Contributed by Parmjeet S. Randhawa, M.D.
PATIENT HISTORY:
Per referral progress report, the patient is a middle aged male. S/P liver transplant for micronodular cirrhosis of uncertain cause at the UPMC. Hepatitis C PCR was positive. He has been doing extremely well. His FK levels and liver function studies have been normal. Hepatitis C PCR remains positive. His only complaint is his recurrent abdominal pain.

On examination, the cause of this pain appears to be a large ventral defect in the epigastrium. Review of outside material.

Final Diagnosis (Case 79)

ALLOGRAFT LIVER, NEEDLE BIOPSY -
  1. MILD PORTAL AND LOBULAR INFLAMMATION; CLINICAL HISTORY OF HEPATITIS C INFECTION (See comment).
  2. FOCAL MACROVESICULAR STEATOSIS WITH MILD PERIPORTAL AND SINUSOIDAL FIBROSIS.
  3. FRAGMENT OF CARTILAGE WITH NO SIGNIFICANT PATHOLOGIC CHANGE.

Comment:
The degree of portal and lobular inflammation present are sufficient for a histologic diagnosis of low grade recurrent hepatitis C.

It is noted that the liver function tests are currently within normal range. Continued monitoring is suggested, and a repeat biopsy should be considered as clinically indicated, since the current sample is small and inadequate for a complete architectural evaluation.

Another notable finding in this specimen is the presence of steatosis and sinusoidal fibrosis. This raises the possibility of an additional insult to the liver, possibly related to diabetes, obesity or ethanol. Clinical correlation is needed.

Previous Biopsies on this Patient:
None

TPIS Related Resources:
Liver Transplant Topics

Gross Description - Case 79

The specimen consists of three (3) consult slides (1 HE, 1 Trichrome, 1 Positive Control) with accompanying progress notes and laboratory results.

Microscopic Description - Case 79

BANFF SCORING OF LIVER ALLOGRAFT BIOPSIES

1. Histological Evaluation
1.1 More than 4 portal triads ( )YES (X)NO
1.2 Specimen o/w adequate ( )YES (X)NO
2. Portal Tract (check one uner each category)
2.1 Overall Inflammatory Intensity ( )None (X)Mild ( )Moderate ( )Severe
2.2 Bile duct inflammation / damage (X)YES ( )NO
2.3 Granuloma(s) ( )YES (X)NO
2.4 Bile duct loss ( )YES (X)NO
2.4.1 If BD loss, total number of triads ( )
2.4.2 If BD loss, number of triads w/o ducts ( )
2.5 Bile duct / cholangiolar proliferation (in any portal tract) ( )YES (X)NO
3. Inflammatory or Necrotizing Arteritis ( )YES (X)NO
4. Obliterative Arteriopathy ( )YES (X)NO
5. Subendothelial Inflammation
5.1 Severity (X)None ( )Mild ( )Moderate ( )Severe
5.2 Location (X)N/A ( )Portal ( )Central ( )Both
6. Fibrosis (check one under each category)
6.1 Portal ( )None (X)Mild ( )Moderate ( )Severe (bridging)
6.2 Central ( )None ( )Mild ( )Moderate ( )Severe (bridging)
6.3 Arch. dist. ( )None (X)Mild ( )Moderate ( )Severe
7. Lobular Disarray / Ballooning ( )None (X)Mild ( )Moderate ( )Severe
8. Necrosis (check one under each category)
8.1 Piecemeal or bridging ( )None ( )Mild ( )Moderate ( )Severe
8.2 Infarct (ischemia) ( )YES ( )No
8.3 Other necrosis (X)YES ( )No
8.4 Central lobular ( )YES ( )No
9. Cholestasis ( )YES (X)NO
10. Fat ( )None (X)Mild ( )Moderate ( )Severe
10.1 Type (X)Micro ( )Macro ( )Mixed ( )N/A
11. Lobular Inflammation (check one under each category)
11.1 Severity ( )None (X)Mild ( )Moderate ( )Severe
11.2 Location ( )N/A ( )Perivenular ( )Panlobular (X)Random / Focal
11.3 Granulomatous ( )YES ( )NO
12. Rejection Activity Index (RAI) Range Score
12.1 Portal inflammation (0-3) (0-1)
12.2 Bile duct inflammation / damage (0-3) (0-1)
12.3 Venous endothelial inflammation (0-3) (0)
12.4 Total Score (RAI = 1/9)

13. OTHER FINDINGS
Mild portal, periportal and sinusoidal fibrosis; low grade lobular inflammation with hepatocyte injury; minimal increase in collagen in zone 3; no definite Mallory's hyaline, granulomas or viral inclusions seen.

KNODELL'S HISTOLOGY ACTIVITY INDEX
Feature RANGE SCORE
Periportal and bridging necrosis (0-10) 0
Intralobular degeneration and necrosis (0-4) 2
Portal inflammation (0-4) 1
Fibrosis (0-4) 1
TOTAL (0-22) 4/22

The numerical scoring system of histologic activity index (HAI) has been developed to grade the liver biopsies of chronic active hepatitis. This is based on four categories of periportal and bridging necrosis, intralobular degeneration and necrosis, portal inflammation and fibrosis, with total score of up to 22. This scoring system is correlated well with the severity of disease. A copy of the original paper published by the American Association for the Study of Liver Disease [Hepatology 1:431, 1981] is available at the Department of Pathology upon request.

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