Recent Developments in Liver Pathology
Moderator: Dr. Helmut Denk
Section 4 -
Biopsies for Cholestatic Liver Disease in Infants and Children
Valeer J. Desmet
Liver biopsy is helpful in the diagnosis of most cholestatic liver diseases in infants and children.
The histopathology of "paediatric" cholestasis comprises: 1) features of cholestasis in general; 2)
features more specific for the neonatal age; and 3)
changes indicative of specific disorders.
1. Features of Cholestasis in General.
Such features include parenchymal changes and periportal / architectural changes.
A. Parenchymal changes comprise bilirubinostasis ( hepatocellular , canalicular and in
Kufffer cells )in the early stage of complete cholestasis ; cholate stasis of periportal
hepatocytes in later stages represented by ballooning , expression of cytokeratin 7 , coarse cytoplasmic
granularity , accumulation of copper and copper-binding protein , and development of Mallory bodies ;
cholestatic liver cell rosettes corresponding to a switch of hepatocytes from normal plate
arrangement into tubular structures with or without bilirubin concrements in the lumen ; occurrence of
single and clustered xanthomatous cells ; so-called feathery degeneration ( resembling cholate
stasis ) in intralobularhepatocytes ; and in later stages of severe cholestasis : development of
paraportal bile infarcts.
B. Periportal / architectural changes gradually develop in later stages of chronic cholestatic
conditions and comprise : ductular reaction recognized as an increase in ductular structures ,
associated with oedema and neutrophil infiltration in the periportal region ; development of
periductular fibrosis which , together with wedge-like extension of the ductular reaction , results
in development of periportal septa that eventually connect adjacent portal tracts , thus creating the
pattern of biliary fibrosis and , with addition of nodular parenchymal regeneration , finally
biliary cirrhosis .
2. Features Specific for the Neonatal Age.
Cholestasis in neonates and young children is usually characterized by the development in hepatocytes
of multinucleated giant cell transforrmation (MGCT) and foci of extramedullary
hematopoiesis ( either erythropoietic, myelopoietic, thrombopoietic, or all of these together ).
3. Features Indicative of Specific Disorders.
Distinction can be made between a) parenchymal disorders ,b) diseases of intrahepatic bile ducts (IHBD),
and c) extrahepatic bile duct atresia ( biliary atresia ).Most show some or all of the features of
"paediatric " cholestasis in the liver biopsy , some show additional characteristics.
A. Parenchymal Disorders.
The number of such specific disorders has increased in recent years due to the discovery of
responsible gene mutations in several genetic disorders, with concomitant decrease of the category of
"cryptogenic cholestasis"  .
- Bile Acid Synthetic Defects ( BASD) are diagnosed on the base of clinical data ( GGT- and
bile acid levels in serum ) , fast atom bombardment - mass spectroscopy ( FAB-MS ) of bile acids , and
liver biopsy . MGCT is seen in all symptomatic patients and appears to be more prominent in BASD than in
many other forms of neonatal cholestasis; there is generalized hepatocellular injury and progressive
periportal fibrosis 
- Canalicular transporter defects are characterized by lobular bilirubinostasis , variable
MGCT, isolated hepatocyte necrosis , and a highly variable rate of progression to cirrhosis.
1)Progressive Familial Intrahepatic Cholestasis type1 ( PFIC type 1 ) and a variant also due
tomutation in the FIC1 gene ( Greenland Familial Cholestasis ) show little ballooning ,
few MGCT , little or no bile duct injury , slow progression of fibrosis , and coarse appearance of bile
in canaliculi in electron microscopy ( EM ).A less severe mutation in FIC1 leads to Benign Recurrent
Intrahepatic Cholestasis type 1 ( BRIC type 1) with similar histology, absence of lesions between
the cholestatic episodes and lack of long term complications.
2)In PFIC type 2 ( Bile Salt Pump or BSEP deficiency ), centrolobular canalicular
bilirubinostasis occurs , hepatocyte ballooning and marked MGCT are common , delicate whispy canalicular
bile is seen on EM ,and centrolobular and periportal fibrosis with progression to cirrhosis are observed
.Negative immunostaining for BSEP is diagnostic.  A less severe mutation of BSEP results in recurrent
episodes of BRIC type 2 .
3)In PFIC type 3 ( Multidrug Resistance associated Protein 3 or MDR3 deficiency ) there
are features of centrolobular bilirubinostasis , some inflammation and hepatocellular injury , damage of
interlobular bile ducts , even mild ductopenia and progressive fibrosis leading to cirrhosis.Gamma
glutamyl transpeptidase ( GGT )
is increased in serum , in contrast with PFIC types I and 2. .
- Cryptogenic neonatal cholestasis still comprises a number of unexplained cholestatic
conditions with obscure aetiology , although further recent discoveries continue to reduce this category.
Recent examples include, amonst others , the Neonatal Ichthyosis Sclerosing Cholangitis ( NISCH )
syndrome and Arthrogryposis - Renal dysfunction - Cholestasis ( ARC )
- Intrauterine and perinatal infections or " hepatitis in the neonate " may cause cholestasis
, associated with features of hepatitic necro-inflammation , and usually immunohistochemically
.demonstrable antigens in the liver biopsy ( e.g. CMV and Herpes hepatitis , viral hepatitis B)
- Metabolic disorders causing cholestasis include galactosemia , fructose intolerance
and tyrosinemia :
characterized by bilirubinostasis, cholestatic rosettes , steatosis , and ductular reaction ;
tyrosinemia further shows variable parenchymal siderosis, and regenerative nodules of variable size.
Alpha-1-Antitrypsin Deficiency reveals besides " paediatric "cholestasis an accumulation of
PAS-positive, diastase-resistant and specific immunoreactive globules in periportal hepatocytes.
B. Disorders of Intrahepatic Bile Ducts (IHBD)
- Syndromic paucity of IHBD ( or Alagille syndrome ) is recognized by typical clinical
features in association with biopsy findings of "paediatric " cholestasis , some ductular reaction and
damage is seen in the first 3 months of life . Later biopsies reveal changes of chronic cholestasis and
- Nonsyndromic paucity of IHBD shows similar histology , but with persistant ductular reaction
and faster development of fibrosis and cirrhosis.
C. Biliary Atresia ( BA ) or Extrahepatic Bile Duct Atresia
Liver biopsy plays an important role in the diagnosis of BA . Early biopsies in some cases may reveal
only non-diagnostic centrolobular bilirubinostasis , necessitating repeat biopsy. In the majority
,diagnostic features are present by ( and even before ) 4 weeks of age ; they consist of changes of
" paediatric "cholestasis, and – importantly - , ductular reaction associated with damage of
interlobular bile ducts and beginning ductopenia. Later biopsies reveal increasing degrees of fibrosis ,
duct damage and ductopenia , and rapidly developing cirrhosis. 
A number of cases ( between 25% and
50% ) show similar lesions , but with bile ducts still in their early embryonic configuration ( so-called
ductal plate malformation )
 with faster development of fibrosis and cirrhosis and a worse prognosis
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