Liver biopsy interpretation

histopathology

1. LIVER BIOPSY INTERPRETATION Dr. MAITHILI KULKARNI Guide Dr. J. K. KUDRIMOTI Dr. M. V. JADHAV

2. NON INVASIVE CLINICAL EVALUATION Detailed history of hepatotoxins , source of infection Physical examination Battery of appropriate lab tests of liver function & integrity Serologic tests for infectious agents & autoimmunity Radiological studies

3. TECHNIQUE Four methods :- Percutaneous needle biopsy ( transcut . Intercostal route), Usg & CT guided Bx Laparoscopy, Laparotomy , Transvenous route ( Transjugular / transfemoral )

4. The choice of one technique over another is based on availability, personal preference, and the clinical situation. Choice Of Technique

5. BIOPSY NEEDLE THREE TYPES OF NEEDLES : Vim-Silverman’s needle, Menghini’s aspiration biopsy needle, ‘ Tru -cut’ biopsy needle (modified Vim-Silverman’s) Biopsy Gun / Biopter (modified Tru -cut needle)

6. INDICATIONS FOR LIVER BIOPSY Diagnosis, grading, and staging of alcoholic liver disease, nonalcoholic steatohepatitis , or autoimmune hepatitis Grading and staging of chronic hepatitis C or chronic hepatitis B Diagnosis of hemochromatosis in index patient and relatives, with quantitative estimation of iron levels Diagnosis of Wilson’s disease, with quantitative estimation of copper levels Evaluation of the cholestatic liver diseases primary biliary cirrhosis and primary sclerosing cholan gitis

7. Evaluation of abnormal results of biochemical tests of the liver in association with a serologic workup that is negative or inconclusive Evaluation of the efficacy or the adverse effects of treatment regimens (e.g. methotrexate therapy for psoriasis) Diagnosis of a liver mass Evaluation of the status of the liver after transplantatio n or of the donor liver before transplantation Evaluation of fever of unknown origin, with a culture of tissue INDICATIONS FOR LIVER BIOPSY Continued …..

8. Contraindications to liver biopsy include the following: Increased prothrombin time, international normalized ratio (INR) greater than 1.6 Thrombocytopenia, platelet count less than 60,000 Ascites ( transjugular route preferred) Difficult body habitus ( transjugular route preferred) Suspected hemangioma Suspected echinococcal infection Uncooperative patient

9. Complications of percutaneous liver biopsy Pain Pleuritic , Peritoneal, Diaphragmatic Hemorrhage Intraperitoneal , Intrahepatic and/or sub capsular Hemobilia Bile peritonitis Bacteremia Sepsis and abscess formation Pneumothorax and/or pleural effusion Hemothorax Arteriovenous fistula Subcutaneous emphysema Anesthetic reaction Needle break Biopsy of other organs :- Lung, Gallbladder, Kidney, Colon

10. Interpretation of liver biopsy starts with gross examination of biopsy specimen Hand lens can be used Cylinders of even color & thickness which not fragment easily- normal liver Cirrhosis- Fragmented, irregular in caliber, obviously nodular Nodular, no fibrous septa – NRH steatosis - Yellow color, greasy sensation , float in fixative

11. Limitations Sampling error – focal lesions (cysts , tumors ) can not be entirely excluded Misdiagnosis – inadequate sample Operative biopsies – hemorrhages , PMN infiltration Artifacts –due to rough handling , poor fixation

12. Adequacy Of Sample In general, a sample of 1.5 cm in length 1.2-2 mm in diameter and contains at least 3 portal triads is considered adequate. This represents approximately 1/50,000th of the adult liver. Adequacy depends on the disease process concerned. In HCC, adequate if malignant cells are seen, amyloidosis , storage disorder

13. Gross Examination Hand lens can be used Fragmented, irregular in caliber , obviously nodular – Cirrhosis Nodular, no fibrous septa – NRH Yellow colour, greasy – float in fixative – steatosis Rusty brown – genetic hemochromatosis Slate gray - malaria, Brown- Black - Dubin Johnson syndrome Black – protoporphyria Light tan to white foci – lymphoma \ carcinoma

14. Gross cont Rusty brown –genetic hemochromatosis Slate gray- malaria Black or dark brown- Dubin Johnson syndrome Black – protoporphyria Deep red - cong Light tan to white foci – lymphoma \ carcinoma

15. Processing Of specimen Excessive manipulation should be avoided USE OF FIXATIVE – FOR LIGHT MICROSCOPY- Routinely - 10 % neutral formalin 3 hrs at room temp For metabolic diseases which contain water soluble stored material – Cystinosis GSD– alcohol Mucopolysaccharidosis – Lindsays dioxane picrate Frozen section – demonstration of lipids , immunohistochemisry FOR ELECTRON MICROSCOPY – minute pieces put into appropriate fixative like glutaraldehyde Uses – inborn error of metabolism, tumor of doubtful histogenesis, viral infection

16. SECTIONS TO BE TAKEN 3 to 5 micron sections –consecutive sections For special stains- Depending on clinical suspicion, no. of sections are taken Serial or step sections – granulomas or tumor deposits ,parasitic egg,larva , Serial biopsies following liver transplant.

17. MICROSCOPY STAINS USED H & E stain Special stains H & E Stain All fragments should be examined Look for – architecture (Special stain is required) Locating terminal hepatic venules – moving in direction of portal areas Look at- portal tracts, Hepatocytes, Bile canaliculi, Sinusoids & their contents, Kupffer cells Abnormal deposits in spaces of Disse–amyloid, collagen

18. Normal portal tract and central vein

19. Special stains Reticulin – structural changes , outlining areas of focal or zonal necrosis, MT- Pericellular fibrosis New collagen formation Changes involving blood vessel Elastin – For recent collapse/fibrosis Orcein – elastic tissue, hepatitis B surface Ag, Cu associated protein PAS – complex CHO, glycogen (benign & malignant hepatocellular tumors) D-PAS – to remove glycogen,  1 antitrypsin –DPAS positive PAS – amyloid , starch, amoebae, pathogenic fungi, basement membrane of acinar ducts PTAH – fibrin in (DIC & Eclampsia )

20. Gomori methanamine silver – fungi Prussian Blue :- Iron Rhodanin e :- Cu( ICC, Chronic cholestasis , wilson ) PTAH -> Fibrin Van Gieson -stains Bile green Congo red - Amyloid AFB -> TB bacilli, schistosoma egg, hooklets in scolices of echinococcal cyst Special stains continued…..

21. Warthin starry - Spirochetes, Leptospira , cat scratch bacilli Geimsa -> Hematopoietic cells Frozen – Oil red O -> Neutral Lipid Bakers acid hematin with pyridine reaction -> Neimannpick

22. Liver, Wilson disease - High power This special stain (rhodanine stain) highlights the accumulation of copper in the hepatocytes of patients with Wilson disease.

23. MICROSCOPY Low power : Quality of biopsy (size, staining), Overall architecture, Presence / absence of normal structures, Pattern of injury, Fibrosis and nodularity , Gross area of necrosis or congestion

24. Medium & High power : Portal tracts : Presence of normal structures (Bile duct, vein, artery), Inflammation (Type, intensity, relation with normal structures), Fibrosis, edema, Bile duct changes (inflammation, proliferation, necrosis, cholestasis , loss), Arterial / venous changes (inflammation, thrombosis) MICROSCOPY

25. Medium & High power : Lobule : Inflammation (type, intensity, location/ zonality ), Necrosis (type, intensity, location/ zonality ), Status of cell plates (regeneration, atrophy), Status of sinusoids (dilated, congested) Other changes : Amyloid deposition, Fibrosis , MICROSCOPY

26. Medium & High power : Central vein : Size, shape (round / compressed), Inflammation, Fibrosis MICROSCOPY

27. PATTERNS OF INJURY

28. Patterns of Injury Degeneration : Ballooning Feathery, Fatty ( Steatosis ),

29. Balooning Hydropic change / Oncosis ): increased cell volume with pale staining granular cytoplasm seen in damage from toxic, ischemic or immunological insult, e.g. Ac Hep ., Alc. Hep .

30. Feathery deg .swollen hepatocytes with thread-like reticular yellowish brown cytoplasm seen in Cholestasis

31. HYALINE DEGENERATION – Mallory's hyaline represents aggregates of intermediate filaments- alcoholic hepatitis , non alcoholic steatohepatitis , HCC, ICC, Wilson Ds,

32. Steatosis Type of deposition Acinar distribution Possible complications Macrovesicular - alcohol, obesity, DM, TPN, PEM Microvesicular - AFLP, Reyes, Tn , jamiakan vomiting sickness Mixed Focal

33. Type of fat Acinar distribution Possible complications Periportal - TPN, AIDS, Kwashiorkar Centrilobular - Alc , obesity, DM Diffuse Steatosis

34. Steatosis Type of fat Acinar distribution Possible complications Steatohepatitis Portal fibrosis Cirrhosis

35. Macrovesicular Steatosis Alcoholic liver disease (ALD), Obesity, diabetes mellitus, Kwashiorkor, Drugs, Ethanol, Methotrexate Chr. HCV, Metabolic diseases

36. Microvesicular Steatosis Acute fatty liver of pregnancy Reye’s syndrome Drugs Tetracyclins , Valproate toxicity Salic ylates , TPN Cholesterol storage diseases Toxic shock syndrome

37. Apoptosis : Acidophil / Councilman bodies Patterns of Injury hepatocyte shrinkage, increased eosinophilia and nuclear pyknosis Acute Viral hepatitis, AIH

38. Necrosis : Spotty / Focal, Confluent / Bridging Submassive , Massive, Zonal, Patterns of Injury

39. Zonal Necrosis Zones Causes Zone 1 Eclampsia , HAV, Infectious mononucleosis, Phosphorous poisoning Zone 2 Yellow fever Zone 3 Shock, CCF, CCL4 Chloroform poisoning

40. Liver Cell Necrosis Focal necrosis- Non specific reaction to disease elsewhere in body, spotty-same lesion with Gap in liver cell plates- Liver cell dropout & inflammatory reaction.- acute hepatitis Haphazardly distributed areas of necrosis- Disseminated herpes virus, micobacteria . Tumor Necrosis- Reticulin pattern Bridging necrosis- Bridging of THV to PT- acute viral hepatitis (No elastic fibers) Piecemeal Necrosis: Destruction of liver cells at an interface between portal tract & parenchyma with lymphoplasmacytic infiltrate- chronic hepatitis

41. Diffuse confluent necrosis: With inflammation : Viral hep , Drug induced hep Without : Shock, LVF

42. Inflammation : Hepatitis, Interface hepatitis, Lymphocytic (Classic), Biliary ( Lympho + Poly) Patterns of Injury

43. PIGMENTS Hemosiderin Golden brown refractile , PB positive In hepatocytes – genetic hemochomatosis In kupffer cells – hemolytic anemia ,viral hepatitis , Parenteral iron , blood transfusion , impaired release of iron – chronic infl , malignancy Lipofuscin – granular, near cytoplasmic membrane Bile:- Homogeneously stained- green/yellow or orange, bile plugs in small ductuels , hall staining Hemozoin pigment:- Malarial pigment in kupffer cells, finely granular, dark brown or black.

44. Pigments Hemosiderin - golden brown, PB + Lipofuschin - Yellow brown DJ pigment- Dark brown & black Bile pigment

45. Regeneration :- Disorganization of structure Mitoses, Multinucleation , Thickening of hepatocyte cords, Patterns of Injury

46. Fibrosis :- Bridging Cirrhosis Patterns of Injury

47. LIVER DISEASES

48. Non neoplastic lesions : Infections : Hepatitis, Cirrhosis, Cholestatic liver dis , Metabolic disorders, Liver transplant , Granuloma Liver in systemic cond n , Tumours & D/Ds : Focal nodular hyperplasia, Hepatocellular Adenoma, Hepatoblastoma Hepatocellular carcinoma, Bile duct adenoma Cholangiocarcinoma

49. HEPATITIS Acute, Chronic, Autoimmune, Steatohepatitis

50. ACUTE HEPATITIS INFECTIVE : Viral, Bacterial, Parasitic, Fungal, DRUG INDUCED, AUTOIMMUNE

51. viral EBV- mild hepatitis during the acute phase; CMV - particularly in the newborn or immunosuppressed patient yellow fever- which has been a major and serious cause of hepatitis in tropical countries. Infrequently, in children and immunosuppressed patients, the liver is affected in the course of rubella, adenovirus, herpesvirus , or enterovirus infections. Hepatotropic viruses cause overlapping patterns of disease. Each hepatotropic virus and the disease conditions it causes will be introduced before a general discussion of hepatitis.

52. Ballooning degeneration ( Hydropic change) Acidophil / Councilman bodies Interface hepatitis Typical Acute Hepatitis

53. Focal necrosis (Spotty necrosis) with collapse & mild lymphocytic infiltra n Typical Acute Hepatitis Same (focal collapse) area on Reticulin stain

54. Lobular disarray, Portal tract infiltrate of lymphocytes & plasma cells with some neutrophils & eosinophils , Lobular infiltration of mixed infiltrate, ‘ Ceroid macrophages’, Cholestasis ( Cholestatic hepatitis), Ductular reaction, Typical Acute Hepatitis Other Features

55. Severe Acute Hepatitis Severe necrotizing hepatitis, with ‘Confluent necrosis’, (usually centrilobular ) Bridging necrosis

56. Submassive & Massive liver necrosis

57. D/Ds of Acute Hepatitis Cause Histological Findings Other Features HAV Mild portal + lobular PL infiltrate, Cholestasis Serological markers, Self limiting HBV Prominent centrilobular bollooning degeneration Serological markers HCV Prominent portal lymphoid follicles, Bile duct damage Rarely acute, Serological markers CMV / HSV / EBV Confluent necrosis with minimal infiltrate , Typical viral inclusions Drugs Mixed infiltrate, Prominent eosinophils , Granulomas , Mixed steatosis History of hepatotoxic drug ingestion, Resolves after discontinuation AIH Abundant plasma cells, periportal areas of collapse, bridging necrosis Serum markers for Ab , ed  Globulins

58. CHRONIC HEPATITIS

59. LIVER DISEASES

60. Non neoplastic lesions : Infections : Hepatitis, Cirrhosis, Cholestatic liver dis , Metabolic disorders, Liver transplant, Liver in systemic cond n , Tumours & D/Ds : Focal nodular hyperplasia, Hepatocellular Adenoma, Hepatoblastoma Hepatocellular carcinoma, Bile duct adenoma Cholangiocarcinoma

61. HEPATITIS Acute, Chronic, Autoimmune, Steatohepatitis

62. ACUTE HEPATITIS INFECTIVE : Viral, Bacterial, Parasitic, Fungal, DRUG INDUCED, AUTOIMMUNE

63. Ballooning degeneration ( Hydropic change) Acidophil / Councilman bodies Interface hepatitis Typical Acute Hepatitis

64. Focal necrosis (Spotty necrosis) with collapse & mild lymphocytic infiltra n Typical Acute Hepatitis Same (focal collapse) area on Reticulin stain

65. Lobular disarray, Portal tract infiltrate of lymphocytes & plasma cells with some neutrophils & eosinophils , Lobular infiltration of mixed infiltrate, ‘ Ceroid macrophages’, Cholestasis ( Cholestatic hepatitis), Ductular reaction, Typical Acute Hepatitis Other Features

66. Severe Acute Hepatitis Severe necrotizing hepatitis, with ‘Confluent necrosis’, (usually centrilobular ) Bridging necrosis

67. Submassive & Massive liver necrosis

68. D/Ds of Acute Hepatitis Cause Histological Findings Other Features HAV Mild portal + lobular PL infiltrate, Cholestasis Serological markers, Self limiting HBV Prominent centrilobular bollooning degeneration Serological markers HCV Prominent portal lymphoid follicles, Bile duct damage Rarely acute, Serological markers CMV / HSV / EBV Confluent necrosis with minimal infiltrate, Typical viral inclusions Drugs Mixed infiltrate, Prominent eosinophils , Granulomas , Mixed steatosis History of hepatotoxic drug ingestion, Resolves after discontinuation AIH Abundant plasma cells, periportal areas of collapse, bridging necrosis Serum markers for Ab , ed  Globulins

69. CHRONIC HEPATITIS

70. Chronic hepatitis HBV HCV HBV+HDV AIH Wilson’s Disease PBC PSC A1AT Hemochromatosis Drugs Cryptogenic NASH ALD

71. CHRONIC HEPATITIS Hepatocellular necrosis (spotty/confluent) Portal / periportal inflammation Fibrosis Cirrhosis

72. Chronic Hepatitis Type Special Features HBV Ground glass hepatocytes HCV Portal lymphoid aggregates, Steatosis , Bile duct injury AIH Plasma cell portal infiltrate, Severe damage with rossettes & giant cell form n Drugs Any possible change

73. Histological Activity Index (HAI) GRADING GRADE INFLAMMATION NECROSIS None None 1 Portal or lobular No ne 2 Mild interface Focal 3 Moderate interface Confluent 4 Severe interface Bridging

74. Histological Activity Index (HAI) STAGING STAGE FIBROSIS No fi rosis 1 Enlarged portal tracts 2 Periportal / P-P septa 3 Bridging fibrosis 4 Cirrhosis

75. AUTOIMMUNE HEPATITIS

76. Usually + nt as chr hepatitis, predominantly affecting females, viral serological markers must be negative, IgG and Gamma globulin levels are raised (> 1.5 times), High titre of ANA, AsmAb and Anti-LKM, Anti-mitochondrial Ab absent, Correct diagnosis is imp. because pt. may benefit from immunosuppressive therapy, High necro -inflammatory pathology, bridging confluent necrosis, marked interface hepatitis, hepatic liver cell rossettes , Plasma cells, usually in clusters – prominent feature, Lymphoid aggregates and follicles – may + nt (< HCV

77. Steatohepatitis ASH & NASH Steatosis , Mallory bodies Neutrophilic infiltrate ( Satellitosis ) Perivenular / pericellular fibrosis Alcoholic cirrhosis

78. CIRRHOSIS Disruption of architecture, Regenerating nodules, Bridging fibrous septae

79. Establish diagnosis Possible aetiology To detect HCC CIRRHOSIS

80. CIRRHOSIS GROSS : Fragmented, Rounded, smooth MICRO ( Retic stain): Thick cell plates, Condensed reticulin fibres surrounding nodules

81. Congenital Hepatic Fibrosis  Parenchyma does not show e/o destruction or regeneration Disease Diffuse Involvement Septa Nodule Cirrhosis + + + Nodular regenerative Hyperplasia + - + Focal Nodular Hyperplasia - + + D/D OF CIRRHOSIS

82. Intrahepatic Cholestatic Liver Diseases Primary Sclerosing Cholangitis Primary Biliary cirrhosis, Sec. Biliary Cirrhosis

83. CANALICULAR – dilated bile canaliculi bet hepatocytes CYTOPLASM OF HEPATOCYTES & KUPFFER CELLS DUCTULAR CHOLESTASIS – sepsis , ductal plate malformation Acute – canalicular ( perivenular ) Chronic – periportal hepatocytes

84. Primary Sclerosing Cholangitis

85. Primary Biliary Cirrhosis Four stages : Florid duct lesion, Ductular proliferation, Scarring , Cirrhosis,

86. AI dis with unknown etiology selectively affecting the small IHBD, Initial lesions may be called ‘chronic non- suppurative destructive cholangitis ’, Middle aged women (peak 40-60 yrs), Presents with intense pruritus d/t cholestatic jaundice, ass with antimitochondrial Ab (95%), granulomas (40-70%), Progressive destruction of intrahepatic biliary tree by lymphoplasmacellular infiltrate, Biopsy needle may fail to sample duct lesions owing to their focal distribution,

87. SECONDARY BILIARY CIRRHOSIS ADULTS Causes – Cholelithiasis , Stricture Malignancies of BT, ca of head of pancrease Histology – Coarse fibrous septae divides the liver into irregular jigsaw pattern pseudolobules FS contais small & large bile ducts with inspissated bile Extensive ductular proliferation Hepatocytes showe xtensive feathery deg, with bile lakes, PMN infiltrate around bile ducts

88. In children EHBA Cystic fibrosis Choledochal cyst

89. Liver Biopsy in Neonatal Cholestasis - Prolonged Conjug . HYperbilirubinemia Aetiology Histological Features Extrahepatic biliary atresia Proliferation of bile ductules in portal tracts; portal fibrosis; ductular cholestasis Neonatal hepatitis Portal & lobular mononuclear cell inflammation; Giant cells ; acidophil bodies

90. Variety of disorders causing conjugated hyperbilirubinemia are called Neonatal hepatitis. Infants present with jaundice, dark urine acholic stools n hepatomegaly Biopsy critical role in distinguish between above two conditions,

91. Metabolic / Storage Disorders Primary Hemochromatosiss Secondary

92. Wilson’s disease, Indian childhood cirrhosis Metabolic / Storage Disorders

93. Liver, alpha1-antitrypsin deficiency, PAS stain - High power In alpha1-antitrypsin (AAT) deficiency, alpha1-antitrypsin accumulates in the cytoplasm of hepatocytes. Due to an inherited metabolic defect, the protein is not secreted and thus accumulates in hepatocytes. This is apparent as eosinophilic globular material in the cytoplasm of hepatocytes in a PAS-with-diastase-stained section.    

94. Tumours & Tumour -like lesions Focal nodular hyperplasia, Adenoma, HCC, Typical, Fibrolamellar , Hepatoblastoma , Cholangiocarcinoma

95. Focal Nodular hyperplasia

96. Adenoma

97. Liver Cell Adenoma :  More or less normal reticulin pattern is detected throughout which is rarely seen even in well differentiated HCC. Absence of fibrous tracts & bile ducts – differentiate from focal nodular hyperplasia Absence of large amount of oedematous mesenchyme - from hamartoma

98. Hepatocellular Carcinoma

99. Hepatocellular Carcinoma:  Trabecular  Misshapen upto many cells thick, sinusoidal stroma Deficiency of reticulinIn low grade Ca Differentiate from adenoma or dysplastic nodule. Quality of stroma separating cords of tumour cells in HCC Empty or blood containing vessels where as in bile duct carcinoma Fibrous connective tissue. Sinusoidal pattern and / or bile production  HCC Glandular pattern and/or mucous secretion  CHOLANGIO CARCINOMA

100. Liver, hepatocellular carcinoma - Medium power This biopsy specimen shows irregular trabeculae or cords of malignant hepatocytes with enlarged nuclei that contain nucleoli, consistent with a well-differentiated hepatocellular carcinoma.  

101. Liver, cholangiocarcinoma - Low power Malignant glands are noted within dense, fibrotic tissue (desmoplastic response) in this case of cholangiocarcinoma of the liver. Normal hepatic parenchyma is present in the upper right of the image.

102. Portal Tracts Points to be noted: Adequacy of biopsy- At least 3 portal tracts Contains hepatic artery, bile duct (of same size in the center), portal vein branch. Number of bile ducts equal hepatic artery branches-look for ductopenia & ductal proliferation. Inflammation Limiting plate

103. INFLAMMATION CONFINED TO PORTAL TRACT Canalicular cholestasis, spotty necrosis, stain for elastic fibers :  Acute hepatitis P,L,E,N – hepatitis A L,P – hepatitis B, D, C N,L – hepatitis E Partial or complete loss of small & medium sized bile ducts ,lymphocytes , neutrophils ,granulomas  Chronic biliary tract disease Wilsons disease –biochemical , clinical PAS positive globules  AAT deficiency Dense , more homogeneous , total or near total involvement of portal tract  Lymphoma – NHL

104. A Liver-Biopsy Specimen from a 32-Year-Old Man Presumed to Have Acute Hepatitis. The specimen shows a portal mononuclear infiltrate with prominent plasma cells (arrow in Panel A) and lobular inflammation with apoptotic hepatocytes (arrow in Panel B), findings consistent with the presence of autoimmune hepatitis (hematoxylin and eosin, ¬100). A B

105. Inflammation Confined To Portal Tract Portal Inflammation, lesions of bile duct in portal tract, periportal injury ( piecemeal necrosis- destruction of limiting plates ), degeneration & necrosis of hepatocytes, fibrosis (periportal or bridging)  Chronic Hepatitis Grading  Degree of activity Staging Degree of fibrosis

106. Portal tract showing stellate "maple leaf" pattern of chronic active hepatitis with extensive piecemeal necrosis and loss of limiting plates

107. Margin of portal tract showing inflammation (predominantly lymphocytes) and piecemeal necrosis

108. Hepatic Artery Systemic arterial diseases- SLE, giant cell arteritis Systemic HTN- Thickened & hyaline Amyloidosis- Thickening of arterial wall, congo red with polarized microscope Infarct- arteritis, aneurysm, thrombosis, embolism

109. Loss of bile ducts (ratio of BD \HA <1) Fibrous obliteration of ducts , dense portal fibrosis with little inflammation  PRIMARY SCLEROSING CHOLANGITIS Four Stages showing- Florid duct lesion , portal hepatitis, ductular proliferation & periportal hepatitis, scarring, bridging necrosis ; septal fibrosis cirrhosis (granulomatous cholangitis ,chronic inflammation of portal tract )  PRIMARY BILIARY CIRRHOSIS Idiopathic GVHD Sarcoidosis Rejection of liver graft

110. Liver, primary sclerosing cholangitis - High power Concentric periductular fibrosis around bile ducts, leading eventually to destruction and stricture of affected bile ducts, is seen in primary sclerosing cholangitis. In between the areas of stricture, bile ducts become ectatic and inflamed. The liver in primary sclerosing cholangitis eventually becomes cirrhotic.

111. Liver, primary biliary cirrhosis - Low power In this biopsy specimen of liver from a patient with primary biliary cirrhosis, the portal areas contain a chronic inflammatory infiltrate, consisting of lymphocytes, macrophages, plasma cells, and eosinophils.

112. Liver, primary biliary cirrhosis - Medium power At higher magnification, it is apparent that the chronic inflammation in the portal areas is associated with bile duct destruction by the inflammatory infiltrate. These are the hallmarks of the florid duct lesions in primary biliary cirrhosis.

113. Liver, primary biliary cirrhosis - Low power As liver damage progresses in patients with primary biliary cirrhosis, fibrous bridges form between portal areas. The end stage of the process is the development of biliary cirrhosis.

114. Bile Duct Proliferation – Ductular proliferation – chronic liver disease (new duct formation ) Elongation & tortuosity of preexisting interlobular ducts – obstruction to large bile ducts

115. PORTAL VEIN Thrombosis – disorders of coagulation , cirrhosis , liver transplantation , invasion by HCC septic thrombi Non cirrhotic portal fibrosis – portal vein branches are thickened , narrowed Pipe stem fibrosis – schistosoma granuloma around parasitic ova

116. HEPATIC VEINS Veno occlusive diseases – terminal hepatic venule , & intercalated veins occluded by fibrous tissue Obstrution to large veins – ( budd chiari syndrome ) – perivenular sinusoids are dilated , hemorrhages & necrosis in zone3

117. SINUSOIDS Dilatation & congestion – CCF Oral contraceptives Venous outflow obstruction , tumor , granuloma Sickle cell disease – Sickled RBCS Neutrophilic infiltration – sepsis Lymphocytes – mononucleosis , TSS Fibrin thrombi – DIC , ( PTAH) Peliosis – blood filled spaces , incomplete endothelial lining Neoplasia – mets , leukemia , systemic mastocytosis Parasites – malaria , microfilaria Obliteration of sinusoids- GSD type 1

118. KUPFFER CELLS Hypertrophy- Malaria- Hemozoin pigment, in acute malaria-parasites, RBCs, iron Leishmaniasis- LD bodies Swollen foamy & DPAS positive neimann pick Enlarged, moderate DPAS positive- Gauchers diseases

119. Aetiology Favoured Site Special Features Sarcoidosis   Portal/Periportal   Clustering, Hyalinization, Inclusion in giant cells Tuberculosis None Necrosis PBC   Portal   Near damaged bile duct, acinar granuloma uncommon Drugs None Eosinophills, Other lesions often presents (Hepatitis, fat, cholestasis) Mineral Oil Portal, perrivenous Oil Vacuoles Cue fever None Fibrin-ring granuloma HEPATIC GRANULOMA

120. CAUSES OF CHRONIC HEPATITIS Agent Morphologic Clues Hepatitis B Ground-glass hepatocytes Hepatitis C       Fat Bile duct injury Portal Lymphoid aggregates Talc (IV drug abuse) Autoimmune Hepatitis Severe hepatocellular injury; Rosettes, giant cell transformation, many plasma cells Drugs None

121. Liver, chronic viral hepatitis (hepatitis C virus) - Low power This image of liver is from a patient with chronic hepatitis C virus infection. Portal inflammatory infiltrates in chronic hepatitis C viral infections frequently contain lymphoid aggregates or lymphoid follicles. Steatosis is also present in HCV infections, in contrast to HBV infection.

122. Grading Activity In Chronic Hepatitis Grade   Piecemeal Necrosis Parenchymal Injury a Activity   Mild Found only after diligent search >5 per 10 X field Both are Mild Moderate Majority of portal areas have atleast some, but most have <50% of circumference 5-20 per 10 X field Either is moderate Marked >50% of circumference of the majority of the portal areas >20 per 10 X field Either is marked. a--> Apoptotic bodies, ballooned cells, inflamatory cell aggregates.

123. Liver, chronic viral hepatitis (hepatitis B virus) - Medium power In this image of liver from a patient with chronic hepatitis due to hepatitis B virus, a chronic inflammatory infiltrate is seen that is limited to the portal area. It does not extend into the adjacent lobule.

124. Liver, chronic viral hepatitis (hepatitis B virus) - Medium power This image is from another patient who has chronic viral hepatitis. In this patient, there is a chronic inflammatory infiltrate in the portal areas of the liver that extends beyond the portal area into the adjacent lobule, where it encircles hepatocytes, many of which are undergoing degeneration and necrosis. This is the morphologic correlate of progressive active liver damage that is present in some patients with chronic viral hepatitis.

125. Change Score No Fibrosis Fibrous expansion of some portal areas, with or without short fibrous septa 1 Fibrous expansion of most portal areas, with or without short fibrous septa 2 Fibrous expansion of most portal areas, with occassional portal to portal (P-P) bridging 3 Fibrous expansion of portal areas, with marked bridging ( portal-portal (P-P) as well as portal-central (P-C)) 4 Marked bridging (P-P and/or P-C) with occassional nodules (incomplete cirrhosis) 5 Cirrhosis, probable or definite 6 Histological Activity Index Staging

126. CIRRHOSIS Establish diagnosis Assess cause as far as possible To detect HCC Microscopic clues  Fragmented biopsy, fragments have rounded edges Alteration in the spatial relationship between portal vessels & central veins Cell plates- > one cell in thickness , compressed sinusoids are invisible Complete loss of acinar structure Reticulin stain – irregular pattern ,thin strips of connective tissue investing margins of fragments Liver cell dysplasia

127. Differential Diagnosis Of Cirrhosis Budd chiari – portal tracts remain largely uninvolved SBC – fibrosis is portal in distribution AAT deficiency – PAS , immunostain Wilsons disease , PBC – Cu stain Biliary cirrhosis – absence of bile ducts Hemochromatosis – iron stain Post necrotic – immunostain for hepatitis B Sag

128. Liver-Biopsy Specimens from a 45-Year-Old Woman with Chronic Hepatitis C Virus Infection, in Whom There Was No Clinical Suspicion of Cirrhosis. Panel B shows a dense portal infiltrate with the formation of lymphoid aggregates (hematoxylin and eosin, ¬66). Panel A shows bridging fibrosis with architectural distortion and early cirrhosis (Masson trichrome, ¬10). A B

129. Congenital Hepatic Fibrosis  Parenchyma does not show e/o destruction or regeneration Disease Diffuse Involvement Septa Nodule Cirrhosis + + + Nodular regenerative Hyperplasia + - + Focal Nodular Hyperplasia - + + D/D OF CIRRHOSIS

130. Liver Biopsy In Transplantation Graft rejection- Hyper acute- hemorrhagic infarct Cellular rejection – acute ,triad of portal inflammation , bile duct & hepatocyte damage , endotheliitis Ductopenic ( chronic rejection ) – - progressive loss of bile ducts - obliterative arteriopathy of small & med sized vessels l/d widespresd ischemic damage to hepatocytes

131. Liver in GVHD Acute - 10-50 days after BMT - Donar Lym attack hepatocytes & bile duct epithelial cells causes injury & necrosis - Inflammation in PT & lobules Chronic- >100 days after - severe PT inflammation - BD destruction - Fibrosis

132. Graft Dysfunction Infections –CMV (intranuclear & cytoplasmic inclusions ), EBV ( portal tract & sinusoids – atypical lymphocytes & immunoblasts ) Vascular thrombosis Drug toxicity - cyclosporine A ( cholestasis) , azathioprin – (sinusoidal congestion& zone3 necrosis ) Recurrent viral hepatitis & PBC Post transplant lymphoproliferative disease

133. Liver, transplant rejection - Medium power Rejection of this transplanted liver is manifest in this image as an inflammatory portal infiltrate with bile ductular destruction. The morphologic evidence of bile ductular damage includes a disordered appearance of bile duct epithelial cells, lack of a visible bile duct lumen, and inflammatory cell infiltrates in the bile duct walls.     

134. Liver, transplant rejection - Medium power Endothelialitis of the central vein is present in this image of the transplanted liver undergoing rejection. This is manifest as an inflammatory infiltrate surrounding and infiltrating the central vein wall.

135. Assessement of viral serologies Microbial culture Review of drug therapy Radiological demonstration of patency of biliary tree & vessels

136.     Rejection   Rec. HBV   Rec. HCV   Bile Duct Obstruction Cholestasis       Yes Portal inflammation         Mixed Yes       L, P   Yes Yes   Neutrophils       Yes Bile Duct Damage Yes   Yes   Endotheliitis Yes       Zone-3 necrosis If chronic       Sinusoidal infla.     ++   Acidophilic Bodies   + ++  

137. Childhood Liver Diseases Is acinar structure normal for age ?,see for fibrosis ,nodularity,cirrhosis early in evaluation Are cholestasis & giant cells present ? – cholestasis – in portal tract-biliary tract obstruction , portal tract & parenchyma- hepatitis Hepatitis – giant multinucleated hepatocytes , liver cell degeneration , mononuclear cell infiltration in acini & portal tract Are interlobular ducts normal -

138. Proliferation of bile ducts Paucity of bile ducts Malformation of bile ducts Does specimen contain iron or Cu – neonatal hemochromatosis , ICC ( Cu toxicity) , Wilson's disease Study by DPAS – AAT deficiency Are storage cells present – metabolic diseases

139. Metabolic Diseases Hepatocytes – glycogenosis , AAT def Macrophages – Gauchers disease Both –Niemann pick , cholesterol ester storage PAS stain – Electron microscopy – Frozen – biochemical & histochemical studies

140. Type 1 GSD – swollen pale staining hepatocytes , centrally placed nuclei , mallory bodies , uniform mosaic pattern AAT defi – periportal hepatocytes show PAS positive DR globules Gauchers – enlarged kupffer cells & portal macrophages, Neimann pick – hepatocytes & macrophages are swollen ,foamy

141. Aetiology Histological Features Extrahepatic biliary atresia Proferation of bile ductules in portal tracts; portal fibrosis; ductular cholestasis Paucity of intrahepatic bile ducts Loss of intelobular bile ducts (bile duct; hepatic artery ratio <1) Neonatal hepatitis Lobular disaaray , cholestasis,Portal & acinar mononuclear cell inflammation; acidphil bodies, giant cells , EMH Metabolic disorders Fat; fibrosis or cirrhosis; storage product in liver cells or Kupffer cells Parenteral nutrition Proliferation of bile ductules, portal fibrosis or cirrhosis Liver Biopsy interpretation in Neonatal Cholestasis

142. CHOLESTASIS A— CANALICULAR – dilated bile canaliculi bet hepatocytes CYTOPLASM OF HEPATOCYTES & KUPFFER CELLS DUCTULAR CHOLESTASIS – sepsis , ductal plate malformation B - Acute – canalicular (perivenular ) Chronic – periportal hepatocytes

143.   Intrahepatic Extrahepatic Causes Pure cholestasis-D-J-S,Rotor S Gallstones,Ca Head pancreas,Inflammatory,strictures,Tumors of bile duct. Acquired cholestasis -Viral hepatitisAlcohlic Hep,Drug induce,PBC,PSC ,   Degree Mild More marked Biopsy HPE findings Dilated bile canaliculi,bile plugs,feathery,degeneration of hepatocytes,proliferation of bile ductules initially followed by destruction and periportal fibrosis Dilated bile ducts,rupture->Bile Lakes->toxic to HEP->Focal necrosis,ascending cholangitis proliferation of bile ductules

144. Biopsy In AIDS Abnormal LFTs AFB & silver stains- mycobacteria & fungus Gram stains or warthin starry stain Portion of biopsy should be sent for culture Opportunistic infection & infestations: Histiocytes-striated appearance  Mycobacterium avium intracellular Mycobacterium Tuberculosis AIDS Cholangoipathy Lymphomas  Nodular masses or portal tract infiltration

145. Liver in Systemic Disorders Pregnancy, Amyloidosis

146. Ac Fatty liver of pregnancy ( Microvesic ), IH Cholestasis , Eclampia :- Fibrin deposits in periportal sinusoids with haemorrhages in space of Disse , Amyloidosis :- in hep art branches, along sinusoids in space of Disse , Light chains of Kappa type

147. Fibrotest - Actitest The Fibrotest-Actitest ™ is a six-parameter scoring system that allows quantification of liver fibrosis and inflammation. This test has been validated by several studies in hepatitis B and C viruses and alcoholic liver disease, with a high correlation between the liver biopsy. Six parameters evaluated are total bilirubin , GGT, alpha-2 macroglobulin, haptoglobin , , and ALT, apolipoprotein-A1. Future of liver biopsy

148. Fibroscan (Transient Elastography ) Transient elastography is an ultrasound-based, non-invasive method, which measures the liver stiffness by means of a FibroScan ® device ( EchoSens , Paris, France). By using an ultrasound transducer probe mounted on the axis of a vibrator , the transmission of low-frequency vibrations from the right intercostal space creates an elastic shear wave that propagates into the liver. A pulse-echo ultrasound acquisition is then used to detect the velocity of wave propagation. This velocity is proportional to the tissue stiffness, with faster wave progression occurring through stiffer material. Measurement of liver stiffness is then performed and measured in kPa . The stiffer the liver, the more severe the hepatic fibrosis (scarring).

149. Thank You!!