pathology histopathology exam md residency

1. Moderator: Prof Mohan Kumar
Speaker: Dr Dushyant Purmanan

2. Basics
Vital organ playing a key role in the maintenance of
body homeostasis
Largest gland of the body situated in the right upper
quadrant of the abdominal cavity.
 It weighs about 1400 to 1600 grams.
 It occupies the whole of right hypochondrium, most
of the epigastrium and part of left hypochondrium.
It is divided anatomically into lobes- right and left,
caudate and quadrate lobes
Physiologically divided into right and left lobes based
on distribution of portal systems.
Functionally, the liver is divided into 8 segments
based on the distribution of its intrahepatic blood
vessels.

3. Microscopic
Classically, the liver is divided into hexagonal hepatic
lobules surrounding the central hepatic vein and having
the portal tracts peripherally.
The hepatic parenchyma is divided into 3 zones
- Zone 1-Periportal
- Zone 2- Midzonal
- Zone 3- Centrilobular
- With maximum vascular supply in zone 1 and least
supply in zone 3

6. The hepatic parenchyma is composed of plates of
polygonal hepatocytes arranged in one cell thick cords,
with vascular sinusoids on either side
The sinusoids are lined by fenestrated and discontinuous
endothelial cells.
The space between the hepatocytes and the sinusoidal
endothelial lining is known as the space of Disse.
 Kupffer cells are found in the luminal side of sinusoids
while perisinusoidal stellate cells are present in the space
of Disse.
Perisinusoidal stellate cells are also known as ITO cells
store vitamin A in their cytoplasmic lipid droplets. They
have contractile property and are converted into collagen
producing myofibroblasts in presence of hepatic
inflammation.
Bile is secreted into bile canaliculi which are 1-2µm
channels between abutting hepatocytes. These channels
drain biliary fluid into the terminal bile ducts within the
portal tract via the canal of Hering

8. Functions of liver
Metabolism of carbohydrates
( Glucose Glycogen)→
Metabolism of lipids
(FFA Triglycerides, Cholesterol, Lipoproteins)→
Metabolism of proteins
(AA keto acid + NH3 Urea +H2O)→ →
Protein synthesis- Albumin and Globulins
Synthesis of clotting factors- Factors II, V, VII, IX &
X , protein C , Protein S

9. Elimination and detoxifying of drugs, hormones and
toxic substances
Production of bile
Excretion of bilirubin
Storage of glycogen, vitamins and other
micronutrients
Extramedullary hematopoiesis

10. Introduction to liver biopsy
1883- First liver biopsy aspiration performed by the
German Paul Ehrlich
1958- One Second needle biopsy technique
introduced by Menghini
The traditional gold standard in the evaluation of
the etiology and extent of disease of the liver.
 Light microscopic examination of liver tissue
remains an essential part of diagnostic procedure
and follow up of majority of liver diseases.

11. Who perform a liver biopsy
 Hepatologist
 Gastroenterologist
 Radiologist
 Pathologist
 Surgeon

12. Types of liver biopsy
Percutaneous
Transjugular
USG / CT guided
Laparoscopic/ laparotomy

14. The choice of one technique over another is based on
availability
 personal preference
the clinical situation
Likewise, various needles are available for use,
depending upon the approach and physician
experience.

15. Types of Biopsy Needle
Suction needle- Menghini, Jamshidi, Klatskin
Cutting needle- Vim Silverman, Tru Cut
Spring loaded needle
The ideal biopsy needle should be 1.4 – 1.8 mm in
diameter.
Wider bore needle are associated with higher risk of
complications.

19. 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 cholangitis

20. 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
Diagnosis of a liver mass
Evaluation of the status of the liver after
transplantation or of the donor liver before
transplantation
Evaluation of fever of unknown origin, with a culture
of tissue

21. Percutaneous Liver Biopsy
Prerequisites for outpatient liver biopsy
•Cooperative patient with clear understanding of the
plan
•Has a chaperone who can observe him or her
closely over the next 24 hours
•Lives within 60 to 90 minutes of a medical facility
(preferably the one at which the biopsy was
performed)
•Platelet count > 60,000
•Prothrombin time < 4 seconds of control
•No recent use of nonsteroidal anti-inflammatory
drugs, aspirin or clopidogrel
•No clinical history suggestive of coagulopathy

22. •The facility where the biopsy is performed should
have an approved blood bank,
•laboratory, inpatient bed, and personnel available
to the patient for at least 6 hours post procedure.
•Hospitalization should accompany evidence of
bleeding, bile leak, pneumothorax,or pain requiring
more than one analgesic dose

23. Procedure
Written consent of patient after explaining procedure
Baseline investigations-Prothrombin time and
complete blood count
Place the patient supine, remove pillows, and elevate
the right arm behind the head.
Percuss the right trunk to the point of maximum
dullness during both inspiration and expiration. This
frequently corresponds to a point along the midaxillary
line at the second or third intercostal space above the
costal margin.
Mark this location with a surgical pen or other method.
Prepare the field with Betadine solution and place
sterile drapes.
Administer local anesthesia with 1% lidocaine in both
superficial and deep planes..

24. Once adequate anesthesia has been obtained, a small
nick in the skin is made with a surgical blade to allow
introduction of the biopsy needle.
 The biopsy needle is introduced within close proximity
to the upper aspect of the lower rib to avoid the
intercostal nerve and vasculature.
As the needle is introduced, a series of several successive
"pops" may be felt.
Small amounts of saline contained in the syringe are
flushed until resistance is encountered.
The resistance is the liver edge; at this point, the needle
is withdrawn slightly and flushed again to remove debris.
Suction is applied to the syringe, and the patient is asked
to expire and to hold his/her breath.
The liver biopsy is then taken

25. Post biopsy
Pressure is applied to the site, followed by an adhesive
bandage.
The patient is rolled onto the right side and
instructed to remain in this position for minimum 1
hour to help prevent bleeding or bile leakage.
 Vital signs are obtained every 15 minutes for the first
hour, every 30 minutes during the second hour and
then hourly
Patient is discharged if no signs of immediate
complications

26. Contraindications of Percutaneous liver biopsy
Absolute contraindications
Uncooperative patient
History of unexplained bleeding
Tendency to bleed
Prothrombin time 3–5 sec more than control
Platelet count <50,000/mm3
Prolonged bleeding time (>10 min)
Use of a NSAIDS within previous 7–10 days
Blood for transfusion unavailable
Suspected hemangioma or other vascular tumor
Inability to identify an appropriate site for biopsy by
percussion or ultrasonography
Suspected echinococcal cysts in the liver

27. Relative contraindications
Morbid obesity
Ascites
Hemophilia
Infection in the right pleural cavity or below the right
hemidiaphragm

28. Plugged liver biopsy
This is a modification of the percutaneous liver
biopsy.
It is done in patients with impaired coagulation
where Transjugular biopsy is not available
In this technique, liver biopsy is done in
conventional manner, but only the obturator is
removed leaving the outer sheath in the liver
parenchyma. Gelatin is then slowly injected as the
sheath is withdrawn.

29. Complications
Complications of liver biopsy occur rarely but
potentially are lethal.
The majority (60%) of complications occurs within the
first 2 hours
 96% occur during the first 24 hours following the
procedure
Approximately 2% of patients undergoing biopsy
require hospitalization for the management of an
adverse event.
Vasovagal episode and pain are the most common
reasons for admission.

30. Complications of percutaneous liver biopsy
Pain (0.056 – 83%)
Pleuritic
Peritoneal
Diaphragmatic
Hemorrhage
Intraperitoneal (0.03 – 0.7%)
Intrahepatic and/or subcapsular( 0.59 – 23%)
Hemobilia( 0.059 – 0.2%)
Bile peritonitis (0.03 – 0.22%)

31. Bacteremia
Sepsis and abscess formation (0.088%)
Pneumothorax and/or pleural effusion (0.08 – 0.28%)
Hemothorax (0.18 – 0.49%)
Arteriovenous fistula (5.4%)
Subcutaneous emphysema (0.014%)
Anesthetic reaction (0.029%)
Needle break (0.02 – 0.059%)
Biopsy of other organs
Lung (0.001 – 0.014%)
Gallbladder (0.034 – 0.117%)
Kidney (0.029 – 0.096%)
Colon (0.00038 – 0.044%)
Mortality (0.0088 – 0.3%)

32. Transjugular Liver Biopsy
Indications
Coagulopathy – INR > 1.5
Thrombocytopenia- Platelelet count <60 000/µL
Ascites
Obesity
Fulminant liver failure
Vascular hepatic tumour
Peliosis hepatis
Failed Percutaneous liver biopsy

33. The route of access is usually the right internal
jugular vein or the right femoral vein.
 Adequate tissue of size 0.3-2 cm is obtained in
80-97% cases.
The biopsy obtained is smaller, fragmented and
include fewer portal tracts as compared to
Percutaneous approach.
 The procedure is technically more difficult and
constant cardiac monitoring is mandatory during
the intervention.

34. Major complications (1.3 – 20%) are:
Hemorrhage with perforation of hepatic capsule
Fistula formation
Pain
Neck hematoma
Cardiac arrhythmias
Pneumothorax

35. Laparoscopic liver biopsy
Use of laparoscopy to evaluate liver disease allows direct
inspection of the liver surface and sampling of tissue.
 It is done safely under LA with conscious sedation.
Indications
Staging of cancer
Ascites of unclear cause
Peritoneal infections
Evaluation of an abdominal mass
Unexplained hepatosplenomegaly

36. Contraindications
Absolute Relative
Severe cardiopulmonary failure Uncooperative
patient
Intestinal obstruction Severe coagulopathy
Bacterial peritonitis Morbid obesity
Large ventral hernia

37. What constitutes an adequate liver biopsy for
accurate evaluation?
A sample of 1 - 3 cm in length
 1.2 - 2 mm in diameter
Containing at least 11 - 15 portal triads is considered
adequate.
 This represents approximately 1/50,000th of the adult
liver

38. Limitations of liver biopsy
• Liver biopsy is an Invasive procedure
There may be variability in assessment due to
sampling errors
(size of biopsy specimen and site of biopsy).
 This discrepancy can cause a variation in both
grading (33-69%) and staging (25-62%).
There is also the intraobserver and interobserver
variability while scoring a biopsy specimen
Associated morbidity and mortality risks

39. Systematic approach to Histopathological
examination of liver biopsy specimen
All fragments of the liver biopsy should be examined
Begin evaluating by locating the central veins then
move in direction of portal area
Assess the veins, hepatocytes, bile canaliculi, stellate
cells, the vascular sinusoids and abnormal deposits in
the canal of Disse
Look for chronic necroinflammatory component and
features of cholestatic disorder in Periportal area
Also look for the Proliferation of ductules and fibrosis
in acinar region

40. Staining Methods
In routine histopathology lab practice,
H & E stain along with a connective tissue stain
(reticulin) in certain cases are more than sufficient for
reporting of the liver biopsy specimen.
However there are certain cases where special staining
is needed for confirmation of diagnosis.
Fibrosis and Connective tissue- Reticulin or Masson
Trichrome
Vascular lesions- Movat pentachrome stain(stains
elastica, acid mucopolysaccharide,collagen & smooth
muscle)

41. Ground glass hepatocytes & Copper associated
protein
- Orcein or Victoria Blue stains
Glycogen, Amyloid, Starch, Fungi – PAS stain
Lipofuscin & α 1 antitrypsin globules – PAS- Diastase
stain
Hemosiderin, bile, lipofuscin- Prussian Blue
Copper- Rhodanine stain
Amyloid- Congo Red, Sirius Red, Crystal violet
Lipids in frozen section- Oil red O

42. Immunostaining
Bile duct epithelial cells- Monoclonal antibodies to
Cytokeratins 7,8,18 & 19
Hepatocytes- Monoclonal antibodies to Cytokeratins 8 &
18
Mallory-Denk bodies- antibodies to Ubiquitin
Viral Hepatitis- Hepatitis B antigen(surface and core)
Hepatocellular carcinoma- Glypican 3

43. Patterns of Hepatic Injury
When exposed to any injurious stimuli, the hepatocytes
undergo certain changes.
Irrespective of the cause, 5 general responses are seen.
These changes may exist alone or in combination
depending upon the etiology.
1) Degeneration & Intracellular accumulation
2) Necrosis & Apoptosis
3) Inflammation
4) Regeneration
5) Fibrosis

44. Degeneration and Intracellular accumulation
The first change that takes place in the hepatocytes is
hydropic change which is a reversible state.
 With more severe damage, ballooning degeneration of
hepatocytes takes place.
These are swollen hepatocytes with irregularly clumped
cytoplasmic organelles and large clear spaces.
In cholestatic liver pathology, retained bile imparts a diffuse
foamy appearance to the hepatocytes giving a yellowish
discoloration of the cytoplasm- feathery degeneration

47. Intracellular accumulations
Lots of substances accumulate in viable hepatocytes in
various conditions.
Steatosis- accumulation of triglyceride fat droplets within
the hepatocytes.
-Microvesicular type as in acute fatty liver of pregnancy or
drug induced( valproate, tetracycline, salicylates)
-Macrovesicular type as in diabetes mellitus & obesity,
CCl4 poisoning, methotrexate use and in HCV infection.
Both types coexist in alcoholic liver disease.

48. This is the histologic appearance of hepatic fatty change. The lipid accumulates in the
hepatocytes as vacuoles...

49.  -Glycogen accumulation in hepatocytes in
hepatic type of glycogenosis- type 1- Von Giercke
disease
-Iron accumulation in hemochromatosis
 -Copper accumulation in Wilson’s disease
-Mallory-Denk Bodies with accumulation of
cytokeratin intermediate filaments in alcoholic
liver disease, PBC, Wilson disease, chronic
cholestatic syndromes & hepatocellular tumours.
-Lipofuscin accumulation

51. a single cell (center) containing intracytoplasmic Mallory’s bodies

55. Necrosis and Apoptosis
Any significant insult to the liver can cause
hepatocyte necrosis, which frequently exhibits a
zonal distribution.
In ischemic coagulative necrosis, the hepatocytes
are poorly stained, mummified and have lysed
nuclei.
Centrilobular necrosis- necrosis of hepatocytes
around the terminal central vein is characteristic of
ischemic injury and also due to drugs and toxic
reactions
Lytic necrosis is the outcome of ballooning
degeneration- rupture of swollen hepatocytes

56. Midzonal and periportal necrosis are rare and
periportal necrosis is seen in eclampsia
Focal or spotty necrosis- scattered hepatocytes
within the lobule undergo necrosis
Bridging necrosis- necrosis of hepatocytes with
portal-portal, central-central or portal-central
extension.
Apoptotic hepatocytes are shrunken, pyknotic and
intensely eosinophilic cells containing fragmented
nuclei. They are known as Councilman bodies or
Acidophil bodies.

57. Inflammation
Injury to the liver associated with influx of inflammatory
cells is termed as hepatitis.
Piecemeal necrosis or Interface hepatitis- it corresponds
to the extension of lymphocytic portal infiltrate beyond
the limits of the portal tract associated with apoptotic cell
death.
Fulminant hepatitis- complete destruction of hepatocytes
in contiguous lobules leaving only a collapsed reticulin
framework and preserved portal tracts,

58. Fibrosis
Fibrous tissue is formed in response to inflammation
or direct toxic injury to the liver.
 It represents irreversible hepatic damage.
 Deposition of collagen fibres in the liver parenchyma
forming delicate septal tracts in mild forms eventually
leading to liver cirrhosis with nodules formation
Liver cirrhosis is considered to be the end stage of liver
damage.

61. Acute Viral hepatitis
Liver biopsy is not advocated in cases of acute
hepatitis.

62. Chronic Hepatitis
Definition:
Clinical and pathological syndrome of
continuing or relapsing hepatic disease of at
least 6 months duration characterized by
varying degree of histologically
documented inflammation and necrosis

63. Etiology
Chronic viral hepatitis (B & C)
Alcoholic cirrhosis
Autoimmune hepatitis
Drug induced hepatitis
Metabolic disorders – Hemochromatosis
- Wilson’s Disease
- α 1 Antitrypsin Deficiency
NASH
Cryptogenic hepatitis

64. Traditionally the histology of chronic
hepatitis was divided into
 Chronic persistent hepatitis (CPH)
 Chronic active hepatitis (CAH)
 Chronic lobular hepatitis (CLH).

65. CPH represents the milder form of liver injury
with limitation of chronic inflammatory infiltrate
to the portal tracts and ABSENCE of interface
hepatitis.
 CAH represents the severe form of liver injury
characterized by periportal inflammation with
piecemeal necrosis (interface hepatitis) with or
without fibrosis.
CLH is characterized by spotty necrosis and
inflammation within the lobule with minimal
portal inflammation

66. Classification and Scoring Systems
Liver biopsy is done not only to confirm the
diagnosis or etiology, but most important for the
grading and staging of the ongoing liver pathology

67. Grading refers to the degree of severity of the disease
activity by assessing the necroinflammatory
components.
- Portal inflammation, interface hepatitis, Intralobular
damage and inflammation & confluent necrosis.
Staging of the disease is an attempt to place the
disease into a specific segment along its assumed
course.
This evolutionary stage has both significant
prognostic and therapeutic implications.
It is assessed by evaluation of extent of fibrosis,
architectural alteration and progression to cirrhosis.

68. There are several scoring systems for the evaluation of
lesions in chronic hepatitis.
Original HAI (Knodell) –
Periportal +/- Bridging necrosis (0-10) + Intralobular
degeneration & focal necrosis( 0-4) + Portal inflammation
(0-4)
and Fibrosis (0-4)
Ishak Modified HAI-
Periportal or interface hepatitis (piecemeal necrosis) (0-4) +
confluent necrosis (0-6) + Focal (spotty) lytic necrosis,
apoptosis & focal inflammation (0-4) + Portal
inflammation(0-4) and Architectural changes, fibrosis &
cirrhosis (0-4)
 Metavir Algorithm is designed to score Chronic Hepatitis C.
It is the combination of interface hepatitis (0-3) and lobular
necrosis (0-3)
 Scheuer is a simple scoring system for chronic hepatitis. Its
grading score consist of Portal inflammation (0-4) and
interface hepatitis and lobular activity (0-4) and staging for
fibrosis (0-4).

69. I Periportal +/-
bridging necrosis
Score II Intralobular degeneration
& focal necrosis
score III Portal inflammation Score Fibrosis score
A None 0 A None 0 A None 0 A.
No fibrosis
0
B.
Mild piecemeal
necrosis
1 B. Mild
(acidophilic bodies,
ballooning degeneration, and
foci of necrosis < 1/3 lobules)
1 B. Mild (inflammatory cells
in < 1/3 portal tracts)
1 B. Fibrous portal
expansion
1
C. Moderate
piecemeal
necrosis(<50% of
most portal tracts)
3 C. Moderate (involvement >
2/3 lobules)
3 C. Moderate (increased
inflammatory cells 1/3 -2/3
portal tracts)
3 C. Bridging fibrosis
(P-P, P-C)
3
D. Severe
piecemeal
necrosis(>50% of
most portal tracts)
4 D. Severe (involvement > 2/3
lobules)
4 D. Severe (dense packing on
inflammatory cells > 2/3
portal tracts)
4 D. Cirrhosis 4
E. Moderate
Piecemeal necrosis
+ bridging necrosis
5
F. Marked
piecemeal necrosis
+ bridging necrosis
6
G. Multinodular
necrosis
10
Original Knodell HAI
HAI SCORE= I + ii + iii + IV (0-22)

70. The Ishak Modified HAI
Modified HAI Grading: Necroinflammatory Scores
Periportal or periseptal interface hepatitis Score
(piecemeal necrosis)
Absent 0
Mild (focal, few portal areas) 1
Mild/moderate (focal, most portal areas) 2
Moderate (continuous around, 50% of tracts or septa) 3
Severe (continuous around .50% of tracts or septa) 4

71. B. Confluent necrosis Score
Absent 0
Focal confluent necrosis 1
Zone 3 necrosis in some areas 2
Zone 3 necrosis in most areas 3
Zone 3 necrosis with occasional
portal-central bridging 4
Zone 3 necrosis with multiple
P-C bridging 5
Panacinar or multiacinar necrosis 6

72. C. Focal (spotty) lytic necrosis, apoptosis and focal
inflammation
Absent 0
One focus or less per 10 3objective 1
Two to four foci per 10 3 objective 2
Five to ten foci per 10 3 objective 3
More than ten foci per 10 3 objective 4

73. D. Portal inflammation Score
None 0
Mild, some or all portal areas 1
Moderate, some or all portal areas 2
Moderate/marked, all portal areas 3
Marked, all portal areas 4
HAI SCORE for GRADING= A + B + C + D (0-18)

74. Modified Staging:
Architectural Changes, Fibrosis, and Cirrhosis
Change Score
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 occasional portal to portal (P-P) bridging
3
Fibrous expansion of portal areas with marked
bridging (P-P) as well as portal-central (P-C) 4
Marked bridging (P-P and/or P-C) with
occasional nodules (incomplete cirrhosis) 5
Cirrhosis, probable or definite 6

77. Relationship of Aggregate Inflammation Scores to
grade of Activity
Sum of inflammation scores in HAI
or modified HAI systems
Description of activity
0 None
1 - 4 Minimal
5 – 8 Mild
9 – 12 Moderate
13 – 18 Marked

78. Chronic Viral Hepatitis B
Liver biopsy is useful in
 assessing severity of liver damage
 predicting prognosis
 monitoring response to treatment.

79. The predominant histologic findings include
Inflammatory cell infiltration (mononuclear cells) in
the portal tracts
Periportal necrosis may be mild or severe with
disruption of the limiting plate (interface hepatitis).
 As the liver damage progresses, there is deposition of
fibrous tissue initially within the portal tracts, later
extending to centrilobular areas and adjacent portal
tracts and eventually cirrhosis.
It is also characterized microscopically by presence of
- ground glass hepatocytes
- sanded nuclei

80.  Ground glass hepatocytes are liver cells with finely
granular and more pale, eosinophilic homogenous
cytoplasm.
The ground glass appearance is due to the marked
hypertrophy of smooth ER, containing the excess
filamentous structures of HBsAg.
Other conditions with ground glass hepatocytes:
Fibrinogen storage disease
Drug induced
Alcohol aversion
Glycogenosis Type IV(Anderson disease)
Lafora’s disease(myoclonus epilepsy)

81. Sanded nuclei are hepatocellular nuclei with finely
granular, pale eosinophilic appearance of larger part
of nuclei
They represent massive accumulation of HBcAg.

83. Chronic viral hepatitis C
HCV infection is characterized by
silent onset mostly
a high rate of viral persistence
worsening chronic liver disease ranging from chronic
hepatitis to cirrhosis and progression to HCC.

84. Histologically it is characterized by:
Mild to moderate degree of necroinflammation
Lymphocyte-rich portal infiltrate, forming
lymphoid aggregates and even follicles with
germinal centres.(follicles also found in Hepatitis B,
AIH & PBC)
Mild to moderate macrovesicular type of steatosis
Bile duct epithelial cell proliferation
Occasional apoptotic bodies and Mallory like
inclusions
5% cases develop epithelioid granuloma(DDX-PBC)
related to Interferon-α therapy

87. Both chronic hepatitis B & C have the potential to
develop premalignant lesions in the form of
- liver cell dysplasia
- macroregenerative nodules
Liver cell dysplasia is of 2 types
- large cell and small cell type
Macroregenerative nodules or adenomatous
hyperplasia are usually nodules > 0.8 cm and are
classified as low grade or high grade nodules.

88. Non Alcoholic Fatty Liver Disease
Condition resembling alcohol induced liver disease
but occurs in patients who are not heavy drinkers
It can be primary or secondary NAFLD
Strong association with Syndrome X- diabetes
mellitus type 2, dyslipidemia, obesity
It is a diagnosis of exclusion
Severe form is known as NASH- non alcoholic
steatohepatitis
Microscopic - steatosis (macrovesicular), multifocal
parenchymal inflammation, Mallory hyaline, balloon
degeneration and apoptosis and sinusoidal fibrosis
and eventually cirrhosis,

89. It is divided histologically into 4 categories:
1) Fat deposition only
2)Fat deposition + non specific inflammation
3)Fat deposition + advanced inflammation &
ballooning degeneration
4)Type 1 + Fibrosis and/ or Mallory-Denk bodies &
cirrhotic changes
Types 3 and 4 = NASH

90. – ballooning in one zone 3 area only

92. Numerous MDBs are present (arrows) within ballooned and nonballooned hepatocytes
near the centrilobular vein (CV) in this explant liver with steatohepatitis. B, Immunostain
for ubiquitin shows positive staining of the irregularly shaped intracytoplasmic MDBs
(arrows) in a liver biopsy with steatohepatitis .

93. Histologic feature Grade Description
Steatosis
0 <5%
1 5-33%
2 33-66%
3 >66%
Lobular inflammation 0 None
1 <2 foci/200x field
2 2-4 foci/200x field
3 >4 foci/200x field
Ballooning
0 None
1 Few balloon cells
2
Many cells/ prominent
ballooning
NASH STAGING AND GRADING - Nonalcoholic Steatohepatitis Clinical Research Network scoring system
(Nonalcoholic Steatohepatitis Activity Score - NAS), 2005
ACTIVITY SCORE
NAS > 5 = NASH, NAS<2 = no evidence of NASH, NAS 3-4 = borderline/possible.

94. Stage Histologic criteria
1
Zone 3 perivenular perisinusoidal/pericellular
fibrosis, focal or extensive
· 1A - delicate perisinusoidal fibrosis
· 1B - dense perisinusoidal fibrosis
· 1C - portal-only fibrosis
2 As above with focal or extensive periportal fibrosis
3 Bridging fibrosis, focal or extensive
4 Cirrhosis
FIBROSIS STAGING

96. Autoimmune Hepatitis
AIH has a worldwide distribution and accounts for
2.6 % of liver transplants.
There are 3 types of AIH:
AIH Type 1- most common form, characterized by
presence of ANA and ASMA.
AIH Type 2- presence of LKM-1 antibodies
AIH type 3- characterized by autoantibodies against
SLA/LP

97. General features
Female predominance
Absence of viral serologic markers
Elevated serum IgG & γ-globulin(>1.5 times
normal) -hypergammaglobulinemia
High serum titers of autoantibodies including
ANA, ASMA, SLA/LP & anti LKM antibodies
Negative AMA
Good response to immunosuppressant therapy

98. Microscopic
The entire spectrum of chronic hepatitis may be seen
in AIH.
 The necroinflammatory activity tends to be high in
untreated patients with
– bridging confluent necrosis
- marked interface hepatitis
- hepatic liver cells rosette formation.
Multinucleated giant cells may also be found
sometimes.
There is also prominent inflammatory infiltrate
composed of mainly lymphocytes and plasma cells.

99. The histologic findings of AIH are divided into 3 groups
Atypical histology
e.g steatohepatitis
Compatible histology
( a picture of chronic hepatitis with lymphocytic
infiltration without all the features considered
typical)
Typical histology
(Interface Hepatitis, lymphocytic/lymphoplasmacytic
infiltrates in portal tracts and extending into the
lobule and hepatic rosette formation).

101. Drug-induced Hepatitis
The liver is the major organ for drug metabolism and
detoxification
It is subject to potential damage by a variety of
hepatotoxic substances.
Injury is the result
1) Direct toxicity
2) Hepatic conversion of a xenobiotic to an active
toxin
3) Through immune mechanism- the drug acting
as a hapten, converting a cellular protein into
antibody.

102. • Drug reactions can be predictable (intrinsic), dose
dependent or unpredictable (idiosyncratic).
The injury may be immediate or may take weeks and
months to develop, presenting with hepatocyte
necrosis, cholestasis or an insidious onset of liver
dysfunction.
Drug induced chronic hepatitis can mimic any natural
liver disease clinically and histologically with different
drugs having different presentation

103. Hepatocellular damage Drug example
1 Microvesicular fatty change Tetracycline, Salicylates(REYE Syndrome)1,
Ethanol
2 Macrovesicular fatty change Ethanol, Methotrexate, Amiodarone
3 Centrilobular necrosis CCl4, bromobezene, Acetaminophen,
Halothane, Rifampicin
4 Diffuse or Massive necrosis Halothane, Isoniacid, Acetaminophen,
Methyldopa, Amanita phalloides toxin
5 Hepatitis, acute or chronic Methyldopa, Isoniacid, Phenytoin
6 Fibrosis- Cirrhosis Ethanol, Methotrexate, Amiodarone
7 Granuloma formation Sulfonamides, Methyldopa, Quinine,
Hydralazine, Allopurinol (fibrin ring)
8 Cholestasis Chlorpromazine, Anabolic steroids,
erythromycin, OCP
9 Ground glass appearance Phenobarbital, Rifampicin,
10 Lipofuscinosis Phenacetin, Chlorpromazine, anticonvulsants
11 Stellate cells hyperplasia Hypervitaminosis A, methotrexate

105. Hemochromatosis
This metabolic disorder is characterized by excessive
accumulation of body iron, mainly in liver and
pancreas.
Hemochromatosis can be hereditary (genetic) or
secondary.
Hereditary hemochromatosis is homozygous recessive
inherited disorder in which regulation of intestinal
iron absorption is lost.
Secondary hemochromatosis is mostly due to iron
overload (transfusions) or ineffective erythropoiesis
(hemolytic anemia).

106. Microscopic
Deposition of golden yellow haemosiderin granules in
the cytoplasm of Periportal hepatocytes
Haemosiderin granules stain blue with Prussian blue
stain.
Micronodular pattern of cirrhosis is seen in severe
cases
Inflammation is characteristically absent

108. This liver biopsy from a patient clinically thought to have genetic hemochromatosis shows predominance of macrophage
hemosiderosis, a highly atypical pattern for classic type 1 HFE hemochromatosis. Alternative causes such as FP disease (type 4
hemosiderosis accompanied by moderate hepatocellular hemosiderosis. Inset: heavy hemosiderin deposits within PT macrophages

109. P
r
u
s
s
i
a
n
bl
u
e
st
ai
n

110. Wilson disease (Hepatolenticular degeneration)
This autosomal recessive disorder is marked by
accumulation of toxic levels of copper in many tissues
and organs, mainly the liver, brain and eye.
Absorbed copper is taken up by hepatocytes and
incorporated in α2- globulin, forming cerruloplasmin,
which is then released in plasma.

111. Microscopic
Mild to moderate macrovesicular steatosis
Moderate to severe inflammation with hepatocyte
necrosis
vacuolated hepatocellular nuclei
Mallory bodies
Special staining with Rhodanine stain for copper
and Orcein stain for copper associated protein
Brain- basal ganglia involved with atrophy and
cavitation of putamen
Eye- Kayser-Fleischer rings( copper deposit in
Descemet’s membrane)

112. α 1 Antitrypsin Deficiency
This is an autosomal recessive disorder marked by
abnormally low serum levels of this important
protease inhibitor.
Absence of this enzyme causes emphysema due to
unopposed action of tissue destructive enzymes like
elastase, cathepsin G and proteinase 3.
It also causes liver disease in neonates and young
adults

113. Microscopic
Characterized by round to oval cytoplasmic globular
inclusions in hepatocytes
With routine H & E stain they are acidophilic and
indistinctly demarcated from surrounding cytoplasm.
Strongly PAS positive and Diastase resistant
Occasionally, fatty change and Mallory-Denk bodies
may be present

115. Primary biliary cirrhosis Secondary biliary cirrhosis Primary sclerosing
cholangitis
Etiology Autoimmune Extrahepatic bile duct
obstruction – biliary atresia,
gallstone, ca head pancreas
Autoimmune
Associated with IBD
Sex predilection Female : Male- 6:1 None Female : Male- 1:2
Symptoms and
signs
Pruritis, jaundice, malaise, dark urine, light stools, hepatosplenomegaly
Lab findings Conjugated hyperbilirubinemia,
↑serum alkaline Phosphatase,
bile acids, cholesterol + IgM
autoantibodies- AMA-M2
Conjugated hyperbilirubinemia,
↑serum alkaline Phosphatase,
bile acids, cholesterol
Conjugated
hyperbilirubinemia,
↑s. alkaline
Phosphatase, bile
acids, cholesterol +
↑ IgM.
hypergammaglobulinem
ia
Histologic
findings
Dense lymphocytic infiltrate in
portal tracts with granulomatous
destruction of bile ducts
Prominent bile stasis in bile
ducts, bile ductular
proliferationwith surrounding
Neutrophils, portal tract edema
Periductal portal
tract fibrosis,
segmental stenosis
of extrahepatic and
intra hepatic bile
ducts
Cholestatic liver disorders

119. Liver transplantion
Liver transplantation is emerging as a saviour for liver
failure patients
Liver biopsy plays a very important role in organ
transplantion
Both donor and recipient livers are biopsied
The donor prior to surgery to rule out any pathology
Recipient biopsy post transplant to monitor
- acute and chronic rejection
- graft versus host disease

120. Microscopic
GVH Rejection
Portal tract inflammation
Selective bile duct destruction
Fibrosis
Cholestasis
Endothelitis - subendothelial lymphocytic infiltrate
lift the endothelium from the basement membrane

124. Acute Rejection
Characterized by infiltration of mixed population of
inflammatory cells in portal tracts, bile ducts
Hepatocyte injury
Endothelitis- subendothelial lymphocytic infiltrate lift
the endothelium from the basement membrane
Chronic Rejection
Severe obliterative arteritis of small and larger arteries
ischemic changes→
Bile duct occlusion

125. Central perivenulitis featuring dropout of hepatocytes near the central vein (*) and
intrasinusoidal lymphocytes and prominent plasma cells is present in this liver
allograft biopsy nearly 2 years after liver transplantation

127. Nodular hyperplasia
- focal nodular hyperplasia
- nodular regenerative hyperplasia
Benign neoplasm
- Cavernous hemangioma (most common)
- liver cell adenoma
Malignant tumours
- hepatocellularcarcinoma
- hepatoblastoma
- cholangiosarcoma
- angiosarcoma

128. These are not true hepatic neoplasm
Characterised by spherical nodules in absence of
fibrosis
FNH consist of a large central scar exhibiting
fibromuscular hyperplasia
NRH affects the entire liver with nodules in absence of
fibrosis

130. Cystically dilated blood vessels lined by single layer of flat endothelial cells
supported by fibrous stroma

131. More than 85% cases of HCC occur in countries with
high rates of chronic HBV and HCV infection
Microscopic
HCC can range from well differentiated to highly
anaplastic lesions
Can be either trabecular pattern or pseudoglandular
pattern
Vascular invasion is common
Immunohistichemistry – reactive to Hep-Par-1 and
Glypican 3 , TTF 1, CK 7

141. 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, gamma-
glutamyltransferase, alpha-2 macroglobulin,
haptoglobin, alanine aminotransferase, and
apolipoprotein-A1.

142.  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).

143. FIBROSCAN
Thresholds >7.9 kPa for
≥F2, 10.3kPa for ≥F3, 11.9
kPa for F4

144. Metriser liver biopsy
This is a quantitative analysis method for liver biopsy
sections with a machine named “Dioguardi
Histological Metriser” which automatically measures
the residual hepatocyte mass (including hepatocytes
vacuolization), inflammation, fibrosis and the loss of
liver tissue tectonics at the speed of 0.1mm2/s

145. The method provides:
(1) the metrical extension in two-dimensions of the
residual hepatocellular set including the area of
vacuoles pertinent to abnormal lipid accumulation;
(2) the geometric measure of the inflammation basin,
distinguishing intra-basin space and extra-basin
dispersed parenchymal leukocytes;
(3) the magnitude of collagen islets, which were
considered truncated fractals and classified into three
classes of magnitude
(4) the Tectonic Index that quantifies alterations
(disorders) in the organization of liver tissue.

146. The century old liver biopsy, our traditional gold standard
in work up of hepatic pathology has been challenged by
several non invasive techniques. Yet It is still playing an
important role in various liver diseases, with a special
reference to chronic hepatitis and liver transplantation.
Being an invasive procedure, it has its own limitations and
we should always have in mind the much dreaded
complications of liver biopsy.
Lots of work is going on to replace this gold standard by
some non invasive technique but none have yet been able
to endanger the place of liver biopsy in clinical practice.
So liver biopsy will still be recommended for years to come
even if gradually its indications are being constantly
modified.