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Difference between revisions of "Liver pathology"
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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. | |||
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. | 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. | ||
Almost every differential in liver pathology has "drugs" -- if it isn't clearly malignancy. | Almost every differential in liver pathology has "drugs" -- if it isn't clearly malignancy. | ||
==Review of liver blood work== | ==Review of liver blood work== | ||
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*''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> | *''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. | *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> | **<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> | ||
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**Bile duct - should have a lumen and be round. | **Bile duct - should have a lumen and be round. | ||
***Cuboidal epithelium, central nucleus, lightly basophilic cytoplasm. | ***Cuboidal epithelium, central nucleus, lightly basophilic cytoplasm. | ||
***IHC: CK7+. | ***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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***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== | ||
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Notes: | Notes: | ||
*" | *The term "acute" is infrequently used in liver pathology. | ||
*In the liver: '' | *In the liver: neutrophils ''is not'' acute -- unlike most elsewhere in the body.<ref>OA. September 2009.</ref> | ||
==Stains== | ==Stains== | ||
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===Liver stains - standard at one hospital=== | ===Liver stains - standard at one hospital=== | ||
IHC panel/special stains:<ref name=ap27may09>AP 27 May 2009.</ref> | IHC panel/special stains:<ref name=ap27may09>AP. 27 May 2009.</ref> | ||
*PAS-D - to detect mucin. | *PAS-D - to detect mucin. | ||
*PAS - to detect glycogen and mucin. | *PAS - to detect glycogen and mucin. | ||
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==="Ground glass" hepatocytes=== | ==="Ground glass" hepatocytes=== | ||
*Eosinophilic dull/hazy, somewhat irregular cytoplasm. | *Eosinophilic dull/hazy, somewhat irregular cytoplasm. | ||
**Ground glass<ref>[http://en.wikipedia.org/wiki/Ground_glass]</ref> = glass with a rough/flat finish; glass that is translucent and has a matte finish. | **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. | ||
***The term is frequently used in radiology to describe hazy radiodense areas in the lung.<ref>[http://www.healthsystem.virginia.edu/internet/radiology/educ/groundglass.cfm http://www.healthsystem.virginia.edu/internet/radiology/educ/groundglass.cfm]</ref> | ***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. | *Usually suggests '''chronic''' [[HBV]] infection. | ||
**Pattern NOT seen in acute HBV. | **Pattern NOT seen in acute HBV. | ||
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====Classification==== | ====Classification==== | ||
*Several different types of GGHs are | *GGHs are not routinely classified. | ||
Notes: | |||
*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> | |||
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 | 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 | ||
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Micrographs: | Micrographs: | ||
*[http://commons.wikimedia.org/wiki/File:Mallory_body_high_mag_cropped.jpg Mallory body (WC)]. | *[http://commons.wikimedia.org/wiki/File:Mallory_body_high_mag_cropped.jpg Mallory body (WC)]. | ||
*[http://en.wikipedia.org/wiki/File:CDC_mallory_bodies.jpg Mallory bodies - CDC/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)]. | ||
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***The normal reticulin pattern is chicken wire-like; in early pre-cirrhosis (Grade 1-2) the chicken wire is collapsed/flattened. | ***The normal reticulin pattern is chicken wire-like; in early pre-cirrhosis (Grade 1-2) the chicken wire is collapsed/flattened. | ||
''Toronto General Hospital'' uses ''Laennec fibrosis''; named after French chest physician.<ref name=pmid3304599>Why does cirrhosis belong to Laennec? Duffin JM. CMAJ. 1987 Sep 1;137(5):393-6. PMID 3304599. URL: [http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1492806&pageindex=4 http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1492806&pageindex=4]</ref> | |||
''Laennec fibrosis'' (grade):<ref>[http://www.pulsus.com/cddw2000/abs/080.htm http://www.pulsus.com/cddw2000/abs/080.htm]</ref> | ''Laennec fibrosis'' (grade):<ref>[http://www.pulsus.com/cddw2000/abs/080.htm http://www.pulsus.com/cddw2000/abs/080.htm]</ref> | ||
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===Cholestasis=== | ===Cholestasis=== | ||
Appearance of bile: | Appearance of bile: | ||
*Smooth/homogenous | *Smooth/homogenous. | ||
*Brown/yellow | *Brown/yellow. | ||
*Globule/droplet - that is larger than an iron granule. | *Globule/droplet - that is larger than an iron granule. | ||
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==Diseases== | ==Diseases== | ||
{{main|Medical liver disease}} | {{main|Medical liver disease}} | ||
The liver is an organ of many diseases. | The liver is an organ of many medical diseases. | ||
==Liver lesions== | ==Liver lesions== | ||
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===Liver mass DDx (simple)=== | ===Liver mass DDx (simple)=== | ||
Basic DDx of a liver mass (5 Hs):<ref> | Basic DDx of a liver mass (5 Hs):<ref>Toronto Notes 2007. DM16.</ref> | ||
*Hepatocellular carcinoma (HCC). | *Hepatocellular carcinoma (HCC). | ||
*Hydatid cyst. | *Hydatid cyst. | ||