Contributed by Michael A. Nalesnik, M.D.
PATIENT HISTORY:
Per referral report, the patient is a 54-year-old white female with significant history of hypertension, prior biliary cirrhosis. The patient presented to the office seeing me on the day of admission complaining of two-day history of increasing fatigue, legs giving out, lightheadedness and nausea, diaphoresis when she would stand or be active. Also on questioning she did note dark stools. The patient has a significant history of taking two aspirin q night for approximately 10 years, also one glass of wine every night and drinking one to two cups of coffee in the morning. Approximately one to two weeks prior to this, the patient noted myalgias and pharyngitis. She was started on antibiotics and also increased her aspirin intake secondary to the myalgias. In my office, the patient was found to have an orthostatic tilt. Conjunctive were pink. The patient had regular rhythm and tachy when she sat up. Abdomen was fairly soft with occasional tenderness in the lower quadrants. Rectal revealed significant black stool. Hematocrit in the office was 23. The patient was transferred by ambulance to the hospital as a direct admission for continued evaluation and care.

Final Diagnosis (Case 50)

PART 1: NATIVE LIVER, NEEDLE BIOPSY (5/2/97) -
  1. CHRONIC HEPATITIS WITH PORTAL FIBROSIS (see comment).

PART 2: NATIVE LIVER, NEEDLE BIOPSY (10/18/84) -

  1. LIVER WITH REDUCED NUMBERS OF BILE DUCTS, FOCAL DUCTULAR PROLIFERATION AND PERIPORTAL FIBROSIS, COMPATIBLE WITH THE CLINICAL HISTORY OF PRIMARY BILIARY CIRRHOSIS.

Comment:
The changes in the 1984 biopsy, namely, reduced numbers of bile ducts and biliary-type piecemeal necrosis, are compatible with the clinical history given that this patient has primary biliary cirrhosis. Supportive laboratory evidence strengthen this opinion.

The more recent biopsy shows apparent progression of changes in the form of slightly more prominent portal fibrosis. I agree that the findings fall short of cirrhosis at this time. In addition, the findings in the most recent biopsy, taken alone, are non specific. However, when combined with the earlier biopsy, the findings can be considered as consistent with the patient's underlying disease.

Previous Biopsies on this Patient:
None

TPIS Related Resources:
Modified Knodell Scoring
Liver Transplant Topics

Gross Description - Case 50


The specimen consists of two (2) consult slides,Part 1, (1) and (1),Part 2, both with their respective blocks (1 each), with accompanying surgical pathology reports and patient history.

Microscopic Description - Case 50


The slide,Part 1, shows bridging fibrosis with patchy inflammation, primarily at the interface regions. Some ductular proliferation is, again, noted and a questionable reduction in bile ducts is appreciated. The uncertainty arises from the small number of identifiable portal tracts seen. The hepatocytes are unremarkable and occasionally contain mild macrovesicular fat globules.

The slide,Part 2,consists of a needle core of hepatic parenchyma with portal inflammation and expansion. The portal tracts contain occasional bile ducts which are partially disrupted by the predominantly mononuclear inflammatory infiltrate. In addition, rare eosinophils are noted. In other portal areas, bile ducts are not seen. Occasional foam cells are noted at these sites. Enlargement of portal tracts raises the possibility of early bridging in some sites. Focal ductular proliferation is noted at the limiting plate regions.

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