However, a key concept to understand is that liver biopsies will often have elements of a variety of injury patterns, and the goal as a pathologist is to recognize the predominant pattern and not necessarily to simply list all of the abnormal findings. As an illustration, a liver biopsy with primary biliary cirrhosis may have mild fatty change, mild cholestasis, minimal lobular chronic inflammation, and mild nodular regenerative hyperplasia, in addition to the predominant findings of chronically inflamed medium-sized bile ducts (septal bile ducts) with active duct injury. Recognizing the predominant injury pattern leads to an accurate diagnosis of primary biliary cirrhosis; listing all abnormal findings without further interpretation leads to confusion.

A second example further illustrates how a histologic injury pattern can have very different meanings depending on the context of other findings in the biopsy. Bile ductular proliferation is a key pattern of injury that often indicates downstream biliary tract obstructive disease from stones, strictures, tumors, etc. However, bile ductular proliferation in acute cholestatic viral hepatitis can reach levels seen in obstructive disease.³ In addition, bile ductular proliferation in some cases of vascular outflow disease, such as Budd-Chiari syndrome, can also reach levels seen in obstructive disease.⁴ Thus, one can see that patterns of injury, such as bile ductular proliferation in this example, should bring to your mind a differential and not a single diagnosis. The pathologist can then help prioritize the differential from most to least likely. In this example, the pattern of bile ductular proliferation as a sole dominant pattern would suggest biliary tract obstruction, but in the setting of other dominant patterns (marked cholestatic lobular hepatitis or venous outflow disease), the ductular proliferation can be a secondary change in response to the dominant form of injury.

Be Systematic

After the major pattern of disease has been identified, then go through the biopsy systematically, examining the architecture and each compartment carefully. Although any systematic approach will work fine, one reasonable method is to start in the portal tracts and work toward the central veins. In the portal tracts, examine the hepatic artery, portal vein, and bile ducts. Examine the inflammatory cells in the portal tracts. In the lobules, examine the hepatocytes for abnormal inclusions or increased pigmented material. Examine the sinusoids for abnormal cells. Finally, examine central veins for inflammation or other pathologies.

EVALUATING FIBROSIS

Related posts:

Other Infections of the Liver The Almost Normal Liver Biopsy Autoimmune Hepatitis Pediatric Cholestatic Liver Disease Drug Effects Transplant Pathology

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