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Liver pathology (view source)

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[[Image:Wątroba marska (Ultima Thule).jpg|thumb|right|Drawing of a [[cirrhosis|cirrhotic]] liver. (WC)]]
The '''liver''' is an organ [[pathologist]]s are seeing less of, as [[radiologist]]s (with multimodal imaging and triphasic CT scans) are pretty good at sorting-out many types of liver lesions.
The '''liver''' is an organ [[pathologist]]s are seeing less of, as [[radiologist]]s (with multimodal imaging and triphasic CT scans) are pretty good at sorting-out many types of liver lesions.


This article is an introduction to liver pathology. Liver neoplasms are dealt with in the ''[[liver neoplasms]]'' article.  Medical liver diseases (e.g. viral hepatitis) is dealt with in the ''[[medical liver disease]]'' article.
This article is an introduction to liver pathology. Liver neoplasms are dealt with in the ''[[liver neoplasms]]'' article.  Medical liver diseases (e.g. viral hepatitis) is dealt with in the ''[[medical liver disease]]'' article.


Liver biopsies are quite often non-specific, as the liver has the same appearance for many mechanisms of injury, especially when the injury is marked.
=Review of liver blood work=
*This is covered in the ''[[Medical_liver_disease#Review_of_liver_blood_work|medical liver disease]]'' article.


Almost every differential in liver pathology has "drugs" -- if it isn't clearly malignancy.
=Normal liver=
==Liver anatomy==
The liver is divided into eight (Couinaud) segments:
*Segment I = caudate lobe.
*Segments II to VIII = clockwise from left upper lobe to left upper quadrant of the liver to the right of the inferior vena cava.
**Segment IV is divided into: IVa (superior) and IVb (inferior).


==Review of liver blood work==
Image:
===Inflammation activity===
*[http://masterofmedicine.com/couinauds-liver-segments/ Couinaud segments (masterofmedicine.com)].
*ALT.
*AST.
 
===Cholestatic markers===
*ALP.
*GGT - used to assess whether the ALP is an "honest" value, elevated in cirrhosis.
 
===Cirrhosis/decompensation===
*PLT - low is suggestive of dysfunction.
*INR - high is bad, unless anticoagulated.
 
===Viral===
*HBV DNA.
*HCV RNA.
*HBs Ag, HBs Ab, HBe Ag, HBe Ab.
*HCV Ab.


Others:
==Liver histology==
*EBV.
*CMV.
====Hepatitis B====
Meaning & utility of the various Hepatitis B tests:<ref>[http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/hepatitis-B/ http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/hepatitis-B/]</ref><ref>[http://www.labtestsonline.org/understanding/analytes/hepatitis_b/test.html http://www.labtestsonline.org/understanding/analytes/hepatitis_b/test.html]</ref>
{| class="wikitable" border="1"
! '''Test name'''
! '''Location'''
! '''Positive test'''
! '''Negative test'''
! '''Usual question'''
|-
| HBs Ag||Surface||Virus active||No active infection||Active infection?
|-
| HBs Ab||Surface||Exposed OR vaccinated||No exposure OR no vaccine OR loss of Ab||Immunization status?
|-
| HBe Ag||Virus core||Infect. w/o immune response||No active infection||Active infect. w/o immune response?
|-
| HBe Ab||Virus core||Exposed to virus||Infect. w/o immune response OR not exposed||Immune response to infection?
|-
| HBV DNA||-||Active||Not active/no exposure||Viral load/how active?
|-
| HBc Ab||Virus core||Virus active/previous exposure||No exposure||Early active infection?
|}
Notes:
*''HBc Ab'' may test for acute (IgM) or chronic infection - dependent on specific antibody test; it is often used to look for early infection.<ref>[http://www.labtestsonline.org/understanding/analytes/hepatitis_b/test.html http://www.labtestsonline.org/understanding/analytes/hepatitis_b/test.html]</ref>
 
===Markers for rare liver diseases===
*Ceruloplasm - low think ''Wilson's disease''; typical value for Wilson's ~ 0.12 g/L.
**<0.20 g/L is a criteria for Wilson's disease.<ref name=pmid18556333>Diagnostic accuracy of serum ceruloplasmin in Wilson disease: determination of sensitivity and specificity by ROC curve analysis among ATP7B-genotyped subjects. Mak CM, Lam CW, Tam S. Clin Chem. 2008 Aug;54(8):1356-62. Epub 2008 Jun 12. PMID 18556333. URL: [http://www.clinchem.org/cgi/reprint/54/8/1356.pdf http://www.clinchem.org/cgi/reprint/54/8/1356.pdf]. Accessed on: 28 September 2009.</ref>
*Alpha-1 antitrypsin - if low think ''deficiency''.
 
===Hemosiderosis===
*Ferritin - high.
*Iron saturation - high.
 
Causes:
*Hemochromatosis.
*Hemolysis, chronic.
*Cirrhosis.
 
==Normal histology==
Liver has a dual blood supply:
Liver has a dual blood supply:
#Portal vein.
#Portal vein.
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#Interconnecting sinusoids - connect branching sinusoids.
#Interconnecting sinusoids - connect branching sinusoids.


==Structural approach==
=Structural approach=
Examine:
Examine:
*Portal triad normal.
*Portal triad normal.
**Artery.
**Artery.
**Vein; vein should be larger than the artery.
**Vein; vein should be larger than the artery.
**Bile duct - should have a lumen and be round.
**Bile duct - round, has a lumen - approximately the size of the artery.
***Cuboidal epithelium, central nucleus, lightly basophilic cytoplasm.
***Cuboidal epithelium, central nucleus, lightly basophilic cytoplasm.
***IHC: CK7 +ve.
***IHC: [[CK7]] +ve.
***Irregular bile ducts without a lumen are called ''bile ductules''; ''ductule'' implies a pathologic process.
***Irregular bile ducts without a lumen are called ''bile ductules''; ''ductule'' implies a pathologic process.
*Lobule - hepatocytes.  
*Lobule - hepatocytes.  
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**Cholestasis - absent/present.
**Cholestasis - absent/present.
**Presence of fibrosis?
**Presence of fibrosis?
***If a core biopsy is fragmented (on gross), think ''cirrhosis'',<ref>S. Fung. October 2007.</ref> as cirrhotic livers commonly cleave at the fibrous bands.
***If a core biopsy is fragmented (on gross), think ''cirrhosis'',<ref>Fung, S. October 2007.</ref> as cirrhotic livers commonly cleave at the fibrous bands.
***Grade the fibrosis.
***Grade the fibrosis.
*Central vein - has a ''collagen collar'' (seen on trichrome).
*Central vein - has a ''collagen collar'' (seen on trichrome).


==Pattern approach==
=Pattern approach=
<!--
<!--
COMMON LIVER PATTERNS
COMMON LIVER PATTERNS
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**Clinical correlate: ALP and GGT increased.
**Clinical correlate: ALP and GGT increased.
*Steatosis - fat.
*Steatosis - fat.
**Clinical correlate: obese patient, changes on medical imaging (increased radiolucency on CT).
**Clinical correlate: [[obese]] patient, changes on medical imaging (increased radiolucency on CT).


<!--
<!--
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**Clinical correlate: non-specific.
**Clinical correlate: non-specific.
*Congestive - dilation of portal venules, perisinusoidal fibrosis/zone III fibrosis.
*Congestive - dilation of portal venules, perisinusoidal fibrosis/zone III fibrosis.
**Clinical correlates: heart failure, imaging finding (portal vein thrombosis), medications.
**Clinical correlates: heart failure, imaging finding (portal vein [[thrombosis]]), medications.
*Ischemic - [[necrosis]].
*Ischemic - [[necrosis]].
**Clinical correlate - shock, known [[atherosclerosis]], known cirrhosis.
**Clinical correlate - shock, known [[atherosclerosis]], known cirrhosis.
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**Clinical correlate: toxin ingestion.
**Clinical correlate: toxin ingestion.


==Biopsy==
=Stains=
===Adequacy===
*The stains ordered (initially) are dependent on the clinical history.
Liver biopsy specimens should be:<ref>{{Ref MacSween|418}}</ref>
*#Anything with "tumour", "mass", or "query metastasis" in the clinical history is "tumour".
*2.0 cm in length and contain 11-15 portal tracts,
*#*Stains:
*The core should be deeper than 1.0 cm from the liver capsule; specimens close to the capsule may lead to over grading of fibrosis.
*#**3 H&E.
*#Everything else is assumed to be "medical".
*#*Stains:
*#**PAS-D - to detect mucin.
*#**PAS - marks glycogen and mucin; useful for microvesicular steatosis
*#**Trichrome - to detect fibrosis/cirrhosis.
*#***Mallory trichrome: red = hepatocytes, blue/black = nuclei, green = fibrosis.
*#**Reticulin - demonstrates architecture.
*#**Iron stain.
*#***Grading (0-4): 0 = none, 1: only at high power, 2: at medium power, 3: at lowest power, 4: seen without microscope.
*#****One should comment on location, i.e. macrophage (Kupffer cell) vs. periportal hepatocytes vs. centrilobular hepatocytes vs. bile ducts vs. endothelial cells.


===Components===
===Additional stains/IHC===
Specimen, procedure:<br>
Non-standard stains:
Diagnosis.
*[[Oil red O]].
<br>
The diagnosis usually contains grading and staging information, e.g. ''activity 2 /4, Laennec fibrosis stage 1 /4''.
 
In the context of medical liver disease:
*Grade = inflammation/activity.
*Stage = severity of fibrosis/architectural changes.
 
Notes:
*The term "acute" is infrequently used in liver pathology.
*In the liver: neutrophils ''is not'' acute -- unlike most elsewhere in the body.<ref>OA. September 2009.</ref>
 
==Stains==
*[[Oil red O]]  
**Useful for steatosis, not commonly done.
**Useful for steatosis, not commonly done.
*[[PAS]].
*[[HPS]].
**Useful for microvesicular steatosis.
**Similar to trichrome.
*[[Trichrome]].
**Useful for fibrosis/cirrhosis; components of trichrome: red = hepatocytes, blue/black = nuclei, green = fibrosis.
***[[Movat's stain]] is ''not'' favoured by hepatic pathologists.<ref>MG. 29 July 2009.</ref>
*Iron stain.
**Grading (0-4): 0 = none, 1: only at high power, 2: at medium power, 3: at lowest power, 4: seen without microscope.
**Should comment on location, i.e. macrophage (Kupffer cell) vs. periportal hepatocytes vs. centrilobular hepatocytes vs. bile ducts vs. endothelial cells.


===Liver stains - standard at one hospital===
Common IHC:<ref name=ap27may2009>Pollet, A. 27 May 2009.</ref>
IHC panel/special stains:<ref name=ap27may09>AP. 27 May 2009.</ref>
*[[CK7]] - bile ducts, and bile ductules +ve.
*PAS-D - to detect mucin.
*PAS - to detect glycogen and mucin.
*Trichrome - to detect fibrosis/cirrhosis.
*Reticulin - demonstrates architecture.
 
Additional stains:<ref name=ap27may09/>
*CK7 - bile ducts, and bile ductules +ve.
*CD34 - should be -ve in normal liver.
*CD34 - should be -ve in normal liver.
**CD34 marks endothelial cells - these are not present in a healthy liver lobule.
**CD34 marks endothelial cells - these are not present in a healthy liver lobule.


==Liver injury terms/histologic findings==
=Liver biopsy=
==="Ballooning degeneration"===
==Medical liver biopsy adequacy==
*Central nucleus.
*This is covered in the ''[[Medical_liver_disease#Medical_liver_biopsy_adequacy|medical liver disease]]'' article.
**"Fat cells" have peripheral nucleus.
*Cytoplasm cleared with "whisps" or cobbwebs.
*Large relative to normal hepatocyte.
**2-3X normal size.<ref>MG. 16 September 2009.</ref>


Notes:
==Reporting==
*The term is used only in conjunction with ''steatohepatitis''.
{{Main|Pathology reports}}
*''Feathery degeneration'' is the term used in the context of non-fatty disease.<ref>MG. 17 September 2009.</ref>
*This is covered in the ''[[Medical_liver_disease#Reporting|medical liver disease]]'' article.
 
=Liver injury terms/histologic findings=
===Bile duct injury===
*Non-specific finding.
**Seen in a number of conditions, e.g. autoimmune hepatitis, primary biliary cirrhosis, viral hepatitis.
 
Microscopic:
*Abnormal epithelium:
**Nuclei ''not'' round.
**Cytoplasmic eosinophilia.
*Intraepithelial lymphocytes.


Images:
===Bile duct hamartoma===
*[http://commons.wikimedia.org/wiki/File:Ballooning_degeneration_high_mag_cropped.jpg Ballooning degeneration (WC)].
*[[AKA]] ''Meyenburg complex'' and ''von Meyenburg complex''.
*[http://www.uthscsa.edu/hscnews/EnlargePicture.asp?PicName=LiverBeforeTreatment_BODY.jpg Ballooning degeneration (uthscsa.edu)].
*Classically associated with ''polycystic kidney disease'' (see ''[[Medical_liver_disease#Polycystic_kidney_disease_and_the_liver|medical liver disease]]'').
*[http://library.med.utah.edu/WebPath/LIVEHTML/LIVER039.html Ballooning degeneration (med.utah.edu)].
*May be seen in a normal liver - incidental finding at autopsy in 0.5-5.6% of cases.<ref name=pmid19018981>Hepatic von Meyenburg complex: a trigger of severe portal hypertension. Yoshida S, Kurokohchi K, Ueno T, Yoshino M, Shimada M, Masaki T. Liver Int. 2009 Apr;29(4):614-5. Epub 2008 Oct 14. PMID 19018981. URL: [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2711260 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2711260]. Accessed on: 28 September 2009.</ref>
*Appearance on ultrasound<ref name=pmid17287178>Bile duct hamartomas--the von Meyenburg complex. Salles VJ, Marotta A, Netto JM, Speranzini MB, Martins MR. Hepatobiliary Pancreat Dis Int. 2007 Feb;6(1):108-9. PMID 17287178.</ref> and CT (hypodense)<ref name=pmid19294869>[The von Meyenburg complex] Schwab SA, Bautz W, Uder M, Kuefner MA. Rontgenpraxis. 2008;56(6):241-4. German. PMID 19294869.</ref> - similar to metastases.


==="Ground glass" hepatocytes===
Microscopic:<ref>{{Ref MacSween|176}}</ref>
*Eosinophilic dull/hazy, somewhat irregular cytoplasm.
*Many bile ducts (tubular structures with cuboidal epithelium).
**Ground glass<ref>URL: [http://en.wikipedia.org/wiki/Ground_glass http://en.wikipedia.org/wiki/Ground_glass]. Accessed on: 7 June 2010.</ref> = glass with a rough/flat finish; glass that is translucent and has a matte finish.
*Surrounded by a fibrous stroma.
***The term is frequently used in radiology to describe hazy radiodense areas in the lung.<ref>URL: [http://www.healthsystem.virginia.edu/internet/radiology/educ/groundglass.cfm http://www.healthsystem.virginia.edu/internet/radiology/educ/groundglass.cfm]. Accessed on: 7 June 2010.</ref>
*Usually suggests '''chronic''' [[HBV]] infection.  
**Pattern NOT seen in acute HBV.
**Caused by virion particles.


DDx:  
Note:
*Pseudo-Lafora bodies in patients on disulfiram (anatabuse) - rare.
*'''Not''' related to ''[[bile duct adenoma]]''.


====Classification====
====Images====
*GGHs are not routinely classified.  
<gallery>
Image:Von_Meyenburg_complex_low_mag.jpg | Von Meyenburg complex - bile duct hamartoma (WC)
Image:Bile_duct_hamartoma_intermed_mag.jpg | Bile duct hamartoma - intermed. mag. (WC)
Image:Von_Meyenburg_complex_liver.jpg | Von Meyenburg complex / bile duct hamartoma (WC)
</gallery>
www:
*[http://radiographics.rsna.org/content/25/3/659/F7.expansion.html Bile duct hamartoma - gross image (rsna.org)].
*[http://radiographics.rsna.org/content/25/3/659/F8.expansion.html Bile duct hamartoma (rsna.org)].


Notes:
===Isolated hepatic artery===
*Several different types of GGHs are recognized.<ref name=pmid14633616>Wang HC, Wu HC, Chen CF, Fausto N, Lei HY, Su IJ. Different types of ground glass hepatocytes in chronic hepatitis B virus infection contain specific pre-S mutants that may induce endoplasmic reticulum stress. Am J Pathol. 2003 Dec;163(6):2441-9. PMID 14633616. Available at: [http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=14633616 http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=14633616]. Accessed on: September 11, 2009.</ref>
*The hepatic artery branches within the liver should always be found together with a vein and bile duct.


Classification:<ref>Wang HC, Wu HC, Chen CF, Fausto N, Lei HY, Su IJ. Different types of ground glass hepatocytes in chronic hepatitis B virus infection contain specific pre-S mutants that may induce endoplasmic reticulum stress. Am J Pathol. 2003 Dec;163(6):2441-9. PMID 14633616. Available at: [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1892360&rendertype=figure&id=f1
DDx:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1892360&rendertype=figure&id=f1]. Accessed on: 17 September 2009.</ref>
*[[Focal nodular hyperplasia]].
*Type I ground glass hepatocytes (GGHs).
*[[Hepatic adenoma]].
**Weak Pre-S2 positive immunostaining; morphology: GGHs scattered singly.
*[[Hepatocellular carcinoma]].  
*Type II GGHs.
**Pre-S2 negative immunostaining; morphology: GGHs in clusters.


There is some suggestion that type II GGHs predispose to HCC, based on data in children<ref name=pmid19719772>Pre-S2 deletion mutants of hepatitis B virus could have an important role in hepatocarcinogenesis in Asian children. Abe K, Thung SN, Wu HC, Tran TT, Le Hoang P, Truong KD, Inui A, Jang JJ, Su IJ. Cancer Sci. 2009 Aug 6. [Epub ahead of print] PMID 19719772.</ref> and based on an animal model.<ref name=pmid18505413>Ground glass hepatocytes contain pre-S mutants and represent preneoplastic lesions in chronic hepatitis B virus infection. Su IJ, Wang HC, Wu HC, Huang WY. J Gastroenterol Hepatol. 2008 Aug;23(8 Pt 1):1169-74. Epub 2008 May 26. Review. PMID 18505413.</ref>
===Ballooning degeneration===
{{Main|Ballooning degeneration}}


Micrographs of GGHs:
===Ground glass hepatocytes===
*[http://commons.wikimedia.org/wiki/File:Ground_glass_hepatocytes_high_mag_cropped.jpg Ground glass hepatocyte (WC)].
{{Main|Ground glass hepatocyte}}
*[http://www.consultantlive.com/aids/article/1145619/1363027 Ground glass hepatocytes (consultantlive.com)].
*[http://www.biomedcentral.com/1471-230X/5/36/figure/F1 Ground glass hepatocytes (biomedcentral.com)].
*[http://pathology.osu.edu/paxit/deptbase/Paxit/Images/10534/PAXIT052.JPG Ground glass hepatocyte (pathology.osu.edu)].


===Mallory bodies===
===Mallory bodies===
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Notes:
Notes:
*Previously thought to indicate alcoholic liver disease; they are more common in alcohol.
*Previously thought to indicate [[alcoholic liver disease]]; they are more common in [[alcohol]].


Prevalence in common liver diseases (based on one study):<ref name=pmid7927209>Jensen K, Gluud C. The Mallory body: morphological, clinical and experimental studies (Part 1 of a literature survey). Hepatology. 1994 Oct;20(4 Pt 1):1061-77. Review. PMID 7927209.</ref>
Prevalence in common liver diseases (based on one study):<ref name=pmid7927209>Jensen K, Gluud C. The Mallory body: morphological, clinical and experimental studies (Part 1 of a literature survey). Hepatology. 1994 Oct;20(4 Pt 1):1061-77. Review. PMID 7927209.</ref>
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|}
|}


Micrographs:
====Images====
*[http://commons.wikimedia.org/wiki/File:Mallory_body_high_mag_cropped.jpg Mallory body (WC)].
<gallery>
Image:Mallory_body_high_mag_cropped.jpg | Mallory body. (WC/Nephron)
</gallery>
www:
*[http://en.wikipedia.org/wiki/File:CDC_mallory_bodies.jpg Mallory bodies - CDC/WP (WP)].
*[http://en.wikipedia.org/wiki/File:CDC_mallory_bodies.jpg Mallory bodies - CDC/WP (WP)].
*[http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800682f6.html Mallory bodies - Mod. Pathol. (nature.com)].
*[http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800682f6.html Mallory bodies - Mod. Pathol. (nature.com)].
===Acidophilic body===
*Seen in ASH and NASH.<ref name=pmid19646834>{{cite journal |author=Tiniakos DG |title=Liver biopsy in alcoholic and non-alcoholic steatohepatitis patients |journal=Gastroenterol. Clin. Biol. |volume=33 |issue=10-11 |pages=930–9 |year=2009 |pmid=19646834 |doi=10.1016/j.gcb.2009.05.009 |url=}}</ref>
Appearance:
*Small (degenerative) hepatocyte with a:
**Pyknotic nucleus.
***Small, shrunken, pale staining.
**Eosinophilic cytoplasm.
Notes:
*[[AKA]] ''Councilman-like bodies''; see ''notes'' in ''Councilman bodies'' below.
====Image====
<gallery>
Image:Ballooning_degeneration_high_mag_cropped.jpg | Councilman body - high mag. (WC)
</gallery>


===Councilman bodies===
===Councilman bodies===
Appearance:
Appearance:
*Eosinophilic globule.
*Eosinophilic globule.
 
*Usu. surrounded by lymphocytes.
Image:
*[http://commons.wikimedia.org/wiki/File:Ballooning_degeneration_high_mag_cropped.jpg Councilman body - high mag. (WC)].


DDx:<ref>URL: [http://www.tissueculturemicroscopy.com/degenerations-and-certain-infiltrations.html http://www.tissueculturemicroscopy.com/degenerations-and-certain-infiltrations.html]. Accessed on: 1 February 2011.</ref>
DDx:<ref>URL: [http://www.tissueculturemicroscopy.com/degenerations-and-certain-infiltrations.html http://www.tissueculturemicroscopy.com/degenerations-and-certain-infiltrations.html]. Accessed on: 1 February 2011.</ref>
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*Yellow fever.
*Yellow fever.
*Others.
*Others.
Notes:
*Some sources say ''acidophilic body = councilman body'',<ref>URL: [http://medical-dictionary.thefreedictionary.com/cytosegresome+formations http://medical-dictionary.thefreedictionary.com/cytosegresome+formations]. Accessed on: 1 February 2011.</ref> others dispute this.<ref>URL: [http://www.tissueculturemicroscopy.com/degenerations-and-certain-infiltrations.html http://www.tissueculturemicroscopy.com/degenerations-and-certain-infiltrations.html]. Accessed on: 1 February 2011.</ref><ref>URL: [http://books.google.com/books?id=MrLfdTZl1dEC&pg=PA62#v=onepage&q&f=false http://books.google.com/books?id=MrLfdTZl1dEC&pg=PA62#v=onepage&q&f=false]. Accessed on: 1 February 2011.</ref>


===Inflammation===
===Inflammation===
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====Interface hepatitis====
====Interface hepatitis====
*May be referred to as ''piecemeal necrosis''.<ref name=aop>Atlas of Pathology. URL: [http://www.pathologyatlas.ro/viral-chronic-moderate-hepatitis.php http://www.pathologyatlas.ro/viral-chronic-moderate-hepatitis.php]. Accessed on: September 1, 2009.</ref>
*May be referred to as ''piecemeal necrosis''.<ref name=aop>Atlas of Pathology. URL: [http://www.pathologyatlas.ro/viral-chronic-moderate-hepatitis.php http://www.pathologyatlas.ro/viral-chronic-moderate-hepatitis.php]. Accessed on: September 1, 2009.</ref>
*Non-specific finding, i.e. seen in several conditions - e.g. viral hepatitis, autoimmune hepatitis.
*Non-specific finding, i.e. seen in several conditions - e.g. [[viral hepatitis]], [[autoimmune hepatitis]].


Features:
Features:
*Inflammation disrupts the "limiting plate", i.e. there is disruption of the hepatocytes that separate the portal tracts from the lobules.
*Inflammation disrupts the "limiting plate", i.e. there is disruption of the hepatocytes that separate the portal tracts from the lobules.


Micrograph:
=====Images=====
*[http://www.pathologyatlas.ro/viral-chronic-moderate-hepatitis.php Interface hepatitis (pathologyatlas.ro)]
<gallery>
Image: Interface hepatitis -- high mag.jpg | IH (mild) - high mag. (WC)
Image: Interface hepatitis -- very high mag.jpg | IH (mild) - very high mag. (WC)
</gallery>
www:
*[http://www.pathologyatlas.ro/viral-chronic-moderate-hepatitis.php Interface hepatitis (pathologyatlas.ro)].
*[http://www.nature.com/modpathol/journal/v20/n1s/fig_tab/3800693f1.html#figure-title Interface hepatitis (nature.com)].<ref name=pmid17486049>{{cite journal |author=Theise ND |title=Liver biopsy assessment in chronic viral hepatitis: a personal, practical approach |journal=Mod. Pathol. |volume=20 Suppl 1 |issue= |pages=S3-14 |year=2007 |month=February |pmid=17486049 |doi=10.1038/modpathol.3800693 |url=http://www.nature.com/modpathol/journal/v20/n1s/full/3800693a.html}}</ref>


===Fibrosis===
===Liver fibrosis===
*More collagen than there should be.
*More collagen than there should be.
*Assessment of fibrosis is based on the trichrome stain.
*Assessment of fibrosis is based on the trichrome stain.
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''Laennec fibrosis'' (stage):<ref>URL: [http://www.pulsus.com/cddw2000/abs/080.htm http://www.pulsus.com/cddw2000/abs/080.htm]. Accessed on: 9 December 2010.</ref>
''Laennec fibrosis'' (stage):<ref>URL: [http://www.pulsus.com/cddw2000/abs/080.htm http://www.pulsus.com/cddw2000/abs/080.htm]. Accessed on: 9 December 2010.</ref>
*Stage 0 - '''no fibrosis'''; "loose" strands of collagen - spaces between collagen bundles.  
*Stage 0 - '''no fibrosis'''; "loose" strands of collagen - spaces between collagen bundles.  
*Stage 1 - '''minimal fibrosis''' - no fibrous septa, no "portal expansion", i.e. no enlargement of portal area.  
*Stage 1 - minimal fibrosis - '''no fibrous septa''', minimal "portal expansion".  
*Stage 2 - mild fibrosis; '''portal expansion''', +/-delicate septa, +/-sinusoidal fibrosis.  
*Stage 2 - mild fibrosis; '''portal expansion''', +/-delicate septa, +/-sinusoidal fibrosis.  
*Stage 3 - moderate fibrosis - '''several fibrous septa''', not bridging.
*Stage 3 - moderate fibrosis - '''several fibrous septa''', not bridging.
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A simplified version:<ref>OA. 10 September 2009.</ref>  
A simplified version:<ref>OA. 10 September 2009.</ref>  
*Stage 0 - '''nil; loose strands of collagen'''.
*Stage 0 - '''nil; loose strands of collagen'''.
*Stage 1 - '''irregular (fibrotic) portal area'''.
*Stage 1 - '''portal expansion (minimal), no septa'''.
*Stage 2 - '''portal expansion'''.  
*Stage 2 - '''portal expansion (mild), few thin septa'''.  
*Stage 3 - '''incomplete nodules'''.
*Stage 3 - '''incomplete nodules'''.
*Stage 4 - '''complete nodules'''.
*Stage 4 - '''complete nodules'''.
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===Cirrhosis===
===Cirrhosis===
*Cirrhosis ''is'' stage 4 (Laennec).
{{Main|Cirrhosis}}
*The etiology of late stage fibrosis (cirrhosis), may be impossible to determine.
*Perisinusoidal fibrosis may suggest congestive hepatopathy.<ref>OA. September 15, 2009.</ref>
*In NAFLD portal-to-portal fibrosis (septal/bridging fibrosis) tends to be more common than perivenular fibrosis.<ref name=pmid14991537>Pathologic features associated with fibrosis in nonalcoholic fatty liver disease. Gramlich T, Kleiner DE, McCullough AJ, Matteoni CA, Boparai N, Younossi ZM. Hum Pathol. 2004 Feb;35(2):196-9. PMID 14991537.</ref>
 
Cirrhosis can be divided (in gross pathology) into:
*Micronodular cirrhosis - classically due to alcohol.
**Uniform, diffuse.
*Macronodular cirrhosis - classically due to viral hepatitis.
**Irregular.
 
Images:
*[http://www.meddean.luc.edu/lumen/MedEd/orfpath/cirhosis.htm Cirrhosis - macronodular & micronodular (meddean.luc.edu)].
*[http://commons.wikimedia.org/wiki/File:Cirrhosis_high_mag.jpg Cirrhotic liver - trichrome stain (WC)].
 
===Steatosis of the liver===
Can be divided into:
#Microvesicular steatosis.
#*Rare.
#*Nucleus is central.<ref>STC. 6 December 2010.</ref>
#Macrovesicular steatosis.
#*Common.
#*Nucleus is eccentric.
 
Microvescicular is considered to be potentially life threatening.<ref>Steatosis. pathconsultddx.com. URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970840-3 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970840-3]. Accessed on: 2 Sep 2009.</ref>
 
Quantity of fat is usually given as a percentage and graded ''mild'', ''moderate'', or ''marked''.
*Mild <33%, moderate >33% & <66%, marked >66%.<ref>MG. September 17, 2009.</ref>
 
Notes:
*It is considered technically incorrect to say the liver, in steatosis/steatohepatitis, contains ''adipocytes''; they are ''lipid-laden hepatocytes'',<ref>MG. September 2009.</ref> despite that:
**Histologically, these cells look like adipocytes.
**Lipid-laden hepatocytes have gene activations suggestive of adipogenic-like transformation.<ref>URL: [http://www.jci.org/articles/view/20513/version/1 http://www.jci.org/articles/view/20513/version/1]. Accessed on: 23 September 2009.</ref>
*Donor livers with more fat = worse outcome.<ref name=pmid20644128>{{cite journal |author=Doyle MB, Vachharajani N, Wellen JR, ''et al.'' |title=Short- and long-term outcomes after steatotic liver transplantation |journal=Arch Surg |volume=145 |issue=7 |pages=653–60 |year=2010 |month=July |pmid=20644128 |doi=10.1001/archsurg.2010.119 |url=}}</ref>
**One cut-point is 30% -- more than 30% and the liver is undesirable for transplantation.<ref>STC. 6 December 2010.</ref>
 
====Microvesicular steatosis====
Microvesicular steatosis DDx:<ref name=pmid2177300>{{cite journal |author=Hautekeete ML, Degott C, Benhamou JP |title=Microvesicular steatosis of the liver |journal=Acta Clin Belg |volume=45 |issue=5 |pages=311–26 |year=1990 |pmid=2177300 |doi= |url=}}</ref>
*Acute fatty liver of pregnancy,
*Reye's syndrome.
*Drug toxicity:
**Sodium valproate toxicity.
**High-dose tetracycline toxicity.
*Jamaican vomiting sickness.
*Congenital defects of urea cycle enzymes.
 
Less common causes:
*Alcoholism.
*Hepatitis D.
*Weird stuff:
**Congenital defects of fatty acid beta oxidation,
**Cholesterol ester storage disease,
**Wolman disease and Alpers syndrome.
 
The classic causes of microvesicular steatosis are:<ref>[http://www.mailman.srv.ualberta.ca/pipermail/patho-l/1996-June/001788.html http://www.mailman.srv.ualberta.ca/pipermail/patho-l/1996-June/001788.html]</ref>
*Fatty liver of pregnancy.
*Aspirin (Reye's syndrome).
*Tetracycline.
It was once thought that all other causes of fatty liver produce macrovesicular steatosis.
 
====Macrovesicular steatosis====
Can sometimes be divided into ''centrilobular'' predominant and ''periportal'' predominant.<ref name=pcddx_steatosis>Steatosis. pathconsultddx.com. URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970840-3 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970840-3]. Accessed on: 2 Sep 2009.</ref>
 
Centrilobular predominant (zone III) - ''DOA'':<ref name=pcddx_steatosis/>
*Diabetes mellitus.
*Obesity, non-alcoholic steatohepatitis (NASH).
*Alcoholic liver disease, alcoholic steatohepatitis (ASH).
 
Image: [http://commons.wikimedia.org/wiki/File:Non-alcoholic_fatty_liver_disease1.jpg Centrilobular steatosis (WC)].
 
Periportal predominant (zone I) - ''TAPES'':<ref name=pcddx_steatosis/>
*Total parenteral nutrition (TPN).
*AIDS.
*Phosphorus poisoning.
*Exogenous steroids.
*[[Starvation]].


Notes:
===Steatosis===
*HCV genotype 3 is reported to cause periportal steatosis.<ref name=pmid16614743>Yoon EJ, Hu KQ. Hepatitis C virus (HCV) infection and hepatic steatosis. Int J Med Sci. 2006;3(2):53-6. Epub 2006 Apr 1. PMID 16614743. Avialable at: [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1415843 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1415843]. Accessed on: September 9, 2009.</ref>
{{Main|Steatosis}}
 
Image: [http://commons.wikimedia.org/wiki/File:Periportal_hepatosteatosis_intermed_mag.jpg Periportal steatosis (WC)].


===Cholestasis===
===Cholestasis===
Appearance of bile:
{{Main|Cholestasis}}
*Smooth/homogenous.
*Brown/yellow.
*Globule/droplet - that is larger than an iron granule.
 
Note:
*Iron in bile ducts or endothelial cell = non-specific, used to be thought to be specific for hereditary hemochromatosis.
 
Histologic findings of large-duct obstruction:<ref>{{Ref MacSween|565}}</ref>
#Perivenular bilirubinostasis.
#Portal tract edema & inflammation (neutrophils & macrophages).
#Large bile plugs.
#Bile duct proliferation.<ref name=pmid7439807>{{cite journal |author=Chapman RW, Arborgh BA, Rhodes JM, ''et al.'' |title=Primary sclerosing cholangitis: a review of its clinical features, cholangiography, and hepatic histology |journal=Gut |volume=21 |issue=10 |pages=870–7 |year=1980 |month=October |pmid=7439807 |pmc=1419383 |doi= |url=}}</ref><ref name=pmid14594129>{{cite journal |author=Leuschner U |title=Primary biliary cirrhosis--presentation and diagnosis |journal=Clin Liver Dis |volume=7 |issue=4 |pages=741–58 |year=2003 |month=November |pmid=14594129 |doi= |url=}}</ref>
 
Small-duct obstruction:
*Abnormal liver plate architecture. (???)
 
Image: [http://commons.wikimedia.org/wiki/File:Cholestasis_high_mag.jpg Cholestasis (WC)].
 
====Brown/yellow cytoplasmic inclusions====
Comparison of brown/yellow cytoplasmic inclusions:<ref>MG. September 2009.</ref>
{| class="wikitable" border="1"
!
! '''Colour'''
! '''Granularity'''
! '''Refractile'''
! '''Usual location'''
! '''Association'''
|-
| Iron||Brown||Coarse granules||Yes - shinny||Periportal (zone I)||Hemolysis, hereditary hemochromatosis
|-
| Bile||Brown - coffee stained||Not granular||No - dull||Portal||Duct injury/obstruction
|-
| Lipofuscin||Yellow||Fine granules||No||Centrilobular (zone III)||Advanced age
|-
|}
 
===Bile duct hamartoma===
*[[AKA]] ''Meyenburg complex'' and ''von Meyenburg complex''.
*Classically associated with ''polycystic kidney disease'' (see ''[[medical liver disease]]'').
*May be seen in a normal liver - incidental finding at autopsy in 0.5-5.6% of cases.<ref name=pmid19018981>Hepatic von Meyenburg complex: a trigger of severe portal hypertension. Yoshida S, Kurokohchi K, Ueno T, Yoshino M, Shimada M, Masaki T. Liver Int. 2009 Apr;29(4):614-5. Epub 2008 Oct 14. PMID 19018981. URL: [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2711260 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2711260]. Accessed on: 28 September 2009.</ref>
*Appearance on ultrasound<ref name=pmid17287178>Bile duct hamartomas--the von Meyenburg complex. Salles VJ, Marotta A, Netto JM, Speranzini MB, Martins MR. Hepatobiliary Pancreat Dis Int. 2007 Feb;6(1):108-9. PMID 17287178.</ref> and CT (hypodense)<ref name=pmid19294869>[The von Meyenburg complex] Schwab SA, Bautz W, Uder M, Kuefner MA. Rontgenpraxis. 2008;56(6):241-4. German. PMID 19294869.</ref> - similar to metastases.
 
Microscopic:<ref>{{Ref MacSween|176}}</ref>
*Many bile ducts (tubular structures with cuboidal epithelium).
*Surrounded by a fibrous stroma.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Von_Meyenburg_complex_low_mag.jpg Von Meyenburg complex - bile duct hamartoma (WC)].
*[http://commons.wikimedia.org/wiki/File:Bile_duct_hamartoma_intermed_mag.jpg Bile duct hamartoma - intermed. mag. (WC)].


==Diseases==
=Diseases=
{{main|Medical liver disease}}
{{main|Medical liver disease}}
The liver is an organ of many medical diseases.
The liver is an organ of many medical diseases.


==Liver lesions==
=Liver lesions=
{{main|Liver neoplasms}}
{{main|Liver neoplasms}}
Includes pre-malignant lesions, i.e. dysplastic lesions, and malignant lesions, e.g. hepatocellular carcinoma (HCC).
Includes pre-malignant lesions, i.e. dysplastic lesions, and malignant lesions, e.g. [[hepatocellular carcinoma]] (HCC).


===Liver mass DDx (simple)===
==Liver mass DDx (simple)==
Basic DDx of a liver mass (5 Hs):<ref>Toronto Notes 2007. DM16.</ref>
Basic DDx of a liver mass (5 Hs):<ref name=Ref_TN2007>{{Ref TN2007|DM16}}</ref>
*Hepatocellular carcinoma (HCC).
*[[Hepatocellular carcinoma]] (HCC).
*Hydatid cyst.
*[[Hydatid cyst]].
**Images: [http://pathmicro.med.sc.edu/parasitology/hydatid-hist1.jpg Hydatid cyst (med.sc.edu)] [http://www.atlas.or.kr/atlas/include/viewImg.html?uid=645 Hydatid cyst (atlas.or.kr)] [http://cal.vet.upenn.edu/projects/paraav/images/lab7-14.jpg]
**Images: [http://pathmicro.med.sc.edu/parasitology/hydatid-hist1.jpg Hydatid cyst (med.sc.edu)] [http://www.atlas.or.kr/atlas/include/viewImg.html?uid=645 Hydatid cyst (atlas.or.kr)] [http://cal.vet.upenn.edu/projects/paraav/images/lab7-14.jpg]
*Hemangioma.
*[[Liver hemangioma]].
**Images: [http://www.pathguy.com/lectures/cavernous_hemangioma.jpg Hemangioma (pathguy.com)] [http://www.ikp.unibe.ch/lab2/Hemang.jpg Hemangioma (ikp.unibe.ch)]
**Images: [http://www.pathguy.com/lectures/cavernous_hemangioma.jpg Hemangioma (pathguy.com)] [http://www.ikp.unibe.ch/lab2/Hemang.jpg Hemangioma (ikp.unibe.ch)]
*Hepatic adenoma.
*[[Hepatic adenoma]].
*(focal nodular) hyperplasia.
*[[Focal nodular hyperplasia|Hyperplasia, focal nodular]].


===Cystic liver lesions===
==Cystic liver lesions==
Radiologic DDx:<ref>[http://radiographics.rsnajnls.org/cgi/content/abstract/21/4/895 http://radiographics.rsnajnls.org/cgi/content/abstract/21/4/895]</ref>
Radiologic DDx:<ref name=pmid11452064>{{Cite journal  | last1 = Mortelé | first1 = KJ. | last2 = Ros | first2 = PR. | title = Cystic focal liver lesions in the adult: differential CT and MR imaging features. | journal = Radiographics | volume = 21 | issue = 4 | pages = 895-910 | month =  | year =  | doi =  | PMID = 11452064 | url=http://radiographics.rsnajnls.org/cgi/content/abstract/21/4/895 }}</ref>
*Bile duct cyst.
*Bile duct cyst.
*Autosomal dominant polycystic liver disease.
*Autosomal dominant polycystic liver disease.
*Biliary hamartoma.
*Biliary hamartoma.
*Caroli disease.
*[[Caroli disease]].
*Undifferentiated embryonal sarcoma.
*Undifferentiated embryonal sarcoma.
*Biliary cystadenoma.  
*Biliary cystadenoma.  
*Cystadenocarcinoma.
*Cystadenocarcinoma.
*Cystic mets.
*Cystic metastasis.
*Pyogenic and amebic abscesses.
*Pyogenic and amebic abscesses.
*Intrahepatic hydatid cyst.
*Intrahepatic [[hydatid cyst]].
*Extrapancreatic pseudocyst.
*Extrapancreatic pseudocyst.
*Biloma.
*Biloma.
*Intrahepatic hematoma.
*Intrahepatic hematoma.


==See also==
=See also=
*[[Pancreas]].
*[[Pancreas]].
*[[Gastrointestinal pathology]].
*[[Gastrointestinal pathology]].
Line 514: Line 355:
*[[Medical liver disease]].
*[[Medical liver disease]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Gastrointestinal pathology]]
[[Category:Gastrointestinal pathology]]
[[Category:Liver pathology]]
[[Category:Liver pathology]]
Mark
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