BUZZ WORDS/ RAPID REVIEW: Liver Inflammation (Hepatitis)


When you are in a time crunch and/or your brain is all fizzled out, knowing these "buzz words" may earn you a few extra points on an exam..

BUZZ WORDS: HEPATITIS

Hepatitis BUZZ Words


Most common cause of...

  • Acute hepatitis in US? Hep A or Hep B

  • Acute hepatitis in India/foreign countries? Hep E

  • Infection from a needle-stick (in developed countries)? Hep C

  • Infection from a needle-stick in UNdeveloped countries? Hep B

  • Fulminant liver failure/death in pregnant lady (esp 3rd trimester) ? Hep E

  • Hepatitis in middle aged woman? Autoimmune hepatitis


High Yield (Testable) Factoids (Hep A, B, C, D, E)

  • Which is picoRNAvirus? HepA (ss RNA)

  • PAS-D highlighting clusters of Ceroid-laden macrophages = Acute Hep B

  • How do you diagnose acute HepA infxn? IgM HAV Ab (IgG antiHAV = lifelong immunity)

  • Which ones have vaccines available? Hep A & Hep B

  • Which are fecal oral? Hep A & Hep E

  • Which one is DNA? Hep B (HepaDNAvirus- partly dsDNA)- all other are RNA

  • Which produces chronic infxn and thus can cause HCC? Hep C most common; Also B +/- D- More common to progress in Hep B if acquired in childhood

  • How to diagnose Chronic hepatitis? >6 months of Symptoms & persistent biochemical indicators (Hepatitis serologic testing) abnormalities, portal inflammation + necrosis

  • Other causes of chronic hepatitis? Autoimmune, Wilson's, Lymphoma, A1AT, Meds

  • What 2 diseases mimic chronic hepatitis? PBC & PSC

  • Which requires Hep B for infxn? Hep D (has Defective HepBsAg)


Hepatitis B Serologic Studies: Test Interpretation

  • Acute infection = HBsAg+ and/or HBcAg+

  • Window period= HBcAg+ ONLY

  • Immunity from vaccinated (never been infected)= IgG anti-HBsAb ONLY

  • Immunity from prior infection= IgG anti-HBsAb+, IgG antiHBcAb


AutoImmune Hepatitis

  • Plasma cells (although not reqd for dx)

  • More prominent interface hepatitis +/- lobular activity (often a good amount present)

  • "Bridging necrosis" = Pink areas of necrosis connecting portal tracts & central veins = Fulminant autoimmune hepatitis

  • Inflammation around Zone 3 + centrilobular inflammation (NO inflammation seen in acetaminophen toxicity)

  • Nonspecific= Giant cell transformations

  • Hypergammaglobulinemia (IgG) & Elevated transaminases (AST/ALT)

  • Treatment= Corticosteroids (the only chronic hepatitis that will show a dramatic response to tx)

TYPES OF AIH

  • TYPE 1= Most common type; ANA+ and/or ASMA or P-ANCA

  • TYPE 2= Most common in CHILDREN; Anti-LKM-1 (microsomal) (more severe disease)

  • TYPE 3= Adults 30-50yo; Soluble liver Ag or Liver pancreas Ag.


Clues to a Diagnosis based on a single Histologic Image

  • "Lobular disarray" (zone 2 or 3) + inflammation/necrosis; NO fibrosis = Acute hepatitis

  • "Ground glass hepatocytes" = CHRONIC Hepatitis B = HB surface Ag+ (cytoplasmic only- the inclusion pushes nucleus to side from proliferation of HBsAg in the endoplasmic reticulum)- In clinical practice, it is usually 2/2 polypharmacy instead of Hep B.

  • "Sanded nuclei" = CHRONIC Hep B infxn = HB core Ag+ (nuC + Cytoplasmic)

  • NOTE: If ACUTE Hep B infxn, the above 2 stains would be NEGATIVE

  • "Portal/Peri-portal (Zone 1) Inflammation" +/- fibrosis = Chronic Hepatitis (Hep C common)

  • "Piecemeal necrosis" or "Interface dermatitis" = Chronic hepatitis (individual hepatocyte injury/damage/apoptosis)

  • Clues to Hep C? blue portal tracts + steatosis & fibrosis ; most commonly a/w genotype 3)

  • "Persistent necroinflammation of the liver" = Portal/peri-portal inflammation with hepatocyte injury/necrosis; variable interface activity; variable lobular inflammation & hepatocyte injury/necrosis = Chronic hepatitis

  • Scarring/Fibrosis = Chronic liver injury

  • "Lymphocytes percolating through sinusoids" aka "Sinusoidal lymphocytosis" = EBV

  • Can look like any histologic pattern = Drug or Wilson Disease


Steatosis/Steatohepatitis

  • "Mallory body" --> Steatohepatitis (Alcohol or NASH)


What to assess in a liver biopsy for chronic hepatitis:

  • Confirm there is necro-inflammation

  • GRADE the severity of inflammation (0-4)

  • STAGE the degree of fibrosis/scarring (0-4)

  • Suggest a possible etiology if possible

  • Provide prognostic data


Grading Liver Inflammation

0. None

1. Minimal

2. Mild

3. Moderate

4. Severe


Staging Liver Fibrosis

0. None

1. Portal tract confined

2. Peri-portal- fibrosis goes into adjacent hepatocytes

3. Bridging (portal tracts connected to central vein)

4. Complete nodules= Cirrhosis


Cholestasis

  • "Bland type cholestasis" = isolated Canalicular cholestasis = Estrogens or Anabolic steroids (esp younger men)

  • "Ductular cholestasis" = Inspissated bile around portal tract = Sepsis

Thanks!


I hope that rapid review helped refresh your memory. Be sure to look at the classic histologic findings in each of these entities. I may get around to even posting it up here myself, haha.


Another post with more liver pathology including Wilson Dz, Hemochromatosis, Liver tumors and more will be coming up soon. Stay tuned!


Ref: David H. Gonzalo, MD. Liver Pathology. Osler.org. AP Pathology. Online Video. 10/9/2018.

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