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Liver Pathology
Monday, March 26, 2007, 7:30 PM
Convention Center 10Liver Biopsy: Let's Make the Most of It!
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Moderator:
ELIZABETH M. BRUNT
St. Louis University Hospital
St. Louis, MO
Disclosure: The speakers have indicated they have nothing to disclose.
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for Text and References
Submitted by: Linda D. Ferrell - University of California, San Francisco, CA
- 12 year old male
- Diabetes, Type 1, poorly controlled
- Presented with ketoacidosis
- PE: Hepatomegaly, RUQ pain
- Lab: Increased ALT/AST 2x normal, Glucose 635; HbA1c 13.5 (nl<6)
- Ultrasound suggested fatty liver
- Liver biopsy performed
- Referred to UCSF to exclude glycogen storage disorder
- Patient treated for ketoacidosis, hyperglycemia
- Transaminases returned to normal, and liver decreased in size
- No known long-term sequelae
Case 1 - Figure 1 - Low magnification of needle biopsy shows diffuse pale staining of hepatocytes in a panacinar pattern (H&E, 10x)
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Case 1 - Figure 2 - Pale and swollen hepatocytes in periportal area. No periportal fibrosis is present. Some nuclei contain glycogen vacuoles. The hepatocellular changes are due to increased glycogen in hepatocytes. (H&E, 20x)
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Case 1 - Figure 3 - Pale swollen hepatocytes in periportal area (zone 1). No periportal fibrosis is present. Some nuclei contain glycogen vacuoles. Only very scant inflammation is present in portal zone. (H&E, 40x)
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Case 1 - Figure 4 - Markedly swollen and pale hepatocytes around central zone (zone 3). A few hepatocytes may contain small fat droplets (H&E 40x)
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Case 1 - Figure 5 - Markedly swollen and pale hepatocytes in midzone (zone 2), and minimal lobular inflammation in sinusoids. (H&E, 40x)
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for Text and References
Submitted by: Maria Isabel Fiel - Mt. Sinai Medical Center, New York, NY
A 52 year old man of Italian heritage is found to have abnormal liver chemistry tests when he undergoes an insurance physical. Aside from non-insulin dependent diabetes of 2 years duration he has no significant medical history. He does have increasing fatigue and some problems with erectile dysfunction which he has ascribed to the long hours he has been working at his new job. The patient drinks two cocktails with every dinner. His father died of liver cancer. There is no other significant family history; he is married with 2 teenage sons.
Liver chemistry tests:
- ALT -- 52 U/L
- AST -- 61 U/L
- AP -- 199 U/L
- BR -- 1.1 mg/dl
- GGTP -- 201 U/L
- Ferritin -- 1800 ug/l
- Platelets -- 129, 000
- INR -- 1.1
Further blood testing reveals:
- Transferrin saturation -- 99 %
Serological testing for viral hepatitis is unremarkable
Genetic testing reveals homozygosity for the C282Y gene mutation. An abdominal U/S demonstrates a heterogeneous liver parenchyma and a slightly enlarged spleen. The patient starts a phlebotomy schedule of one unit every 2 weeks so as to bring his ferritin down to 100. An EGD is performed to evaluate GERD-type symptoms and Grade 1 esophageal varices are found.
Case 2 - Slide 1
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Case 2 - Figure 1 - Fine needle liver biopsy specimen, low power magnification showing established cirrhosis with features of burnt-out steatohepatitis. The H&E stain panel shows lobular inflammatory infiltrates and parenchymal collapse. Irregular fibrous tissue bands that bridge and connect adjacent portal and central areas that partially enclose nodules are seen on Masson trichrome stain. Perls' Prussian blue stain shows coarse granular iron deposits within hepatocytes and Kupffer cells.
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Case 2 - Figure 2 - Same patient as in figure 1 with an iron-free focus in a high-grade dysplastic nodule. The biopsy is taken from a "mass". The H&E stain panel shows thickened trabeculae consisting of 3 to 4 cell thick plates. The hepatocytes are small and uniform. No portal tract is identified in this field. Trichrome stain shows no significant fibrosis. Iron stain shows very little or no iron deposition except in occasional Kupffer cells.
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for Text and References
Submitted by: Dina Tiniakos - University of Athens, Athens, Greece
The patient, a lean 39-year-old woman from the Philippines, was found to be HBsAg positive 14 years prior when she immigrated to Greece. There was no other significant past medical history. In The spring of 2005, during evaluation for employment, there was an an abdominal ultrasound examination which showed signs of chronic liver disease and focal fatty change. At that time liver tests were normal. Viral hepatitis panel showed: HBsAg +, HBeAg -, anti-HBe +, anti-HBs -, anti-HAV IgG +, HCV and HDV markers -. Her HBV DNA was 131,500 copies/ml.
Six months later, the patient presented with acute exacerbation of chronic viral hepatitis with AST 2399 IU/L, ALT 2682 IU/L and γ-GT 251 IU/L. One month later when liver tests had rapidly begun to resolve, a percutaneous liver biopsy was performed, and is submitted for review. At the time of the biopsy the liver tests were : AST 61 IU/L, ALT 129 IU/L, alkaline phosphatase 74 U/L , γ-GT 211 U/L, total bilirubin 0.8 mg/dl, direct bilirubin 0.5 mg/dl and albumin 4.0 mg/dl. There was no change in her viral hepatitis markers. The liver biopsy is submitted for review.
Case 3 - Slide 1
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for Text and References
Submitted by: Julia Iezzoni - University of Virginia, Charlottesville, VA
The patient, a 42-year-old African-American male, underwent a cholecystectomy for cholelithiasis. During the surgical procedure, a liver biopsy was performed. [Figure 4-1 (H&E, 200X), Figures 4-2, 4-3, 4-4 (H&E, 400X), Figure 4-5 (Trichrome, 200X), Figure 4-6 (Prussian blue, 200X).
Case 4 - Figure 1 - Sections of the liver biopsy show the characteristic sickled hepatocytes within congested and dilated sinusoids. (H&E, 200X and 400X, respectively)
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Case 4 - Figure 2 - Sections of the liver biopsy show the characteristic sickled hepatocytes within congested and dilated sinusoids. (H&E, 200X and 400X, respectively)
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Case 4 - Figure 3 - Erythrophagocytosis by Kupffer cells is identified. (H&E, 400X)
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