Difference between revisions of "Medical liver disease"

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Medical liver disease (view source)

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==Autoimmune hepatitis with obstruction - combined changes==
==Autoimmune hepatitis with obstruction - combined changes==
{|
A. [[File:1 AIH OBS 1.tif|Low power shows inflammation; portal triads, lobules, central veins cannot be distinguished (40X).]]
[[File:1 AIH OBS 1.tif|Low power shows inflammation; portal triads, lobules, central veins cannot be distinguished (40X).]]
[[File:2 AIH OBS 1.tif|Trichrome shows central venous sclerosis (red arrowhead), periportal fibrosis (green arrowhead), & space of Disse collagenization (yellow arrowhead); juxtaposition of central vein & portal tract indicates collapse, no definite bridging was seen (100X)]]
<br>
<br>
[[File:3 AIH OBS 1.tif|Central vein is inflamed with a rare plasma cell (cyan arrowhead) (400X).]]
B. [[File:2 AIH OBS 1.tif|Trichrome shows central venous sclerosis (red arrowhead), periportal fibrosis (green arrowhead), & space of Disse collagenization (yellow arrowhead); juxtaposition of central vein & portal tract indicates collapse, no definite bridging was seen (100X)]]
[[File:4 AIH OBS 1.tif|Interface hepatitis with plasma cells (yellow arrows) and ballooned hepatocytes (red arrows).  Lobule is disorganized (400X).]]
<br>
<br>
[[File:5 AIH OBS 1.tif|Proliferating bile ductules (blue arrows) with occasional neutrophils (fucsia arrows), indicative of obstruction, but not acute cholangitis, which requires inflamed bile duct itself, best diagnosed with associated blood vessel (400X).]]
C. [[File:3 AIH OBS 1.tif|Central vein is inflamed with a rare plasma cell (cyan arrowhead) (400X).]]
[[File:6 AIH OBS 1.tif|Rare distorted rosettes with greenish brown strands of bile (left arrow) or bile plugs (right arrow) (400X).]]
<br>
|}
D. [[File:4 AIH OBS 1.tif|Interface hepatitis with plasma cells (yellow arrows) and ballooned hepatocytes (red arrows).  Lobule is disorganized (400X).]]
Patient with SLE and obstructive jaundice that resolved with apparent passage of stone. Low power shows inflammation; portal triads, lobules, central veins cannot be distinguished (left row 1 40X). Trichrome shows central venous sclerosis (red arrowhead), periportal fibrosis (green arrowhead), & space of Disse collagenization (yellow arrowhead); juxtaposition of central vein & portal tract indicates collapse, no definite bridging was seen (right row 1 100X). Central vein is inflamed with a rare plasma cell (cyan arrowhead) (left row 2 400X). Interface hepatitis with plasma cells (yellow arrows) and ballooned hepatocytes (red arrows). Lobule is disorganized (right row 2 400X). Proliferating bile ductules (blue arrows) with occasional neutrophils (fucsia arrows), indicative of obstruction, but not acute cholangitis, which requires inflamed bile duct itself, best diagnosed with associated blood vessel (left row 3 400X). Rare distorted rosettes with greenish brown strands of bile (left arrow) or bile plugs (right arrow) (right row 3 400X).
<br>
E. [[File:5 AIH OBS 1.tif|Proliferating bile ductules (blue arrows) with occasional neutrophils (fucsia arrows), indicative of obstruction, but not acute cholangitis, which requires inflamed bile duct itself, best diagnosed with associated blood vessel (400X).]]
<br>
F. [[File:6 AIH OBS 1.tif|Rare distorted rosettes with greenish brown strands of bile (left arrow) or bile plugs (right arrow) (400X).]]
<br>
Patient with SLE and obstructive jaundice that resolved with apparent passage of stone. A. Low power shows inflammation; portal triads, lobules, central veins cannot be distinguished. B. Trichrome shows central venous sclerosis (red arrowhead), periportal fibrosis (green arrowhead), & space of Disse collagenization (yellow arrowhead); juxtaposition of central vein & portal tract indicates collapse, no definite bridging was seen. C. Central vein is inflamed with a rare plasma cell (cyan arrowhead). D. Interface hepatitis with plasma cells (yellow arrows) and ballooned hepatocytes (red arrows). Lobule is disorganized. E. Proliferating bile ductules (blue arrows) with occasional neutrophils (fucsia arrows), indicative of obstruction, but not acute cholangitis, which requires inflamed bile duct itself, best diagnosed with associated blood vessel. F. Rare distorted rosettes with greenish brown strands of bile (left arrow) or bile plugs (right arrow).


==Autoimmune hepatitis-primary biliary cirrhosis overlap syndrome==
==Autoimmune hepatitis-primary biliary cirrhosis overlap syndrome==
Line 331: Line 333:
===Microscopic===
===Microscopic===
:See: ''[[autoimmune hepatitis]]'' and ''[[primary biliary cirrhosis]]''.
:See: ''[[autoimmune hepatitis]]'' and ''[[primary biliary cirrhosis]]''.
{|
A. [[File:1 AIH PBC 1 680x512px.tif|Expanded portal tracts with fuzzy edges (40X).]]
[[File:1 AIH PBC 1 680x512px.tif|Expanded portal tracts with fuzzy edges (40X).]]
<br>
[[File:2 AIH PBC 1 680x512px.tif|Interface hepatitis with plasma cells (400X).]]
B. [[File:2 AIH PBC 1 680x512px.tif|Interface hepatitis with plasma cells (400X).]]
<br>
C. [[File:3 AIH PBC 1 680x512px.tif|Loose granuloma (400X).]]
<br>
D. [[File:4 AIH PBC 1 680x512px.tif|Damaged bile duct (400X).]]
<br>
<br>
[[File:3 AIH PBC 1 680x512px.tif|Loose granuloma (400X).]]
AIH/PBC overlap. AMA & ANA positive with Alkaline phosphatase > 2 upper limit of normal & one ALT > 5 times upper limit of normal. A. Expanded portal tracts with fuzzy edges. B. Interface hepatitis with plasma cells. C. Loose granuloma. D. Damaged bile duct.
[[File:4 AIH PBC 1 680x512px.tif|Damaged bile duct (400X).]]
|}
 
AIH/PBC overlap. AMA & ANA positive with Alkaline phosphatase > 2 upper limit of normal & one ALT > 5 times upper limit of normal. Expanded portal tracts with fuzzy edges (UL 40X). IInterface hepatitis with plasma cells (UR 400X). Loose granuloma (LL 400X). Damaged bile duct (LR 400X).


==Primary sclerosing cholangitis==
==Primary sclerosing cholangitis==
Line 384: Line 386:


=Other=
=Other=
==Primary Systemic Sclerosis==
[[File:5 05168051 sl 1.png |Primary systemic sclerosis in the liver]]
[[File:5 05168051 sl 2.png |Primary systemic sclerosis in the liver]]
[[File:5 05168051 sl 3.png |Primary systemic sclerosis in the liver]]
[[File:5 05168051 sl 4.png |Primary systemic sclerosis in the liver]]
[[File:5 05168051 sl 5.png |Primary systemic sclerosis in the liver]]
[[File:5 05168051 sl 6.png |Primary systemic sclerosis in the liver]]
<br>
Primary systemic sclerosis in a 67 year old White, non-Hispanic man who had undergone renal transplantation for idiopathic nodular glomerusclerosis, which had recurred in 2013. He had been scheduled to receive a second transplantation, but had not yet received one.  The patient had a positive anti-nuclear antigen study, with a positive scleroderma antibody (SCL-70), a high SCL-70 antibody index of 3.9, and negative DNA, Chromatin, Anti-Riboscomal P, SS-A, SS-B, anti Smith, RNP, JO-1, anticentromere antibody and rheumatoid factor serologic studies.  Hepatitis A, B, and C serologic studies were negative. Liver function tests showed normal albumin and total bilirubin levels with alkaline phosphatase of 712 IU/L (35-129 normal range), alanine aminotransferase 59 IU/L (5-41 normal range), and aspartate aminotransferase 68 IU/L (5-37 normal range). This case provisions many of the features known to be present in primary systemic sclerosis as seen in the skin. A. At low power, triads appear almost as white ghosts against a relatively normal set of hepatocyte lobules. B. Closer examination reveals some triads to be expanded, with peripheral bile ductular proliferation and modest associated chronic inflammation without interface hepatitis. C. Portal arterioles had thick walls; inflammation included lymphocytes and occasional plasma cells. D. Trichrome failed to stain the material in the triads blue, but did show space of Disse collagenization. E. PAS with diastase showed positive staining of the material with emphasis on the arteriole walls. F. Hemosiderosis was seen on iron stain.
==Budd-Chiari syndrome==
==Budd-Chiari syndrome==
*[[AKA]] ''hepatic vein obstruction''.
*[[AKA]] ''hepatic vein obstruction''.
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*[[CK7]] -ve.
*[[CK7]] -ve.
**Marks bile ducts.
**Marks bile ducts.
==Hepatic Graft versus Host Disease (L-GVHD)==
[[File:3 579232643 sl 1.png| Hepatic graft versus host disease (L-GVHD)]]
[[File:3 579232643 sl 2.png| Hepatic graft versus host disease (L-GVHD)]]
[[File:3 579232643 sl 3.png| Hepatic graft versus host disease (L-GVHD)]]
[[File:3 579232643 sl 4.png| Hepatic graft versus host disease (L-GVHD)]]
[[File:3 579232643 sl 5.png| Hepatic graft versus host disease (L-GVHD)]]
[[File:3 579232643 sl 6.png| Hepatic graft versus host disease (L-GVHD)]]
[[File:3 579232643 sl 7.png| Hepatic graft versus host disease (L-GVHD)]]
<br>
Hepatic graft versus host disease (L-GVHD) in a 22 yo man who underwent bone marrow transplantation after developing ALL. A. Low power view shows brownish discoloration in triad, but is otherwise of little interest. B. Arterioles in triads were accompanied by bile ducts in only 30% of cases; this image shows an arteriole without a bile duct. Note the pigment and the accompanying macrophage/lymphocyte inflammation, not extreme. The added chronic inflammation is a feature of chronic L-GVHD. C. Bile ducts, when shown, showed extensive damage, here seen as loss of cytoplasm,  and nuclear pleomorphism and hyperchromasia (other degenerative changes, not seen here, include nuclear dropout or necrosis, cytoplasmic eosinophilia, loss of duct lumen). Lymphocytosis into the ducts was not seen. D. Ballooned hepatocytes and dilated canaliculi were seen. E. Pigment was present, but mostly in Kupffer cells, not hepatocytes or as bile plugs. F. Up to two foci of spotty necrosis were seen in a 100X field (field shown is 200X); not shown are rare apoptotic hepatocytes. G. An iron stain showed the pigment represented extemsive iron deposition, with emphasis on Kupffer cells and portal triad macrophages, frustrating definite assessment of bile plugs in canaliculi. The hemosiderosis resulted from the many blood transfusions the patient had received.


==Extrahepatic biliary obstruction==
==Extrahepatic biliary obstruction==
{|
A. [[File:1 OBS 3 680x512px.tif|Sinusoidal dilatation, circular spaces of hepatocytes, small portal triads(40X).]]
[[File:1 OBS 3 680x512px.tif|Sinusoidal dilatation, circular spaces of hepatocytes, small portal triads(40X).]]
<br>
[[File:2 OBS 3 680x512px.tif|Bile in hepatocytes about central vein & in plugs in canaliculi [yellow arrowhead] (400X).]]
B. [[File:2 OBS 3 680x512px.tif|Bile in hepatocytes about central vein & in plugs in canaliculi [yellow arrowhead] (400X).]]
<br>
C. [[File:3 OBS 3 680x512px.tif|Trichrome shows fibrosis about central vein (400X).]]
<br>
D. [[File:4 OBS 3 680x512px.tif|PAS with diastase shows portal triads with mild edema and chronic inflammation, without tortuous bile duct (400X).]]
<br>
Early extrahepatic biliary obstruction, demonstrated radiographically, transient, with rise in bilirubin, alkaline phosphatase, and transaminases. Pure canalicular cholestasis near terminal hepatic venules also seen in acute hepatitis, drug reactions, benign recurrent cholestasis, pregnancy, sepsis, & lymphomas. A. Sinusoidal dilatation, circular spaces of hepatocytes, small portal triads. B. Bile in hepatocytes about central vein & in plugs in canaliculi [yellow arrowhead]. C. Trichrome shows fibrosis about central vein. D. PAS with diastase shows portal triads with mild edema and chronic inflammation, without tortuous bile duct.
<br>
<br>
[[File:3 OBS 3 680x512px.tif|Trichrome shows fibrosis about central vein (400X).]]
A. [[File:1 OBS 2 680x512px.tif|Expanded inflamed portal triads, swollen hepatocytes (40X)]]
[[File:4 OBS 3 680x512px.tif|PAS with diastase shows portal triads with mild edema and chronic inflammation, without tortuous bile duct (400X).]]
|}
Early extrahepatic biliary obstruction, demonstrated radiographically, transient, with rise in bilirubin, alkaline phosphatase, and transaminases. Pure canalicular cholestasis near terminal hepatic venules also seen in acute hepatitis, drug reactions, benign recurrent cholestasis, pregnancy, sepsis, & lymphomas.  Sinusoidal dilatation, circular spaces of hepatocytes, small portal triads(UL 40X). Bile in hepatocytes about central vein & in plugs in canaliculi [yellow arrowhead] (UR 400X). Trichrome shows fibrosis about central vein (LL 400X). PAS with diastase shows portal triads with mild edema and chronic inflammation, without tortuous bile duct (LR 400X).
 
{|
[[File:1 OBS 2 680x512px.tif|Expanded inflamed portal triads, swollen hepatocytes (40X)]]
[[File:2 OBS 2 680x512px.tif|Edematous stroma, proliferating ductules [yellow arrowheads], PAS-D macrophages [red arrowhead] (PAS with diastasse, 200X)]]
<br>
<br>
[[File:3 OBS 2 680x512px.tif|Disordered, often swollen hepatocytes,some with feathery degeneration (net like spaces in cytoplasm [blue arrowhead], rare Councilman body [green arrowhead] (400X)]]
B. [[File:2 OBS 2 680x512px.tif|Edematous stroma, proliferating ductules [yellow arrowheads], PAS-D macrophages [red arrowhead] (PAS with diastasse, 200X)]]
[[File:4 OBS 2 1360x1024px.tif|Bile in hepatocytes [cyan arrrowhead] & in canaliculi [purple arrowheads]. Empty acinar spaces bounded by hepatocytes [orange arrowhead] (400X, higher pixel),]]
|}
Changes of extrahepatic biliary obstruction, months duration. Expanded inflamed portal triads, swollen hepatocytes (UL 40X). Edematous stroma, proliferating ductules [yellow arrowheads], PAS-D macrophages [red arrowhead] (UR PAS with diastasse, 200X). Disordered, often swollen hepatocytes,some with feathery degeneration (net like spaces in cytoplasm)  [blue arrowhead], rare Councilman body [green arrowhead] (LL 400X). Bile in hepatocytes [cyan arrrowhead] & in canaliculi [purple arrowheads]. Empty acinar spaces bounded by hepatocytes [orange arrowhead] (LR 400X).
{|
[[File:1 Bd obs 4 680x512px.tif|Expanded, light colored portal triads (arrows)(20X).]]
[[File:2 Bd obs 4 680x512px.tif|Proliferating bile ductules (cyan arrows) with neutrophils (yellow arrows), not specific for acute cholangitis, of assistance with large bile duct obstruction (400X)..]]
<br>
<br>
[[File:3 Bd obs 4 680x512px.tif|Uninflamed interlobular duct (yellow arrow) with, accompanying blood vessel (red arrow) (400X)]]
C. [[File:3 OBS 2 680x512px.tif|Disordered, often swollen hepatocytes,some with feathery degeneration (net like spaces in cytoplasm [blue arrowhead], rare Councilman body [green arrowhead] (400X)]]
[[File:4 Bd obs 4 680x512px.tif|Bile infarct with pyknotic nuclei (arrows)(400X).]]
<br>
<br>
[[File:5 Bd obs 4 680x512px.tif|Bile (arrow) in interlobular bile duct with disordered nuclei (400X).]]
D. [[File:4 OBS 2 1360x1024px.tif|Bile in hepatocytes [cyan arrrowhead] & in canaliculi [purple arrowheads]. Empty acinar spaces bounded by hepatocytes [orange arrowhead] (400X, higher pixel),]]
[[File:6 Bd obs 4 680x512px.tif|Bile plugs in cannaliculi (red arrows), feathery degeneration producing foamy macrophage like hepatocytes (yellow arrows)(400X).]]
|}
Large bile duct obstruction. Expanded, light colored portal triads (arrows)(Row 1 Left 20X). Proliferating bile ductules (cyan arrows) with neutrophils (yellow arrows), not specific for acute cholangitis, of assistance with large bile duct obstruction (Row 1 Right 400X). Uninflamed interlobular duct (yellow arrow) with, accompanying blood vessel (red arrow) (Row 2 Left 400X). Bile infarct with pyknotic nuclei (arrows)(Row 2 Right 400X). Bile (arrow) in interlobular bile duct with disordered nuclei (Row 3 Left 400X). Bile plugs in cannaliculi (red arrows), feathery degeneration producing foamy macrophage-like hepatocytes (yellow arrows)(Row 3 Right 400X).
 
==Congestive hepatopathy==
===General===
*Liver failure due to (right) heart failure.
*AKA ''cardiac cirrhosis'' - a term used by clinicians.
**Generally, it does not satisfy pathologic criteria for cirrhosis.<ref>URL: [http://emedicine.medscape.com/article/151792-overview http://emedicine.medscape.com/article/151792-overview]. Accessed on: 17 June 2010.</ref>
 
===Gross===
*"Nutmeg" liver - yellow spotted appearance.
 
===Microscopic===
Features:<ref>URL: [http://emedicine.medscape.com/article/151792-diagnosis http://emedicine.medscape.com/article/151792-diagnosis]. Accessed on: 17 June 2010.</ref>
*Zone III atrophy.
*Portal venule (central vein) distension.
*Perisinusoidal fibrosis - progresses to centrilobular fibrosis and then diffuse fibrosis.
*Dilation of sinusoids in ''all'' zone III areas - '''key feature'''.<ref>Suggested by OA. September 2009.</ref>
 
DDx:
*[[Hemangioma of the liver]] - should be focal lesion.
Cardiac (congestive) hepatopathy, wherein outflow obstruction occurs secondary to backflow from a failing heart, and Budd Chiari syndrome, wherein obstruction of outflow occurs secondary to obstruction, usually thrombotic, have overlapping features, including sinusoidal dilation with emphasis upon the central vein, space of Disse erythrocytes, centrilobular inflammation, hemorrhage, bile ductules, and hemosiderin, and portal inflammation, fibrosis and bile ductular reaction. Centrilobular dropout/necrosis is more common in Budd Chiari syndrome, while peri-central venous and sinusoidal fibrosis are more common in cardiac hepatopathy.  In end stage liver, fibrosis for cardiac hepatopathy  comprises stellate centrizonal fibrous with haphazard spread, as opposed to the more frequent nodular cirrhosis in Budd-Chiari. Clinical findings are important to take into account, as cardiac failure is usually well known at the time of diagnosis as are the clinical predictors of Budd Chiari syndrome, prothrombotic states, myeloproliferative diseases, and oral contraceptive use. <ref name=pmid27681331 >{{cite journal |author=Gonzalez RS, Gilger MA, Huh WJ, Washington MK |title=The spectrum of histologic findings in hepatic outflow obstruction |journal= Arch Pathol Lab Med |volume=141 |issue= |pages=98 |year=2017 |pmid= 27681331 ||doi= 10.5858/arpa.2015-0388-OA |url=http http://www.archivesofpathology.org/doi/10.5858/arpa.2015-0388-OA?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&code=coap-site }}</ref> 
====Images====
<gallery>
Image:Congestive_hepatopathy_high_mag.jpg | Mild congestive hepatopathy. (WC)<br>
A.[[File:1 CEN NEC 1 680x512px.tif|PAS without diastase shows ovoids of necrosis {40X).]]<br>
B. [[File:2 CEN NEC 1 680x512px.tif|Necrosis with central vein [yellow arrowhead], inflammatory cells, residual Councilman body [green arrowhead], and hepatocyte with mitotic figure [red arrowhead] (400X).]]
<br>
<br>
C. [[File:3 CEN NEC 1 680x512px.tif|Trichrome highlights fibrosis about central vein [yellow arrowhead] & shows beginning scar formation [green arrowheads]. Note residual atrophic hepatocytes [blue arrowheads] (400X).]]
Changes of extrahepatic biliary obstruction, months duration. A. Expanded inflamed portal triads, swollen hepatocytes. B. Edematous stroma, proliferating ductules [yellow arrowheads], PAS-D macrophages [red arrowhead]. C. Disordered, often swollen hepatocytes,some with feathery degeneration (net like spaces in cytoplasm)  [blue arrowhead], rare Councilman body [green arrowhead]. D. Bile in hepatocytes [cyan arrrowhead] & in canaliculi [purple arrowheads]. Empty acinar spaces bounded by hepatocytes [orange arrowhead].
<br>
<br>
D. [[File:4 CEN NEC 1 680x512px.tif|Portal triads are largely unaffected (400X).]]
A. [[File:1 Bd obs 4 680x512px.tif|Expanded, light colored portal triads (arrows)(20X).]]
|}<br>
Centrilobular necrosis (seen in circulatory failure and with toxins/drugs). A. PAS without diastase shows ovoids of necrosis. B. Necrosis with central vein [yellow arrowhead], inflammatory cells, residual Councilman body [green arrowhead], and hepatocyte with mitotic figure [red arrowhead]. C. Trichrome highlights fibrosis about central vein [yellow arrowhead] & shows beginning scar formation [green arrowheads]. Note residual atrophic hepatocytes [blue arrowheads]. D. Portal triads are largely unaffected (LR 400X)
<br>
<br>
A. [[File:1 CHF 1 680x512px.tif|Dilated and undilated sinusoidal regions (40X).]]
B. [[File:2 Bd obs 4 680x512px.tif|Proliferating bile ductules (cyan arrows) with neutrophils (yellow arrows), not specific for acute cholangitis, of assistance with large bile duct obstruction (400X)..]]
<br>
<br>
B. [[File:2 CHF 1 680x512px.tif|Thrombi in sinusoids; glycogenated nuclei likely reflect patient’s diabetes mellitus (400X).]]
C. [[File:3 Bd obs 4 680x512px.tif|Uninflamed interlobular duct (yellow arrow) with, accompanying blood vessel (red arrow) (400X)]]
<br>
<br>
C. [[File:3 CHF 1 680x512px.tif|Dilated portal vein (400X).]]
D. [[File:4 Bd obs 4 680x512px.tif|Bile infarct with pyknotic nuclei (arrows)(400X).]]
<br>
<br>
D. [[File:4 CHF 1 680x512px.tif|Reticulin shows collapse (thick black lines) as well as a dilated portal vein (200X).]]
E. [[File:5 Bd obs 4 680x512px.tif|Bile (arrow) in interlobular bile duct with disordered nuclei (400X).]]
<br>
<br>
E. [[File:5 CHF 1 680x512px.tif|Trichrome shows space of Disse collagenization (pericellular fibrosis) (200X).]]
F. [[File:6 Bd obs 4 680x512px.tif|Bile plugs in cannaliculi (red arrows), feathery degeneration producing foamy macrophage like hepatocytes (yellow arrows)(400X).]]
<br>
<br>
F. [[File:6 CHF 1 680x512px.tif|Trichrome shows periportal fibrosis; no bridging was seen (200X).]]
Large bile duct obstruction. A. Expanded, light colored portal triads (arrows). B. Proliferating bile ductules (cyan arrows) with neutrophils (yellow arrows), not specific for acute cholangitis, of assistance with large bile duct obstruction. C. Uninflamed interlobular duct (yellow arrow) with, accompanying blood vessel (red arrow). D. Bile infarct with pyknotic nuclei (arrows). E. Bile (arrow) in interlobular bile duct with disordered nuclei. F. Bile plugs in cannaliculi (red arrows), feathery degeneration producing foamy macrophage-like hepatocytes (yellow arrows).


Patient with congestive heart failure and stage I fibrosis. A. Dilated and undilated sinusoidal regions. B. Thrombi in sinusoids; glycogenated nuclei likely reflect patient’s diabetes mellitus. C. Dilated portal vein. D. Reticulin shows black lines of bridging, too thick for collapse. E. Trichrome shows space of Disse collagenization (pericellular fibrosis). F. Trichrome shows bridge beginning off to right; when it is more than a mere spike, it is a bridge.
==Congestive hepatopathy==
{{Main|Congestive hepatopathy}}


==Drug-induced liver disease==
==Drug-induced liver disease==
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==Peliosis hepatis==
==Peliosis hepatis==
===General===
{{Main|Peliosis hepatis}}
*Associated with:
**Infections.
**Malignancy.
**Other stuff.
*Rarely biopsied.
 
===Microscopic===
Features:
*Cyst lined by endothelium.
**Usu. incomplete.
*Blood.
{|
[[File:1 PEL 1 680x512px.tif|Hemorrhage at left end, dilated sinusoids elsewhere (20X).]]
[[File:2 PEL 1 680x512px.tif|Ramifying dilated sinusoidal spaces (100X).]]
<br>
[[File:3 PEL 1 680x512px.tif|PAS with diastase shows flat lining (400X).]]
[[File:4 PEL 1 680x512px.tif|Necrotic hepatocytes in cords, presumably due to pressure (400X).]]
|}
Peliosis hepatis. Hemorrhage at left end, dilated sinusoids elsewhere (UL 20X). Ramifying dilated sinusoidal spaces (UR 100X). PAS with diastase shows flat lining (LL 400X). Necrotic hepatocytes in cords, presumably due to pressure (LR 400X).


==Total parenteral nutrition==
==Total parenteral nutrition==
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Image:Hepatic_amyloidosis_-_very_high_mag.jpg | Amyloidosis of the liver - very high mag. (WC)
Image:Hepatic_amyloidosis_-_very_high_mag.jpg | Amyloidosis of the liver - very high mag. (WC)
</gallery>
</gallery>
{|
A. [[File:1 AMY 1 680x512px.tif|Amorphous material replaces hepatic parenchyma [4X]]]
[[File:1 AMY 1 680x512px.tif|Amorphous material replaces hepatic parenchyma [4X]]]
[[File:2 AMY 1 680x512px.tif|Material barely stains blue on trichrome [10X]]]
<br>
<br>
[[File:3 AMY 1 680x512px.tif|Material stains red on unpolarized Congo Red [40X]]]
B. [[File:2 AMY 1 680x512px.tif|Material barely stains blue on trichrome [10X]]]
[[File:4 AMY 1 680x512px.tif|Material stains apple green on polarized Congo Red [40X]]]
<br>
|}
C. [[File:3 AMY 1 680x512px.tif|Material stains red on unpolarized Congo Red [40X]]]
Amyloidosis. Amorphous material replaces hepatic parenchyma [UL 4X]. Material barely stains blue on trichrome [UR 10X] Material stains red on unpolarized Congo Red [LL 40X] Material stains apple green on polarized Congo Red [LR 40X]
<br>
D. [[File:4 AMY 1 680x512px.tif|Material stains apple green on polarized Congo Red [40X]]]
<br>
Amyloidosis. A. Amorphous material replaces hepatic parenchyma. B. Material barely stains blue on trichrome. C. Material stains red on unpolarized Congo Red. D. Material stains apple green on polarized Congo Red.


===Stains===
===Stains===
Line 690: Line 658:


==Fulminant hepatic necrosis==
==Fulminant hepatic necrosis==
===General===
{{Main|Fulminant hepatic necrosis}}
Etiology:
*Viral, i.e. [[Hepatitis A]], [[Hepatitis B]]; [[Hepatitis C]] - extremely rare.
*Trauma.
*Shock.
 
===Microscopic===
{|
[[File:1 Necrosis 2 680x512px.tif| Submassive hepatic necrosis.]]
[[File:2 Necrosis 2 680x512px.tif| Submassive hepatic necrosis.]]
<br>
[[File:3 Necrosis 2 680x512px.tif| Submassive hepatic necrosis.]]
[[File:4 Necrosis 2 680x512px.tif| Submassive hepatic necrosis.]]
<br>
[[File:5 Necrosis 2 680x512px.tif| Submassive hepatic necrosis.]]
[[File:6 Necrosis 2 680x512px.tif| Submassive hepatic necrosis.]]
|}
Submassive hepatic necrosis. Patient had transaminases in the thousands that rapidly dropped to normal. Pink preserved parenchyma strews empty necrotic spaces (Row 1 Left 20X). Focus of necrosis with no apparent hepatocytes macrophages abuts apparently normal liver (Row 1 Right 200X). Iron stain shows the macrophages bear hemosiderin (Row 2 Left 200X). Reticulin stain highlights the recently dead liver cells (Row 2 Right 200X). Reticulin stain shows a necrotic bridge forming; the multiple small black circles preclude diagnosis of a fibrous bridge (Row 3 Left 200X).  Trichrome shows the necrotic bridge (“collapse”) lacks much collagen deposition, as would be expected for bridging fibrosis (Row 3 Right 200X).
 
Features:
*Hepatocyte [[necrosis]].
*Bile duct proliferation.
 
DDx:
*[[Cholangiocarcinoma]].
*[[Angiosarcoma]].


==Secondary hemochromatosis==
==Secondary hemochromatosis==
Michael
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