Difference between revisions of "Steatohepatitis"

 

A. [[File:1 Nash 8 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]

B. [[File:2 Nash 8 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]

C. [[File:3 Nash 8 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]

D. [[File:4 Nash 8 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]

E. [[File:5 Nash 8 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]

F. [[File:6 Nash 8 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]

 

 

Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. A. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads. B. Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen. C. A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen . D. Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it. E. Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis. F. Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis.  

 

 

A. [[File:1 NASH 09 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]

B. [[File:2 NASH 09 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]

C. [[File:3 NASH 09 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]

D. [[File:4 NASH 09 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]

E. [[File:5 NASH 09 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]

F. [[File:6 NASH 09 680x512px.tif| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]

 

Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2. A. Steatosis is not pan-acinar, precluding grade 3. B. Cytoplasmic tufts [arrows] were commonly seen establishing frequent ballooning degeneration of grade 2. C. Trichrome shows periportal fibrosis [arrow] establishing fibrosis stage 2. D. PAS D shows a triad with mild damage, with an interlobular bile duct [green arrow] with luminal sheered epithelium, not neutrophils, a hepatic arteriole [red arrow], a hepatic venule [blue arrow], proliferating bile ductules [cyan arrows]; PAS-D macrophages [black arrows] in triad & sinusoid evidence damage; Neutrophils [magenta arrows] in proliferating bile ductules mean nothing, but in sinusoids indicate damage. E. Reticulin fibers in steatosis afflicted areas can appear abnormally lost, which should not be deemed evidence of hepatocellular carcinoma. F. Reticulin stain here shows hepatocyte acini [arrows], evidence of hepatocellular injury (Row 3 Right 400X).  

 

A. [[File:1 Steatohep 4 680x512px.tif|Panacinar steatosis with unremarkable, small triads (40X).]]

B. [[File:2 Steatohep 4 680x512px.tif|Ballooning degeneration, with cytoplasmic tufts (arrows) (400X).]]

C. [[File:3 Steatohep 4 680x512px.tif|Lipogranuloma (400X).]]

D. [[File:4 Steatohep 4 680x512px.tif|Triad with mild chronic inflammation without interface hepatitis (400X).]]

 

Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1. A. Panacinar steatosis with unremarkable, small triads. B. Ballooning degeneration, with cytoplasmic tufts [arrows]. C.  Lipogranuloma. D. Triad with mild chronic inflammation without interface hepatitis.

 

 

A. [[File:1 Steatohep 5 680x512px.tif|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]

B. [[File:2 Steatohep 5 680x512px.tif|An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The patient had a normal bilirubin. (Row 1 Right 200X).]]

C. [[File:3 Steatohep 5 680x512px.tif|Cytoplasmic tufts (arrows) prove  ballooning degeneration (Row 2 Left 400X).]]

D. [[File:4 Steatohep 5 680x512px.tif|PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X).]]

E. [[File:5 Steatohep 5 680x512px.tif|Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X).]]

F. [[File:6 Steatohep 5 680x512px.tif|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]

 

Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. A. Steatosis afflicts almost all hepatocytes (pan-acinar). B. An isolated septal duct with concentric fibrosis [arrow] should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. C. Cytoplasmic tufts [arrows] prove  ballooning degeneration. D. PAS with diastase shows PAS-D Kupffer cells (arrows). E. Reticulin shows thick black lines [red arrows] of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis [double head cyan arrow] should not be considered regeneration or hepatoma. F.  Trichrome shows a bridge [arrow].

 

 

Cirrhosis with steatohepatitis in a 54 year old man with type II diabetes, negative viral serologies, negative alcohol history, negative AMA/ANA, normal ceruloplasmin, low albumin/platelet count, and elevated bilirubin/alkaline phosphatase/transaminase, with hepatosplenomegaly.  A. At lower power, no definite triads are seen, but there are potential bands (green arrows) and foci with steatosis (blue arrows). The low percent of hepatocytes afflicted by steatosis would indicate a Brunt necroinflammatory grade 1, here irrelevant as cirrhosis is present. B. Tufts (green arrows) prove ballooning degeneration needed for a diagnosis of steatohepatitis. Foamy macrophage-like hepatocytes (blue arrows) show feathery degeneration is also present. C. Reticulin shows two cell thick cords (green arrows) of regeneration. D. Trichrome shows blue bands and definite nodules (white arrows). At one time, 75% of the biopsy would have had to have been occupied to diagnose cirrhosis. Currently, under the Metavir system, one need only have extensive fibrosis, which would include developing cirrhosis of the HAI system, to obtain a grade IV status, acceptable for transplantation.