hepatocytes secondary to the toxic effects of retained bile: cytoplasmic swelling with protein condensation (feathery degeneration) and Mallory-Denk bodies (Figs. 13.2 and 13.3).1 In severe cases, foci of hepatocyte necrosis with extravasated bile can be seen, which is referred as bile infarcts. In chronic biliary disease, cholestasis is typically not seen until late in the course of the disease.
Figure 13.1 Cholestasis. Canaliculi are not visible under normal circumstances but can be seen in cholestasis when they become dilated with inspissated bile plugs. |
there is a visible proliferation of ductules along the perimeter of the portal tracts (Figs. 13.4 and 13.5). The lumina of the ductules are typically not visualized unless they are expanded by bile plugs. Bile plugs within ductules (ductular or cholangiolar cholestasis) is termed cholangitis lenta. Although this pattern may be seen in late stage chronic biliary disease, it is also present in other conditions such as sepsis, shock, or uremia (Figs. 13.6 and 13.7).2 When the obstruction is acute onset and involves a large duct, ductular reaction is typically accompanied by portal edema. With chronicity, the edema subsides and is replaced by fibrosis.2 Inflammatory cells, including lymphocytes, plasma cells, and neutrophils, are an integral component of ductular reaction. The presence of neutrophils along the limiting plate can serve as a valuable clue to the presence of ductular reaction.
Figure 13.3 Cholestasis. Cholate stasis preferentially affects periportal and periseptal hepatocytes. |
Figure 13.8 Ductopenia. The portal tract contains a portal vein and hepatic artery branch but no bile duct. |
indicates a chronic disorder and argues against an acute process, such as a cholestatic drug reaction or acute large duct obstruction.
Table 13.1 Common causes of ductopenia in adults | |
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Figure 13.10 Rhodanine stain. In early cholestatic liver disease, copper deposits can be very focal, identified in only rare periportal hepatocytes, requiring careful high-power examination. |
Table 13.2 Clinicopathologic features of the three major autoimmune cholangiopathies | ||||||||||||||||||||||||||||||||||||||||
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the most sensitive and specific.14 At Mayo Clinic, an enzyme immunoassay is used to detect AMA-M2 autoantibodies. Roughly half of patients will be antinuclear antibody (ANA) and antismooth muscle antibody (ASMA) positive.7,15
“compatible with” the clinical diagnosis of primary biliary cirrhosis, after drug effect has been excluded. After making a diagnosis of primary biliary cirrhosis, attention should next be focused on excluding other disease processes (e.g., steatohepatitis) and accurate staging.
intermediate hepatocytes when there is chronic cholestatic injury. The rhodanine stain for copper is also a useful ancillary test to support the impression of a chronic biliary disease, as it will show patchy deposition of copper in the periportal hepatocytes.
granulomatous cholangitis, hepatocanalicular cholestasis, ductopenia, and copper accumulation.39 Fibrosis may be present and extensive in some cases.39
Figure 13.20 Sarcoidosis. Granulomas of sarcoidosis are often tumefactive and readily apparent on low-power inspection. Unlike in primary biliary cirrhosis, giant cells are typically numerous. |
Figure 13.21 Sarcoidosis. Note how the granulomatous component in the right aspect of the field is not centered on the bile duct, as in primary biliary cirrhosis. |
in asymptomatic patients varied from 50% to 70%, but dropped to 5 to 8 years once symptoms appeared.13 Ursodeoxycholic acid is an effective treatment and slows fibrosis and improves survival in the majority of patients.13 However, ursodeoxycholic acid is not curative, and patients must remain on treatment indefinitely.