Cholestasis

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Micrograph showing cholestasis, as is apparent by the yellow bile. H&E stain. (WC)

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

Cholestatic hepatitis and feathery degeneration redirect to this article.

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:
  • 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

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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. //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.