LIVER LAB ANSWERS (with stylish bile yellow background for your enjoyment!!!!)
1 Liver LP: Normal liver architecture with several portal trats and central veins.
2 Liver MP: Normal portal tract and central vein
3 Liver Gross: Normal liver
Case 1:Questions:
Should the hematologic workup have been performed, and if so why?
Yes, to eliminate the possibility of hemolysis as a cause of unconjugated hyperbilirubinema
What is your diagnosis?
Gilbert's disease
Case 2:
5 Liver LP: Needle biopsy, prominent macrovesicular fatty metamorphosis
6 Liver MP: Macrovesicular fatty metamorphosis
7 Liver HP: Macrovesicular fatty metamorphosis, neutrophils, Mallory's hyalin
8 Liver HP: Same as 7
9 Liver Same
10 Liver: Same, stained darker and Mallory's hyalin more clearly defined in cytoplasm of hepatocytes.
Differential diagnosis:
1. post-transfusion chronic hepatitis with ascites
2. alcoholic liver disease, chronic with cirrhosis and ascites
3. acute alcoholic hepatitis
4. HCC arising in a stable cirrhotic
Look at glass slide. What is your diagnosis? Acute alcoholic hepatitis
Case 3:
16 Liver LP: Cirrhosis, with monolobular pattern of some nodules still retaining central veins. Portion of larger nodule in lower field.
17 Liver MP Large area of fibrosis showing hepatic arteries, portal vein branches, lymphocytic infiltrate and loss of bile ducts.
18 Liver HP: Showing portal vein, hepatic artery and now accompanying bile duct.
19 Liver HP: Another portal area showing vessels and inflammatory cells, with some cholestasis, but no bile ducts.
20 Liver MP: Lobule showing hepatocytes around central vein and some cholestasis
21 Liver HP: Hepatocytes showing cholestasis, canalicular plugs, bile in Kupffer cells, and central vein lower right hand corner.
What disease category would you put this disease in from the history and lab values? Obstructive/infiltrative
Look at glass slide. What is your diagnosis? PBC
Case 4:
23 Liver LP Needle biopsy, showing acute bridging lesion
24 Liver MP Acute bridging lesion and lobular unrest
25 Liver MP Lobular unrest, with hepatocyte sweilling, regeneration, Kupffer cell hypertrophy and hyperplasia, cholestasis and inflammation
26 Liver HP Lobular unrest. Acidophilic body left center
27 Liver HP Lobular unrest, bile-stained cell in center
28 Liver Gross: External surface, massive hepatic necrosis, wrinkled capsule, red color from red blood cells in sinusoids with no hepatocytes remaining.
What is your differential form the laboratory values?
1. Drugs, toxins
2. congestive ischemia
3. acute hepatitis
What additional test would be of value in deciding on an etiology in this case?
Hepatitis screen.
Look at the slide. What is your diagnosis? Acute hepatitis with submassive necrosis
Case 5:
30 Liver LP: Needle biopsy of liver with irregular broad bands of fibrosis transecting biopsy and encircling a few small regenerating nodules, partially encircling multilobular nodules
31 Liver LP: Showing broad band of fibrosis with inflammation on left with piecemeal necrosis at interface with hepatocytes.
32 Liver LP: Bands of fibrosis with piecemeal necrosis transecting biopsy
33 Liver HP: Margin of fibrous tissue and hepatocytes showing moderate activity with piecemeal necrosis
34 Liver HP: Margin of fibrous tissue and hepatocytes in quiescent area of minimal to no activity
What do you think the surgical procedure was for? cholecystectomy
Do you think the severe pain is related to the cause of the liver disease? no
Look at the slide. What is your diagnosis? Postnecrotic cirrhosis, moderately active. Cirrhosis is enough
What additional history and laboratory tests would be useful?
Hepatits screen, AMA, ceruloplasmin, serum alpha1-antitrypsin level, ANA, serum globulins. Addtl history: diarrhea and look for possible IBD
Case 6:
Liver 39 LP: Needle biopsy of liver showing blue inflammatory cells outlining enlarged portal tracts
40 Liver MP: Portal tract showing stellate "maple leaf" pattern of chronic active hepatitis with extensive piecemeal necrosis and loss of limiting plates.
41 Liver HP: Margin of portal tract showing inflammation (predominantly lymphocytes) and piecemeal necrosis
42 Liver HP: Same
43 Liver HP: Acidophilic (apoptotic) bodywith pyknotic nucleus in center of hepatocytes in lobule
Explain the hepatitis A,B, and C determinations.
IgG anti-HAV + and IgM - mean old HAV infection in past
HBsAg negative with positive anti-HBs and anti-HBc mean old HBV infection now over.
anti-HCV initially negative, becoming positive 7 months later means infection initially too soon to get antibody
What is the most likely diagnosis in this patient? Chronic hepatitis C, active with breakdown of limiting plates, or Chronic active hepatitis C
Check the slide. Do you still agree with your diagnosis? yes