Chronic Viral Hepatitis - Part 1 - Kuwait
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Neil D. Theise, MD
Depts. of Pathology and Medicine (Digestive Diseases)
Beth Israel Medical Center – Albert Einstein College of Medicine
New York City
www.neiltheise.com
Chronic Viral Hepatitis
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Neil D. Theise, MD
Depts. of Pathology and Medicine (Digestive Diseases)
Beth Israel Medical Center – Albert Einstein College of Medicine
New York City
SLIDESHARE.NET
www.neiltheise.com
See: “Chronic Viral Hepatitis: A Personal, Practical Guide”
Chronic Viral Hepatitis
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The Viruses
Clinical Aspects
Role of Liver Biopsy, part 1
Histologic/Immunostaining features
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The Viruses
Clinical Aspects
Role of Liver Biopsy, part 1
Histologic/Immunostaining features
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ACUTE
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ACUTE
HAV
HEV
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ACUTE
HAV
HEV
Incidence in Kuwait: 13/100,000
Incidence in Kuwait: 1.4/100,000
RATE OF SPORADIC ENTERICALLY TRANSMITTED VIRAL HEPATITIS IN KUWAIT BETWEEN 1998 AND 2001AQ Al-Anezi, R Al-Awayesh, F Al-Ali, KM PeltekianKuwait Health Sciences Centre, Kuwait City, Kuwait & Division of Gastroenterology, Dalhousie University, Halifax, Nova Scotia
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CHRONIC
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C O N S O N A N T SHRONIC
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HBVHCVHDV
C O N S O N A N T SHRONIC
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HBVHCVHDV
Prevalence: 4.6%
Prevalence of Hepatitis B and C infection in patients admitted at Tertiary Eye Care Centre: A hospital based study. Junejo SA, Khan NA, Lodhi AA. Pak J Med Sci 2009;25(4):597-600.
Prevalence: 13%
C O N S O N A N T SHRONIC
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HBVHCVHDV
Prevalence of Hepatitis B and C infection in patients admitted at Tertiary Eye Care Centre: A hospital based study. Junejo SA, Khan NA, Lodhi AA. Pak J Med Sci 2009;25(4):597-600.
Prevalence of co-infection: 3.9%
C O N S O N A N T SHRONIC
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HBVHCVHDV
Hepatitis delta virus infection in acute hepatitis in Kuwait.Al-Kandari S, Nordenfelt E, Al-Nakib B, Hansson BG, Ljunggren K, Al-Nakib Scand J Infect Dis. 1988;20(1):15-9.
Prevalence: 4% in acute HBV31% in chronic HBV
C O N S O N A N T SHRONIC
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The Viruses
Clinical Aspects
Role of Liver Biopsy, Part 1
Histologic/Immunostaining features
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Prevalence of HCV Antibody NHANES III
Adapted from Alter MJ, et al.,. N Engl J Med. 1999;341:556–562.
0
500,000
1,000,000
1,500,000
2,000,000
Pre
vale
nce
6-11 12-19 20-29 30-39 40-49 50-59 60-69 70-79 80+
Age distribution
90s 00s
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Natural History of Hepatitis C
Acute Hepatitis C
Chronic Hepatitis 75%-85 %
Cirrhosis 20 %
10-20+ years
- Hoofnagle JH, Hepatology. 1997 - Di Bisceglie A, Hepatology, 2000
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Decompensation,Decompensation,6%6%
HCC,HCC,4%4%
Death or Tx, 4%Death or Tx, 4%
Annual rate
- Hoofnagle JH, Hepatology. 1997 - Di Bisceglie A, Hepatology, 2000
Natural History of Hepatitis C
Cirrhosis, 20 %Cirrhosis, 20 %
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Liver Fibrosis in Chronic Hepatitis C
Intermediate progressors
Slow progressors
Poynard et al, Hepatology 1999
n=1157n=1157
0
1
2
3
4
0 10 20 30 40 50
Years
F M
etav
ir
Rapid progressors
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Factors Associated with Disease Progression
• Alcohol consumptionAlcohol consumption– 30 g/day in men30 g/day in men– 20 g/day in women20 g/day in women
• Disease acquisition at >40 yearsDisease acquisition at >40 years• Male genderMale gender• HIV co-infection HIV co-infection (treated vs. untreated)(treated vs. untreated)• Fatty liverFatty liver• Hepatitis B virus co-infectionHepatitis B virus co-infection• ImmunosuppressionImmunosuppression
NIH Consensus Development Conference Statement. 2002.Poynard et al. Lancet. 1997;349:825-832.
~ 2 drinks per day
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Chronic hepatitis
with fibrosis10-50 years
Natural History of Chronic Liver Disease
Cirrhosis
Normal liver
HepatocellularCarcnoma
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The Viruses
Clinical Aspects
Role of Liver Biopsy, Part 1
Histologic/Immunostaining features
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Role of Liver Biopsy
Confirm clinical Confirm clinical diagnosisdiagnosis
Confirm clinical Confirm clinical diagnosisdiagnosis
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Role of Liver Biopsy
Confirm clinical Confirm clinical diagnosisdiagnosis
Confirm clinical Confirm clinical diagnosisdiagnosis
Grade Grade necroinflammationnecroinflammation
Grade Grade necroinflammationnecroinflammation
StageStagefibrosisfibrosisStageStage
fibrosisfibrosis
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The Normal LiverLobule:
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The Limiting Plate
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Portal inflammationDEFINES
Chronic Hepatitis
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“Piecemeal Necrosis” or, better,
“Interface Hepatitis”
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Chronic PersistentHepatitis
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Chronic ActiveHepatitis
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Chronic LobularHepatitis
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RecoveryDeath/Transplant
Chronic Hepatitis
CPH CAH CLH
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RecoveryDeath/Transplant
Chronic Hepatitis
CPH CAH CLH
CirrhosisProgression
Unlikely
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RecoveryDeath/Transplant
Chronic Hepatitis
CPH CAH CLH
CirrhosisProgression
Unlikely
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Gnomes’ clinical problems:• Chronic hepatitis B• Autoimmune hepatitis
Gnomes’ clinical problems:• Chronic hepatitis B• Autoimmune hepatitis
1968
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Gnomes’ clinical problems:• Chronic hepatitis B• Autoimmune hepatitis
Gnomes’ clinical problems:• Chronic hepatitis B• Autoimmune hepatitis
Contemporary clinical problems:• Chronic hepatitis C• Mixed viral infections
Contemporary clinical problems:• Chronic hepatitis C• Mixed viral infections
1968
1990’s
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RecoveryDeath/Transplant
Chronic Hepatitis
CPH CAH CLH
CirrhosisProgression
Unlikely
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RecoveryDeath/Transplant
Chronic Hepatitis
STAGINGOf
Progression
GRADINGOf
Activity
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GRADINGOf
Activity
• Portal inflammation• Interface hepatitis• Lobular hepatitis• Confluent necrosis
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GRADINGOf
Activity
• Portal inflammation• Interface hepatitis• Lobular hepatitis• Confluent necrosis
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GRADINGOf
Activity
• Portal inflammation• Interface hepatitis• Lobular hepatitis• Confluent necrosis
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GRADINGOf
Activity
• Portal inflammation• Interface hepatitis• Lobular hepatitis• Confluent necrosis
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ConfluentNecrosis
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ConfluentNecrosis
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ConfluentNecrosis
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Bridging confluent necrosis
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Confluent necrosis, think about: - HBeAg to Ab conversion - HDV super-infection on HBV - HCV acute exacerbation - HIV co-infection - Autoimmune hepatitis - Drug induced injury, as always
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LIVER: NEEDLE BIOPSY - Chronic hepatitis, ………. active with……. (stage …/4), compatible with hepatitis C.
Comment:A. Interface hepatitis: Absent (0/4).A. Interface hepatitis: Focal, few portal areas (1/4).A. Interface hepatitis: Focal, most portal areas, >5-50% (2/4).A. Interface hepatitis: Continuous around <50% of tracts/septa (3/4).A. Interface hepatitis: Continuous around >50% of tracts/septa (4/4).
B. Confluent necrosis: Absent (0/6).B. Confluent necrosis: Focal (1/6).B. Confluent necrosis: Zone 3 necrosis in some areas (2/6).B. Confluent necrosis: Zone 3 necrosis in most areas (3/6).B. Confluent necrosis: Occasional portal-central bridging necrosis (4/6).B. Confluent necrosis: Frequent portal-central bridging necrosis (5/6).B. Confluent necrosis: Panacinar or multiacinar collapse (6/6).
C. Lobular necrosis or inflammation: Absent (0/4)C. Lobular necrosis or inflammation: < 1 focus per acinus (1/4)C. Lobular necrosis or inflammation: 2-4 foci per acinus or nodule (2/4).C. Lobular necrosis or inflammation: 5-10 foci per acinus or nodule (3/4).C. Lobular necrosis or inflammation: >10 foci per acinus nodule (4/4).
D. Portal inflammation: None (0/4).D. Portal inflammation: Mild, some or all portal tracats (1/4).D. Portal inflammation: Moderate, some or all portal areas (2/4).D. Portal inflammation: Marked, not all portal areas (3/4).D. Portal inflammation: Marked, all portal areas (4/4).
E. Staging: No fibrosis (0/4).E. Staging: Fibrous portal enlargement (1/4).E. Staging: Fibrous septa (2/4).E. Staging: Transition to cirrhosis (3/4).E. Staging: Cirrhosis (4/4).
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No fibrosis0
Fibrous expansion of some portal areas, with or without short fibrous septa
1Fibrous expansion of most portal areas, with or without
short fibrous septa 2Fibrous expansion of most portal areas, with occasionalportal to portal bridging
3Fibrous expansion of portal areas with marked bridging
portal-portal and/or portal-central 4Marked bridging (portal-portal and/or portal-central)
with occasional nodules (incomplete cirrhosis) 5Cirrhosis, probable or definite
6
So what do I do…?
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LIVER: NEEDLE BIOPSY - Chronic hepatitis, ………. active with……. (stage …/4), compatible with hepatitis C.
Comment:A. Interface hepatitis: Absent (0/4).A. Interface hepatitis: Focal, few portal areas (1/4).A. Interface hepatitis: Focal, most portal areas, >5-50% (2/4).A. Interface hepatitis: Continuous around <50% of tracts/septa (3/4).A. Interface hepatitis: Continuous around >50% of tracts/septa (4/4).
B. Confluent necrosis: Absent (0/6).B. Confluent necrosis: Focal (1/6).B. Confluent necrosis: Zone 3 necrosis in some areas (2/6).B. Confluent necrosis: Zone 3 necrosis in most areas (3/6).B. Confluent necrosis: Occasional portal-central bridging necrosis (4/6).B. Confluent necrosis: Frequent portal-central bridging necrosis (5/6).B. Confluent necrosis: Panacinar or multiacinar collapse (6/6).
C. Lobular necrosis or inflammation: Absent (0/4)C. Lobular necrosis or inflammation: < 1 focus per acinus (1/4)C. Lobular necrosis or inflammation: 2-4 foci per acinus or nodule (2/4).C. Lobular necrosis or inflammation: 5-10 foci per acinus or nodule (3/4).C. Lobular necrosis or inflammation: >10 foci per acinus nodule (4/4).
D. Portal inflammation: None (0/4).D. Portal inflammation: Mild, some or all portal tracats (1/4).D. Portal inflammation: Moderate, some or all portal areas (2/4).D. Portal inflammation: Marked, not all portal areas (3/4).D. Portal inflammation: Marked, all portal areas (4/4).
E. Staging: No fibrosis (0/4).E. Staging: Fibrous portal enlargement (1/4).E. Staging: Fibrous septa (2/4).E. Staging: Transition to cirrhosis (3/4).E. Staging: Cirrhosis (4/4).
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LIVER: NEEDLE BIOPSY - Chronic hepatitis, ………. active with……. (stage …/4), compatible with hepatitis C.
Comment:A. Interface hepatitis: Absent (0/4).A. Interface hepatitis: Focal, few portal areas (1/4).A. Interface hepatitis: Focal, most portal areas, >5-50% (2/4).A. Interface hepatitis: Continuous around <50% of tracts/septa (3/4).A. Interface hepatitis: Continuous around >50% of tracts/septa (4/4).
B. Confluent necrosis: Absent (0/6).B. Confluent necrosis: Focal (1/6).B. Confluent necrosis: Zone 3 necrosis in some areas (2/6).B. Confluent necrosis: Zone 3 necrosis in most areas (3/6).B. Confluent necrosis: Occasional portal-central bridging necrosis (4/6).B. Confluent necrosis: Frequent portal-central bridging necrosis (5/6).B. Confluent necrosis: Panacinar or multiacinar collapse (6/6).
C. Lobular necrosis or inflammation: Absent (0/4)C. Lobular necrosis or inflammation: < 1 focus per acinus (1/4)C. Lobular necrosis or inflammation: 2-4 foci per acinus or nodule (2/4).C. Lobular necrosis or inflammation: 5-10 foci per acinus or nodule (3/4).C. Lobular necrosis or inflammation: >10 foci per acinus nodule (4/4).
D. Portal inflammation: None (0/4).D. Portal inflammation: Mild, some or all portal tracats (1/4).D. Portal inflammation: Moderate, some or all portal areas (2/4).D. Portal inflammation: Marked, not all portal areas (3/4).D. Portal inflammation: Marked, all portal areas (4/4).
E. Staging: No fibrosis (0/4).E. Staging: Fibrous portal enlargement (1/4).E. Staging: Fibrous septa (2/4).E. Staging: Transition to cirrhosis (3/4).E. Staging: Cirrhosis (4/4).
MildModerateSevere
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STAGING
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No fibrosis0
Fibrous expansion of some portal areas, with or without short fibrous septa
1Fibrous expansion of most portal areas, with or without
short fibrous septa 2Fibrous expansion of most portal areas, with occasionalportal to portal bridging
3Fibrous expansion of portal areas with marked bridging
portal-portal and/or portal-central 4Marked bridging (portal-portal and/or portal-central)
with occasional nodules (incomplete cirrhosis) 5Cirrhosis, probable or definite
6
No fibrosis 0
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 occasionalportal to portal bridging 3
Fibrous expansion of portal areas with marked bridging, portal-portal and/or portal-central 4
Marked bridging (portal-portal and/or portal-central)with occasional nodules (incomplete cirrhosis) 5
Cirrhosis, probable or definite 6
Ishak et al. staging scheme
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No fibrosis0
Fibrous expansion of some portal areas, with or without short fibrous septa
1Fibrous expansion of most portal areas, with or without
short fibrous septa 2Fibrous expansion of most portal areas, with occasionalportal to portal bridging
3Fibrous expansion of portal areas with marked bridging
portal-portal and/or portal-central 4Marked bridging (portal-portal and/or portal-central)
with occasional nodules (incomplete cirrhosis) 5Cirrhosis, probable or definite
6
No fibrosis 0
Portal fibrosis 1
Focal Septa 2
Frequent septa 3
Cirrhosis, probable or definite 4
METAVIR staging
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No fibrosis 0
Portal fibrosis 1
Focal Septa 2
Frequent septa 3
?Cirrhosis, probable or definite 4
METAVIR staging
?
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No fibrosis0
Fibrous expansion of some portal areas, with or without short fibrous septa
1Fibrous expansion of most portal areas, with or without
short fibrous septa 2Fibrous expansion of most portal areas, with occasionalportal to portal bridging
3Fibrous expansion of portal areas with marked bridging
portal-portal and/or portal-central 4Marked bridging (portal-portal and/or portal-central)
with occasional nodules (incomplete cirrhosis) 5Cirrhosis, probable or definite
6
So what do I do…?
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No fibrosis 0
Focal portal fibrosis, w or w/o short fibrous septa 1
Widespread portal fibrosis, w or w/o short fibrous septa 2
Focal portal-portal septa 3
Frequent septa (portal-central and/or portal portal) 4
Marked septa with occasional nodules 5
Cirrhosis, probable or definite 6
No fibrosis 0
Portal fibrosis 1
Focal Septa 2
Transition to cirrhosis 3
Cirrhosis, probable or definite 4
Theise modification of Ishak staging
?
Ishak et al. staging scheme
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Stages of Fibrosis
Ishak
5 61 2focal frequent
1 2 3 4
PortalFibosis
FibrousSepta
Transitionto Cirrhosis
Cirrhosis
1 42 3focal frequent
Metavir
Theise ND. Human Pathology 2007
Modified Ishak Batts-Ludwig
3 4focal frequent
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How much tissue is enough?How much tissue is enough?
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How much tissue is enough?1.8 cm? 2.2 cm? 2.5 cm?
How much tissue is enough?1.8 cm? 2.2 cm? 2.5 cm?
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How much tissue is enough?1.8 cm? 2.2 cm? 2.5 cm?
How much is too little???
How much tissue is enough?1.8 cm? 2.2 cm? 2.5 cm?
How much is too little???
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Case 1A
34 year old woman
Hepatitis C positive; biopsy for staging and grading.
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Case 1A, 4x, H&E
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Case 1A, 4x, H&E
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Case 1A, 4x, H&E
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Case 1A, 4x, Trichrome
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Case 1A, 4x, Trichrome
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Case 1A, 10x, Trichrome
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For example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis, mildly active with transition to cirrhosis (modified Ishak stage 3/4), compatible with hepatitis C.
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For example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis, mildly active with transition to cirrhosis (modified Ishak stage 3/4), compatible with hepatitis C.
Comment: There is a mild to moderate portal/septal mononuclear infiltrate associated with widespread interface hepatitis and focal lobular hepatitis.
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For example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis, mildly active with transition to cirrhosis (modified Ishak stage 3/4), compatible with hepatitis C.
Comment: There is a mild to moderate portal/septal mononuclear infiltrate associated with widespread interface hepatitis and focal lobular hepatitis. There is no confluent necrosis.
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For example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis, moderately active with transition to cirrhosis (modified Ishak stage 3/4), compatible with hepatitis C.
Comment: There is a mild to moderate portal/septal mononuclear infiltrate associated with widespread interface hepatitis and focal lobular hepatitis. There is no confluent necrosis. Trichrome and reticulin stains highlight focal fibrous septa, and focal nodularity Indicative of cirrhosis.
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For example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis, moderately active with transition to cirrhosis (modified Ishak stage 3/4), compatible with hepatitis C.
Comment: There is a mild to moderate portal/septal mononuclear infiltrate associated with widespread interface hepatitis and focal lobular hepatitis. There is no confluent necrosis. Trichrome and reticulin stains highlight focal fibrous septa, and focal nodularity Indicative of cirrhosis. There is focal steatosis in a pattern typical of that seen with chronic hepatitis C.
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For example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis, moderately active with transition to cirrhosis (modified Ishak stage 3/4), compatible with hepatitis C.
Comment: There is a mild to moderate portal/septal mononuclear infiltrate associated with widespread interface hepatitis and focal lobular hepatitis. There is no confluent necrosis. Trichrome and reticulin stains highlight focal fibrous septa, and focal nodularity Indicative of cirrhosis. There is focal steatosis in a pattern typical of that seen with chronic hepatitis C.
No significant hemosiderosis or alpha-1-antitrypsin globules are identified (iron, PAS-D stains).
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For example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis, moderately active with transition to cirrhosis (modified Ishak stage 3/4), compatible with hepatitis C.
Comment: There is a mild to moderate portal/septal mononuclear infiltrate associated with widespread interface hepatitis and focal lobular hepatitis. There is no confluent necrosis. Trichrome and reticulin stains highlight focal fibrous septa, and focal nodularity Indicative of cirrhosis. There is focal steatosis in a pattern typical of that seen with chronic hepatitis C.
No significant hemosiderosis or alpha-1-antitrypsin globules are identified (iron, PAS-D stains).
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Case 1B
47 year old man
Hepatitis C positive; ultrasound guided biopsy of left lobe, for staging and grading.
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Case 1B, 2x, H&E
GLISSON’SCAPSULE
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Case 1B, 4x, H&E
SUBCAPSULAR ZONE
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Case 1B, 2x, H&E
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Case 1B, 2x, H&E
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LIVER: NEEDLE BIOPSY - Chronic hepatitis, mildly active with portal fibrosis
(modified Ishak stage 1/4), compatible with hepatitis C.
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The Viruses
Clinical Aspects
Role of Liver Biopsy, Part 1
Histologic/Immunostaining features
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HBV: Ground glass hepatocytes
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HBV: Ground glass cells (surface antigen inclusions)
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Immunostain: HBV Surface Antigen
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HCV: lymphoid aggregates
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Plasma cells in Autoimmune Hepatitis
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Mixed Viral Infections
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HBV + ?
= utility of immunostains
for HBV core Ag
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Immunostain for HBcAG:Confirms active viral replication
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Another example:
LIVER: NEEDLE BIOPSY - Chronic hepatitis B, mildly active with transition to cirrhosis (stage 3/4).
Comment: ….Ground glass hepatocytes (or immunostains for HBV surfaceantigen) confirm chronic hepatitis B virus infection. Immunostain for core antigen confirms hepatitis B viral replication….
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No HBcAgSuspect:
HBV DNA neg., Spontaneously resolved or treated infection
orsampling
orCo-infection with HCV,HDV
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Diffuse HBcAg
Suspect:Immunosuppression,
in particular: HBV + HIV!!!
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HCV + HIV?
Increased ActivityDecreased Activity
Increase rate of progressionDecreased rate of progression
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HCV + HIV?
On HAART: In large cohorts,
possibly more aggressive, but individual biopsies look the same
as HCV alone.
Beware: drug toxicity
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HCV + HIV?
Untreated:Often more severe activity.
Often more advanced disease.
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HCV + HIV?
Untreated:Often more severe activity.
Often more advanced disease.
Rare: fibrosing cholestatic hepatitis
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HCV + HIV?
Untreated:Often more severe activity.
Often more advanced disease.
Rare: fibrosing cholestatic hepatitis
Beware: Infiltrating neoplasms, granulomas, HSV, CMV, biliary tract disease, etc.
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