Talk:Medical liver disease

TPN

Microscopic description

The specimen consists of liver cores with at least twelve partial portal tracts. There is a moderate macrovesicular steatosis without clear zonation. There are no mallory bodies.

There is marked cholestasis and focal hepatocyte enlargement with nuclear pyknosis and karyolysis (feathery degeneration). There is no interface inflammation or lobular inflammation and only mild portal inflammation, that is predominantly mononuclear. There is a suggestion of scant, mild iron deposition at high power and mild-to-moderate periportal copper deposition. There is no obvious bile duct injury on routine stains. Cytokeratin staining (panker) demonstrates bile ductular proliferation. There is marked fibrotic portal expansion, with thick fibrous septa. There are rare rounded septa, suggestive of focal nodule formation; Laennec fibrosis stage is II-III / IV. The PAS and PAS-D stains are non-contributory.

Final diagnosis

Liver, core biopsy -
i) Macrovesicular steatosis, moderate.
ii) Cholestasis with bile ductule proliferation.
iii) Moderate-to-marked fibrosis, periportal; Laennec fibrosis stage II-III / IV.

See diagnosis comment.

Comment

The histomorphologic findings (cholestasis, fibrosis and steatosis) are compatible with changes seen in total parenteral nutrition (TPN).

Glycogen storage disease

Microscopic description

The sections show hepatocytes with moderate enlargement and pale cytoplasm diffusely, with cobweb-like cytoplasmic material. Focally, hepatocytes have marked enlargement with pynotic nuclei. There are ten portal tracts present in the specimen.

There is minimal focal portal inflammation and moderate inflammation of the lobule, characterized by eosinophils and neutrophils, with focal hepatocyte necrosis. There is no inflammation at the interface. The Laennec inflammation grade is I-II/IV. There is significant fibrosis, which includes the presence of portal expansion and septa; the Laennec fibrosis stage is II / IV.

There is no cholestasis, no iron deposition, no bile duct injury and no copper deposition. PAS staining is equivocal for glycogen deposition. PAS-D marks scattered, predominantly periportal, macrophages.

Electron microscopy demonstrates electron dense material consistent with glycogen that is not membrane bound.

Final diagnosis

Liver, core biopsy -
i) Changes consistent with glycogen storage disease, see comment.
ii) Fibrotic portal expansion and focal septa (Laennec fibrosis stage II / IV).

Comment

The periportal predominant fibrosis, diffuse hepatocyte distension with whispy and pale cytoplasm, and non-membrane bound electron dense (glycogen-like) material, are suggestive of glycogen storage disease type III (Cori disease).

Possibly PSC

Microscopic

The specimen has an adequate length (>2.0 cm) but contains only six complete portal tracts (11-15 desired).

There is mild periductal fibrosis (with a suggestion of an onion skin-like arrangement in one portal tract), mild periportal intrahepatocyte copper deposition, focal bile ductular proliferation, focal bile duct lymphocytic infiltration, and bile duct cell anisonucleosis. There is disruption of the hepatocyte plates and hepatocyte anisonucleosis, suggestive of a hepatocellular injury; however, there is no frank hepatocyte necrosis and the plate thickness is within normal limits.

There is no cholestasis, interface hepatitis, or portal or lobular inflammatory infiltrate (Laennec inflammation Grade 0/IV). The PAS, PAS-D and Shikata stains are non-contributory. There is no fatty change of hepatocytes. The portal tracts have an irregular outline focally and occasional delicate periportal fibrous septae (Laennec fibrosis Stage I/IV).

Final diagnosis

Liver, core biopsy - Focal bile duct abnormalities without cholestasis and no significant inflammation, see comment.

Comment

The bile ducts have focal non-specific abnormalities without cholestasis that are not sufficient to diagnose primary sclerosing cholangitis (PSC). It is possible that this represents PSC, which is often patchy, and may have not been sampled in the relatively small number of portal tracts present in this biopsy. The histomorphologic findings are not compatible with autoimmune hepatitis.

Steatohepatitis & viral hepatitis

Microscopic

Size of biopsy: Adequate
Fragmentation: Absent
Fibrosis: Stage 2-3/4, mostly stage 2
Fibrous septa: Present
Septa with curved contours: Present – focally only
Large droplet steatosis (% of hepatocytes): Present, moderate 60%
Ballooning of hepatocytes: Present, rare
Mallory-Denk bodies: Present, rare
Portal inflammation: Present
Interface activity: Minimal (0-1/4)
Lobular necroinflammation: Minimal
Ducts: Present in normal numbers
Duct injury: Absent
Ductular reaction: Absent
Cholestasis: Absent
Terminal hepatic venules: Present
Iron stain: Absent
Ground glass cells with routine stains: Absent
PASD for alpha-1 antitrypsin droplets: Negative 

Final diagnosis

Liver (random) medical core biopsies:
- Liver with minimal chronic hepatitis (grade 0-1/4), with moderate fibrosis (stage 2-3/4).
- Minimal steatohepatitis.
- Moderate steatosis.

Possible drug-induced hepatitis

Final diagnosis

Liver (random) medical core biopsies:
- Liver with mild steatosis.
- Marked fibrosis (stage 3 of 4).
- Negative for steatohepatitis.
- Scattered eosinophils in the portal tracts, see comment.

Comment

The findings are consistent with a resolving steatoheptitis.

The eosinophils in the portal tracts raise the possibility of a drug-induced or herbal-induced hepatitis. The use of ibuprofen is noted in the clinical history; however, this is not typically associated with steatosis.