﺤﺒﻮﺳﺔ ﺟﻮا اﻟـ ‪hepatocyte‬؟ ‪ chole ،this is cholestasis‬ﻳﻌﻨﻰ ‪ bile‬و اﻟـ ‪stasis‬‬
‫ﻳﻌﻨﻰ ‪.retention‬‬

‫اﻟـ ‪ cholestasis‬ﻫﻮ اﳌﺴﺌﻮل ﻋﻦ إن اﻟﻠﻮن ﻳﺒﻘﻲ ‪ grossly‬أﺧﻀﺮ‪ ،‬ﻣﺶ اﻟـ ‪ bile‬أﺧﻀﺮ؟‬

‫ﻃﻴﺐ ﻟﻴﻪ ﺣﺼﻞ ‪ cholestasis‬؟! ﻷن اﻟـ ‪ hepatocytes‬ﻛﺮﺒت ﻓﻔﻌﺼﺖ اﻟـ ‪canaliculi‬‬
‫ﻓﺎﺗﺤﻮش اﻟـ ‪ bile‬ﺟﻮاﻫﺎ‪ ،‬أﻫﻢ ﺣﺎﺟﺔ ﻓﻰ اﻟـ ‪ microscopic picture‬ﺧﻠﻮا ﺑﺎﻟﻜﻮا إﻧﻪ اﻟﻜﺒﺪ‬
‫ﻳﺒﻘﻲ ﻛﺒ� ﺑـ ‪ 3 mechanisms‬و أﺧﻀﺮ ﺑـ ‪. 1 mechanism‬‬

‫ﺍﻳﻪ ﻛﻤﺎﻥ؟‬
‫أﻫﻢ ﻛﻠﻤﺔ زى ﻣﺎ اﻧﺘﻮا ﺷﺎﻳﻔ� ﻫﻨﺎ اﻟـ ‪intact or disturbed ← frame work‬؟‬
‫‪ ،completely intact‬ﺣﺪ ﻳﻌﺮف ﻟﻴﻪ ؟! ﻷن اﳌﺸﻜﻠﺔ ﻓﻰ اﻟـ ‪ central zone‬أﺑﻌﺪ ﻣﺎ ﻳﻜﻮن‬
‫ﻋﻦ اﻟـ ‪.frame work‬‬
‫ﻣﻤﻜﻦ ﻧﻼﻗﻰ ﻓﻴﻪ ﺷﻮ�ﺔ ﺗﻜﺎﺛﺮ ﻟﻠـ ‪ von kupffer cells‬و ﺗﺎﻛﻞ ﺷﻮ�ﺔ ‪ pigment‬ﺑﺲ ده‬
‫ﻣﻠﻮش اى ﻗﻴﻤﺔ ‪.‬‬

‫ﻋﺸﺎن ﻛﺪا اﻟﻨﺎس اﻟ� ﺑﻴﺠﻴﻠﻬﺎ ‪ acute viral hepatitis‬اﻟﺼﻔﺮا ‪ ،‬اﻟـ ‪acute viral‬‬
‫‪ hepatitis‬ﻣﺸﻬﻮرة ﻣﻦ ﺳﻦ ‪ 4 : 9‬ﺳﻨ� ﻷن دا ﺑﺪاﻳﺔ دﺧﻮل اﳌﺪارس ‪ ،‬اﻳﻪ اﻟ� ﺑﻴﺤﺼﻞ ؟!‬
‫اﻟﻮﻟﺪ او اﻟﺒﻨﺖ اﻣﻬﺎ ﺑﺮﺘﺑﻴﻬﺎ ﻗﺎﻋﺪة ﻣﻌﺎﻫﺎ ﻓﻰ اﻟﺒﻴﺖ ﺗﺤﺖ رﻋﺎﻳﺘﻬﺎ‪،‬وﻟﻜﻦ اﻣﺎ اﻟﻌﻴﺎل ﻳﺘﻨﻘﻠﻮا‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﻟﻠﻤﺪارس و اﻟﺤﻀﺎﻧﺔ ﺑﻴﺒﺪأوا ﻳﺎﻛﻠﻮا ﻣﻦ إﻳﺪ ﻧﺎس ﺗﺎﻧ� ﺻﺢ ﻛﺪا ؟ ﻫﻤﺎ أﺑﻬﺎﺗﻬﻢ و أﻣﻬﺎﺗﻬﻢ ؟‬
‫ﺑﺎﻟﺬات ﺑﻘﻰ ﻳﺪﺧﻠﻮا اﳌﺪارس و اﻟﺤﻀﺎﻧﺎت اﻣﺘﻰ ؟ ﻓﻰ اﻟﺨﺮ�ﻒ ﻓ�وﺣﻮا ﻋﻨﺪ ﻋﺒﺪه ﺗﻠﻮث‬
‫و�ﺘﻌﺪوا ‪3:‬‬

‫اﻟـ ‪ acute viral hepatitis‬دا ‪ autumn‬ﻋﻠﺸﺎن اﻟﻌﻴﺎل ﺑﻴﺒﺪأوا ﻳﺪﺧﻠﻮا اﳌﺪارس‪ ،‬ﻳﻴﺠﻰ‬
‫اﻟﻮاد ده ﺑﻌﺪ دﺧﻮل اﳌﺪرﺳﺔ ﻣﻦ ‪ ٦ : ٢‬أﺳﺎﺑﻴﻊ ﻳﺒﺪأ ﻳﺒﻘﻰ ﻋﻨﺪه ‪vomiting , nausea ,‬‬
‫‪ fever‬و ﻳﺼﻔﺮ‪ ،‬و�ﺒﻘﻰ ﻋﻨﺪه ‪ tender liver‬ﻓﺄﻣﻪ ﺗﻘﻠﻖ ﻋﻠﻴﻪ اوى و ﺗﺎﺧﺪه ﻟﻠﺪﻛﺘﻮر‪ ،‬ﻟﻮ راح‬
‫ﻟﺪﻛﺘﻮر ﻣﺤﺮﺘم ﺑﻴﻔﻬﻢ ﺳﺎﻋﺘﻬﺎ ﻳﻜﺘﺐ ادو�ﺔ و ﻻ ﻣﺎ ﻳﻜﺘﺒﺶ ؟ ﺳﺎﻋﺘﻬﺎ ﻳﻘﻮﻟﻬﺎ ﻛﻞ اﳌﻄﻠﻮب ﻣﻦ‬
‫ﺣﻀﺮﺗﻚ اﻧﻚ ﺗﺄﻛﻠﻴﻪ ﻋﺴﻞ و ﻣﺮﺑﻰ و ﻣﻜﺮوﻧﺔ ﻣﻦ ﻏ� ﺻﻠﺼﺔ و ﻣﺶ ﻫﻨﻜﺘﺒﻠﻪ أدو�ﺔ ﺧﺎﻟﺺ‬
‫ﻓﺎﻷم ﺗﻘﻮل إزاى ؟ ﻳﻌﻨﻰ إزاى ﻣﺎ ﻳﺎﺧﺪش أدو�ﺔ؟ ﺗﻘﻮﻟﻬﺎ آه و ﺗﺨﻠﻴﻪ ﳌﺎ ﻳﺠﻰ ﻳـ‪ micturate‬أو‬
‫ﻳـ‪ defecate‬ﻳﻐﺴﻞ إﻳﺪه ﻛﻮ�ﺲ ﻋﻠﺸﺎن ﻣﻴﻌﺪﻳﺶ إﺧﻮاﺗﻪ ﺑﺲ‪.‬‬

‫ﻟﻴﻪ ﺑﻘﻰ؟ ﻫﻮ اﻟﻌﺴﻞ ﻓﻴﻪ ‪ antibodies‬ﺗﻀﺮب اﻟـ ‪virus‬؟ ﻃﻴﺐ ﻋﺴﻞ أﺳﻮد و ﻻ ﻋﺴﻞ‬
‫أﺑﻴﺾ؟ أﺳﻮد ‪ ،‬ﻷﻧﻪ ‪ ، simple carbohydrate‬ﻋﺴﻞ و ﻣﺮﺑﻰ ‪.‬‬
‫ﻲﻓ اﻟـ ‪ acute viral hepatitis‬ﻛﻞ اﻟ� ﺑﺘﻄﻠﺒﻪ اﻟﺪﻛﺘﻮرة إﻧﻬﺎ ﺗﺒﻌﺪ ﻋﻦ اﻟـ ‪ fat‬و اﻟـ ‪protein‬‬
‫و ﺗﺄﻛﻠﻪ ﻋﺴﻞ و ﻣﺮﺑﻰ و ﻣﻜﺮوﻧﺔ ﻟﻴﻪ؟ ﻋﻠﺸﺎن ﻧﺮ�ﺢ اﻟﻜﺒﺪ ‪ ،‬ﻟﻴﻪ ؟ ﻷن اﻟـ ‪metabolism of‬‬
‫‪ fat and protein‬ﻳﺴﺘﻬﻠﻚ ‪ ATP‬ﻛﺘ�‪ ،‬و ﻣﺎﻧﺪﻳﻬﻮش أدو�ﺔ ﻷن اﻷدو�ﺔ ﺑﺘﺴﺘﻬﻠﻚ اﻟـ ‪ATP‬‬
‫ﺣﺪ ﻓﺎﻫﻢ ﺣﺎﺟﺔ ؟!‬

‫‪ This acute viral hepatitis‬و ‪ 95%‬ﻣﻦ اﻷﻃﻔﺎل اﻟ� ﺑﻴﺼﺎﺑﻮا ﺑﻴﻪ ﺑﻴﺨﻔﻮا‪ ،‬ﻳﻨﻔﻊ ﻳﻌﻤﻞ‬
‫‪ cirrhosis‬؟ ﻳﻨﻔﻊ ﻳﻌﻤﻞ ‪ cirrhosis‬؟ ﻷ ﻷﻧﻪ ﺑﻌﻴﺪ ﻋﻦ اﻟـ‪ ،framework‬و ﻟﻜﻦ ﻣﻤﻜﻦ‬
‫ﻳﻘﻠﺐ ﺑﺤﺎﺟﺔ أﺳﻤﻬﺎ ‪ ، fulminant‬إﻳﻪ اﻟـ ‪fulminant‬؟‬

‫‪FULMINANT VIRAL HEPATITIS‬‬

‫اﻟـ ‪ fulminant hepatitis‬ﻳﺎدﻛﺎﺗﺮة اﻛﺘﺒﻮا ﻋﻠﻴﻬﺎ ‪.cat B‬‬

‫‪Aetiology‬‬
‫اﻟـ ‪ ، fulminant hepatitis‬اﻻﻟﺘﻬﺎب اﳌﻠﻬﻠﺐ ‪ ،‬ﺑﻴﺤﺼﻞ ﻓﻰ أﻗﻞ ﻣﻦ ‪ %١‬ﺑﺴﺒﺐ ‪،HAV‬‬
‫ﻳﻌﻨﻰ ﻋﻴﻞ ﺻﻐ� اﻗﻞ ﻣﻦ ‪ ،%١‬ﺑﻴﻨﻰ و ﺑﻴﻨﻜﻮا اﻗﻞ ﻣﻦ ‪ ١‬ﻣﻦ اﳌﻠﻴﻮن ﺑﺲ اﳌﺆﻟﻒ ﺑﺤﺒﺤﻬﺎ ﺑﺴﺒﺐ‬
‫إن اﻟـ ‪ B‬ﻳﺒﻘﻰ ﻣﻦ ﺣﺪود ‪ % ٤ : ١‬واﻟـ ‪ C‬زود واﺣﺪ ﻣﻦ ‪.% ٥ : ٢‬‬
‫اﻟـ ‪ D‬ﻣﺎﻳﻨﻔﻌﺶ ﻳﻌﻤﻠﻪ ﻃﺒﻌﺎ أﻧﺘﻮا أﻛﻴﺪ ﻓﺎﻫﻤ� ‪ ،‬اﻟـ ‪ E‬ﺑﻴﻌﻤﻠﻪ ﻓﻰ اﻟﻌﺎدى ﻣﻦ ‪ % ٣ : ١‬ﻟﻜﻦ‬
‫ﻟﻮ ﺟﻪ ﻓﻰ ﺳﺖ ﺣﺎﻣﻞ ‪ %٥٠‬و ‪ %٢٥‬ﺑﻴﻤﻮﺗﻮا ﻣﻊ اﻟﻌﻠﻢ أﻧﻪ زى اﻟـ ‪ A‬ﺑﺎﻟﻈﺒﻂ ‪ ،‬أﻣﺎل اﺷﻤﻌﻨﺎ اﻟـ‪E‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﺑﻴﻤﻮت؟ و إﻳﻪ اﻟﺘﻔﺮﻗﺔ ﺑﻴﻨﻬﻢ ؟ ﻫﺎﻧﺸﻮف‪.‬‬

‫اﻟـ ‪ Fulminant hepatitis‬ﻳﻌﻨﻰ إﻳﻪ ؟ واﺣﺪ ﻳﺠﻴﻠﻪ ‪ acute‬و ﻟﻜﻦ ﻣﻠﻬﻠﺐ ‪ ،‬ﻳﻌﻨﻰ إﻳﻪ‬
‫ﻣﻠﻬﻠﺐ ؟ ﻳﻌﻨﻰ ‪ die within days‬و ﻫﺬا ﻋﻨﻮان اﻟﺸﺮح اﻟ� ﻫﺎﺷﺮﺣﻬﻮﻟﻜﻮا ‪.‬‬

‫ﻣﻌﻈﻢ اﳌﺼﺮ�� أول أﻣﺎ دﺧﻠﻮا اﳌﺪارس أﻛﻠﻮا ﺳﻨﺪوﺗﺸﺎت ﻣﻦ ﻋﻨﺪ ﻋﺒﺪه ﺗﻠﻮث ﻓﺠﺎﻟﻬﻢ‬
‫اﻟﺼﻔﺮا اﻟﻌﺎدﻳﺔ ﻓﺄﻛﻠﻮا ﻋﺴﻞ و ﻣﺮﺑﻰ و ﻓﻴﻪ ﺑﻌﻀﻬﻢ ﻣﻈﻬﺮش ﻋﻠﻴﻪ اﻷﻋﺮاض و اﳌﻮﺿﻮع‬
‫اﺧﺘﻔﻰ‪.‬‬
‫اﳌﺸﻜﻠﺔ ﻛﻠﻬﺎ إﻧﻪ اﻟـ ‪ viral hepatitis‬ده اﻟ� ﻣﺒﻴﻌﻤﻠﺶ ﺣﺎﺟﺔ ﻓﻰ اﻟﻌﻴﺎل اﻟﺼﻐ��ﻦ ﻟﻮ ﺟﻪ‬
‫ﻓﻰ واﺣﺪ ﻛﺒ� ﻫﻴﻌﻤﻞ ﻣﺸﻜﻠﺔ‪.‬‬

‫ﻳﺤﻜﻰ ﻓﻰ ﻗﺪﻳﻢ ﺍﻟﺰﻣﺎﻥ‪ :‬ﻓﻴﻪ ﻃﺎﻟﺒﺔ ﻣﺠﺘﻬﺪة و ﻓﻴﻪ ﻃﺎﻟﺐ ﻣﺠﺘﻬﺪ ﺑﻴﻄﻠﻊ ﻣﻦ أواﺋﻞ‬
‫اﻟﺪﻓﻌﺔ‪،‬اﻟﻔﺮق ﺑﻴﻨﻬﻢ إن اﻟﻮﻟﺪ ده أﺑﻮه وأﻣﻪ أﺳﺎﺗﺬة رﻣﺪ‪ ،‬اﻷواﺋﻞ ﳌﺎ ﺑﻴﻴﺠﻮا ﻳﺘﻌﻴﻨﻮا ﻓﻰ اﻟﻨﻴﺎﺑﺔ‬
‫ﺑﻴﺘﻌﻴﻨﻮا ﺑﺎﳌﺠﻤﻮع اﻻﻋﺘﺒﺎرى ﺗﻌﺮﻓﻮا ﻳﻌﻨﻰ إﻳﻪ ﻣﺠﻤﻮع اﻋﺘﺒﺎرى؟ اﳌﺠﻤﻮع اﻻﻋﺘﺒﺎرى ﻫﻮ ﻣﺠﻤﻮع‬
‫اﻟﺴﺖ ﺳﻨ� و ﺗﻀﻴﻒ ﻋﻠﻴﻬﻢ ﻣﺎدة اﻟﺘﺨﺼﺺ‪ ،‬ﻓﺎﻟﺒﻨﺖ ﺳﺒﻘﺖ اﻟﻮﻟﺪ و اﺗﻌﻴﻨﺖ ﻧﺎﻳﺒﺔ رﻣﺪ ﻓﻰ‬
‫اﻟﻘﺴﻢ اﻟ� ﻓﻴﻪ أﺑﻮه و اﻣﻪ و ﻓﻰ ﺧﻼل ﺷﻬﺮ أﺑﻮه و أﻣﻪ ﺿﺎﻳﻘﻮﻫﺎ و ﻟﻢ ﺗﺠﺪ أﻣﺎﻣﻬﺎ ﻏ� إﻧﻬﺎ‬
‫ﺗﻘﺪم اﺳﺘﻘﺎﻟﺘﻬﺎ‪.‬‬
‫اﳌﻬﻢ اﻟﻘﺎﻧﻮن ﺑﻴﻘﻮﻟﻚ إﻳﻪ؟ ﻋﻨﺪ وﻓﺎة اﻟﻨﺎﻳﺐ اﻷﺳﺎﻰﺳ أو اﺳﺘﻘﺎﻟﺘﻪ ﻧﺎﺧﺪ اﻟـ ‪ ،2 senior‬ﻣ�‬
‫‪nd‬‬

‫اﻟـ ‪ 2nd senior‬؟ اﺑﻨﻬﻢ‪ ،‬ﻓﺠﻪ ﻓﻰ ﻗﺴﻢ أﺑﻮه و اﻣﻪ ﺑﺲ دا ﻧﺎﻳﺐ‪ ،‬اﻟﻨﻮاب ﺑﻴﺎﻛﻠﻮا و ﻳﺸﺮﺑﻮا و‬
‫ﻳﺤﺒﻮا ﻓﻰ اﻟﺘﻠﻴﻔﻮن ﻋ� ﺣﺴﺎب اﻟﻘﺼﺮ اﻟﻌﻴﻨﻰ‪ ،‬ﺷﻮﻓﺘﻮا ﺳﻜﻦ اﻟﻨﻮاب؟ ﻃﻴﺐ ﺷﻮﻓﺘﻮا أﻛﻞ‬
‫اﻟﻨﻮاب ؟ ﺷﻮﻓﺘﻮا ﻋﻨﺮﺘ ؟ ﻣﺎﺷﻮﻓﺘﻮش ﻋﻨﺮﺘ ‪.‬‬

‫أﻧﺎ واﺣﺪ ﻣﻦ اﻟﻨﺎس ﻗﺒﻞ ﻣﺎ أﺗﻌ� ﻧﺎﻳﺐ ﻋﻈﺎم ﺷﻮﻓﺘﻮا ﺻﻮرﻰﺗ ﻛﺎﻧﺖ ﻋﺎﻣﻠﺔ ازاى؟ رﻓﻴﻊ ﻛﺪه‪،‬‬
‫اول ﻣﺎ دﺧﻠﺖ ﻧﺎﻳﺐ ﻋﻀﻢ ‪ ،‬اﻟﻌﻀﻢ ﻟﻴﻪ ﺷﻨﺔ و رﻧﺔ ‪ ،‬ﺟﻪ ﻋﻨﺮﺘ اﻫﻼ ﻫﻼ ﻳﺎ ﺑﻴﻪ ﺗﺤﺐ ﺗﻔﻄﺮ اﻳﻪ ؟‬
‫ﻗﻮﻟﺘﻠﻮا اﻧﺘﻮا ﻋﻨﺪﻛﻮا اﻳﻪ ؟ ﻗﺎﻰﻟ ﺷﻜﺸﻮﻛﺔ ﻗﻮﻟﺖ ﻟﻪ و اﻳﻪ ﻛﻤﺎن ؟ ﻗﺎﻰﻟ ﺷﻜﺸﻮﻛﺔ‪ ،‬ﻗﻮﻟﺘﻠﻪ ﺣﻠﻮ‬
‫ﺑﺘﻌﻤﻞ ﻟﻠﻮاﺣﺪ ﻛﺎم ﺑﻴﻀﺔ ﻟﻠﺸﻜﺸﻮﻛﺔ ﻗﺎﻰﻟ اﺗﻨ� ﻗﻮﻟﺘﻠﻪ ﻋﺎوز ‪ ١٠‬ﻗﺎﻰﻟ ﻟﻴﻪ ؟ ﻗﻮﻟﺘﻠﻪ اﺳﺘﺨﺴﺎر‬
‫ﺑﻘﻰ اﺳﺘﺨﺴﺎر ﻫﺎﻋﻤﻞ اﻳﻪ ‪.‬‬

‫اﻟﻨﺎﻳﺐ ﻣﺎ ﺑﻴﻌﻤﻠﺶ ﺣﺎﺟﺔ ﻏ� إﻧﻪ ﺑﻴﺎﻛﻞ و ﻳﺸﺘﻐﻞ و ﺧﻼص‪ ،‬ﻛﺎن ﺑﻴﻌﻤ� أد ﻛﺪا ﺷﻜﺸﻮﻛﺔ و‬
‫ﻓﻴﻬﺎ ﺣﺎﺟﺎت ﺑﻨﻰ ‪ ،‬اﻟﺤﺎﺟﺎت اﻟﺒﻨﻰ اﻟ� اﻧﺎ ﻗﻮﻟﺘﻠﻜﻮا ﻋﻠﻴﻬﺎ دى اﻟـ‪3: feces‬‬
‫أﺧﻠﺺ اﻟﺸﻜﺸﻮﻛﺔ ‪ ،‬اﺟﻰ ﻋ� اﻟﻐﺪا اﻗﻮﻟﻪ اﻋﻤ� ﺷﻜﺸﻮﻛﺔ ﻣﻊ اﻟﻠﺤﻤﺔ ‪ ،‬ﺣﺎﺟﺎت ﻛﺪا‬
‫ﻓﻄﺒﻌﺎ ﻓﻰ ﺧﻼل اﻳﺎم ﺑﻌﺪ ﻣﺎ ﻋﻨﺮﺘ ﻧﻔﺨﻨﻰ‪ ،‬اﻟﻮاد ده ﻛﻤﺎن ﺑﻘﻰ ﻧﺎﻳﺐ ﻓﻠﻘﻰ ﻛﻞ زﻣﺎﻳﻠﻪ ﺑﺮﺘوح‬
‫ﻋﻨﺪ ﻋﻨﺮﺘ ﻳﺎﻛﻠﻮا ﺷﻜﺸﻮﻛﺔ ﺑﺲ اﻟﻮاد ده اﺑﻮه و اﻣﻪ ﻧﺎس ‪ class‬ﺣﺘﻰ ﻓﻰ اﻟﻜﻠﻴﺔ اﻣﻪ ﺗﺪﻳﻠﻪ‬
‫ﺳﺎﻧﺪوﺗﺶ و ﺗﺪﻳﻠﻪ اﳌﻴﺔ ﻓﻰ ازازة ﻛﺪا و ﺗﻘﻮﻟﻪ اوﻋﻰ ﺗﺸﺮب ﺣﺪ ﻣﻦ اﻟﺰﻣﺰﻣﻴﺔ و ﺗﻤﺴﺤﻠﻪ ﺑﻮﻗﻪ‬
‫ﺑﺎﳌﻨﺪﻳﻞ‪ ،‬ﻣﺶ زى ﻋﻨﺪﻧﺎ ﺑﻘﻰ‪ ،‬ﻓﺎﻟﻮاد ده راح أﻛﻞ ﺷﻜﺸﻮﻛﺔ زى أي ﻣﻮاﻃﻦ ﻋﺎدى ﻓﺮاح و اﻛﻞ‬
‫ﺑﻌﺪﻫﺎ ﻣﻦ ‪ 2 : 6 weeks‬اﻟﻮاد اﺻﻔﺮ‪ ،‬اﺑﻮه و اﻣﻪ ﺧﺎﻓﻮا ﻷﻧﻪ ﺑﻴﺸﺘﻐﻞ ﺟﺮاﺣﺔ و ﻣﻌﻈﻢ‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﻋﻴﺎﻧ� اﻟﻘﺼﺮ ﻋﻨﺪﻫﻢ ‪ C‬ﻓﺮاﺣﻮا ﻋﺎﻣﻠ� ‪ Hepatitis marker‬ﻓﻄﻠﻊ ‪ E‬ﻓﺎﻧﺒﺴﻄﻮا أوى ﻷن‬
‫اﻟـ ‪ E‬ﻓﻰ ﻣﻌﻈﻢ اﻻﺣﻴﺎن ﺑﻴﺎﻛﻠﻮا ﻋﺴﻞ و ﻣﺮﺑﻰ و ﻳﺨﻔﻮا ‪ ،‬ﺑﻌﺪﻫﺎ ﺑﻴﻮﻣ� ﻣﺎت ‪.‬‬
‫اﻟﻘﺎﻧﻮن ﺑﻴﻘﻮل اﻳﻪ ؟ ﻗﺒﻞ ‪ ٦‬ﺷﻬﻮر ﻣﻦ اﻻﺳﺘﻘﺎﻟﺔ ﻧﺎﺧﺪ اﳌﺴﺘﻘﻴﻞ ﻟﻮ ﻋﺎوز و اﻟﺒﻨﺖ دى رﺟﻌﺖ‪،‬‬
‫اﳌﻬﻢ اﻟﺤﺎﺟﺎت دى ‪ rare‬وﻟﻜﻦ ﻫﻨﺎ ﻛﺈﻧﻬﺎ ﻋﺪاﻟﺔ اﻟﺴﻤﺎء‪.‬‬

‫‪Pathology‬‬
‫‪1- Acute massive necrosis:‬‬

‫ﻣﺎت ﻟﻴﻪ ﺑﻘﻰ؟ ﻣﺎت ﻣﻦ اﻟـ ‪ acute fulminant hepatitis‬ﻳﻌﻨﻰ اﻳﻪ؟‬

‫اﻟـ ‪ acute fulminant‬ﺑﻴﺤﺼﻞ ﺑﺴﺒﺐ ان اﻟﻔ�وس ﺑﻴﺪﺧﻞ ﻓﻰ واﺣﺪ ﻣﻨﺎﻋﺘﻪ ﻋﺎﻟﻴﻪ ‪ ،‬ﻓﻴﻐ�‬
‫اﻟـ ‪ antigenicity‬ﺑﺘﺎﻋﺔ اﻟـ ‪ hepatocyte‬ﻓﻴﻴﺠﻰ ﺟﻬﺎز اﳌﻨﺎﻋﺔ ﻳﻀﺮﺑﻬﺎ و ﻳﻌﻤﻞ ﻓﻴﻬﺎ ﺑﻴﻨﻰ و‬
‫ﺑﻴﻨﻜﻮا ‪ apoptosis‬ﻣﺶ ‪ ،necrosis‬ﻫﺎﻗﻮﻟﻚ ﻟﻴﻪ ﺑﻴﻌﻤﻞ ‪ apoptosis‬دﻟﻮﻗﺘﻰ‪.‬‬

‫ﻷن ‪ grossly‬ﺑﻨﻼﻗﻰ اﻟﻜﺒﺪ ﺑﻬﺬا اﳌﻨﻈﺮ‪ :‬اول ﻧﻮع اﺳﻤﻪ ‪ acute yellow atrophy‬أو‬
‫‪ massive liver necrosis‬ﻷن ﺑﻨﻼﻗﻰ اﻟـ ‪ ، liver is shrunken‬ﻟﻮﻧﻪ ﻣﺼﻔﺮ ‪acute ،‬‬
‫‪ ، yellow atrophy‬و ﻣﺒﻄﺶ ‪. Hemorrhage‬‬

‫ﻫﻮ ﻋﻨﺪﻣﺎ ُﺗﻘﺘﻞ ﺧﻠﻴﺔ ﺗﻜﺮﺒ و ﻻ ﺗﺼﻐﺮ ؟ ﺗﻜﺮﺒ ‪ ،‬اﳌﻔﺮوض اﻟﻜﺒﺪ ﻟﻮ دا ‪ necrosis‬ﻳﺒﻘﻰ اﻳﻪ؟‬
‫ﻳﻜﺮﺒ ﻟﻜﻦ ده ‪ underweight‬ﻟﻴﻪ ؟ ﻷن اﻟـ ‪ lymphocyte‬ﺑﺘـ ‪ attack‬و ﺗـ ‪induce‬‬
‫‪ apoptosis‬ﻓﻴﻪ‪ ،‬ﺑﺲ اوﻋﻮا ﺗﻜﺘﺒﻮا ‪ apoptosis‬ﻷن ﻋﻨﺪﻛﻢ ﻣﻜﺘﻮب ‪.necrosis‬‬

‫اﻟـ ‪ liver‬ﺑﻴﺒﻘﻰ ‪ ، shrunken‬ﻣﺼﻔﺮ ‪ ،mottled yellow & red (hemorrhage) ،‬ﻷن‬

‫ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب ﺧﻠﻴﻨﺎ ﻣﺎﺷﻴ� ﻋ� ﻛﻼﻣﻪ ﺑﻼﻗﻰ اﻟﺨﻼﻳﺎ ‪ most of hepatic cells‬ﻲﻓ‬
‫ﻛﻞ اﻟـ ‪ hepatic lobule‬ﺑﻘﺖ ‪ necrotic‬ﻟﻜﻦ ﺑﻴﻨﻰ و ﺑﻴﻨﻜﻮا ده ‪ apoptosis‬و ﺑﺎﻟﺘﺎﻰﻟ ﻓﻴﻪ‬
‫‪ rupture of sinusoids‬و ﺑﺎﻟﺘﺎﻰﻟ اﻟـ ‪ liver function‬راﺣﺖ‪.‬‬

‫ﻣﺎﺗﻴﺠﻰ ﻧﺒﺺ ﺑﻴﺤﺼﻞ ﺃﻳﻪ ؟‬

‫اﻟـ ‪ liver‬ده ﻣﻬﻢ ﻋﻠﺸﺎن اﻟـ ‪ toxification‬ﻟﺤﺎﺟﺎت ﻛﺘ�‪ ،‬أﻣﺎ ﺑﻴﻘﻊ أول ﺣﺎﺟﺔ ﺑﺘﻘﻊ ﺑﻌﺪه‬
‫اﻟﻜ� و ﺑﻴﺤﺼﻞ ‪ ،renal failure‬ﺑﻴﺤﺼﻞ ‪ acute tubular necrosis‬ﺑﻴﺴﻤﻮﻫﺎ ‪renal‬‬
‫‪ failure shutdown‬و ﺑﺘـ ‪ affect basal ganglia‬ﻓﻴﺒﺪأ اﻟﻌﻴﺎﻧ� ﻳﺠﻴﻠﻬﻢ ‪extra‬‬
‫‪.pyramidal manifestation‬‬

‫‪ ،This is acute yellow atrophy‬دا اول ﻧﻮع ﻣﻦ اﻧﻮاع اﻟـ ‪ ،fulminant‬اﻟﻨﻮع دا‬
‫ﺑﻴﺤﺼﻞ ‪ very rare‬ﻓﻰ اﻟـ ‪ A‬و ﻟﻮ ﺣﺼﻞ ﻓﻰ اﻟـ ‪ A‬ﻳﺒﻘﻲ ﳌﺎ ﺑﻴﻴﺠﻰ ﻓﻰ ﺳﻦ ﻛﺒ� ‪ ،‬ﻃﻴﺐ ﻟﻴﻪ‬
‫ﻓﻰ اﻟﺴﻦ اﻟﺼﻐ� ﻣﺎﺑﻴﺤﺼﻠﺶ؟ ﻷن اﳌﻨﺎﻋﺔ ﺑﺘﺒﻘﻰ ﻗﻠﻴﻠﺔ ﻓﻤﻬﻤﺎ ﺗﻌﻤﻞ ﻋﻤﺮﻫﺎ ﻣﺎ ﺗﻌﺮف ﺗﻌﻤﻞ‬
‫ﻓﻴﻪ اﻟﻜﻼم ده‪.‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﻓﻰ اﻟـ ‪ E‬ﻟﻮ ﺳﺖ ﺣﺎﻣﻞ ﻳﺤﺼﻞ ﻓﻴﻬﺎ ﺑﻨﺴﺒﺔ ‪ ،25%‬و دا ﻗﺼﺔ اﻛﺘﺸﺎف اﻟـ ‪ ،E‬اﻟ� اﻛﺘﺸﻒ ان‬
‫ﻓﻴﻪ ﻗﺮ�ﺔ ﻲﻓ اﻟﻬﻨﺪ رﺑﻊ اﻟﺴﺘﺎت اﻟﺤﻮاﻣﻞ ﻣﺎﺗﻮا ﻷن ﻛﻠﻬﻢ ﻛﺎﻧﻮا ﺑﻴﺸﺮﺑﻮا ﻣﻦ ﺑ� و ﻓﻴﻪ ﻋﻴﻞ ﻛﺎن‬
‫ﺑﻴﻌﻤﻞ ﻓﻴﻪ ﺑﻴﺒﻰ ﻓﺠﺎﻟﻬﻢ ‪. E‬‬
‫ﻃﻴﺐ ﻣﺎ اﳌﻔﺮوض اﻟـ ‪ E‬زي اﻟـ‪ A‬ﻛﺪه؟ ﻻ اﻟـ ‪ E‬ﻓﻰ اﻟﺤﻮاﻣﻞ ﺑﻴﻤﻮت‪ ،‬ﻓﻴﻪ ﻧﺎس ﻗﺎﻟﻮا ﻟﺤﺪ ‪50%‬‬
‫ﻓﺎﻟﻌﻴﺎن دا ‪ die within few days‬ﻣﻠﻮش ﻋﻼج ‪ ،‬ﺗﻌﺎﻟﺠﻪ ازاى ؟ ﺣﺪ ﻳﻘﻮﻰﻟ ‪liver‬‬
‫‪ transplantation‬ﻣﻤﻜﻦ؟ ﻣﺴﺘﺤﻴﻞ ‪.‬‬
‫‪ ،Fulminant hepatitis → hepato-renal shutdown‬اﻧﺘﻬﻰ اﳌﻮﺿﻮع‪.‬‬

‫‪2- Subacute massive necrosis:‬‬

‫ﻣﻤﻜﻦ اﻟﻌﻴﺎن ﻳﻤﻮت ‪ within weeks‬و ﻧﺴﻤﻴﻪ ‪ subacute‬ﻷن ﺑﻨﻔﺲ اﳌﻨﻈﺮ وﻧﻔﺲ اﻟﻜﻼم‬
‫ﻟﻜﻦ اﻟـ ‪ severity‬ﺑﺘﺎﻋﺘﻪ ﻣﺶ ﺟﺎﻣﺪة اوى ‪.this is Fulminant hepatitis ،‬‬

‫‪CHRONIC HEPATITIS‬‬

‫ﻓﻴﻪ ﺣﺎﺟﺔ ﺗﺎﻧﻴﺔ اﺳﻤﻬﺎ ‪ chronic hepatitis‬اﻛﺘﺒﻮا ﻋﻠﻴﻬﺎ ‪ cat A‬ﻷن دا اﻟﺠﺪ ﺑﻘﻰ‪.‬‬

‫‪Aetiology‬‬
‫ﻓﻰ ﻣﺼﺮ أﺷﻬﺮ ﻧﻮع ﻣﻦ اﻟـ ‪ chronic hepatitis‬ﻫﻮ اﻟـ ‪ ، chronic viral‬ﻳﻼ ﻣ�‬
‫اﻟﻔ�وﺳﺎت اﻟ� ﺗﻌﻤﻞ اﻟـ ‪chronic‬؟ اﻟـ ‪ C , B‬و اﻟـ ‪ ،D on top of B‬ﻳﻌﻨﻰ ﻛﻠﻪ ﻣﺎ ﻋﺪا اﻟـ ‪A‬‬
‫و اﻟـ ‪ ، E‬اﻟـ ‪ A‬و اﻟـ ‪ E‬ﻣﺎﻓﻴﻬﻮﻣﺶ ‪.C‬‬
‫و ﺗﺮﺟﻊ ﺗﻜﺘﺐ اﻟﺠﺪول ﺑﺲ ﻣﻦ ﻏ� ﻣ� ؟ ﺗﻘﻮل ان اﻟـ ‪ A‬و اﻟـ ‪ E‬ﻣﺶ ﺑﻴﻌﻤﻠﻮا ‪.‬‬

‫ﻓﻴﻪ ﺣﺎﺟﺎت ‪ common‬و اﺷﻬﺮ ﺣﺎﺟﺔ ﻋﻨﺪﻧﺎ ﻓﻰ ﻣﺼﺮ ‪ ،chronic viral hepatitis‬ﻟﻜﻦ‬
‫ﺑﺮه ﻣﺼﺮ ﻣﻤﻜﻦ ﻳﺒﻘﻰ اﻟـ ‪ chronic hepatitis‬دا ‪ autoimmune‬و دا ﻣﺸﻬﻮر ﻓﻰ‬
‫اﻟﺴﺘﺎت‪ autoantibodies ،‬ﺗﻀﺮب اﻟـ ‪ Hepatocyte‬و أﺷﻬﺮﻫﺎ ‪Antinuclear‬‬
‫‪ anti actin antibody ، ant mitochondrial antibody ، antibody‬ﻛﻞ دى‬
‫ﻣﻤﻜﻦ ﺗﺸﻮﻓﻬﺎ ‪.‬‬
‫ﺧﻠﻮا ﺑﺎﻟﻜﻮا ده ﺑﻴﺎﺧﺪ ‪ immunosuppressive‬اﻟـ ‪ autoimmune‬اﻟـ ‪ viral‬ﻟﻮ ادﻳﺘﻮا‬
‫‪ immunosuppressive‬ﻳﻤﻮت ﻓﺎﻫﻤ� ﺣﺎﺟﺔ ؟‬

‫وﻣﻤﻜﻦ ﻳﺒﻘﻰ اﻟﺴﺒﺐ ‪ ،drugs‬ﻓﻴﻪ أدو�ﺔ أﺧﺪﺗﻮﻫﺎ ﻓﻰ اﻟﻔﺎرﻣﺎ ‪ Hepatotoxic‬و ﻣﻌﻈﻢ‬

‫اﻷدو�ﺔ دى اﺗﻠﻐﺖ ﻣﻦ اﻟﻄﺐ ﺧﻼص زى دوا اﺳﻤﻪ ‪ isoniazid‬ﺣﺪ ﺳﻤﻊ ﻋﻨﻪ ؟ دا‬
‫ﺑﻴﺴﺘﺨﺪم ﻓﻰ ﻋﻼج اﻟـ ‪ TB‬وﺧﻼص ﺑﻘﻰ ‪ ،obsolete‬وﻓﻴﻪ دوا ﺗﺎ� اﺳﻤﻪ‬
‫‪ acetaminophen‬أو اﻟـ ‪ paracetamol‬ﺑﺲ ﻣﺶ ‪ hepatotoxic‬اﻻ ﻓﻰ اﻟﺠﺮﻋﺎت اﻟﻜﺒ�ة‬
‫اﻟ� ﻗﺪ ﺗﺼﻞ ﻟـ ‪ ٦‬ﺟﺮام ‪.‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﻓﻴﻪ ﻋﻨﺪﻧﺎ ﻣﻦ اﻟﺤﺎﺟﺎت اﻟـ ‪ hepatotoxic‬اﻟـ ‪ ،alpha methyl dopa‬ﺣﺪ ﻳﻌﺮﻓﻪ؟‬

‫ﻳﺴﺘﺨﺪم ﻛـ ‪ obsolete ، antihypertensive‬ﻣﺤﺪش ﺑﻴﺴﺘﺨﺪﻣﻪ إﻻ ﻓﻰ اﻟـ ‪toxemia‬‬
‫‪.of pregnancy‬‬
‫إﻳﻪ ﻛﻤﺎن؟ ﻓﻴﻪ دوا اﺗﻠﻐﻰ ﻣﻦ ‪ ٧٠‬ﺳﻨﺔ اﺳﻤﻪ ‪ ،Oxyphenisatin‬اﻟﺪوا ده ‪ cathartic‬ﻳﻌﻨﻰ‬
‫‪. severe purgative‬‬
‫اﻟـ ‪ Oxyphenisatin‬اﺗﻠﻐﻰ ﻣﻦ اﻟﻄﺐ ﻷﻧﻪ ﺑﻴﻌﻤﻞ ‪ ،chronic necrosis‬ﻣﺎ دا ﺿﻤﻦ اﻟـ‬
‫‪ mechanism of action‬إﻧﻪ ﻳﺒﻮظ اﻟـ ‪ mucosa‬ﻛﻠﻬﺎ ﻓﻰ اﻻﻧﺴﺎن ‪ ،‬إﻳﻪ اﻟﺤﻼوة دى ‪،‬‬
‫اﺗﻠﻐﻰ ﻣﻦ اﻟﻄﺐ‪ ،‬ﻛﻞ دى أدو�ﺔ ‪ hepatotoxic‬ﻣﺎ ﺑﺘﺸﻮﻓﻬﺎش ﻓﻰ اﻟﻄﺐ دﻟﻮﻗﺘﻰ ﺣﺎﻟﻴﺎ‪.‬‬

‫ﻣﻤﻜﻦ ﻛﻤﺎن اﻟ� ﻳﺒﻮظ ﻟﻴﻨﺎ ﺧﻼﻳﺎ اﻟﻜﺒﺪ و ﻳﻌﻤﻞ ‪ chronic hepatitis‬ﻫﻮ ‪metabolic‬‬
‫‪ disease‬زى ‪ α1 antitrypsin deficiency‬ﻣﺶ أﺧﺪﻧﺎﻫﺎ ﻗﺒﻞ ﻛﺪا ؟‬
‫ﻛﺎن ﺑﻴﻌﻤﻞ اﻳﻪ ﻋ� ﻣﺴﺘﻮى اﻟـ ‪ respiratory‬؟ ‪.congenital ← Emphysema‬‬

‫وﻣﻤﻜﻦ ﻣﻦ اﻷﺳﺒﺎب ان اﻟـ ‪ copper‬ﻳﺰ�ﺪ ﺟﻮاﻫﺎ‪ ،‬ﺣﺎﺟﺔ اﺳﻤﻬﺎ ‪Wilson’s disease‬‬

‫ﻫﺎﻧﺘﻜﻠﻢ ﻋﻨﻪ ﺑﻌﺪﻳﻦ‪ ،‬و ﻟﻜﻦ ﻓﻴﻪ ﺣﺎﻻت ﻛﺘ� أوى ﺑﻨﻼﻗﻴﻬﺎ ‪ ،cryptogenic‬ﻳﻌﻨﻰ اﻳﻪ ﻛﻠﻤﺔ‬
‫‪ cryptogenic‬؟ ‪ crypt‬ﻳﻌﻨﻰ ﻣﺴﺘﺨﺒﻰ‪ ،‬ﻣﺶ ﺑﻴﻘﻮﻟﻮا ﻫﺘﻠﺮ ﻛﺎن ﻋﻨﺪه ‪crypto-‬‬
‫‪ orchidism‬ﻳﻌﻨﻰ إﻳﻪ ؟ ﺧﺼﻴﺔ ﻣﻌﻠﻘﺔ ﻣﺴﺘﺨﺒﻴﺔ ﻓﻰ ﺑﻄﻨﻪ‪.‬‬

‫اﻟـ ‪ cryptogenic hepatitis‬ﻓﻴﻪ ﻧﺎس ﺑﺘﺴﻤﻴﻬﺎ ‪ idiopathic‬ﻣﻠﻮش ﺳﺒﺐ‪ ،‬اﻟﺴﺒﺐ ﻏ�‬

‫ﻣﻌﺮوف‪ ،‬ﻋ� ﻓﻜﺮة دا اﺷﺘﻬﺮ ﻓﻰ ﻣﺼﺮ اﻟﻔﺮﺘة اﻟ� ﻓﺎﺗﺖ و اﻷﻳﺎم دى اﻟـ ‪ incidence‬ﺑﺘﺎﻋﻪ‬
‫ﺑﺘﺰ�ﺪ ﻟﻴﻪ؟ ﻷﻧﻪ ﻣﺶ ‪ cryptogenic‬ﻓﻰ ﻣﺼﺮ و اﺣﻨﺎ ﻋﺎرﻓ� اﻟﺴﺒﺐ ‪.‬‬
‫اﻟﺴﺒﺐ اﳌﻬﺰﻟﺔ اﻟ� ﺑﻴﻌﻤﻠﻮﻫﺎ اﻟﺪﻛﺎﺗﺮة دﻟﻮﻗﺘﻰ و ﺑﻴﻮاﻓﻘﻮا ﻋﻠﻴﻬﺎ‪ ،‬ﻳﺠﻴﻠﻚ اﻋﻼن ﻓﻰ اﻟﺘﻠﻔﺰ�ﻮن‬
‫ﻳﻘﻮﻟﻚ ﻓﻰ ﺟﺎﻣﻌﺔ ﻛﻔﺮ أﺑﻮ ﻃﺸﻂ اﺟﺮ�ﺖ أﺑﺤﺎث ﻋﻠﻴﻪ و ﻳﺠﻴﺒﻠﻚ ﻓﻴﺪﻳﻮ ﻳﻘﻮﻟﻚ اﻛﺘﺸﻔﻨﺎ‬
‫ﻣﺴﺘﺨﺮج ﻣﺎدة ﻃﺒﻴﺔ ﻋﺒﺎرة ﻋﻦ ﻣﺠﻤﻮﻋﺔ ﻣﻦ اﻻﻋﺸﺎب اﻟﻄﺒﻴﻌﻴﺔ اﻟﻐ� ﺿﺎرة ‪ ،‬ﻣﺴﺘﺨﺮﺟﺔ‬
‫ﻣﻦ ﻧﺒﺎت اﺗﺪﺣﺮج و اﺟﺮى ﻳﺎ رﻣﺎن‪ ،‬ﻣﻦ ﺧﻠﻴﻂ ﻣﻦ ﻧﺒﺎت اﻟﺰﺣﻠﻘﻮم‪ ،‬اﳌﻬﻢ ﺑﻴﻌﺎﻟﺞ اﻟﺒﻮاﺳ� و اﻟـ‬
‫‪ chronic hepatitis‬و ﻳﻌﺎﻟﺞ اﻟـ ‪ AIDs‬و اﻟﺴﺮﻃﺎن و اﻟﺒﻼدة و اﻟﺴﻜﺮ و أى ﺣﺎﺟﺔ ﻓﺎﻛﺮﻫﺎ‬
‫ﻳﻘﻮﻟﻬﺎ و اﻟ� ﻣﺶ ﻓﺎﻛﺮه ﺣﺘﻰ ﺑﻴﻘﻮﻟﻪ‪.‬‬

‫و اﻟﻐﺮ�ﺒﺔ ﺗﻴﺠﻰ ﺗﻘﻮل ﻟﻠﻮاد ﺑﺘﺠﻴﺒﻪ ﻟﻴﻪ ﻳﺎ اﺑﻨﻰ ؟ﻳﻘﻮﻟﻚ ﻓﻴﻪ دﻛﺎﺗﺮة ﺟﺎﺑﻮه ﻋﻠﺸﺎن ﻛﺪه اﻧﺎ‬
‫ﻣﺶ ﺧﺎﻳﻒ دى ﻣﺎدة ﻃﺒﻴﻌﻴﺔ ‪.‬‬
‫اﻧﺖ ﻟﻮ ﺑﺘﻔﻬﻢ ﻓﺎرﻣﺎ أو ﻟﻮ ﺑﺘﻔﻬﻢ ﻃﺐ أﻣﺎ ﻳﻘﻮﻰﻟ دى ﻣﺎدة ﻃﺒﻴﻌﻴﺔ اﳌﻔﺮوض ﺑﻴﻘﻮﻰﻟ دى ﺳﺎﻣﺔ‬
‫ﻷن ﺣﻀﺮاﺗﻜﻮا ﻋﻨﺪﻧﺎ ﻣﻌﻈﻢ اﻷدو�ﺔ ‪ ،from plant organ‬ﻳﻌﻨﻰ ‪ for example‬ﺗﻌﺮﻓﻮا‬
‫اﻟـ ‪ quinine‬ﻋﻼج اﳌﻼر�ﺎ؟ﻣﺶ ﻣﻬﻢ‪ ،‬اﻟـ ‪ cinchona‬دى ﺷﺠﺮة ﻓﻴﻬﺎ ورق‪ ،‬ﻋﻠﺸﺎن ﺣﻀﺮﺗﻚ‬
‫ﺗﻄﻠﻊ ﻛﻤﻴﺔ اﻟـ ‪ quinine‬اﻟ� ﺗﻜﻔﻰ ﻟﻘﺘﻞ اﳌﻼر�ﺎ ﻣﺤﺘﺎج ﻛﻴﻠﻮ ورق ‪ ،‬ﻛﻴﻠﻮا اﻟﻮرق ده ﳌﺎ ﺗﻐﻠﻴﻪ‬
‫و ﺗﺎﺧﺪ ﻋﺼﺎرﺗﻪ ﻫﻞ ﻫﺎﻳﺒﻘﻰ ﻓﻴﻪ ﻓﻘﻂ ‪quinine‬؟ ﻷ دا ﻫﺎﻳﺒﻘﻰ ﻓﻴﻪ ‪herbal alkaloid‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ﺑﺘﺴﺘﺨﺪﻣﻬﺎ ﻛـ ‪ enzymes‬ﻟﻠـ ‪ metabolism‬ﺑﺘﺎﻋﻬﺎ و ‪ repellant‬ﻟﻠﺤﺸﺮات ‪ ،‬اﻟﺤﺎﺟﺎت‬

‫دى ‪ ، hepatotoxic‬أﻣﺎل ﻫﻤﺎ ﻟﻴﻪ ﻋﻤﻠﻮا ﻋﻠﻢ اﻟﻔﺎرﻣﺎ ؟!‬
‫ﻋﻠﺸﺎن ﻧﺎﺧﺪ اﻟـ ‪ active ingredient‬و ﻣﻨﺎﺧﺪش ‪ whole plant‬ﻓﺎﻫﻤ� ﺣﺎﺟﺔ و ﻻ ﻣﺶ‬
‫ﻓﺎﻫﻤ� ؟!!‬

‫‪We are pioneers in chronic viral hepatitis‬‬

‫ﻳﻌﻨﻲ اﻳﻪ ﻳﺎدﻛﺎﺗﺮه ‪pioneers‬؟ ﻟﻼﺳﻒ ﻛﻞ ﻗﻮم ادري ﺑﺎﻣﺮاﺿﻬﻢ‪ ،‬اﻛﺮﺘ ﺣﺘﻪ ﻲﻓ اﻟﻌﺎﻟﻢ ﻓﻴﻬﺎ‬
‫‪ viral hepatitis‬ﻫﻲ ﻣﺼﺮ واﺷﻬﺮ ﻧﻮع ﻣﻨﻪ ﻫﻮ ال ‪ .C‬ﻓﻌ� ﻣﺪي ال ‪ generations‬ﻛﺎﻧﻮا‬
‫اﺣﺴﻦ ﻧﺎس ﻳﺸﺨﺼﻮه و�ﻌﺎﻟﺠﻮه ﻫﻤﺎ اﳌﺼﺮ��‪ ،‬ﺣﺘﻲ ﺳﺨﺮ�ﻪ اﻟﻘﺪر اﻧﻪ اﻟـ ‪molecular‬‬
‫‪ genetic study‬اﻟ� ﻋﻤﻠﻬﺎ ﻛﺎن ﻳﻬﻮدي وﻟﻴﻪ اﺻﻮل ﻣﺼﺮ�ﻪ‪.‬‬

‫اﻟـ ‪ chronic hepatitis‬ﻫﺘﻼﻗﻮا اﻟﺘﻌﺮ�ﻒ ﻏﺮ�ﺐ ﺟﺪا ﻻﻧﻨﺎ ﺑﻨﻌﺮﻓﻪ ﻣﻴﻜﺮوﺳﻜﻮﺑﻴﺎ‪.‬‬

‫‪Definition‬‬
‫ﻫﻮ ‪ ،chronic necro-inflammatory disease‬ﺧﻠﻮا ﺑﺎﻟﻜﻮا ﻣﻦ ‪necro-‬‬
‫‪ inflammatory‬دى‪ ،‬ﻣ� ﻳﺴﺒﻖ ﻣ� ؟ ﻫﻞ ال ‪ necrosis‬ﻳﺴﺒﻖ ال ‪ inflammation‬وﻻ‬
‫اﻟﻌﻜﺲ؟؟‬
‫اﻟـ ‪ inflammation‬ﻳﺴﺒﻖ ال ‪ ،necrosis‬ال ‪ inflammation‬اﻻول ﻻﻧﻪ ﻓ�وس ﻳﺨﺶ‬
‫ﻓﺘﻴﺠﻲ ال ‪ inflammatory cells‬ﺗﻤﻮت اﻟﺨﻼﻳﺎ اﻟ� ﻓﻴﻬﺎ اﻟﻔ�وس ‪.‬‬
‫ﻫﻮ ‪ ،chronic necro-inflammatory disease‬ﻲﻓ ﻣﺼﺮ ﻋﻨﺪﻧﺎ ﻣﻌﻤﻮل ﺑﺎل ‪.C and B‬‬
‫ﺧﻠﻮا ﺑﺎﻟﻜﻮا اﻧﺎ ﺑﺤﻂ ال ‪ C‬ﻗﺒﻞ اﻟـ ‪ B‬ﻻن ﻣﻌﻈﻢ اﻟﺤﺎﻻت ﻋﻨﺪﻧﺎ ‪.C‬‬

‫ﻋﺸﺎن ﻛﺪه ﻛﻞ ال ‪ changes‬ﺑﺘﺒﻘﻲ ﻣﻮﺟﻮده ﻋ� ال ‪. interface‬‬

‫ﻣﺶ اﻟﺪم ﺑﻴﺠﻴﺐ ال ‪ inflammatory cells‬واﻟﻔ�وس ‪portal‬؟؟ واول ﺧﻼﻳﺎ ﺑﻴﺨﺶ ﻓﻴﻬﺎ‬
‫اﻟﻔ�وس ‪peripheral‬؟؟ ﻓﺒﺎﻟﺘﺎﻲﻟ اﻟـ ‪ antibodies and lymphocyte‬ﺑﺘﺠﻴﻠﻬﺎ‬
‫‪.peripheral‬‬
‫ﻳﺒﻘﻲ اﳌﺸﻜﻠﻪ ﻲﻓ اﻟـ ‪ interface‬ﻣﺎﺑ� ال ‪.portal tract and lobules‬‬

‫ﻋﺸﺎن ﻛﺪه اﻻﺳﻢ اﻟﺤﺪﻳﺚ ﻟﻞ ‪ Chronic viral hepatitis‬ﻫﻮ ‪chronic interface‬‬

‫‪ .hepatitis‬ﻋﺮﻓﺘﻮا ﻟﻴﻪ ﺑﻴﺴﻤﻮه ‪ interface‬؟ ﻻن ﻛﻞ ال ‪ lesions‬ﺑﺘﻜﻮن ﻲﻓ اﻟﺤﺘﻪ دي‬
‫ودي ﻣﺼﻴﺒﻪ ﻻن اﳌﻨﻄﻘﻪ دي ﻣﻨﻄﻘﻪ اﻟـ‪.framework‬‬

‫‪Pathology‬‬
‫‪:Grossly‬‬
‫ﻓﺎﻛﺮ�ﻦ ﻲﻓ ال ‪ acute viral hepatitis‬اﻟﻜﺒﺪ ﻛﺎن ﺑﻴﺒﻘﻲ ﺷﻜﻠﻪ ﻋﺎﻣﻞ ازاي ؟‬
‫ﻛﺒ� واﺧﻀﺮ‪ ،‬ﻟﻜﻦ ﻫﻨﺎ ﺑﻴﻜﻮن ‪ mildly enlarged‬وﻋﺸﺎن ﻛﺪه ال ‪ gross‬ﻣﻠﻬﻮش أي ﻗﻴﻤﻪ‪.‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫ال ‪ acute viral hepatitis‬ﺑﻨﺸﺨﺼﻪ ‪ clinically‬ﻣﺶ ﻣﺤﺘﺎﺟ� ‪ ،biopsy‬اﻣﺎ ال‬

‫‪ chronic‬ﻣﺤﺘﺎﺟ� ‪ ،biopsy‬ﻃﺐ ﻟﻴﻪ ﻣﺤﺘﺎﺟﻴﻨﻬﺎ ﻋﺸﺎن ﻧﻘﻮل ده ﻋﻨﺪه ‪Chronic viral‬‬
‫‪ hepatitis‬؟؟‬

‫ﻋﺸﺎﻥ ﻋﻠﻲ ﺍﻷﻗﻞ ﺃﺭﺑﻊ ﺣﺎﺟﺎﺕ‪:‬‬

‫‪ -١‬ﻫﻮ اﻟـ ‪ chronic viral hepatitis‬ده ‪C or B‬؟‬

‫ودي ﻣﺶ ﺷﻐﻠﺘﻨﺎ‪ ،‬دي ﺷﻐﻠﻪ ال ‪ clinical pathology‬ﺑﺲ اﺣﻨﺎ ﺑﻨـ ـ ‪.suggest‬‬
‫‪ Chronic viral hepatitis -٢‬ﺑﺴﺮﻋﻪ اد اﻳﻪ؟ ﻳﻌﻨﻲ اﻟﻌﻴﺎن ده اﻟﻜﺒﺪ ﺑﺘﺎﻋﻪ ﻫﻴﺒﻮظ ﻲﻓ‬
‫اد اﻳﻪ؟‬
‫‪ -٣‬ﻣﺮﺣﻠﻪ اﻳﻪ؟ وﻓﻴﻪ ﻓﺮق ﺑ� اﻟﺴﺮﻋﻪ واﳌﺮﺣﻠﻪ‪.‬‬
‫ﻟﻮ ﻗﻠﺘﻠﻜﻮا ان ﻛﺎن ﻓﻴﻪ ‪ ٢‬ﺳﻮاﻗ� واﺣﺪ ﻛﺎن ﺳﺮﻋﺘﻪ ‪ 100km\h‬واﻟﺘﺎ� ﺳﺮﻋﺘﻪ‬
‫‪ 10m\h‬ﻣ� ﻳﻜﺴﺐ اﻟﺴﺒﺎق؟؟ ﺗﻮﺗﻮ ﺳﺮﻋﺘﻪ ‪ 100km\h‬وﺳﻮﺳﻮ ﺳﺮﻋﺘﻪ ‪10m\h‬‬
‫ﻣ� ﻳﻜﺴﺐ اﻟﺴﺒﺎق؟ ﻟﻮ اﻧﺖ ﻣﺶ ﻓﺎﻫﻢ ﻫﺘﻘﻮﻲﻟ ﻃﺒﻌﺎ ‪ – 100km\h‬ﻟﻜﻦ اﻧﺖ‬
‫ﻣﺒﺘﻌﺘﻤﺪش ﻋ� اﻟﺴﺮﻋﻪ اﻧﺖ ﺑﺘﻌﺘﻤﺪ ﻋ� اﳌﺮﺣﻠﻪ‪.‬‬

‫ﺟﻴﺖ ﻗﻮﻟﺘﻠﻚ ﺗﻮﺗﻮ ﻛﺎن ﻟﺴﻪ ﺑﺎدئ اﻟﺴﺒﺎق ﻲﻓ اﻟﺮﺘاك اﻻوﻻ� وﺳﻮﺳﻮ ﺑﻴﻨﻪ وﺑ� ﺧﻂ‬
‫اﻟﻨﻬﺎﻳﻪ ‪ ٢‬ﻣﺮﺘ وﻛﺎن ﺑﻴﻀﺮب ﻓﺮاﻣﻞ ﻋﺸﺎن ﻳﻘﻒ‪ ،‬ﻓﻬﻤﺘﻮا ﺣﺎﺟﻪ وﻻ ﻣﺶ ﻓﺎﻫﻤ�؟‬
‫‪this is the stage, this is the grade.‬‬

‫ﻫﻨﺸﻮﻑ ﺍﻳﻪ ﻓﻲ ﺍﻝ ‪ chronic viral hepatitis‬ﺗﺤﺖ ﺍﻟﻤﻴﻜﺮﻭﺳﻜﻮﺏ؟‬

‫ﻫﺸﻮف ارﺑﻊ ﺣﺎﺟﺎت ‪:‬‬
‫‪ -١‬ﻫﻨﺸﻮف ‪ inflammation‬ﻳﺮﺘاوح ﻣﺎﺑ� ‪mild‬ﻟـ ‪.very marked‬‬
‫ﻳﻨﻔﻊ ﻳﺒﻘﻲ ﻓﻴﻪ ‪ viral hepatitis‬ﻣﻦ ﻏ� ‪inflammation‬؟ ﻷ‪ ،‬اوﻣﺎل ﻳﺒﻘﻲ‬
‫‪ hepatitis‬ازاي!!‬
‫اﻳﻪ ال ‪ inflammation‬؟؟‬
‫ﻣﺶ ده ﻓ�وس ؟ ﻓ�وس وﻻ ﻣﺶ ﻓ�وس؟! ﻋﻦ ﻃﺮ�ﻖ اﻟﺪم اﻳﻪ اﻟﺨﻼﻳﺎ ال‬
‫‪ inflammatory‬اﻟ� ﻫﺘﻄﻠﻊ ﻟﻬﺬا اﻟﻔ�وس؟‬
‫‪macrophage – lymphocyte – plasma cells‬‬
‫ﻟﻮ ﺟﻴﺘﻮا ﺗﺒﺼﻮا ادي ال ‪ portal tract‬ﻻﻧﻪ اﳌﻮﺿﻮع ﺑﻴﺒﺪأ ‪ portal‬ﻣﻦ اﻟﺪم وﻫﻨﺎ ﻓﻴﻪ‬
‫‪macrophage – lymphocyte – plasma cells‬‬

‫ﺳﺎﻋﺎت ﺗﻼﻗﻲ ال ‪ bile duct epithelium‬ﻳﺮﺘاوح ﺑﺮﺿﻪ ﻣﺎﺑ� ‪ mild‬ﻟـ ‪very‬‬

‫‪ marked inflammation‬وداﺧﻞ ﺟﻮاﻫﺎ ‪ lymphocyte‬ﻓﺴﺎﻋﺘﻬﺎ ﻫﻨﺴﺘﺪل ﻣﻦ ذﻟﻚ‬
‫ﻋ� اﻧﻪ ‪ viral hepatitis C‬ﻻن ال ‪ viral hepatitis C‬ﻳﺤﺐ ال ‪hepatocyte‬‬
‫وال ‪.tropism = bile duct epithelium‬‬
‫ﻓﺪي ﺑﺘﺎﺧﺪﻫﺎ ﻋ� اﻧﻪ ‪.most probably C‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫اﻟـ ‪ inflammation‬ﺑﻴﺒﺪأ ‪ portal‬وﺑﻌﺪﻳﻦ ﺑﻴﺪﺧﻞ ‪ ،lobular‬وﻟﻜﻦ ‪ lobular‬ﺑﻴﺒﻘﻲ‬

‫‪ .mild‬ﻻﻧﻪ ﻫﻮ ﺑﻴﺒﺪأ اﻟﻘﺼﻪ ﻛﻠﻬﺎ ﻣﻨ�؟ ‪. portal‬‬

‫‪ -٢‬ﺗﺎ� ﺣﺎﺟﻪ ﻫﺸﻮﻓﻬﺎ –ﻧﻜﺮﺒ ﺷﻮ�ﻪ اﻟﺤﺘﺖ دي ‪ -‬ﻫﻨﺒﺪأ ﻧﺸﻮف اﻟـ ‪،necrosis‬‬
‫اﻟـ‪ necrosis‬ﻲﻓ اﻟـ ‪ chronic hepatitis‬ﻳﺮﺘاوح ﻣﺎﺑ� ‪،absent to very marked‬‬
‫ﺣﺪ ﻳﻌﺮف ﻟﻴﻪ؟؟‬
‫ﻟﺴﻪ ﻲﻓ اﻻول ﻣﻔﻴﺶ ﺧﻼﻳﺎ اﺗﻘﺘﻠﺖ ﻓﻬﻤﺘﻮا ﺣﺎﺟﻪ؟ اﻟ� ﺑﻴﻘﺘﻞ اﻟﺨﻼﻳﺎ ﻫﻮ ال‬
‫‪ inflammation‬اﻟ� ﺑﻴﺴﺒﻖ اﻟـ‪ ،necrosis‬ﻓﺒﺎﻟﺘﺎﻲﻟ ﻟﺴﻪ ﻓﻌﺸﺎن ﻛﺪه ﻳﺮﺘاوح ﻣﺎﺑ�‬
‫‪.absent to very marked‬‬

‫ﺍﺷﻬﺮ ﻧﻮﻉ ﻣﻦ ﺍﻟـ ‪ necrosis‬ﺗﺸﻮﻓﻪ ﺍﻳﻪ؟‬

‫ﺷﺎﻳﻔ� اﻟﺨﻼﻳﺎ اﳌﻀﺮوﺑﻪ ﻲﻓ ال ‪ interface‬دا اﻟ� ﺣﻮاﻟ� ال ‪ ،portal tract‬ده‬
‫ﺑﻴﺴﻤﻮه ‪ piecemeal necrosis‬وده اﻫﻢ ﻧﻮع‪.‬‬
‫ﻳﻌﻨﻲ اﻳﻪ ‪ piecemeal‬؟؟‬
‫اﻟﺘﺴﻤﻴﻪ دي ﻋﺮﺑﻴﻪ ﻟﻮ ﺑﺘﺎﺧﺪوا ﺑﺎﻟﻜﻮا‪ ،‬اﻟﺮاﺟﻞ اﻟ� ﺷﺎف اﳌﻨﻈﺮ ده ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب‬
‫ﺗﺨﻴﻞ ان ال ‪ classical hepatic lobule‬رﻏﻴﻒ ﻋﻴﺶ‪ ،‬وﺣﻀﺮﺗﻚ اﻟﺤﺘﻪ اﳌﻘﻄﻮﻋﻪ دي‬
‫– اﻣﺎ ﺗﻴﺠﻲ ﺗﺎﻛﻞ اﻟﻌﻴﺶ ﺑﺘﺎﻛﻞ ﻣﻦ اﻟﻨﺺ وﻻ ﻣﻦ ال ‪ periphery‬؟! ﻣﻦ اﻟـ‪،periphery‬‬
‫ﻓﻜﺄﻧﻬﺎ ﻟﻘﻤﻪ‪.‬‬
‫ال ‪ piecemeal necrosis‬ﻳﻌﻨﻲ ﺗﺸﺒﻪ اﻟﻠﻘﻤﻪ اﻟ� ﻫﻲ ﻣﻘﻄﻮﻋﻪ ﻣﻦ ﺣﺘﻪ رﻏﻴﻒ‬
‫اﻟﻌﻴﺶ‪ ،‬ﺣﺘﻲ ﻳﺎﺟﺪع اﻣﺎ ﺑﺘﻴﺠﻲ ﺗﺎﻛﻞ ﺑﻴﻘﻮﻟﻚ اﻳﻪ؟ )ﺑﺴﻢ اﻟﻠﻪ ﻣﻌﺎﻳﺎ( ﻳﻌﻨﻲ‬
‫‪.piecemeal‬‬

‫اﳌﻬﻢ ﺧﻠﻮا ﺑﺎﻟﻜﻮا اﺻﻞ ﻛﻞ واﺣﺪ ﺑﻤﺰاﺟﻪ‪ ،‬ﻓﻴﻪ ﻋﺎﻟﻢ اﺧﺮ ﺷﺎف ال ‪ toxic goiter‬ال‬
‫‪ colloid‬ﻣﺘﺎﻛﻞ ﻣﻦ ﻋﻨﺪ ال ‪ periphery‬ﺑﺲ ﻫﻮ ﻣﺎﻛﻨﺶ ﺑﻴﺤﺐ اﻟﻌﻴﺶ ﻓﻘﺎﻟﻚ اﺳﻤﻴﻪ‬
‫‪ scaloppini‬ﻣﻦ ﻛﻠﻤﻪ اﺳﻜﺎﻟﻮب ﺑﺎﻧﻴﻪ‪ ،‬ﻳﻌﻨﻲ ﺑﻮﻓﺘﻴﻚ‪ ،‬ﻓﻬﻮ ﺗﺨﻴﻞ ان دي ﺑﻮﻓﺘﻴﻜﺎﻳﻪ‬
‫وﻣﻘﻄﻮع ﻣﻨﻬﺎ ﻗﻄﻤﻪ – ﻛﻞ واﺣﺪ وﻣﺰاﺟﻪ‪.‬‬
‫ﻃﺒﻌﺎ اﺣ� ﺣﺎﺟﻪ اﺷﻮف ﺑﻴﻬﺎ اﻟﺒﺎﺛﻮﻟﻮﺟﻲ ﻫﻲ اﻻﻛﻞ‪.‬‬

‫اﻟـ ‪ necrosis‬اﺳﻤﻪ ‪ piecemeal‬وده اﺧﻄﺮ ﻧﻮع ﻻن ﻲﻓ ال ‪ piecemeal‬ﻫﻞ ال‬

‫‪ framework‬ﺳﻠﻴﻢ؟‬
‫ﻷ ﻃﺒﻌﺎ ده ﻣﻀﺮوب ﻻﻧﻪ ﻗﺎﻋﺪ ﻋ� ال ‪ gate‬ﺧﻼص‪ ،‬ﻟﻮ اﺗﻀﺮب اﻧﺘﻬﻲ اﳌﻮﺿﻮع ‪.‬‬
‫ﻳﻨﻔﻊ ﻳـ ـ ‪ normally heal‬؟ ‪never‬‬
‫ﻫﻮ ﻫﻴ ـ ـ ‪ .heal by cirrhosis‬وال ‪ cirrhosis‬ﻫﻴﺒﻘﻲ ‪ bridging‬ﻋﺎرﻓ� ﻳﻌﻨﻲ اﻳﻪ؟؟‬
‫ﻳﻌﻨﻲ ﻳﻮﺻﻠﻨﺎ ال ‪ portal‬ﺑﺎﻟـ ـ ‪ central‬وﻫﻜﺬا‪ ،‬ﺿﺮب ال ‪ frame work‬وﻻ ﻣﻀﺮﺑﺶ؟!!‬
‫ﺿﺮب‪.‬‬

‫ﺍﻳﻪ ﻛﻤﺎﻥ ؟؟‬

‫ﻫﺘﺒﺪأ اﻟﺨﻼﻳﺎ اﻟ� ﺑﺘﻤﻮت ﺗـ ـ ‪ heal by fibrosis‬وﻫﻨﺎ ال ‪ fibrosis‬ﻫﻴﺮﺘاوح ﻣﺎﺑ� ‪absent‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫‪.to very marked‬‬

‫ﺧﻠﻮا ﺑﺎﻟﻜﻮا اﻟﺤﺎﺟﻪ اﻟﻮﺣﻴﺪه اﻟ� ﻣﻴﻨﻔﻌﺶ ﺗﺒﻘﻲ ‪ absent‬ﻫﻲ ال ‪ inflammation‬ﻷﻧﻪ‬
‫أول ﺣﺪث‪ ،‬ﻓﻬﻴﺎﺧﺪ اﻟﺸﻜﻞ‪ ،‬ﻟﻮ ﻫﻮ ‪ piecemeal‬ﻫﻴﺒﻘﻲ ‪piecemeal fibrosis‬‬
‫وﻟﻮ ﻫﻮ ‪ bridging‬ﻓﻬﻴﺒﻘﻲ ‪.bridging fibrosis‬‬

‫‪Other features‬‬

‫ﻟﻮ ﺟﻴﺖ ﻟﻘﻴﺖ ﻣﻌﻈﻢ ال ‪ hepatocytes‬ﻓﻴﻬﺎ ‪ fatty changes‬زي ﻣﺎاﻧﺘﻮا ﺷﺎﻳﻔ� ﻳﻌﻨﻰ‬
‫‪ steatosis‬اﻗﻮل ‪ most probably‬ان ده ﻓ�وس ﻲﺳ ‪.‬‬

‫ﻓ�وس ﻲﺳ ﺑﻴﻘﻌﺪ ﻲﻓ اﻟﻜﺒﺪ ‪ dormant‬ﺳﺎﻛﻦ ﻟﻔﺮﺘه ﻃﻮ�ﻠﻪ ﻓﻤﺶ ﺑﻴﻤﻮﺗﻬﺎ ﻓﺒﺎﻟﺘﺎﻲﻟ ﺑﻴﺘﺤﻮش‬
‫ﺟﻮاﻫﺎ ‪.fat‬‬

‫دﻟﻮﻗﺘﻲ اﻧﺎ ﻛـ ‪ pathologist‬اﻧﺎ ﻣﺒﺤﻠﻔﺶ اﻧﺎ ﺑﺲ ﺑـ ـ ‪ suggest‬ﻳﻌﻨﻰ اﻗﻮل ‪most‬‬

‫‪ probably‬ان ده ﻓ�وس ﻲﺳ ﳌﺎ اﺷﻮف‪:‬‬
‫‪steatosis of hepatocyte + affection of bile duct epithelium by‬‬
‫‪inflammation.‬‬

‫ﻃﻴﺐ ﻟﻮ ﻟﻘﻴﺖ ﻣﻌﻈﻢ اﻟﺨﻼﻳﺎ ال ‪ cytoplasm‬ﺑﺘﺎﻋﻬﺎ ‪ ground glass‬ﻳﻌﻨﻲ ازاز ﻣﺼﻨﻔﺮ‬

‫ﻟﻮﻧﻪ اﺣﻤﺮ اﻗﻮل ‪ most probably‬ان ده ‪ B‬ﻟﻴﻴﻴﻪ؟؟‬
‫ﻻن ﺣﻀﺮاﺗﻜﻮا ال ‪ B‬ﻲﻓ ﺻﻮره ال ‪ acute‬ﻫﺘﻼﻗﻮا اﻟﺨﻠﻴﻪ اﻟﻜﺒ�ه دي واﻟﺨﻠﻴﻪ دي ﻓﻴﻬﺎ ﻧﻘﻂ‬
‫ﺣﻤﺮا ﻛﺘ� ﻓﺎﻗﻮل ان ‪ most probably‬ده ‪ B‬ﻻن اﻟـ‪ viral particles‬ﺑﻴﺒﻘﻲ ﻣﺘﻜﺎﺛﺮ ﺟﻮه‬
‫اﻟﺨﻠﻴﻪ وﺑﻴﺼﺒﻐﻬﺎ ﺑﺎﻟﻠﻮن اﻻﺣﻤﺮ – ﻷﻧﻪ ﺑﺮوﺗ� ﻓﺒﻴﺒﺎن ﻋ� ﺷﻜﻞ ﻧﻘﻂ ﺣﻤﺮا‪.‬‬
‫اﻗﻮل ان ‪ most probably‬ده ‪ B‬وﻟﻜﻦ اﺣﻠﻒ؟؟ ﻷ – ﻟﻴﻪ ﻣﺤﻠﻔﺶ؟!!‬
‫دى ﺷﻐﻼﻧﻪ ﺑﺘﻮع ال ‪ clinical pathology‬ﻳﻌﻤﻠﻮﻫﺎ ‪ serological‬ﻳﻌﻤﻠﻮﻫﺎ ﺑﺎل ‪PCR‬‬
‫ﻳﻌﻤﻠﻮﻫﺎ ﺑﺎل ‪ ELISA‬ز ي ﻣﺎﻫﻤﺎ ﻋﺎﻳﺰ�ﻦ‪.‬‬

‫‪-٣‬ﻟﻮ ﻟﻘﻴﺖ اﻧﻪ اﻟﺨﻼﻳﺎ ﻓﻴﻬﺎ ‪ ،cholestasis‬ﻋﺎرﻓ� ال ‪ cholestasis‬؟! اﻗﻮل ان اﻟﻌﻴﺎن ده‬
‫اﻟـ ‪ liver functions‬ﺑﺘﺎﻋﺘﻪ ﻫﺘﻨﻬﺎر ﺑﺴﺮﻋﻪ‪.‬‬
‫‪-٤‬ﻟﻮ ﻟﻘﻴﺖ اﻟﻌﻴﺎن اﻟﺨﻼﻳﺎ ﻓﻴﻬﺎ ‪ dysplasia‬ﻫﻘﻮل اﻧﻪ ﻫﻴﻘﻠﺐ ﺳﺮﻃﺎن‪.‬‬
‫ﻓﻬﻤﺘﻮا ﺣﺎﺟﻪ؟‬

‫ﻳﺒﻘﻲ اذن ال ‪ microscopic picture‬دي ﻣﺶ ﺑﺘﺘﺤﻔﻆ‪ ،‬دي ﺑﺘﺪﻳﻨﻲ ﻛﻞ ﺣﺎﺟﻪ ﻋﻦ‬

‫اﻟﻌﻴﺎن‪.‬‬
‫اﳌﻔﺮوض ﳌﺎ ﻳﺠﻴ� ﻋﻴﻨﻪ ‪ liver core‬ﻣﻘﻮﻟﻮش ‪ chronic viral hepatitis‬ﻣﺎﻫﻮ ﻋﺎرف!!‬
‫وﻛﺎﻧﻮا ﺑﻴﻌﻠﻤﻮﻫﺎﻟﻨﺎ ﻛﺪه زي ﻣﺎﻣﻜﺘﻮﺑﻪ ﻋﻨﺪﻛﻮا ﻲﻓ اﻟﻜﺘﺎب ‪.‬‬
‫ﺑﺲ اﺣﻨﺎ ﻛﻨﺎ ﺑﻨﺤﺪد ‪ grading , staging‬ﻳﻌﻨﻲ اﻳﻪ اﻟ� اﻧﺖ ﺑﺘﻘﻮﻟﻪ ده؟‬

‫رﻛﺰوا ﻣﻌﺎﻳﺎ‪ ،‬ﻣﺸﻜﻠﻪ ال ‪ viral hepatitis‬اﻧﻪ ﻣﺶ ﻫﻴﺨﻒ ده ﻫﻴ ـ ‪heal by cirrhosis‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫وﻫﻴﻘﻠﺐ ‪ carcinoma‬ﻓﺎﻫﻤ� ﺣﺎﺟﻪ؟ ﻃﻴﺐ‪.‬‬

‫اﳌﺸﻜﻠﻪ ﻛﻠﻬﺎ ﻻزم ﺗﻌﺮﻓﻮا ان ال ‪ chronic hepatitis‬اﻟ� ﻳﻬﻤﻨﺎ ﻫﻮ ال ‪grading ,‬‬
‫‪ staging‬ﻳﻌﻨﻲ اﻳﻪ ال ‪grading , staging‬؟ ﻓﻴﻪ ﻣﺤﺎوﻻت ﻛﺘ�ه ﻟﻌﻤﻞ ال ‪grading ,‬‬
‫‪ staging‬ﻟﻞ ‪.chronic hepatitis‬‬

‫اول واﺣﺪ ﻋﻤﻠﻬﺎ ﻛﺎن ﻋﺎﻟﻢ اﳌﺎ� ﺳﻨﻪ ‪ ١٩٨١،‬ﺟﻪ ﺑﻌﺪ ﻛﺪه دﻛﺘﻮر ﺑﻴﺮﺘ ﻋﻤﻞ ﺣﺎﺟﻪ ﺳﻨﻪ ‪.٩٥‬‬
‫ﺟﻪ ﺑﻌﺪﻳﻪ ‪ Metavir‬وﺟﻪ ﺑﻌﺪ ﻛﺪه واﺣﺪ ﺑﻴﻘﻮﻟﻮا ﻋ� اﻟـ‪ system‬ﺑﺘﺎﻋﻪ اﺣﺴﻦ ‪،system‬‬
‫اﺳﻤﻪ ‪ ،Ishak‬ﻣ� ‪ Ishak‬اﻓﻨﺪي ده؟‬

‫اوﻻ اﻳﺸﺎك ﻫﻮ اﺳﺤﺎق وده ﻣﺼﺮي وﻃﻔﺶ ﻣﻦ اﻟﺒﻠﺪ وزﻫﻖ ﻓﻌﻤﻞ ﻫﺠﺮه ﻻﻣﺮ�ﻜﺎ – ﻫﻤﺎ‬
‫زﻫﻘﻮه ﻳﻌﻨﻲ ﻣﺶ ﻣﺸﻜﻠﻪ‪.‬‬
‫اﻣﺎ راح اﻣﺮ�ﻜﺎ ﻫﻨﺎك اﻟ� اﺗﻌﻠﻤﻪ ﻣﻦ اﺳﺘﺎذﺗﻨﺎ ﻛﺘﺒﻪ ﺑﺲ ﻋ� ﺷﻜﻞ ارﻗﺎم؛ ﻻن اﳌﻔﺮوض اﻟـ‬
‫‪ staging , grading‬ﻣﺶ ﺑﻴﻘﻮﻟﻚ ده ﻓﻘﻂ ‪ severe or mild‬ﻻن اﻟﻌﻴﺎن اﻟﻌﻼج ﺑﺘﺎﻋﻪ‬
‫ﺑﻴﻌﺘﻤﺪ ﻋ� اﻟﻜﻼم ده‪.‬‬
‫اﳌﻔﺮوض ﻲﻓ أي ‪ classification system‬ﻲﻓ اﻟـ ‪ chronic hepatitis‬ﻳﺒﻘﻲ ﻟﻴﻪ ‪etiology‬‬
‫اﻟﺴﺒﺐ اﻳﻪ؟‬
‫و�ﺒﻘﻲ ﻟﻴﻪ ‪ grading‬اﻟﺴﺮﻋﻪ اﻳﻪ؟ اﻟﺴﺮﻋﻪ ﺑﻴﻌﺮﺒ ﻋﻨﻬﺎ ال ‪necrosis and inflammation‬‬
‫اﻟ� ﻫﻲ ﻛﻠﻤﺔ ‪.necro-inflammatory‬‬
‫وال ‪ stage‬أو اﳌﺮﺣﻠﺔ ﺑﻴﻌﺮﺒ ﻋﻨﻬﺎ ﺑﺎل ‪.fibrosis‬‬

‫و�ﻘﻮﻟﻚ ﻓﻜﺮه ﻋﻦ اﻟـ‪.complications‬‬

‫ﻓﺮاح ﻫﻮ ﻛﺘﺐ اﻟﻜﻼم ﺑﺘﺎع ‪ severe, mild‬ﻋ� ﺷﻜﻞ ارﻗﺎم‪ ،‬ﺑﻴﺴﻤﻮه ال ‪histological‬‬
‫‪.activity index‬‬
‫ازاي؟!‬
‫اﻳﺸﺎك ﺑﻴﺪي ال ‪ grading‬درﺟﻪ ﻣﻦ ‪ ،١٨‬ﻳﻌﻨﻰ ﺑﻴﺪي اﻟﺴﺮﻋﻪ درﺟﻪ ﻣﻦ ‪.١٨‬‬
‫ﻓﻠﻮ واﺣﺪ ﺟﺎﻟﻚ اﻟﺴﺮﻋﻪ ﻋﻨﺪه ‪ ١٥‬ﻣﻦ ‪ ١٨‬ﺗﺒﻘﻲ ﺳﺮﻋﻪ اﻟﺘﻜﺴ� ﻋﺎﻟﻴﺔ‪ ،‬وﻟﻮ واﺣﺪ ‪ ٣‬ﻣﻦ ‪١٨‬‬
‫ﺗﺒﻘﻲ ﺳﺮﻋﻪ اﻟﺘﻜﺴ� ﻗﻠﻴﻠﺔ‪.‬‬
‫ﻣ� ﻓﻴﻬﻢ ﻳﺴﺘﻔﻴﺪ اﻛﺮﺘ ﻣﻦ ال ‪ interferon‬؟؟ اﻟ� اﻟﺘﻜﺴ� ﻋﻨﺪه ﻋﺎﻲﻟ‪.‬‬

‫ﻟﻜﻦ ﻟﻮ ﺟﻴﺖ أﺳﺘﺪرك وﻗﻠﺖ ﻟﻚ إﻧﻪ ﻛﺎن ﺑﻴﺪي ال ‪ fibrosis‬وال ‪ staging‬درﺟﻪ ﻣﻦ ‪٦‬‬
‫ﻟﻮ ﻗﻠﺖ ﻟﻚ اﻧﻪ ‪ ٦‬ﻣﻦ ‪ ٦‬ﻳﻌﻨﻲ اﻳﻪ؟‬
‫‪ cirrhosis‬ﻳﻨﻔﻊ ادﻳﻠﻪ ؟ ﻷ – ﺧﻼص ﺑﺎظ – ادﻳﻠﻪ ﻟﻴﻪ‪.‬‬
‫ﻓﻬﻤﺘﻮا ﺣﺎﺟﻪ ﻣﻦ اﻟ� ﺑﻘﻮﻟﻪ؟‬
‫اﻟﺴﺮﻋﻪ واﳌﺴﺎﻓﻪ ﻧﻔﺲ اﻟﻔﻜﺮه ‪.‬‬

‫ﻟﻴﻪ ﺍﻧﺎ ﺑﻜﺮﻩ ﺇﻳﺸﺎﻙ؟ ﺩﻱ ﻗﺼﺔ‪:‬‬

‫ﻻﻧﻪ رﺋﻴﺴﻪ اﻟﻘﺴﻢ اﻟﺴﺎﺑﻘﻪ رﺑﻨﺎ ﻳﺪﻳﻬﺎ اﻟﺼﺤﻪ ﻛﺎﻧﺖ رﺋﻴﺴﻪ ال ‪histopathologist‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫‪ association‬ﻲﻓ اﻟﻌﺎﻟﻢ وﻛﺎﻧﻮا ﻋﺎﻣﻠ� ﻣﺆﺗﻤﺮ وﻛﺎن اﻟﻜﻼم ده ﺳﻨﻪ ‪ ٢٠٠٢ -٢٠٠١‬واﻧﺎ ﺳﺎﻋﺘﻬﺎ‬
‫ﻛﻨﺖ ﺣﻠﻮ ﻛﺪه وﻋﻨﺪي ﺷﻌﺮ ﻃﻮ�ﻞ واﻧﺎ ﻛﻨﺖ اﻟـ ‪ speaker‬ﻋﻦ اﻟﻘﺴﻢ ﺑﺘﺎﻋﻨﺎ‪ ،‬اﻧﺎ اﻟ� ﺑﻘﺪم‬
‫اﻟﻨﺎس ﻳﻌﻨﻲ‪ .‬ﻛﺎن ﻗﺒﻠﻬﺎ ﻓﻴﻪ دﻛﺘﻮر ﻣﻜﺮم ﻟﺴﻪ ﻋﺎﻳﺶ رﺑﻨﺎ ﻳﺪﻳﻠﻪ اﻟﺼﺤﻪ‪.‬‬

‫ﻫﺤﻜﻲ ﻗﺼﻪ ﺍﺳﺤﺎﻕ‪:‬‬

‫اﻟـ ‪ system‬ﺑﺘﺎﻋﻪ ﻛﺎن ﻟﺴﻪ ﻃﺎﻟﻊ ﺟﺪﻳﺪ وﻋﺎﻣﻞ ﺷﻐﻞ ﺟﺎﻣﺪ ﻓﺤﺒﻴﺖ ا� اﺗﻔﺸﺨﺮ ﺷﻮ�ﻪ‬
‫ﻓﻘﺪﻣﺘﻪ ﻛﺪه ﺑﻬﺬه اﻟﻄﺮ�ﻘﻪ ﻋ� إﻧﻪ ‪ Egyptian pathologist‬واﺳﻤﻪ إﺳﺤﺎق‪.‬‬

‫ﻗﺎم ﻗﺎل‪I am not Egyptian, I am an American :‬‬

‫‪My name is Ishak not (Is7aq).‬‬
‫ﺗﺨﻴﻠﻮا ﺑﻘﺎ اﻧﺎ ﻣﻨﻈﺮي ﻛﺎن ﻋﺎﻣﻞ ازاي؟!! وﻗﺪام اﺳﺎﺗﺬﺗﻨﺎ!!‬
‫واﻟﻠﻪ ﺳﺎﻋﺘﻬﺎ اﻧﺎ ﻛﻨﺖ ﻫﻌﻴﻂ‪ ،‬ﻣﻨﻈﺮي وﺣﺶ ﺟﺪا وﻓﻴﻪ ﻋﻴﺎل ﻳﺎﺑﺎﻧ� ﻗﺎﻋﺪﻳﻦ وﻋﻴﺎل وﺑﺘﺎع‬
‫ده ﻛﺎن ﻗﺎﻳﻢ ﺑﻴﻬﺰﻗﻨﺎ ﻳﻌﻨﻲ‪ ،‬واﻟﻠﻪ اﻧﺎ ﻛﻨﺖ ﻫﻀﺮﺑﻪ‪.‬‬

‫ﺟﻪ ﺳﺎﻋﺘﻬﺎ اﺳﺘﺎذ ﻗﻌﺪ ﻳﻘﻮﻲﻟ ﻣﻌﻠﺶ ﻣﻌﻠﺶ ﻓﻘﻌﺪت ﺑﻘﺎ وﻫﻮ ﺑﻴﺸﺮح ﻲﻓ اﻟﺴﻴﺴﺘﻢ اﻟﺠﺪﻳﺪ‬
‫وﻃﻠﻌﺖ ﻋﻴﻨﻪ‪ ،‬ﻛﻞ اﻣﺎ ﻳﻘﻮل ﺣﺎﺟﻪ اﻗﻮﻟﻪ ! ‪we didn’t find this‬‬
‫?‪what is the sources of the cases u have‬‬
‫ﻲﻓ اﻣﺮ�ﻜﺎ ﻫﻮ ﻋﻨﺪه ‪ chronic hepatitis‬ﻳﻘﺪر ﻳﻌﻤﻞ ﻋﻠﻴﻬﺎ اﻟﻜﻼم ده؟؟ ﻷ ﻃﺒﻌﺎ ‪it is‬‬
‫‪.completely wrong‬‬
‫اﻗﻮﻟﻪ ‪I don’t know , it is completely wrong‬‬

‫ﻲﻓ ‪ ٢٠١٣ – ٢٠٠٩ – ٢٠٠٦‬ﺑﻘﺎ ‪ the most accurate system‬وﺑﻴﻤﺸﻮا ﺑﻴﻪ ﺑﺮه‪.‬‬

‫ﻣﻴﺠﻴﻠﻜﺶ ﻲﻓ اﻻﻣﺘﺤﺎن و�ﻘﻮﻟﻚ اﻋﻤﻞ ﻲﻟ ‪ grading‬و ‪ staging‬ﻣﺎ ﺑﻴﺤﺼﻠﺶ‬

‫واﺣﻨﺎ ﻣﺒﻨﺤﻔﻈﺶ ‪ grading‬و ‪.staging‬‬
‫ﻣﺶ ﻻزم ﺑﺲ ﻏ� ‪ Ishak‬ﻓﻴﻪ ‪ Metavir‬وﻓﻴﻪ ‪ Scheuer‬وﻓﻴﻪ ‪Modified Scheuer‬‬
‫‪ ،system‬ﻓﻴﻪ ﻛﺘ�‪.‬‬

‫ﻋﺎﻳﺰﻛﻮا ﺗﻌﺮﻓﻮا ﻋﻨﺪﻛﻮا إﻧﻪ ال ‪ grading‬أو اﻟﺴﺮﻋﻪ ﻳﻌﺮﺒ ﻋﻨﻬﺎ ﺑﺎل ‪necrosis‬‬
‫وال‪inflammation‬‬
‫وال ‪ stage‬ﻳﻌﺮﺒ ﻋﻨﻬﺎ ﺑﺎل ‪ ،fibrosis‬وﺗﻌﺮﻓﻮا اﺳﻤﺎء اﻟﻨﺎس دي‪ ،‬دول ﻛﺘ� اوي ‪.‬‬

‫ﻛﺎن ﻓﻴﻪ ﺑﺮدو ‪ system‬ﻗﺪﻳﻢ ﻛﺎن ﺑﻴﻘﺴﻢ ال ‪ hepatitis‬ل ‪ active‬و‬

‫‪ lobular/persistent‬و ‪ ،.......‬ودا اﺗﻠﻐﻲ ﻣﺤﺪش دﻟﻮﻗﺘﻲ ﺑﻴﺴﺘﺨﺪﻣﻪ‪.‬‬

‫ﻃﺐ ﺍﺣﻨﺎ ﺑﻨﻌﻠﻤﻜﻮﺍ ﺍﻟﻜﻼﻡ ﺩﻩ ﻟﻴﻪ؟‬

‫دﻟﻮﻗﺘﻲ اﺣﻨﺎ ﺑﻨﺪي اﻟﻌﻴﺎن ‪ ،Sovaldi‬واﻟﺪوا دا ‪expensive‬‬
‫ﻋﺸﺎن ﻛﺪه ﻻزم ﻧﻌﻤﻞ ﻟﻠﻌﻴﺎن ‪ biopsy‬ﻟﻮ ﻟﻘﻴﻨﺎه ‪ whatever‬ال ‪ grade‬ﺑﺘﺎﻋﻪ ﺑﺲ ال‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫‪ stage‬ﺑﺘﺎﻋﻪ ‪ 5‬او ‪ 6‬ﻧﺪﻳﻠﻪ ‪Sovaldi‬؟ ﻻ ﻣﻨﺪﻳﻠﻮش ﻻن ﺧﻼص دا ‪cirrhosis‬‬

‫ﻟﻘﻴﻨﺎه ‪ 1‬او ‪ 2‬ﻧﺪﻳﻠﻪ‪ 3 ،‬او ‪ 4‬ﻧﺤﺎول ﻓﺎﻫﻤ� ﺣﺎﺟﻪ؟‬
‫اﻟﻔﻜﺮه ﻛﻠﻬﺎ ﻲﻓ ال ‪ grading‬وال ‪.stage‬‬

‫ﻣ� ﻗﺒﻞ ﻣ�؟‬

‫اﺗﻨ� اﺗﺴﺎووا ﻲﻓ ال ‪ stage‬ﻣ� ﻧﺪﻳﻠﻪ ﻗﺒﻞ ﻣ�؟ ال ‪ grade‬اﻻﻋ� ﻻﻧﻪ ﻫﻲ اﻟ� ﻓﻴﻬﺎ ﺗﻜﺴ�‬
‫اﻋ� ﻓﺎﻫﻤ� ﺣﺎﺟﻪ؟‬
‫اﻻﺗﻨ� اﺗﺴﺎووا ﻲﻓ ال ‪ grade‬وال ‪ stage‬ﻳﺒﻘﻲ ﻧﺤﺘﻜﻢ ﻟﻠـ ‪ cholestasis‬واﻟـ ‪،dysplasia‬‬
‫اﻟ� ﻫﻴﺒﺪا ﻳﻈﻬﺮ ﻓﻴﻬﺎ ﻧﺪﻳﻠﻪ ﻓﻬﻤﺘﻮا ﺣﺎﺟﻪ؟‬

‫اه ﻣﻤﻜﻦ ﻳﺘﺴﺎل ‪ written‬ﻳﻌﻨﻲ اﻳﻪ ال ‪ grading‬و�ﻌﻨﻲ اﻳﻪ ال ‪ staging‬وﻣ� ﻫﻲ ال‬

‫‪ grading systems‬واﻳﻪ اﻫﻤﻴﺘﻬﺎ ﺑﺲ‪.‬‬
‫اﻋﺘﻘﺪ اﻧﺎ ﻗﻠﺖ اﻟﻜﻼم دا ﻣﻴﺖ ﻣﺮه‪ ،‬ﻳﺎ دﻛﺘﻮر دي ﻋﺎﻣﻠﻪ زي اﻟﺠﺪول اﻟﺪوري اﺣﻨﺎ‬
‫ﻣﺒﻨﺤﻔﻈﻬﻮش اﺣﻨﺎ ﺑﻨﻄﺒﻖ اﻟﻜﻼم دا ﻋ� اﻟﻮرق‪.‬‬

‫‪CIRRHOSIS‬‬

‫دا اﻫﻢ ﻣﻮﺿﻮع ﻲﻓ اﻟﻜﺒﺪ‪ ،‬ﻻ� ﻗﻠﺖ اﻟﻜﻼم دا ﻣﻦ زﻣﺎن ﻗﻠﺖ‪:‬‬

‫‪cirrhosis isn’t a liver disease, cirrhosis is the end of any liver disease.‬‬
‫ال )‪ (cirrhosis‬ده ‪.fibrosis is a part of cirrhosis & doesn’t mean fibrosis‬‬

‫ال ‪ cirrhosis‬ﻟﻴﺲ ﺑﻤﺮض ﻲﻓ اﻟﻜﺒﺪ واﻧﻤﺎ ﻫﻮ ﻧﻬﺎﻳﻪ اي ﻣﺮض ﻲﻓ اﻟﻜﺒﺪ‪.‬‬

‫ال ‪ cirrhosis‬ﺑﺎﻟﻌﺮﺑﻲ ﻟﻴﺲ ﺗﻠﻴﻒ اﻟﻜﺒﺪ واﻧﻤﺎ ﻫﻮ ﻣﺮض اﻟﻜﺒﺪ اﻻﺻﻔﺮ‪ ،‬وﺣﺘﻰ دى ﻛﻤﺎن‬
‫ﻏﻠﻂ ﻷﻧﻪ ﻣﺶ داﻳﻤً ﺎ أﺻﻔﺮ زي ﻣﺎ ﻫﻨﺸﻮف دﻟﻮﻗﺘﻰ‪.‬‬

‫اﻟـ ‪ cirrhosis‬ده)‪:CATEGORY (A‬‬

‫ﻧﻈﺮي وﺟﺎر وﺳﻼﻳﺪ و ‪class A in exam‬‬
‫ال ‪ literally cirrhosis‬ﻣﻌﻨﺎه ﻣﺮض اﻟﻜﺒﺪ اﻻﺻﻔﺮ‪.‬‬

‫اﻟ� اﻛﺘﺸﻒ ال ‪ cirrhosis‬ﻫﻮ دﻛﺘﻮر ﻓﺮﻧﺴﺎوي اﺳﻤﻪ )ﻟﻴﻨﻜﺲ( اﺳﻤﻪ اﻳﻪ؟ اﺳﻤﻊ ﻛﺪا ؟‬
‫ﻛﻠﻴﻨﻴﻜﺲ ‪ . 0_o‬اﻧﺎ ﻗﻠﺖ )ﻟﻴﻨﻜﺲ ‪ (Laennec‬ﻳﺎ ﺟﻤﺎﻋﻪ !‬

‫ﻟﻴﻨﻜﺲ ﻋﺎش ﻲﻓ اﻟﻔﺮﺘه اﻟ� ﻛﺎن ﻓﻴﻬﺎ اﻟﺜﻮره اﻟﻔﺮﻧﺴﻴﻪ ﻣﺴﺘﻤﺮه‪ ،‬اﻟﺜﻮره اﻟﻔﺮﻧﺴﻴﻪ ﻗﻌﺪت‬
‫‪٧٢‬ﺳﻨﻪ‪ ،‬واﻟﺒﻠﺪ اﺣﻮاﻟﻬﺎ زي اﻟﺰﻓﺖ ﻓﺎﻟﻨﺎس ﻣﺤﺒﻄﻪ وﻋﻨﺪﻣﺎ ُﺗﺤﺒﻂ اﻟﺸﻌﻮب ﺗﻠﺠﺎ اﻲﻟ اﻟﻨﺴﻴﺎن‬
‫واﻟﻨﺴﻴﺎن ﺑﺎﻟﺨﻤﻮر‪.‬‬

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Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis

‫ واﻟـ‬steatosis ‫ﻓﺎﻟﻌﻴﺎل اﻟﻔﺮﻧﺴﺎو�� ﺷﺮﺑﻮا ﺧﻤﺮه ﻛﺘ�ه ﻓﺨﻼﻳﺎ اﻟﻜﺒﺪ ﺑﺎﻇﺖ وﺣﺼﻠﻬﺎ‬
.‫ واﻟﻜﺒﺪ ﺑﻘﻲ ﺻﻐ� وﻣﺤﺒﺐ وﻟﻮﻧﻪ اﺻﻔﺮ‬cirrhosis ‫ ﺑﺎظ ﻓﺪﺧﻠﻮا ﻲﻓ‬framework

‫ وﺷﺎﻳﻒ ﻛﺒﺪ ﻟﻮﻧﻪ اﺻﻔﺮ‬shrunken ‫ و‬nodular ‫ﻓﺎﻣﺎ ﺟﻪ )ﻟﻴﻨﻜﺲ( ﻳﻔﺘﺢ ﺑﻄﻨﻬﻢ ﻟﻘﻲ اﻟﻜﺒﺪ‬
.‫ أو ﳌﻮن( ودي ﺗﺴﻤﻴﻪ ﺧﺎﻃﺌﻪ‬citrus) ‫ ﺟﺎﻳﻪ ﻣﻦ‬cirrhosis ، cirrhosis ‫ﻓﺮاح ﻣﺴﻤﻴﻪ‬
. yellow‫ ﺑﻴﺒﻘﻲ‬cirrhotic liver ‫ﻻن ﻣﺶ ﻛﻞ ال‬

‫ ﻣﻔﻴﻬﻮش‬cirrhosis ‫ اﻟ� ﻳﻐﻠﻂ ﻓﻴﻪ ﻻزم ﻧﺴﻘﻄﻪ ﻻن ال‬cirrhosis ‫وﻟﻜﻦ ﺗﻌﺮ�ﻒ ال‬
‫ ﻛﺜ� ﻣﻦ اﻻﻃﺒﺎء ﺑﻴﻘﻮﻟﻮا ﻋﻠﻴﻪ ﻲﻓ اﻟﺘﻠﻴﻔﺰ�ﻮن ﺗﻠﻴﻒ اﻟﻜﺒﺪ وده‬cirrhosis ‫ ﻲﻓ ﻣﺼﺮ ال‬،‫ﺗﻔﺎﻫﻢ‬
‫ ﻲﻓ ﻣﺼﺮ ﻛﺎن ﺑﺴﺒﺐ‬liver fibrosis ‫ وال‬liver fibrosis ‫ ﺗﻠﻴﻒ اﻟﻜﺒﺪ ﻫﻮ ال‬، ‫ﻏﻠﻂ‬
.‫ ﺑﻠﻬﺎرﺳﻴﺎ‬bilharziasis

Definition:
:cirrhosis ‫ال‬
:‫ ﺷﻬﻮر‬٦ ‫ ﻲﻓ اﻟﻜﺒﺪ ﻳﻌﻨﻰ اﻛﺮﺘ ﻣﻦ‬chronic‫ و‬،‫ ودي اول ﻛﻠﻤﻪ‬،chronic ‫ﻫﻮ‬
chronic diffuse liver disease :‫( ﻛﻠﻤﺎت‬٣)

:(٣) ‫ﻳﺘﻤﻴﺰ ﺏ‬
Diffuse progressive liver cells necrosis and destruction .١
with destruction of the ‫ ﻳﺎر�ﺖ ﻋ� ﻛﺪه وﺑﺲ ده ﻛﻤﺎن‬،‫اﻟﺨﻼﻳﺎ ﻛﻠﻬﺎ ﺑﺎﻇﺖ‬
.‫ ﻳﻌﻨﻰ ﻛﺴﺮﻧﺎ ﺑﻌﺪ ﻛﺪه اﻻرض ﻛﻤﺎن ﺑﻌﺪ ﻣﺎ ﻛﺴﺮﻧﺎ اﻟﻜﺮاﻲﺳ‬framework
‫ ﻧﻮﻗﻔﻬﺎ ﻋﻠﻴﻪ‬framework ‫وﻟﻜﻦ ﻧﻴﺠﻲ ﻧﻤﺴﻚ اﻟﻜﺮاﻲﺳ اﻟ� ﺑﺎﻇﺖ وﻧﻌﻮﺿﻬﺎ ﻟﻜﻦ ﻣﻔﻴﺶ‬
‫ﻓ�وح ﺟﺎﻳ� ﺣﺎﻃ� اﻟﻜﺮاﻲﺳ ﻓﻮق ﺑﻌﺾ ﻲﻓ اﻟﺤﺘﻪ اﻟ� ﺑﺎﻗﻴﻪ وﻧﻴﺠﻲ ﺑﺤﺒﺎل ﻧﺮﺑﻄﻬﻢ‬
‫وﻧﻘﻮﻟﻜﻮا اﻗﻌﺪوا ﻋﻠﻴﻪ ﻫﺘﻘﻌﺪوا؟‬

repair by regeneration (in the form of regeneration .٢

nodules)/fibrosis
.central vein ‫وﻟﻜﻦ دي ﻣﻔﻴﻬﺎش‬

eccentric central vein- absent central vein .٣

surrounded by fibrosis ‫و‬
nodules are not functioning ‫ ﻻﻧﻪ ﻫﺬه ال‬،lost ‫ ﺑﺘﺒﻘﻲ‬liver function‫وﺑﺎﻟﺘﺎﻲﻟ‬
are necrotic ‫ﻻﻧﻬﺎ ﻣﻌﻈﻢ اﻟﺨﻼﻳﺎ اﻟ� ﺟﻮاﻫﺎ‬

.‫ ﻋﻨﺪك ﻲﻓ اﳌﻨﻬﺞ‬definition ‫ وده اﻃﻮل‬this is the definition

liver function never to be restored ‫ال‬
classic hepatic lobules ‫ﻣﺶ‬regeneration nodules ‫ﻻﻧﻪ دي‬

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Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis

cirrhosis ‫ ال‬،‫ ﺑﺲ ﻣﺶ ﻫﺘﻜﻠﻢ‬etiology ‫ اﳌﻔﺮوض اﺗﻜﻠﻢ ﻋﻨﺎل‬definition ‫ﺑﻌﺪ ال‬

:‫ ﻣﺮات‬٨-٧ ‫ ﻫﺘﻜﻠﻢ ﻋﻦ اﺳﻄﻤﺒﻪ اﻟ� ﻫﻄﺒﻘﻬﺎﻟﻜﻮا اﻟﻨﻬﺎرده‬،‫ﻣﺶ ﻧﻮع واﺣﺪ دا اﻧﻮاع‬

Pathology:
Site:

‫ ﻳﻴﺠﻲ ﻓ� ؟ اﻟﻔﺺ اﻟﻴﻤ� وﻻ اﻟﺸﻤﺎل؟‬cirrhosis ‫اﻟـ‬

.diffuse in liver ‫ ﺑﻴﺒﻘﻲ‬cirrhosis‫ اﺳﺎﺳﺎ ﻻن ال‬site ‫ﻣﻴﻨﻔﻌﺶ اﻋﻠﻖ ﻋ� ال‬

Grossly:

.‫ﻻﻧﻪ دي اﺳﻄﻤﺒﻪ وﻫﺘﻜﺮرﻫﺎ ﻟﻮﺣﺪك‬

firm‫ وﻫﺘﺒﻘﻲ‬consistency ‫ اول ﺣﺎﺟﻪ ﻫﻨﻌﻠﻖ ﻋﻠﻴﻬﺎ ال‬cirrhosis ‫اﻟﻜﺒﺪ ﻟﻮ ﺣﺼﻞ ﻓﻴﻪ‬
‫ ؟‬firm ‫ﻟﻴﻪ‬
‫ ﻓﻴﻪ‬part <----- fibrosis ‫ﻻﻧﻪ ال‬
.‫ ﺳﻬﻠﻪ‬،firm <---- fibrous tissue ‫وال‬

‫؟‬enlarged ‫ وﻻ‬shrunken ‫ ﻳﺒﻘﻲ‬،size ‫ﺗﺎ� ﻧﻘﻄﻪ ال‬

.biliary cirrhosis‫ ﻣﺎﻋﺪا ال‬shrunken ‫ﻲﻓ ﻛﻞ اﻟﺤﺎﻻت ﻳﺒﻘﻲ‬
.‫ ﺑﻴﻜﺶ‬fibrosis ‫؟‬shrunken ‫ﻟﻴﻪ ﻲﻓ ﻛﻞ اﻟﺤﺎﻻت ﺑﻴﺒﻘﻲ‬
bile ‫ اﺗﺤﻮش وﺑﻮظ اﻟﻜﺒﺪ وﻫﻴﺒﻘﻲ ﻓﻴﻪ‬bile ‫ ﺑﺴﺒﺐ ان ال‬biliary cirrhosis ‫ﻣﺎ ﻋﺪا ال‬
enlarged ‫ ﻛﻤﺎن ﻓﺒﺎﻟﺘﺎﻲﻟ‬retention
shrunken ‫ ﺑﺘﺒﻘﻲ‬cirrhotic livers ‫ﻳﺒﻘﻲ ﻛﻞ ال‬
except: biliary cirrhosis.

‫ﺍﻳﻪ ﻛﻤﺎﻥ؟‬
‫؟‬nodular ‫ وﻻ‬smooth ‫ ﻫﻴﺒﻘﻲ‬،cut section ‫ وال‬surface ‫ﺑﻨﺤﺲ اﻟـ‬
�‫( ﻋ‬grossly) cirrhosis ‫ اﻟ� اﻧﺘﻮا ﺷﺎﻳﻔﻴﻨﻬﺎ دي وﻛﺎﻧﻮا ﺑﻴﻘﺴﻤﻮا زﻣﺎن ال‬nodular
regeneration nodules ‫ﺣﺴﺐ ال‬
micronodular ‫ ﻫﻨﺴﻤﻴﻪ‬2-3mm ‫ اﻗﻞ ﻣﻦ‬regeneration nodules ‫ﻗﺎﻟﻚ ﻟﻮ ال‬
cirrhosis
‫ ﻫﻨﺴﻤﻴﻪ‬6 cm ‫ وﺑﻴﻮﺻﻞ ل‬3mm ‫ اﻛﺮﺒ ﻣﻦ‬regeneration nodules ‫ﻟﻮ ﻛﺎن ال‬
macronodular cirrhosis

‫ ﻳﻌﻨﻰ ﺷﻮ�ﻪ ﺻﻐ��ﻦ وﺷﻮ�ﻪ ﻛﺒﺎر ﻟﻴﻪ ؟‬mixed ‫ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ اﻻﻏﻠﺒﻴﻪ ﺑﻴﺒﻘﻲ‬
‫ﻫﻮ ﻓﻴﻪ ﺣﺪ ﺑﻴﻘﺴﻢ ﻣﻦ ﻏ� ﻫﺪف؟‬
‫ ﻟﻴﻪ؟‬macronodular ‫ و‬micronodular ‫ ﻟـ‬cirrhosis ‫ﻟﻴﻪ ﻗﺴﻤﻨﺎ ال‬
regeneration ‫ ؛ﻻﻧﻪ ﳌﺎ ﺗﻼﻗﻲ ال‬purpose ‫ ﻻزم ﻳﺒﻘﻲ ﻟﻴﻪ‬classification ‫ﻻﻧﻪ اي‬

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Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis

.‫ ﻛﺒ�ه ﻣﻌﻨﺎﻫﺎ ﺳﺮﻋﻪ ﺗﻜﺎﺛﺮ اﻟﺨﻼﻳﺎ ﺳﺮ�ﻌﻪ وﻣﻌﻨﺎﻫﺎ ان ﻫﻲ ﻫﺘﻘﻠﺐ ﺑﺴﺮﻃﺎن اﺳﺮع‬nodules
macro nodular cirrhosis ‫ﻓﺎﻫﻤ�؟ اﻛﺮﺘ ﻧﻮع ﻳﻘﻠﺐ ﺳﺮﻃﺎن ال‬

‫ﺍﻳﻪ ﻛﻤﺎﻥ؟‬
‫ ؟‬yellow ‫ ﻻزم ﺗﺒﻘﻲ‬cirrhotic livers ‫ ﻫﻞ ﻛﻞ ال‬color ‫ﻣﻦ ﺣﻴﺚ ال‬
‫ و ﻲﻓ‬malnutrition‫ اﻟﻨﺎﺗﺠﺔ ﻋﻦ اﻟـ‬nutritional ‫ ﻲﻓ ﺣﺎﻻت ال‬yellow ‫ﻣﻤﻜﻦ ﻳﺒﻘﻲ اﺻﻔﺮ‬
.fat ‫ ﻷن دول ﻓﻴﻬﻢ‬alcoholics ‫ال‬
.biliary cirrhosis ‫وﻣﻤﻜﻦ ﻳﺒﻘﻲ اﺧﻀﺮ ﻲﻓ ﺣﺎﻻت اﻟـ‬
‫ وﻟﻜﻦ‬، ‫ اﻣﺎ ﻳﺮﺘﺳﺐ ﺣﺪﻳﺪ‬hemochromatosis ‫ ﻲﻓ ﺣﺎﻻت اﻟـ‬brownish ‫وﻣﻤﻜﻦ ﻳﺒﻘﻲ‬
.‫ﻣﺶ ﻻزم ﻳﺒﻘﻲ ﻟﻮﻧﻪ اﺻﻔﺮ‬
.‫ﻣﺮض اﻟﻜﺒﺪ اﻻﺻﻔﺮ ﻣﺶ ﻻزم ﻳﺒﻘﻲ ﻟﻮﻧﻪ اﺻﻔﺮ‬

Microscopy:

‫ اﻳﻪ‬2 component ‫ ﺑﻴﺒﻘﻲ‬،‫ دا ﺷﻜﻠﻪ‬cirrhotic liver ‫ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب اﺳﻄﻤﺒﻪ – اي‬

‫ﻫﻤﺎ؟‬

with loss of ‫ ﻻزم ﺗﻮﺻﻔﻬﺎ‬regeneration nodules : ‫• اﻟﺒﻄﺶ اﻟﺤﻤﺮا دي‬

normal architecture
classic hepatic lobule ‫ﻻﻧﻪ دي ﻣﺶ‬
central vein ‫؟ ﻣﻔﻴﺶ‬lack normal hepatic architecture ‫ﻃﺐ ﻟﻴﻪ‬
.eccentric portal vein ‫( أو ﻳﺒﻘﻲ‬absent)
regeneration nodules ‫ ﻲﻓ ﻣﻌﻈﻢ ﺧﻼﻳﺎ ال‬portal tract ‫وﻣﻤﻜﻦ ﻣﺘﻼﻗﻴﺶ‬
‫ ﺟﻮاه‬fibrosis ‫ اﻟ� ﻲﻓ اﻟﻨﺺ دا ؟‬tissue ‫ ؟ اﻳﻪ ال‬Separated by •
proliferating bile ‫ و‬chronic inflammatory cells ،lymphocytes
.‫ ﺑﺘﺤﺎول ﺗﺘﻜﺎﺛﺮ ﻋﺸﺎن ﺗﻌﻮض‬ducts
slide ‫ ﻓﻴﻪ ﻣﻨﻪ‬liver cirrhosis ‫ اﻧﺘﻮا ﻋﻨﺪﻛﻮا‬، slide ‫ ال‬comment ‫دا‬
.jar ‫ اﻟ� ﻓﻮق دا ﻛﺎن‬،jar ‫وﻋﻨﺪﻛﻮا‬

Types
1. Nutritional and alcoholic cirrhosis:

‫ اﺷﻬﺮ ﻧﻮع واول ﻧﻮع ﻣﻦ‬،‫ ﻻن اﻟ� اﺣﻨﺎ ﻗﻮﻟﻨﺎه دا اﺳﻄﻤﺒﻪ ﻫﻨﻘﻌﺪ ﻧﻜﺮرﻫﺎ‬،‫ﺗﻌﺎﻟﻮا ﻧﻘﺴﻢ ﺑﻘﻲ‬
‫ ﺑﺲ اﺳﻤﻪ‬،‫( اﺳﻢ اﻟ� اﻛﺘﺸﻔﻪ‬Laennec's cirrhosis) ‫ اﻛﺘﺸﻔﻮه ﺑﻴﺴﻤﻮه‬cirrhosis ‫ال‬
nutritional/alcoholic cirrhosis ‫اﻟﻌﻠﻤﻲ‬
‫ او‬malnutrition ‫ﻻﻧﻪ اﻛﻴﺪ ﺳﻴﺎدﺗﻜﻮا ﻋﺎرﻓ� إﻧﻪ اﻟﻨﺎس اﻟ� ﻣﺒﺘﺎﻛﻠﺶ ﺑﺮوﺗ� ﻲﻓ اﻟـ‬
.‫اﻟﺨﻤﻮرﺟﻴﻪ اﻟﺨﻴﺎﺑﺔ اﻟ� ﺑﻴﺸﺮﺑﻮا ﺧﻤﺮه‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫اﻟﺨﻤﻮرﺟﻲ اﻟﺸﺎﻃﺮ ﺑﻴﺤﻂ ﺟﻨﺐ اﻟﺨﻤﺮة إﻳﻪ؟ ﻣَ َﺰة‪،‬ﻛﺒﺪه ﻧﻴﻪ ﻋﺸﺎن اﻟﺮﺒوﺗ�‪.‬‬

‫اﻟﺨﻤﺮه ‪ + hepatotoxic‬اﻧﻪ اﻟﻨﺎس دي ﻋﻨﺪﻫﺎ ‪ malnutrition‬ﻓﺒﻴﺒﺪا ﻳﺤﺼﻠﻬﻢ‬

‫‪hepatic steatosis‬‬
‫ﺳﺎﻋﺘﻬﺎ ال ‪ hepatic cells‬ﻫﺖ ‪ rupture‬وﺗﻄﻠﻊ ال ‪ fatty acids‬اﻟ� ﺑﺘﺒﻮظ ال‬
‫‪framework‬‬
‫ﺳﺎﻋﺘﻬﺎ اﻟﻜﺒﺪ ﻫﻴﻌﺮف ﻳﻌﻮض؟! ﻻ ﻃﺒﻌﺎ‬
‫ﻫﻴﻌﻮض ‪by cirrhosis‬‬
‫ادي دا ﺷﻜﻞ ال ‪ hepatic cirrhosis‬ﻫﻨﺎ‬

‫‪Grossly:‬‬

‫اﻟﻜﺒﺪ ﻫﻴﺒﻘﻲ ‪ shrunken‬وﻻ ‪enlarged‬؟‬

‫اﻧﺖ ﺑﺘﻔﻜﺮ؟! ﻛﻠﻬﻢ ﻫﻴﺒﻘﻲ ‪ shrunken‬ﻣﺎﻋﺪا ال ‪biliary‬‬
‫ﻳﺒﻘﻲ اﻛﻴﺪ ﻟﻮﻧﻪ ازرق وﻻ اﺳﻮد؟ اﺻﻔﺮ ﻻﻧﻪ ﻫﻮ ﻓﻴﻪ ‪ fat‬و‪steatosis‬‬
‫اﻟﺤﺎﺟﻪ اﻟ� ﺗﺤﻔﻈﻬﺎ اﳌﻬﻤﻪ اﻧﻪ ال ‪ regeneration nodules‬ﺑﺘﺒﻘﻲ اﻳﻪ ﻫﻨﺎ؟ ‪micro‬‬
‫‪nodular‬‬
‫‪ micro nodular‬ﻣﻌﻨﺎﻫﺎ اﻧﻪ ﺑﻴﻘﻠﺐ ﺳﺮﻃﺎن وﻻ ﻣﺒﻴﻘﻠﺒﺶ ؟ ﻣﺶ ‪ common‬اﻧﻪ ﻫﻮ‬
‫ﻳﻘﻠﺐ‪ ،‬ﻳﻌﻨﻰ ﻣﻤﻜﻦ ﻳﻘﻠﺐ ﺑﺲ ﻣﺶ ‪common‬‬

‫ﺗﺤﺖ ﺍﻟﻤﻴﻜﺮﻭﺳﻜﻮﺏ ﻫﻨﺸﻮﻑ ﺍﻳﻪ ؟‬

‫‪ regeneration nodules‬و ‪) fibrous septa‬اﺷﺮح اﻟﺴﻄﻤﺒﺔ(‬
‫دا ﻣﺶ ﻣﻬﻢ ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ﻻن ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ﻣﻔﻴﺶ ﺧﻤﻮرﺟﻴﻪ وﻣﻔﻴﺶ ‪malnutrition‬‬
‫‪ enough‬إﻧﻬﺎ ﺗﻌﻤﻞ ﻛﺪه‪.‬‬
‫ﻻﻧﻪ اه ﻲﻓ ﻣﺼﺮ ﻣﻔﻴﺶ ﻟﺤﻤﻪ و ﻟﻜﻦ ﻲﻓ اﻟﻌﻴﺪ ﺑﻴﺎﻛﻠﻮا ﻟﺤﻤﻪ ﻳﺒﻘﻲ ﺧﻼص ﻣﺶ ﻫﻴﺤﺼﻞ‬
‫ﻓﻤﺶ ‪ common‬ﻋﻨﺪﻧﺎ‪.‬‬

‫‪2. Post-hepatitic cirrhosis:‬‬

‫ودي ال ‪ common‬ﻋﻨﺪﻧﺎ ﻫﻨﺎ ﻲﻓ ﻣﺼﺮ‬

‫اﺳﻤﻪ اﻳﻪ؟ ‪post hepatitis cirrhosis‬‬
‫وﻛﻠﻜﻮا ﺑﺘﻜﺘﺒﻮﻫﺎ ﻲﻓ اﻻﻣﺘﺤﺎن ‪ post hepatic‬ﺑﺪل ‪ post hepatitis‬وﺑﻨﻨﻘﺼﻜﻮا ﻋﻠﻴﻬﺎ‪.‬‬

‫ﻳﻌﻨﻲ اﻳﻪ ﻛﻠﻤﻪ ‪ post hepatitic‬؟ ﻳﻌﻨﻲ ﺑﻌﺪ اﻟـ ‪ hepatitis‬ودا ﻋﻨﺪﻛﻮا ‪ case‬ﻓﻴﻪ‪.‬‬
‫ال ‪ post hepatitis cirrhosis‬ﺑﻴﺠﻲ ﺑﻌﺪ ال ‪ chronic active hepatitis‬اﻟ� ﺷﺮﺣﺘﻪ‬
‫ﻲﻓ اﻟـ ‪viral hepatitis‬‬
‫اﻳﻪ اﺷﻬﺮ ﺣﺎﺟﻪ ﺗﻌﻤﻠﻪ ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ؟ ال ‪ C‬وﺑﻌﺪﻳﻦ ال ‪B‬‬

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‫‪Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis‬‬

‫‪Grossly:‬‬

‫‪ shrunken‬وﻻ ‪enlarged‬؟ اﻧﺖ ﺑﺘﻔﻜﺮ؟! ‪Shrunken‬‬

‫وزي ﻣﺎ اﻧﺘﻮا ﺷﺎﻳﻔ� ﻟﻮﻧﻪ ‪ brownish‬وزي ﻣﺎ اﻧﺘﻮا ﺷﺎﻳﻔ� اﻧﻪ ‪ mixed‬ﻳﻌﻨﻲ‪ macro‬و‬
‫‪ micro nodules‬وﻋﺸﺎن ﻛﺪه ال ‪ incidence‬اﻧﻪ ﻳﻘﻠﺐ ﺳﺮﻃﺎن اﻋ� ﻣﻦ اﻟ� ﻗﺒﻠﻴﻪ‪.‬‬
‫ﻓﻬﻤﺘﻮا ﺣﺎﺟﻪ؟‬

‫ﺗﺤﺖ ﺍﻟﻤﻴﻜﺮﻭﺳﻜﻮﺏ ﻫﻨﺸﻮﻑ ﺍﻳﻪ؟‬

‫ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب ﻫﻨﺸﻮف ‪) cirrhosis‬اﺳﻄﻤﺒﺔ ﺗﻜﺘﺒﻬﺎ ﻣﻦ اﻟ� اﺗﺸﺮح ﻓﻮق(‬
‫وﻟﻜﻦ ﻫﻨﺸﻮف ‪picture of chronic hepatitis‬‬
‫وﺗﺸﺮﺣﻠﻪ اﳌﻴﻜﺮوﺳﻜﻮب ﺑﺘﺎع ال ‪ chronic hepatitis‬ﻋﺸﺎن زﻣﺎن دا ﻛﺎن ﺑﻴﺠﻲ ﺳﺆال ب‬
‫‪ ١٥‬درﺟﻪ‬
‫دﻟﻮﻗﺘﻲ ﻃﺒﻌﺎ ﻣﻤﻜﻦ ﻳﺰﻧﻘﻚ و�ﻘﻮﻟﻚ ﻗﻮﻲﻟ ﻋ� ال ‪microscopic picture of post‬‬
‫‪hepatitic cirrhosis‬‬
‫ﺗﻘﻮم ﺗﻘﻮﻟﻪ اﻳﻪ؟‬
‫‪see before :pic of cirrhosis‬‬
‫‪see before :pic of chronic hepatitis‬‬
‫ﺗﺎﺧﺪ ﻛﺎم ﻣﻦ ﺳﺒﻌﻪ؟ ‪see you in the summer :p‬‬
‫ﻣﺶ ﻫﻨﺪﻳﻠﻪ ﺣﺎﺟﻪ – ﻓﻬﻤﺘﻮا ﺣﺎﺟﻪ؟‬

‫‪3. Post-necrotic cirrhosis‬‬

‫دا ﺑﻌﺪ ال ‪ – necrosis‬دا ﻣﻤﻜﻦ ﻳﺤﺼﻞ ‪very rare in case of subacute or‬‬
‫‪subacute massive diffuse liver necrosis‬‬
‫ﻋﺎرﻓ� ﻳﻌﻨﻲ اﻳﻪ ‪subacute‬؟‬
‫ﻳﻌﻨﻲ ﻫﻴﻤﻮت ﻲﻓ ﺧﻼل ‪ weeks‬وﻣﻮﺻﻠﺘﺶ ﻏ� ﻲﻓ ﺣﺎﻟﻪ واﺣﺪه‬

‫اﻟﻜﺒﺪ ﻫﻴﺒﻘﻲ ‪ shrunken‬وﻫﻴﺒﻘﻲ ﻟﻮﻧﻪ ‪ brown‬او ‪hemorrhagic‬‬

‫واﻫﻢ ﺣﺎﺟﻪ ال ‪ nodules‬اﺧﺒﺎرﻫﺎ اﻳﻪ ؟ ‪macro nodular‬‬
‫ﻳﻌﻨﻲ اﺣﺘﻤﺎﻟﻴﻪ اﻧﻪ ﻳﻘﻠﺐ ل ‪ carcinoma‬اﻳﻪ؟ ﻋﺎﻟﻴﻪ‪.‬‬

‫‪ Very rare‬ودي ﺣﺎﺟﻪ ‪ ،theoretical‬اﻟﻌﺎﻟﻢ ﻛﻠﻪ ﻣﻔﻴﻬﻮش اﻻ اﻟﺼﻮره دي واﺗﺤﺪاﻛﻮا ﻟﻮ‬

‫ﺟﺒﺘﻮا ﻏ� اﻟﺼﻮره دي‪ ،‬وﻟﻴﻪ ‪rare‬؟ ﻻن اﻟﻌﻴﺎن ﺑﻴﻤﻮت ‪ during hepatitis‬ﻗﺒﻞ ﻣﺎ ﻳﺨﺶ‬
‫ﻲﻓ ال ‪.cirrhosis‬‬

‫‪4. Biliary cirrhosis:‬‬

‫اﺧﺮ ﺣﺎﺟﻪ ﺑﻘﻲ وﻫﻨﺨﺘﻢ ﺑﻴﻬﺎ ال ‪.biliary cirrhosis‬‬

‫اﻫﺪوا ﺑﻘﻲ ﻋﺸﺎن ﻫﺴﺎل ﺳﺆال ﻛﻠﻜﻮا ﺑﺘﺠﺎوﺑﻮه ﻏﻠﻂ‪:‬‬

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Flash Notes in Pathoogy | from liver necrosis till secondary biliary cirrhosis

.‫؟ اﻟ� اﻟﻜﺒﺪ ﺑﻴﺨﺮﺟﻪ و�ﺮﻣﻴﻪ ﻲﻓ اﻟﺮﺒاز‬bile ‫ﺗﻌﺮﻓﻮا ال‬

‫ ؟‬toxic ‫ وﻻ‬neutral ‫ ؟‬bile
!!‫ و�ﺮﻣﻴﻪ ﻲﻓ اﻟﺮﺒاز ؟؟‬neutral ‫ ﻳﻌﻨﻲ ﻫﻮ‬toxic ‫ اﻛﻴﺪ‬،silly ‫اﻧﺎ ﻗﻮﻟﺖ اﻧﻪ ﺳﺆال‬
‫ﻓﺒﺎﻟﺘﺎﻲﻟ ﻟﻮ اﺗﺤﻮش ﺟﻮا اﻟﻜﺒﺪ ؟ ﻫﻴﻌﻤﻞ اﻳﻪ ﻲﻓ اﻟﻜﺒﺪ؟؟‬
cirrhosis ‫ ﻓﻴﺤﺼﻞ‬framework ‫ﻫﻴﺒﻮظ اﻟﺨﻼﻳﺎ وال‬
.‫ ﺑﺎﺧﺘﺼﺎر‬biliary cirrhosis ‫ﻫﻮا دا ال‬

:‫ ﻧﻮﻋﻴﻦ‬biliary cirrhosis ‫ﻷﻧﻪ ﺍﻝ‬

‫ ﻳﺒﻘﻲ ﺳﺒﺒﻪ ﻣﺶ‬primary ‫ وﻟﻮ ﻗﻮﻟﺘﻠﻚ‬primary biliary cirrhosis : ‫اول ﻧﻮع‬

intra hepatic biliary cirrhosis ‫ ﺑﻴﺴﻤﻮه‬،�‫ ﻟﻪ اﺳﻢ ﺗﺎ‬،‫ﻣﻌﺮوف‬
‫ ؟‬intra hepatic ‫ﻳﻌﻨﻲ اﻳﻪ‬
intra hepatic bile duct ‫ ﻓﻴﻪ‬liver ‫ واﻧﺘﻮا ﻋﺎرﻓ� ال‬liver ‫ادي دا ال‬
extrahepatic bile duct ‫اﻟ� ﺑﺘﺘﺠﻤﻊ ﻲﻓ ال‬
�‫ وﻟﻜﻦ ﻓﻴﻪ ﻧﻮع ﺗﺎ‬،intra hepatic duct destruction ‫ دا ﺳﺒﺒﻪ‬،‫ﻻﻧﻪ ﻓﻴﻪ اﻧﻮاع‬
.secondary biliary cirrhosis‫اﺳﻤﻪ‬

�‫ اﺳﻤﻪ اﻟﺘﺎ‬secondary‫؛ ﻻن ال‬other diseases ‫ ﻻﻳﻪ؟‬secondary ‫ﻫﻮ‬

.extrahepatic biliary cirrhosis
.extra hepatic bile duct obstruction ‫ﻻن ﺳﺒﺒﻪ‬
destruction ‫اﻳﻪ؟‬primary‫ال‬
obstruction ‫اﻳﻪ؟‬secondary‫ال‬

A. Primary biliary cirrhosis:

.case ‫وﻋﻠﻴﻪ‬written ‫ ﻋ� ﻓﻜﺮة ده‬،primary‫ﻧﺒﺪا ﺑﺎل‬
.‫ ده ﻣﻨﻈﺮ اﻟﻜﺒﺪ‬secondary‫او‬primary ‫ ﺳﻮاء‬،‫ادى ﺻﻮرة اﻟﻜﺒﺪ‬

Aetiology:

‫ ﺑﺲ ﻓﻴﻪ ﻧﺎس ﺑﻴﻘﺘﻨﻌﻮا اﻧﻪ‬،‫ ﻳﺒﻘﻰ ﺳﺒﺒﻪ ﻣﺶ ﻣﻌﺮوف‬primary‫ﻫﻮ اﺳﻤﻪ‬

‫ﻟﻴﻪ؟‬،autoimmune
‫ ﻃﺎﳌﺎ اﻧﻪ ﻓﻴﻪ‬،antimitochondrial Abs ‫ ﻣﻦ اﻟﺤﺎﻻت دى ﻋﻨﺪﻫﻢ‬%٩٥ ‫ﻻﻧﻬﻢ ﻟﻘﻮا ان‬
.aetiology ‫ ﻳﺒﻘﻰ ده ﻣﺶ‬%٩٥ ‫ وﻟﻜﻦ ﺑﻨﺴﺒﺔ‬،autoimmune‫ ﻳﺒﻘﻰ‬Abs
very common in ‫ وﻋﻨﺪك دﻟﻴﻞ ﺗﺎ� ﻗﺎﻟﻪ اﺗﻔﻀﻞ؟ ﻗﺎﻟﻮا ده‬autoimmune ‫ﻗﺎﻟﻮا ﻻ ده‬
.aetiology ‫ ﺑﺮﺿﻪ ده ﻣﺶ‬،9:1 ‫واﻟﻨﺴﺒﺔ‬females
‫ وﻓﻴﻪ ﻧﺎس ﻗﺎﻟﻮا ﻻ‬،‫؟ ﻣﻨﻌﺮﻓﺶ‬virus‫ ﻃﺐ اﻳﻪ ال‬،viral ‫ﻓﻴﻪ ﻧﺎس ﻗﺎﻟﻮا ﻻ اﺣﺘﻤﺎل ﻳﺒﻘﻰ‬

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‫ وﻋﺎﻣﻠ� ﻋﻠﻴﻪ ﻫﻴﺼﺔ ﻫﻮ‬drug ‫ وﻛﺎن اﻛﺮﺘ‬،sensitivity to drugs ‫اﺣﺘﻤﺎل ﻳﺒﻘﻰ‬

primary ‫ ﻳﺤﺼﻠﻬﺎ اﳌﺼﻴﺒﺔ دى وﺗﻤﻮت ﻣﻦ‬androgen ‫ﺧﺪت‬female ‫ ﻟﻮ‬،androgen‫ال‬
.biliary cirrhosis

‫ اﻣﺘﻰ؟ أﺷﻬﺮ ﺳﺒﺐ‬estrogen ‫؟ اﻟﺮاﺟﻞ ﻣﻤﻜﻦ ﻳﺎﺧﺪ‬androgen ‫ﻣﻤﻜﻦ ﺗﺎﺧﺪ‬female‫ﻫﻮ ال‬

dependant ‫ ﻻﻧﻬﺎ ﺑﺘﻴﺠﻰ‬carcinoma of prostate ‫ ﻫﻮ‬estrogen ‫ﻟﻠﺮاﺟﻞ اﻧﻪ ﻳﺎﺧﺪ‬
�‫؟ اه اﻟ‬androgen ‫ﻟﻜﻦ اﻟﺴﺖ ﺗﺎﺧﺪ‬androgen ‫ وﻫﻮ ال‬physiological cause �‫ﻋ‬
‫ دول ﺑﻴﺘﺒﻬﺪﻟﻮا ﺑﺴﺒﺐ ﻫﺬا‬,athletes‫ال‬females‫ ال‬،muscle builders ‫ﻫﻤﺎ اﻟﻌﻴﺎل ال‬
.‫ ﻣﺶ ﻣﻬﻢ ﻣﺶ ﻣﻜﺘﻮﺑﺔ ﻋﻨﺪﻛﻮا‬،disease‫ال‬

Pathology:

Grossly:

‫ ﺑﻴﺒﻘﻰ‬،‫ ادى ﺷﻜﻠﻪ اﻟﻜﺒﺪ‬secondary ‫او‬primary ‫ ﻟﻮ‬biliary cirrhosis‫ﻛﻞ ال‬

.enlarged ‫؟‬enlarged ‫ وﻻ‬shrunken
.micronodular cirrhosis ‫ اﻧﻪ ﻳﺒﻘﻰ‬+ (bile stained) ‫ﻟﻮﻧﻪ؟ ﻟﻮﻧﻪ اﺧﻀﺮ ز�ﺘﻰ‬
.post necrotic‫ و‬post hepatitic ‫ اﻻ ﻓﻰ ﺣﺘﺔ اﻟـ‬macro ‫ﻟﺤﺪ دﻟﻮﻗﺘﻰ ﻣﺠﺘﺶ ﻛﻠﻤﺔ‬

‫ﺍﻳﻪ ﻛﻤﺎﻥ؟‬
:‫ رﻛﺰوا ﻣﻌﺎﻳﺎ‬،‫ ﻣﺮاﺣﻞ‬٤‫ﺑﻴﻤﺮ ب‬primary biliary cirrhosis‫ال‬

* Stage of florid duct lesions:

.severe ‫ ﻳﻌﻨﻰ‬florid ‫ و‬،stage of florid ductal lesion ‫اول ﻣﺮﺣﻠﺔ ﺑﻴﻘﻮﻟﻮا ﻋﻠﻴﻬﺎ‬

‫؟‬florid ductal lesions ‫ﻳﻌﻨﻰ اﻳﻪ‬

auto ‫ ﻣﺶ اﻟـ‬،chronic inflammatory cells ‫ ﻓﻴﻬﺎ‬portal tract‫ﺑﻨﻼﻗﻰ اﻧﻪ ال‬
lymphocytes, ‫؟ وﻫﻤﺎ ال‬chronic inflammatory cells ‫ﻳﺒﻘﻰ ﻓﻴﻪ‬immune
.plasma cells, macrophages

attack the wall of bile ducts ‫ ﺑﺘـ‬chronic inflammatory cells‫ﺑﻨﻼﻗﻰ ﻫﺬه ال‬
‫ ﻫﻴﺒﻘﻲ ﻋﺎﻣﻞ إزاي؟‬bile ducts‫ وﻓﻰ اﻟﻨﻬﺎﻳﺔ ﻋﺪد ال‬،granuloma ‫وﺑﺎﻟﺘﺎﻰﻟ ﻣﻤﻜﻦ ﻳﻌﻤﻞ‬
‫ ﻓﻰ‬bile ducts ‫ ﻳﺒﻘﻲ ﻋﺪد ال‬،autoimmune destruction ‫ﻣﺶ اﺣﻨﺎ ﻗﻮﻟﻨﺎ ده‬
‫ ﻳﻌﻨﻰ ﻗﻞ ﻋﺪد اﻟـ‬ductopenia ‫ وﺑﺎﻟﺘﺎﻰﻟ ﻳﺤﺼﻞ‬،‫ ﻫﻴﺰ�ﺪ وﻻ ﻳﻘﻞ؟ ﻳﻘﻞ‬portal tract‫ال‬
.medium sized bile ducts

autoimmunity ‫وﻟﻜﻦ ال‬proliferate‫ اﻧﻬﺎ ﺗﻌﻮض ﻓﻬﺘﺒﺪا ﺗـ‬small ducts ‫ﻫﺘﺤﺎول ال‬

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.compete ductopenia ‫ﻣﻮﺟﻮدة ﻓﻬﺘﻜﺴﺮﻫﺎ ﻓﻔﻰ اﻟﻨﻬﺎﻳﺔ ﻫﻴﺒﻘﻰ ﻓﻴﻪ‬

* Stage of ductular proliferation:

stage of ductular ‫ ﻳﻠﻴﻬﺎ‬،stage of florid duct lesion ‫ﻳﺒﻘﻲ اول ﻣﺮﺣﻠﺔ اﺳﻤﻬﺎ‬
‫ ﻟﻴﻪ ﻣﺒﺸﻮﻓﻬﺎش؟‬،‫ ﺑﺲ اﻧﺎ ﻣﺒﺸﻮﻓﻬﺎش‬،proliferation
.destroyed ‫ﻻﻧﻬﺎ ﻫﺘﺒﻘﻲ‬
‫ اﺗﺠﺎﻫﻪ اﻳﻪ؟ ﻣﻦ‬bile‫ ﻫﻮ ال‬،‫ﻟﻠﻜﺒﺪ ﻫﻴﻌﺮف ﻳﺨﺮج؟ ﻻ‬toxic �‫ اﻟ‬bile ‫وﺑﺎﻟﺘﺎﻰﻟ ﻫﻞ ال‬
hepatocytes ‫ ﻳﺘﺤﻮش ﺟﻮه ال‬bile ‫ ﻓﻬﻴﺒﺪا ال‬،central to portal
.cholestasis‫ﻓﻴﺤﺼﻞ‬
،framework‫ وﺑﻌﺪ ﺷﻮ�ﺘ� ﻳﺘﻜﺴﺮ ال‬،necrosis ‫؟‬hepatocytes‫ﻓﻴﺤﺼﻞ اﻳﻪ ﻓﻰ ال‬

‫ ﻓﻰ اﻻول؟‬bile‫ﻣ� اﻛﺮﺘ اﻟﺨﻼﻳﺎ اﻟ� ﻫﺘﺘﻌﻮر اﻻول؟ ﻣ� اﻟ� ﻫﻴﺎﺛﺮ ﻓﻴﻬﺎ ال‬
،‫ﻳﺎ ﻧﻬﺎر أﺑﻴﺾ‬،piecemeal necrosis ‫ ﻫﻮ‬destruction‫ ﻓﻬﻴﺒﻘﻰ ال‬،peripheral‫ال‬
‫؟ ﻧﻔﺮق ازاى؟‬chronic viral‫ ده ﺑﻴﺤﺼﻞ ﻓﻰ ال‬piecemeal ‫ﻣﺶ اﺣﻨﺎ ﺧﺪﻧﺎ ال‬
chronic viral ‫ﻓﻰ ﺣﺎﻻت ال‬piecemeal‫ﻣﻦ اﻟﺼﻮرة اﻟ� ﻗﺪاﻣﻚ ﺗﻔﺮق ازاى ﺑ� ال‬
‫؟‬primary biliary cirrhosis‫ وﺣﺎﻻت ال‬hepatitis
‫ﻣﺶ‬bile ducts ‫ ﻟﻜﻦ ﻣ� ﻓﻴﻬﻢ اﻟ� ﻫﻼﻗﻰ ال‬،‫ ﻳﺎ دﻛﺘﻮرة‬inflammation ‫اﻻﺗﻨ� ﻓﻴﻬﻢ‬
.primary biliary cirrhosis‫؟ ال‬Ductopenia ‫ﻣﻮﺟﻮدة‬

* Stage of scarring:

* Stage of established cirrhosis:

To summarize:

‫ ﺳﺒﺒﻪ‬intrahepatic biliary cirrhosis‫ اﻟ� اﺳﻤﻪ ال‬primary biliary cirrhosis‫ال‬

‫اﻳﻪ؟‬
‫؛ ﻻن ﻓﻴﻪ‬autoimmune process‫ ﺑﻬﺬه ال‬intrahepatic bile duct destruction
‫ﻣﻦ‬primary‫ ﺑﺲ اﻧﺘﻮا ﺗﺬاﻛﺮوا ال‬،secondary‫ ﺑﺎل‬primary ‫ﺟﺪول ﺑﻴﻘﺎرﻧﻠﻜﻮا ال‬
‫ ﻓﺎﻫﻤ� ﺣﺎﺟﺔ؟‬،‫ ﻣﻦ اﳌﻘﺎرﻧﺔ‬secondary‫اﻟﺮﺒاﺟﺮاف واﻟـ‬

B. Secondary biliary cirrhosis:

‫ﻟ� ﻋﺎﻳﺰ ﻳﻠﺨﺼﻪ ﺳﺒﺒﻪ اﻳﻪ؟‬secondary‫ﻫﺘﻼﻗﻮا ﻋﻨﺪﻛﻢ ال‬
.extrahepatic bile duct obstruction ‫ اﻧﻤﺎ‬،‫؟ ﻻ‬autoimmune destruction‫ﻫﻞ‬

‫ ﻋ� ﻣﺎذا ﺗﻨﺺ ﻫﺬه اﻟﻨﻈﺮ�ﺔ؟‬،(‫ﻟﻮ ﻋﺎﻳﺰ اﺳﺪ اﻧﺒﻮﺑﺔ اﺗﺒﻊ ﻧﻈﺮ�ﺔ )ﺻﺒﺎع اﳌﺤﻰﺸ‬
‫؟‬bile duct‫ ﺑﺘﺎع ال‬lumen‫اﻳﻪ اﻟ� ﻳﺴﺪ ال‬

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bile ‫ ﻃﺒﻌﺎ ﻻن ﻣ� ﻓﻴﻜﻮا ﺑﻴﺸﺮق ﻓﻰ ال‬foreign body ‫ ﻟﻜﻦ ﻣﻴﻨﻔﻌﺶ ﻧﻘﻮل‬،stones‫اﻟـ‬

.‫ ﻟﻮ اﻧﺖ ﻓﺎﻫﻢ ﻣﺶ ﻫﺘﻘﻮل اى ﻛﻼم‬،‫ﺑﺘﺎﻋﺘﻪ؟!!!! ﻣﺎﻫﻮ ﻣﺶ اى ﻛﻼم‬duct

:‫ﻳﺒﻘﻲ‬
.stone‫ ﻳﺒﻘﻰ‬lumen‫ ﺣﺎﺟﺔ ﺗﺴﺪ ال‬.١
common bile duct‫ ﻳﻌﻨﻰ واﺣﺪ ﻣﺘﻔﺘﺤﺶ ﻋﻨﺪه ال‬،atresia ‫ ﻳﺒﻘﻰ‬wall‫ ﺣﺎﺟﺔ ﻲﻓ ال‬.٢
.‫ و�ﺒﻘﻰ ﻃﻔﻞ وﻫﻴﻤﻮت‬biliary cirrhosis ‫ﻓﺴﺎﻋﺘﻬﺎ ﺑﻴﺠﻴﻠﻪ‬
cancer head of ‫؟ ﻫﻮ‬bile duct‫ اﻟ� ﺟﻨﺐ ال‬tumor ‫ ﻣ� ال‬،tumor ‫ ﻳﻴﺠﻰ ﻣﻦ ﺑﺮه‬.٣
.pancreas
‫؟‬secondary cirrhosis ‫ ﻳﻌﻤﻞ‬cancer head of pancreas‫ﻫﻞ ال‬
within ‫ ﺑﻴﻤﻮت‬cancer head of pancreas‫ﻣﺴﺘﺤﻴﻞ ﺣﺪ ﻳﻌﺮف ﻟﻴﻪ؟ ﻋﺸﺎن اﺳﺎﺳﺎ ال‬
‫ ﻳﺒﻘﻲ ﻫﻴﺤﺼﻞ ان ﺷﺎء اﻟﻠﻪ ﻓﻰ‬،‫ﺷﻬﻮر‬٦ ‫ ﻻزم‬cirrhosis‫ وﻋﺸﺎن ﻳﺤﺼﻞ ال‬3 months
.�‫اﻟﺒﺴﺎﺗ‬
exception ‫ و‬mcq ‫ﺑﺲ اﳌﺆﻟﻒ ﻛﺎﺗﺒﻬﺎ وﻫ�ﺟﻊ ﺑﻌﺪ ﺷﻮ�ﺔ ﻳﻘﻮﻟﻚ ﻣﺒﻴﺤﺼﻠﺶ وﺟﺎﺑﻮﻫﺎ ﻣﺮة‬
.‫ ادﻳﻨﻰ ﺑﻨﺒﻪ ﻋﻠﻴﻚ‬،‫ اﻫﻮ ده اﻟ� ﺣﺼﻞ‬،‫وﻣﻜﺘﻮﺑﺔ ﻓﻰ اﻟﻜﺘﺎب‬

Grossly:

‫ﺑﻌﻨﻴﺎ؟‬secondary ‫ﻣﻦ‬primary ‫ﻫﻞ ﻧﻘﺪر ﻧﻔﺮق‬

.micronodular cirrhosis ‫ وﻓﻴﻪ‬enlarged, greenish ‫ ﻛﻠﻬﻢ اﻟﻜﺒﺪ ﺑﻴﺒﻘﻰ‬،‫ﻳﻨﻔﻊ؟ ﻷ‬

:‫ﻟﻜﻦ ﻳﺘﻔﺮق ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب‬

.‫زى ﻣﺎ اﻧﺎ ﺷﺮﺣﺖ‬primary‫ ﻣ� ﺑﻴﻤﺮ ﺑﻤﺮاﺣﻞ؟ اﻟـ‬،‫رﻛﺰوا‬
inflammatory ‫ اﻳﻪ ﻧﻮع ال‬primary‫ﻟﻜﻦ اﻫﻢ ﻛﻠﻤﺔ ﻓﻰ اﳌﻴﻜﺮوﺳﻜﻮب ﻓﻰ ال‬
‫ اﺷﻤﻌﻨﻰ؟ ﻻﻧﻬﺎ‬،lymphocytes, plasma cells, macrophages ‫اﳌﻮﺟﻮدة؟‬cells
‫ ﻓﺎﻫﻤ� ﺣﺎﺟﺔ؟‬autoimmune
.cell mediated immunity, mainly lymphocytes �‫ﻫﻨﻤﻮت ﺧﻼﻳﺎ ﻓﻤﺤﺘﺎﺟ‬

2ry biliary ‫اﻳﻪ؟ اﻳﻪ اﻟ� ﺑﻴﺤﺼﻞ ﻲﻓ اﻟـ‬acute inflammation‫ﻟﻜﻦ ﻓﻰ ال‬

intrahepatic bile duct ‫ ﻓﺎل‬،extrahepatic bile duct obstruction‫؟‬cirrhosis
‫ وﺑﻌﺪﻳﻦ اﻣﺎ ﺗﺒﻘﻰ‬،dilated ‫ زى ﻣﺎ اﻧﺘﻮا ﺷﺎﻳﻔ� ﻫﻨﺎ ﻗﺪاﻣﻜﻮا‬،no‫ﻫﻞ ﻫﺘﺒﻘﻰ ﻣﺘﻜﺴﺮة ؟‬
.acute event ‫ وده‬bile‫ﻳﺮﺷﺢ ﻣﻨﻬﺎ ال‬dilated
.bile is chemical irritant‫ال‬

‫؟‬main inflammatory cells (chronic)‫ﻳﺒﻘﻲ ﻣ� ﺗﺤﺖ اﳌﻴﻜﺮوﺳﻜﻮب ال‬

.primary biliary cirrhosis‫ده‬
.secondary‫ ﻣ�؟ ال‬،neutrophils ‫ﻟﻜﻦ ﻣ� ﻫﻴﺒﻘﻰ ﻓﻴﻪ‬

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bile duct ‫ﻣ� اﻟ� ﻓﻴﻪ‬،primary‫؟ ال‬bile duct destruction ‫ﻣ� اﻟ� ﻓﻴﻪ‬
.secondary ‫؟ اﻟـ‬dilatation

‫ ﺟﻮه‬bile ‫؟ ﻳﻌﻨﻰ‬cholestasis ‫؟ ﻋﺎرﻓ� ﻳﻌﻨﻰ اﻳﻪ‬cholestasis ‫ﻣ� ﻓﻴﻪ‬

!!!‫ ﻣﺎ ﻫﻮ اﻳﻪ اﻟ� ﺑﻮﻇﻪ‬،‫ اﻻﺗﻨ� ﻃﺒﻌﺎ‬،hepatocytes ‫ال‬

�‫ ﻓﻰ اﻟﺪم؟ ﻣ�؟ اﻻﺗﻨ‬cholebilirubin‫ ﻣ� ﻓﻴﻬﻢ ﻫﻴﺰ�ﺪ ال‬،‫ ﺑﻘﻰ‬serious‫اﻟﻨﻘﻄﺔ اﻟـ‬

anti ‫ ﺑﺘﺎع واﺣﺪ ﻣﻨﻬﻢ‬serum ‫ ﻟﻜﻦ ﻫﻨﻼﻗﻰ ﻓﻰ ال‬،obstructive jaundice‫وﻫﻴﻨﺘﻬﻰ ب‬
‫ وﺻﻠﺖ‬،autoimmune ‫ اﻟ� ﻫﻮ‬primary‫ ده ﻲﻓ اﻟـ‬،mitochondrial antibodies
‫اﳌﻌﻠﻮﻣﺔ؟‬
intrahepatic bile duct destruction ‫ ﻟﻮ اﻟﺴﺒﺐ‬،‫ اﺗﺤﻮش‬bile‫ﻫﻮ اﻟﻔﻜﺮة ﻛﻠﻬﺎ ان ال‬
.this is primary‫ﻳﺒﻘﻰ‬
.secondary ‫ ﻳﺒﻘﻰ‬extrahepatic bile duct obstruction ‫وﻟﻮ‬
.‫ ﻋﻠﻴﻪ وﺑﻴﺠﻴﺒﻮه ﻓﻰ اﻻﻣﺘﺤﺎن‬case ‫ﻋ� ﻓﻜﺮة داﻳﻤﺎ ﺑﻴﺠﻰ‬

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