Dr magdy (liver biopsy)

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  • 1. Pr.Dr .Magdy IsmaelAhmed

2. Routine H&E, special stains are greatly helpfulSTAIN SHOWS GOOD FORM. trichrome Type I collagen Fibrosis.Reticulin Type III collagen.Necrosis(collapse).Van Giesson stain Collagen type I FibrosisSirusred Type I&III collagen Permanent stainPAS with diastaseComplexcarbohydrate(Non-glycogen)B.M , 1- anti-trypsin globules.Prussian blue(Perl`s stain)Iron Blue pigmentOrcein stainVictoria blue stainCopper,elatsinChroniccholestasis. 3. Perls` stain` 4. Orcein stainHBV 5. I. Diagnosis, grading &staging ofII-Investigation ofcholestatic liverdisease:Indications/ III-Chronic Hepatitis (C &B)-Fatty liver disease(steatosis/steatohepatitis)-Auto-immunehepatitis-Haemochromatosis &Wilsons disease-Other metabolicliver diseases-Large duct biliaryobstruction-Primary biliarycirrhosis-Primary sclerosingcholangitis-Drug reaction-Biliary atresia &ductopenia-Diagnosis of a liver mass-Evaluation of fever ofunknown origin-Evaluation of post-transplant status 6. Ultilization of appropriate needle (type ,size..) Careful choice of sampled area:--Away from the capsule(>0.5 cm,to avoidseptum and focal nodularity)-Right lobe better than left lobe (larger insize ,covered by little capsule) Appropriate sample (length=1.5cm,wideth1-2 mm6-8 portal triads ) Appropriate preparation and reading. 7. Semiquantitative analysis (Ishake &METAVIR) Morphometric analysis (not clinically useful) Non-invasive techniques {serological assess ment (fibro test ,acti test) ,radiological /USmeasurements (fibroscan)} Liver biopsy (gold standard) 8. The two most widely applied scoring systemsin assessment of Chronic hepatitis C are:Ishak et al., 1995 (Modified Knodell and hiscolleagues)METAVIR System(A group of Frenchinvestigators, 1994 )still most commonlyused system 9. Grading:- describe the intensity of necro-inflamm atory activity in chronic hepatitis .itsrange (0-18).Staging :-It measures fibrosis and architectualalteration . Its range (0-6)Grading and staging must be regarded asapproxim -ation ,considering the size and samplequality. 10. Parameters of grading :1- Portal inflammation: Score (1- 4).2- Interface hepatitis: Score (1- 4).3- Spotty (Focal) lytic necrosis:Score (1- 4).4- Confluent necrosis: Score (1- 6).-----------------18 11. 0 Absent1 Mild, some orall portal tracts2 Moderate, someor all portal tracts3 Moderate/ marked,all portal tracts4 Marked, all portaltracts 12. Types of necrosis :- Focal (spotty) lytic necrosis and Apoptosis with liver celldrop out :- Death and removal of individual hepatocytes within intactparenchyma performed by T-lymphocyte and the residual of cells removedby blood flow or phagocytosis. Confluent necrosis (simple & zonal) :-death and removal ofadjacent group of hepatocyts .It is commonly peri-venular.(zone 3) Bridging necrosis:- Confluent necrosis connecting two structures(either C-C or P-C or P-P) Panacinar (multiacinar):-confluent necrosis involve the three zonesand destroy the entire acinus. Interphase hepatitis(Piece meal necrosis ):- Death of hepatocytsat interphase of parenchyma and C.T of portal area ( Interphas hepatitis ispreferred than piece meal necrosis due to inflammation > necrosis anddue to apoptosis other than necrosis) 13. 0 Absent 1 Mild (focal, fewportal tracts) 2 Mild/ moderate (focal, most portal tracts) 3 Moderate (involving50% of all tractscircumferences) 14. Interface hepatitisInterface hepatitis50%/ Moderate 15. 0 Absent 1 One focus or less per10X objective 2 2-4 foci 3 5-10 foci 4 More than 10 foci 16. 0-Absent 1 Focal (away from zone 3) 2 Zone 3 necrosis, in some areas 3 Zone 3 necrosis in most areas 4 Zone 3 + occasional p-c. 5 Zone 3+ multiple p-c. 6 Panacinar or multiacinar necrosis 17. 4 Portal inflammation 4 Interface hepatitis 4 Spotty necrosis 6 Confluent necrosis 18 Maximum Total 18. (S) 19. Change Score-No fibrosis 0- Some portal (Expanded) short fibrous septa 1-Most portal areas(Expanded) short fibrous septa 2-Most portal areas (Expanded) + occasional (P-P)bridging3-Portal areas (expanded) + Marked (P-P) & (P-C) Bridging 4-Marked bridging (P-P and/or P-C) + occasional nodules( incomplete cirrhosis or merging into cirrhosis)5Probable or definite cirrhosis 6 20. 0 1 2 3 4 5 6 21. F3 22. F4 23. F5 24. F6 25. Separately assess the degree of Activity(A) and Fibrosis (F)Stages of fibrosis (F0-F4), similar toScheuer.F0: No fibrosis.F1: Portal tract fibrosis without septaF2: Portal tract fibrosis with rare septaF3: Numerous septa without cirrhosis.F4: Cirrhosis. 26. F1F2F4F3 27. Ishak, 1995. activity grade : A( 0-18)METAVIR. Activity grade: A( 0-3 ) Score (1-6 ) Score (7-12) Score (13-18) A1 A2 A3 28. Grade of activity (A0-A3)A0: No histologic necro-inflammatory injuryA1: Minimal activityA2: ModerateA3: Marked (Severe) activity 29. The degree of activity is assessed byintegration of both piecemeal necrosisand lobular necrosis as described in asimple algorithm. Portal lymphoid infiltrate andbridging necrosis are not considered . 30. Interface hepatitis, with detected apoptoticbody 31. PMN=0LN= oLN= 1LN= 2LN=0,1LN=2LN=0,1LN=2LN=0,1,2PMN=1PMN=2PMN=3A=0A=1A=2A=1A=2A=2A=3PMN=piece meal nerosis.0=none,1=mild,2=mderate ,3=severeLN=Lobular necrosis.). 0=none or mild ,1=moderate ,2=severeA=Histological activity .0=None ,1=Mild,2=moderate,3=Severe 32. MILD ACTIVITY (A1)+Periportal necrosis = 1 Lobular necrosis =1 33. METAVIR - AlgorithmNL = 0 A = 0NP = 0 NL = 1 A = 1NL = 2 A = 2NP = 1 NL = 0,1 A = 1NL = 2 A = 2NL = 0,1 A = 2NP = 2 NL = 2NP = 3 NL = 0,1,2 A = 3 34. SEVERE ACTIVITY (A3)+Periportal necrosis = 2 Lobular necrosis = 2P. Bedossa 35. METAVIR - AlgorithmNL = 0 A = 0NP = 0 NL = 1 A = 1NL = 2 A = 2NP = 1 NL = 0,1 A = 1NL = 2 A = 2NL = 0,1 A = 2NP = 2 NL = 2NP = 3 NL = 0,1,2 A = 3 36. 1-auto-immune hepatitis:--Clinical findings1-Common in females (M:F -1:9(2-Elevated liver enzymes at disease activity.3-Presence of polyclonal hyper- gammaglobulinemia andauto-immune Abs (ASMA,ANA,ALVKM.ect(4-Absence of viral markers-Histological findings:-1-Extensive interface hepatitis rich in plasma cells2-Rosetting of hepatocyts3-Lobular inflammation may or may not be present4-Intact bile ducts (D.D PBC)5-The inflammation may lead to portal fibrosis , bridging &cirrhosis 37. BD 38. a-Absence of viral markersb-Presence of PAS +ve DR globules or Hx&E stainedglobules in periportal areas, in cases of 1-anti-trypsin deficiency.(genetic disorder ,discoveredin infants and children. In which the synthesizedprotein fail to migrate from (ER) to Golgi zoneand thus accumulates inside ER as hyalineglobules (arrows).c-Or Presence of Mallory hayline bodies ,fattychange ,micronodular cirrhosis and cu inperiportal heptocytes in cases of Wilson,s diasese 39. PAS +ve DR 40. Mallory bodies 41. 3-Drug induced hepatitis(Aldomet,inhibix,macrodantin,diclofenac)a-Absence of viral markers orb-Drug induced auto-antibodies or CU.c-History of taking the drug. 42. D.D diseases mimic Ch.V.hepatitis .1- PBC :-a-Markdely elevated Alk.phosphatase & GGT.b->90 % of cases, with high titres of circulating anti-mitochondrial antibodies (AMA)c- Granulomatous destruction of small and medium sizedintrahepatic bile ductsd-Ductular proliferatione-Peripheral cholestasisf-The inflammation may lead to scarring & cirrhosis 43. A chronic cholestatic liver disease(raised alkaline phosphatase) In which there is progressive fibro-oblitrative destruction of segments of theextrahepatic and large intrahepatic bileducts On endoscopy gives a specific beadedappearance (strictures & dilatations) There is ulcerative colitis in 70% ofpatients 44. Cholestasis 45. 2-Lymphoma &leukemia (denselymphoplasmacytic infiltrates):-a-No-true interface hepatitisb-No true apoptosis only hepatocyteatrophyc-No fibrosis.d-No acidophil bodies.e-Monomorphism ,marked atypia 46. 1.Count the number of portal tracts(6-8) 47. 2. Note portal tract expansion & septa formation(best done with reticulin stain) 48. 3. Examine the portal tracts 49. 4. AssessInterface hepatitis 50. 5. Spotty necrosis6. Confluent necrosis 51. 7. Any steatosis, what type & how much 52. 8. Any iron, and how much 53. 9. Any copper-associated protein? 54. 1-The statement that it is chronic hepatitisand mention the known or suspected cause ofthe hepatitis 2-The grade of activity (including the name ofscoring system itself) 3-The stage of activity (including the name ofscoring system itself)