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Page 1: Dr magdy (liver biopsy)

Pr.Dr .Magdy Ismael Ahmed

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Routine H&E, special stains are greatly helpful

STAIN SHOWS GOOD FOR

M. trichrome Type I collagen Fibrosis.

Reticulin Type III collagen.Necrosis

(collapse).Van Giesson

stain Collagen type I Fibrosis

Sirus redType I&III collagen

Permanent stain

PAS with diastase

Complex carbohydrate

(Non-glycogen)

B.M , α1- anti-trypsin globules.

Prussian blue (Perl`s stain)

Iron Blue pigment

Orcein stainVictoria blue stain

Copper,elatsin

Chronic cholestasis.

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Perls` stain`

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Orcein stain

HBV

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I. Diagnosis, grading & staging of

II-Investigation of cholestatic liver disease:

Indications/ III

-Chronic Hepatitis (C & B)

-Fatty liver disease

(steatosis /steatohepatitis)

-Auto-immune hepatitis-Haemochromatosis & Wilson’s disease

-Other metabolic liver diseases

-Large duct biliary obstruction

-Primary biliary cirrhosis

-Primary sclerosing cholangitis

-Drug reaction

-Biliary atresia & ductopenia

-Diagnosis of a liver mass

-Evaluation of fever of unknown origin

-Evaluation of post-transplant status

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Ultilization of appropriate needle (type ,size..) Careful choice of sampled area:- -Away from the capsule(>0.5 cm,to

avoid septum and focal nodularity) -Right lobe better than left lobe

(larger in size ,covered by little capsule) Appropriate sample (length=1.5cm,wideth1-2

mm 6-8 portal triads ) Appropriate preparation and reading.

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Semiquantitative analysis (Ishake &METAVIR)

Morphometric analysis (not clinically useful)

Non-invasive techniques {serological assess –ment (fibro test ,acti test) ,radiological /US measurements (fibroscan)}

Liver biopsy (gold standard)

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The two most widely applied scoring

systems in assessment of Chronic

hepatitis C are:

Ishak et al., 1995 (Modified Knodell and

his colleagues)

METAVIR System(A group of French

investigators, 1994 )still most

commonly used system

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Grading:- describe the intensity of necro-

inflamm atory activity in chronic hepatitis .its

range (0-18).

Staging :-It measures fibrosis and

architectual alteration . Its range (0-6)

Grading and staging must be regarded as

approxim -ation ,considering the size and

sample quality.

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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

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0 Absent1 Mild, some or all portal tracts2 Moderate, some or all portal tracts3 Moderate/ marked, all portal tracts4 Marked, all portal tracts

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Types of necrosis :- Focal (spotty) lytic necrosis and Apoptosis with liver

cell drop out :- Death and removal of individual hepatocytes within intact parenchyma performed by T-lymphocyte and the residual of cells removed by blood flow or phagocytosis.

Confluent necrosis (simple & zonal) :-death and removal of adjacent 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 zones and destroy the entire acinus.

Interphase hepatitis(Piece meal necrosis ):- Death of hepatocyts at interphase of parenchyma and C.T of portal area ( Interphas hepatitis is preferred than piece meal necrosis due to inflammation > necrosis and due to apoptosis other than necrosis)

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0 Absent 1 Mild (focal, few portal tracts) 2 Mild/ moderate (focal , most portal tracts) 3 Moderate (involving <50% of all tract’ circumferences) 4 Severe (involving >50% of all tracts’ circumferences)

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Interface hepatitisInterface hepatitis

<50% >50%/ Moderate

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0 Absent 1 One focus or less per 10X objective 2 2-4 foci 3 5-10 foci 4 More than 10 foci

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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

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4 Portal inflammation 4 Interface hepatitis 4 Spotty necrosis 6 Confluent necrosis 18 Maximum Total

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(S)

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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) bridging

3

-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)

5

Probable or definite cirrhosis 6

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0 1 2 3 4 5 6

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F3

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F4

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F5

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F6

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Separately assess the degree of Activity (A) and Fibrosis (F)Stages of fibrosis (F0-F4), similar to Scheuer.F0: No fibrosis.F1: Portal tract fibrosis without septaF2: Portal tract fibrosis with rare septaF3: Numerous septa without cirrhosis.F4: Cirrhosis.

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F1F2

F4

F3

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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

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Grade of activity (A0-A3) A0: No histologic necro-inflammatory injury A1: Minimal activity A2: Moderate A3: Marked (Severe) activity

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The degree of activity is assessed by integration of both piecemeal necrosis and lobular necrosis as described in a simple algorithm.

Portal lymphoid infiltrate and bridging necrosis are not considered .

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Interface hepatitis, with detected apoptotic body

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PMN=0LN= oLN= 1LN= 2

LN=0,1LN=2

LN=0,1LN=2

LN=0,1,2

PMN=1

PMN=2

PMN=3

A=0A=1A=2

A=1A=2

A=2

A=3

PMN=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

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MILD ACTIVITY (A1)

+

Periportal necrosis = 1 Lobular necrosis =1

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METAVIR - Algorithm

NL = 0 A = 0 NP = 0 NL = 1 A = 1 NL = 2 A = 2 NP = 1 NL = 0,1 A = 1 NL = 2 A = 2 NL = 0,1 A = 2 NP = 2 NL = 2 NP = 3 NL = 0,1,2 A = 3

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SEVERE ACTIVITY (A3)

+

Periportal necrosis = 2 Lobular necrosis = 2

P. Bedossa

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METAVIR - Algorithm

NL = 0 A = 0 NP = 0 NL = 1 A = 1 NL = 2 A = 2 NP = 1 NL = 0,1 A = 1 NL = 2 A = 2 NL = 0,1 A = 2 NP = 2 NL = 2 NP = 3 NL = 0,1,2 A = 3

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1-auto-immune hepatitis-: -Clinical findings

1-Common in females (M:F -1:9) 2-Elevated liver enzymes at disease activity .

3-Presence of polyclonal hyper- gammaglobulinemia and auto-immune Abs (ASMA,ANA,ALVKM.ect)

4-Absence of viral markers-Histological findings: -

1-Extensive interface hepatitis rich in plasma cells 2-Rosetting of hepatocyts

3-Lobular inflammation may or may not be present 4-Intact bile ducts (D.D PBC) 5-The inflammation may lead to portal fibrosis , bridging

& cirrhosis

[.

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BD

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a-Absence of viral markersb-Presence of PAS +ve DR globules or Hx&E

stained globules in periportal areas, in cases of α 1-anti-trypsin deficiency.(genetic disorder ,discovered in infants and children. In which the synthesized protein fail to migrate from (ER) to Golgi zone and thus accumulates inside ER as hyaline globules (arrows).

c-Or Presence of Mallory hayline bodies ,fatty change ,micronodular cirrhosis and cu in periportal heptocytes in cases of Wilson,s diasese

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PAS +ve DR

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Mallory bodies

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3-Drug induced hepatitis

(Aldomet,inhibix,macrodantin,diclofenac)

a-Absence of viral markers or b-Drug induced auto-antibodies or CU. c-History of taking the drug.

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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

sized intrahepatic bile ducts d-Ductular proliferation e-Peripheral cholestasis f-The inflammation may lead to scarring & cirrhosis

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A chronic cholestatic liver disease (raised alkaline phosphatase)

In which there is progressive fibro-oblitrative destruction of segments of the extrahepatic and large intrahepatic bile ducts

On endoscopy gives a specific beaded appearance (strictures & dilatations)

There is ulcerative colitis in 70% of patients

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Cholestasis

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2-Lymphoma &leukemia (dense lymphoplasmacytic infiltrates):-

a-No-true interface hepatitis b-No true apoptosis only

hepatocyte atrophy c-No fibrosis. d-No acidophil bodies. e-Monomorphism ,marked atypia

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1.Count the number of portal tracts(6-8)

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2. Note portal tract expansion & septa formation (best done with reticulin stain)

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3. Examine the portal tracts

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4. Assess Interface hepatitis

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5. Spotty necrosis6. Confluent necrosis

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7. Any steatosis, what type & how much

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8. Any iron, and how much

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9. Any copper-associated protein?

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1-The statement that it is chronic hepatitis and mention the known or suspected cause of the hepatitis

2-The grade of activity (including the name of scoring system itself)

3-The stage of activity (including the name of scoring system itself)

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