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Liver Pathology
Monday, February 28, 2011, 7:30 PM
CC 007 A-D
Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Just Some Good Cases
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Moderator:
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KENNETH BATTS
Abbott Northwestern Hospital and Virginia Piper Cancer Institute
Minneapolis, MN
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Disclosure:
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In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose.
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Panelists:
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Laura Lamps, University of Arkansas, Little Rock, AR
Dhanpath Jain, Yale University, New Haven, CT
Lawrence Burgart, Abbott Northwestern Hospital, Minneapolis, MN
Dale Snover, Fairview Southdale Hospital, Edina, MN
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Clinical histories are displayed below.
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for Text and References
Submitted by: Laura W. Lamps -
The patient was a 60 year old white man with rheumatoid arthritis. He presented to a local physician with new onset jaundice and thrombocytopenia. A liver biopsy was performed, and the pathologist thought the biopsy had features of chronic biliary disease, but could not classify the biliary disease further. He was evaluated in the hospital for a week. He then presented several days after discharge to a hepatologist to whom he had been referred. He had worsening ascites, acute renal failure, and mild encephalopathy. His bilirubin was 43 mg/dl. Review of his complete medical records at that time, which had been previously unavailable, gave a vague history of noncirrhotic portal hypertension. An MRI scan subsequently showed chronic portal vein thrombosis, multiple superior mesenteric vein and splenic vein collaterals, and mild irregularities of the common bile duct. His bilirubin rose to greater than 60 mg/dl, and other labs included an AST of 418 IU/L, ALT 423 IU/L, and alkaline phosphatase of 202 IU/L. A second liver biopsy was performed.
Case 1 - Figure 1
The initial liver biopsy in this patient showed a cholestatic hepatitis with portal edema, interlobular bile duct atrophy, and cholangiolar proliferation, suggesting large bile duct obstruction.
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Case 1 - Figure 2
This higher power view of a portal tract in the patient's first biopsy shows edema, ductal duplication, and cholangiolar proliferation. Cholestasis is prominent. It is difficult to appreciate portal venules as well.
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Case 1 - Figure 3
Another portal tract from the patient's first biopsy shows interlobular bile duct epithelial disarray. A portal venule is visible in this portal tract. The patient also had increased iron of unknown etiology.
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Case 1 - Figure 4
A low power view of the second biopsy shows a marked cholestatic hepatitis with worsening cholestasis and lobular inflammation.
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Case 1 - Figure 5
This portal tract in the second biopsy shows an intact bile duct and relatively sparse inflammation. Portal venules are slit-like but are easily seen.
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Case 1 - Figure 6
Another portal tract from the second biopsy shows a markedly atrophic interlobular bile duct and cholangiolar proliferation with admixed neutrophils. Portal venules are difficult to appreciate. Note the marked cholestasis.
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Case 1 - Figure 7
A trichrome stain from the second biopsy highlights a portal tract with irregular periportal fibrosis, and no bile duct. A small slit-like portal venule can be seen.
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Case 1 - Figure 8
A high power view of a portal tract in the second biopsy shows bile duct epithelial disarray, an apoptotic epithelial cell, and marked cholangiolar proliferation with admixed neutrophils.
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for Text and References
Submitted by: Dhanpat Jain -
Patient is a 55 year old male who presented with fever and Jaundice.
Transaminases (AST and ALT) were elevated in about ~250 U range. Antinuclear antibodies were weakly positive (ANA 1:40), Anti smooth muscle antibodies (SMA), antimitochondrial antibodies (AMA), liver kidney and microsomal (LKM) antibodies, serology for hepatitis (A, B and C) were all negative. Liver biopsy was performed.
Case 2 - Figure 1
Low magnification of the liver biopsy showing multiple granulomas scattered through-out the parenchyma.
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Case 2 - Figure 2
Higher magnification of the liver biopsy showing the morphology of the granulomas
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Case 2 - Figure 3
Higher magnification of the granuloma showing epithelioid histiocytes surrounded by a rim of dense eosinophilic fibrinous material and many neutrophils.
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Case 2 - Figure 4
Low magnification of the liver biopsy (trichrome stain) showing areas of hepatocyte loss and early fibrosis.
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Case 2 - Figure 5
Higher magnification of the granuloma (trichrome stain) showing the fibrin-ring much better.
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for Text and References
Submitted by: Lawrence J. Burgart -
Thirty-six year old woman presented with upper abdominal fullness and acute onset of right upper quadrant pain. Ct scan showed a 10 cm complex cystic and solid mass with hemorrhage in posterior right hepatic lobe.
for Text and References
Submitted by: Dale C. Snover -
64 year old male who presented with an acute febrile illness with abdominal and back pain and headache. Antibiotics were given but he continued to deteriorate. CT and ultrasound showed a thickened gallbladder and gallstones and the possibility of cholecystitis and choledocholithiasis was considered. At that point he had developed abnormal liver function tests. CT of the head was unremarkable. He was admitted on October 27 and underwent cholecystectomy and wedge liver biopsy on November 6. During his course he developed a peripheral blood lymphocytosis and right middle lobe atelectasis. The lymphocytes were initially described as reactive appearing, however over time increased basket cells with atypical lymphocytes were reported. ERCP was reported to be normal and hepatitis A, B and C studies were negative.
October 27: ALT 270, AST 225, Alk Phos 217, T. Bili 1.6, Hgb 13.3
October 31: ALT 326, AST 310, Alk Phos 495, T. Bili 4.6, Hgb 12.9, WBC 16.9 X 10^9/L (12% Neutrophils, 88% lymphocytes)
November 4: ALT 209, AST 246, Alk Phos 600, T. Bili 3.0, Hgb 10.9, WBC 26.7 X 10^9/L (13% Neutrophils, 78% lymphocytes, 9% others)
[Normals: ALT 0-70 U/L, AST 0-55 U/L, Alk Phos 40-150 U/L, T. Bili 0.2 – 1.3 mg/dl, Hgb 13.3 – 17.7 X 10^9/L , WBC 4.0 – 11.0 X 10^9/L ]
Case 4 - Slide 1
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