Difference between revisions of "Cholestasis"

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#redirect [[Liver pathology#Cholestasis]]
In [[liver pathology]], '''cholestasis''' is a stoppage or abnormally slow flow of bile.
 
==General==
Clinical - classic:<ref>URL: [http://www.patient.co.uk/doctor/cholestasis http://www.patient.co.uk/doctor/cholestasis]. Accessed on: 28 November 2013.</ref>
*Dark urine and light stools.
 
Short DDx - by etiology:
*Congenital: Bile duct cyst, biliary atresia, liver cysts.
*Infectious: Worm.
*Tumour: pancreas, bile duct, liver.
*Endocrine: cholestasis of pregnancy.
*Trauma -> sepsis.
*Autoimmune: PSC, PBC.
*Toxins: alcohol -> cirrhosis.
*Everything else: drugs, e.g. [[NSAID]]s.
 
Short DDx - structural:
*Obstruction - large duct:
**Tumour.
**Gallstone.
**Worm.
**PSC.
*Small duct - autoimmune:
**PBC.
*Other:
**Rx.
**Toxins.
**Cholestasis of pregnancy.
 
==Microscopic==
Appearance of bile:
*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]].
 
===Brown/yellow cytoplasmic inclusions===
Comparison of brown/yellow cytoplasmic inclusions:<ref>Guindi, M. September 2009.</ref>
{| class="wikitable sortable" border="1"
! Finding
! Colour
! Granularity
! Refractile
! Usual location
! Association
! Stain
! Image
|-
| Iron||Brown||Coarse granules||Yes - shinny||Periportal<br>(zone I)||Hemolysis, hereditary hemochromatosis || [[Prussian blue stain|Prussian blue]] +ve || [[Image:Sickle_cell_disease_and_cirrhosis_-_very_high_mag.jpg|thumb|center|100px|Iron and bile. (WC)]]
|-
| Bile||Brown - coffee stained||Not granular||No - dull||Portal||Duct injury/obstruction
| None || [[Image:Cholestasis_high_mag.jpg|thumb|100px|center|Bile. (WC)]]
|-
| Lipofuscin||Yellow||Fine granules||No||Centrilobular<br>(zone III)||Advanced age || [[PAS stain]] +ve || [[Image:Ground_glass_hepatocytes_high_mag_cropped.jpg|thumb|100px|center|Lipofuscin. (WC)]]
|-
|}
 
===Large duct obstruction===
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>
 
Note:
*''Ductular reaction'' = increased number of ducts + [[neutrophil]]s.<ref name=pmid9845427>{{Cite journal  | last1 = Roskams | first1 = T. | last2 = Desmet | first2 = V. | title = Ductular reaction and its diagnostic significance. | journal = Semin Diagn Pathol | volume = 15 | issue = 4 | pages = 259-69 | month = Nov | year = 1998 | doi =  | PMID = 9845427 }}</ref>
 
===Small duct obstruction===
Small-duct obstruction:
*Abnormal liver plate architecture. (???)
 
====Images====
<gallery>
Image:Cholestasis_high_mag.jpg | Cholestasis. (WC/Nephron)
</gallery>
www:
*[http://www.humpath.com/spip.php?article4340&id_document=20040 Centrilobular cholestasis (humpath.com)].
 
==Sign out==
<pre>
LIVER, CORE BIOPSY:
- CENTRILOBULAR CHOLESTATSIS (MILD), SEE MICROSCOPIC DESCRIPTION AND COMMENT.
- NEGATIVE FOR FIBROSIS.
 
COMMENT:
There is no apparent feathery degeneration. There is no bile ductular proliferation. No
definite onion-skin lesions are identified.
 
The centrilobular distribution of the bile favours a large duct obstruction. Possible
causes include gallstones, other obstructing lesions, herbals and drugs.
 
Clinical and radiologic correlation is suggested.
</pre>
 
==See also==
*[[Ballooning degeneration]].
*[[Drug-induced liver injury]].
 
==References==
{{reflist|1}}
 
[[Category:Diagnosis]]
[[Category:Liver pathology]]

Revision as of 22:47, 3 January 2016

In liver pathology, cholestasis is a stoppage or abnormally slow flow of bile.

General

Clinical - classic:[1]

  • Dark urine and light stools.

Short DDx - by etiology:

  • Congenital: Bile duct cyst, biliary atresia, liver cysts.
  • Infectious: Worm.
  • Tumour: pancreas, bile duct, liver.
  • Endocrine: cholestasis of pregnancy.
  • Trauma -> sepsis.
  • Autoimmune: PSC, PBC.
  • Toxins: alcohol -> cirrhosis.
  • Everything else: drugs, e.g. NSAIDs.

Short DDx - structural:

  • Obstruction - large duct:
    • Tumour.
    • Gallstone.
    • Worm.
    • PSC.
  • Small duct - autoimmune:
    • PBC.
  • Other:
    • Rx.
    • Toxins.
    • Cholestasis of pregnancy.

Microscopic

Appearance of bile:

  • Smooth/homogenous.
  • Brown/yellow.
  • Globule/droplet - that is larger than an iron granule.

Note:

Brown/yellow cytoplasmic inclusions

Comparison of brown/yellow cytoplasmic inclusions:[2]

Finding Colour Granularity Refractile Usual location Association Stain Image
Iron Brown Coarse granules Yes - shinny Periportal
(zone I)		 Hemolysis, hereditary hemochromatosis Prussian blue +ve
Iron and bile. (WC)
Bile Brown - coffee stained Not granular No - dull Portal Duct injury/obstruction None
Bile. (WC)
Lipofuscin Yellow Fine granules No Centrilobular
(zone III)		 Advanced age PAS stain +ve
Lipofuscin. (WC)

Large duct obstruction

Histologic findings of large-duct obstruction:[3]

  1. Perivenular bilirubinostasis.
  2. Portal tract edema & inflammation (neutrophils & macrophages).
  3. Large bile plugs.
  4. Bile duct proliferation.[4][5]

Note:

Small duct obstruction

Small-duct obstruction:

  • Abnormal liver plate architecture. (???)

Images

  • Cholestasis. (WC/Nephron)

www:

Sign out

LIVER, CORE BIOPSY:
- CENTRILOBULAR CHOLESTATSIS (MILD), SEE MICROSCOPIC DESCRIPTION AND COMMENT.
- NEGATIVE FOR FIBROSIS.

COMMENT:
There is no apparent feathery degeneration. There is no bile ductular proliferation. No
definite onion-skin lesions are identified.

The centrilobular distribution of the bile favours a large duct obstruction. Possible
causes include gallstones, other obstructing lesions, herbals and drugs.

Clinical and radiologic correlation is suggested.

See also

References

  1. ↑ URL: http://www.patient.co.uk/doctor/cholestasis. Accessed on: 28 November 2013.
  2. ↑ Guindi, M. September 2009.
  3. ↑ Burt, Alastair D.;Portmann, Bernard C.;Ferrell, Linda D. (2006). MacSween's Pathology of the Liver (5th ed.). Churchill Livingstone. pp. 565. ISBN 978-0-443-10012-3.
  4. ↑ Chapman RW, Arborgh BA, Rhodes JM, et al. (October 1980). "Primary sclerosing cholangitis: a review of its clinical features, cholangiography, and hepatic histology". Gut 21 (10): 870–7. PMC 1419383. PMID 7439807. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1419383/.
  5. ↑ Leuschner U (November 2003). "Primary biliary cirrhosis--presentation and diagnosis". Clin Liver Dis 7 (4): 741–58. PMID 14594129.
  6. ↑ Roskams, T.; Desmet, V. (Nov 1998). "Ductular reaction and its diagnostic significance.". Semin Diagn Pathol 15 (4): 259-69. PMID 9845427.
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