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Liver biopsy and the etiologic diagnosis of chronic hepatitis
S112
Journal of Hepatology, 1993; 17 (Suppl. 3): S112-SI15 © 1993ElsevierScientific Publishers Ireland Ltd. All rights reserved. 0168-8278/93/$06.00
HEPAT 01308
Liver biopsy and the etiologic diagnosis of chronic hepatitis A. Moreno", C.J. Martinez" and V. Carrefio b "Department of Pathology. Hospital Rambn y Cajal, Madrid and bDepartment of Gastroenterology. Hepatology Unit, Fundaci6nJim~nez Diaz, Madrid, Spain
The histological features of chronic viral hepatitis differ according to etiological agent and replicative phases. Thus, in chronic HBV hepatitis with a high level of HBV replication the histological lesion is generally mild. During the seroconversion phase, a lobular lesion is present in the liver biopsy followed by amelioration of the disease. Chronic delta hepatitis is very aggressive histologically, progression to cirrhosis is frequent, and sanded nuclei are often observed in liver biopsies of patients with anti-HIV. In contrast, chronic hepatitis C shows a milder histological picture and immunohistochemical techniques to detect HCV-Ag in the liver tissue should be developed. In summary, the majority of cases of chronic viral hepatitis have distinctive histological features that may be identified in liver biopsies. K e y words: Histology; Chronic hepatitis; HBV; HDV; HCV; Autoimmune
Conceptually, chronic hepatitis is an inflammatory primary disease of the liver with persistent biologic abnormalities for more than 6 months, and etiologically related to B, delta, C hepatitis viruses and autoimmune factors. The aims of histopathological studies of liver biopsies are to evaluate the degree of necroinflammatory activity, to determine the severity of the disease, to define a histological diagnosis and to evaluate the effect of therapy. The histological features in liver biopsies in relation to the etiology will be reviewed here. The histological hallmark of chronic infection with the hepatitis B virus in the liver is the presence of ground-glass hepatocytes. It is a frequent change, easy to recognize in haematoxylin-eosin stained histological sections. The number of liver cells affected varies considerably in inverse relation to the degree of inflammatory activity. On the basis of several previous studies (1-3), we know that the natural history of chronic hepatitis B infection begins with a high viral replicative phase with HBeAg and HBV-DNA in the serum and is histologically characterized by a scarce necroinflammatory change usually corresponding to chronic persistent or mild chronic active hepatitis. Generally scattered ground-glass cells expressing cytoplasmic and membranous HBsAg antigen (Fig. 1) and abundant nuclear
HBcAg are observed. This initial period is followed by seroconversion (from HBeAg to anti-HBe) with a marked increase in necroinflammatory activity during that phase (2,4). Immunostaining usually reveals nuclear and cytoplasmic HBcAg which are focally distributed. In the subsequent non-replicative phase, as the disease progresses the hepatitis activity subsides and finally disappears. Groups of ground-glass cells, showing an intense positive staining for HBsAg, become prominent, and inversely, the HbcAg positivity disappears. The inflammatory activity is of low degree or absent (5). Scattered hyperplastic rounded areas are intermingled with polymorphic hepatocytes and 'ground-glass' fields, producing distortion and irregularity of the laminar pattern. The hepatitis delta agent is an mRNA defective virus with ! 700 bases and it is a frequent cause of reactivation of chronic hepatitis B. Delta superinfection causes activation and worsening of the liver disease (6). Thus, chronic delta hepatitis usually shows a severe histological picture with marked lobular inflammatory activity and piecemeal necrosis, frequently associated with bridging and multilobular necrosis or cirrhosis. Liver lesions experiment variations in different histological fields of the same biopsy specimen. Thus, areas severely involved coexist with more quiescent areas sometimes showing ground-glass cells or prominent nuclear dysplasia (7).
Correspondence to: Dr. Alberto Moreno, Fundaci6n para el Estudio de las Hepatitis Virales, C/Guzm~n el Bueno,72. Bajo, 28015 Madrid, Spain.
LIVER B1OPSY FOR DIAGNOSIS OF CHRONIC HEPATITIS
SI 15
Occasionally, sanded nuclei, a virtually p a t h o g n o m o n i c feature of delta infection, are observed (Fig. 2) (8). In our experience, these nuclei are relatively c o m m o n in patients co-infected with h u m a n immunodeficiency virus. I m m u nohistochemical demonstration of tissue delta antigen, usually nuclear, is indicative of active viral replication (9). Chronic hepatitis C is a c o m m o n liver disease caused by a persistent infection with a single-stranded R N A hepatotropic virus (10). F r o m a histological point of view, the C antigens cannot yet be detected by standard techniques; and some recent reports need further study and confirmation (I 1). The histopathological picture of chronic hepatitis C is highly characteristic although it is not p a t h o g n o m o n i c (Fig. 3) (12). The features include sinusoidal lymphocytosis, acidophilic r h o m b o i d degeneration and lymphoid follicles with or without bile duct damage (16). These features taken single m a y be observed in m a n y different etiologies, but their coexistence in the same specimen makes the histologic diagnosis of C viral hepatitis highly possible. At least two characteristic pictures m a y be observed. In most cases chronic hepatitis C presents a mild histological picture, showing laminar m o n o m o r p h i s m , slight periportal piecemeal necrosis, a few lobular acidophilic bodies and prominent portal lymphoid follicles. However, in the acute stages and in the early stages of the chronic phase a prominent lobular sinusoidal lymphocytosis and a moderate acidophilic degeneration, without significant lobular disarray, m a y
be observed. This peculiar picture of chronic iobular hepatitis is frequent and characteristic of hepatitis C virus-induced liver disease (13). A u t o i m m u n e chronic hepatitis is another type of chronic hepatitis that courses with severe polyclonal hypergammaglobulinemia and several n o n - o r g a n o specific autoantibodies detected in the serum (14). The histopathoiogy of a u t o i m m u n e chronic hepatitis is heterogeneous, but in most cases a severe type of chronic active hepatitis with bridging hepatic necrosis and disturbed lobular architecture is present (15). In addition to this basic picture, at least 3 different types of histological pattern can be found superimposed. One pattern is characterized by confluent lytic necrosis, zonal, paravenular or intervenular, with cell 'drop-out'. A second, and highly characteristic, pattern shows extensive laminar rosetting involving several acini (Fig. 4) ('multilobular') usually with clusters of plasma cells. This diffuse rosetting is virtually absent in chronic hepatitis C and is rarely observed at this intensity in hepatitis B or delta. Finally in other cases of a u t o i m m u n e chronic hepatitis, the most significant histological finding is multinucleate giant hepatocytes with severe lytic confluent .lesions and fibrosis. In summary, n o w a d a y s in most cases of chronic hepatitis it is possible to make a precise diagnosis of the various etiologic forms by using histological parameters a n d / o r immunohistochemical techniques, together with serological studies.
References
8 Moreno A, Ram6n y Cajal S, Marazuela M, et al. Sanded nuclei in delta patients. Liver 1989; 9: 367-71. 9 Lau JYN, Hansen LJ, Bain VG, et al. Expression of intrahepatic hepatitis D viral antigen in chronic hepatitis D virus infection. J Clin Pathol 1991;44: 549-53. 10 Choo Q-L, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. Science 1989; 244: 1-3. 11 Infantolino D, Bonino F, Zanetti AR, Lesniewski RR, Barbazza R, Chiaramonte M. Localization of hepatitis C virus (HCV) antigen by immunohistochemistry on fixed-embedded liver tissue, ital J Gastroenterol 1990;22: 198-9. 12 Scheuer PJ, Ashrafzadeh P, Sherlock S, Brown D, Dusheiko GM. The pathology of hepatitis C. Hepatology 1992; 15: 567-71. 13 Moreno A, Bfircena R, Erdozain JC, Martinez J, Quiroga JA, Carrefio V. A clinico-pathological prospective study of posttransfusion hepatitis C. Submitted for publication. 14 Johnson PJ, Mcfarlane JG, Eddelston ALWF. The natural course and heterogeneity of autoimmune-type chronic active hepatitis. Semin Liver Dis 1991;44: 187-96. 15 Bach N, Thung SN, Schaffner F. The histology of chronic hepatitis C and autoimmune chronic hepatitis: a comparative analysis. Hepatology 1992; 15: 572-7. 16 Gerber M, Chronic hepatitis C: The beginning of the end of a time-honored nomenclature? Hepatology 1992; 15: 733-4.
1 Chu C-M, Karayiannis P, Fowler MJF, Monjardino J, Liaw Y-F, Thomas HC. Natural history of chronic hepatitis B virus infection ,n Taiwan: studies of hepatitis B virus DNA in serum. Hepatology 1985; 5: 431-4. 2 Desmet VJ. lmmunopathology of chronic viral hepatitis. Hepatogastroenterology 1991; 38: 14-21. 3 Franca STM, Kiyosawa K, Imai Y, et al. Change of intrahepatic expression of hepatitis-B core antigen during the clinical course of type-B chronic hepatitis. Scand J Gastroenterol 1989, 24: 454-60. 4 Liaw YF, Chu C-M, Su I-H, Huang M-J, Lind DY, Chang-Chien CS. Clinical and histological events preceding hepatitis B 'e' antigen seroconversion in chronic type B hepatitis. Gastroenterology 1983; 84:216-9. 5 Liaw YF, Pao C, Chu CM, Sheen IS, Huang MJ. Changes of sei-um hepatitis B virus DNA in two types of clinical events preceding spontaneous hepatitis B e antigen seroconversion in chronic type B hepatitis. Hepatology 1987; 7: I-3. 6 Lok ASF, Lindsay I, Scheuer P J, Thomas HC. Clinical and histological features of delta infection in chronic hepatitis B virus carriers. J Clin Pathol 1985; 38: 530-3. 7 Kanel GC, Govindarajan S, Peters RL. Chronic delta infection and liver biopsy changes in chronic active hepatitis B. Ann Intern Med 1984; 10h 51-4.
Journal of Hepatology, 1993; 17 (Suppl. 3): S112-SI15 © 1993ElsevierScientific Publishers Ireland Ltd. All rights reserved. 0168-8278/93/$06.00
HEPAT 01308
Liver biopsy and the etiologic diagnosis of chronic hepatitis A. Moreno", C.J. Martinez" and V. Carrefio b "Department of Pathology. Hospital Rambn y Cajal, Madrid and bDepartment of Gastroenterology. Hepatology Unit, Fundaci6nJim~nez Diaz, Madrid, Spain
The histological features of chronic viral hepatitis differ according to etiological agent and replicative phases. Thus, in chronic HBV hepatitis with a high level of HBV replication the histological lesion is generally mild. During the seroconversion phase, a lobular lesion is present in the liver biopsy followed by amelioration of the disease. Chronic delta hepatitis is very aggressive histologically, progression to cirrhosis is frequent, and sanded nuclei are often observed in liver biopsies of patients with anti-HIV. In contrast, chronic hepatitis C shows a milder histological picture and immunohistochemical techniques to detect HCV-Ag in the liver tissue should be developed. In summary, the majority of cases of chronic viral hepatitis have distinctive histological features that may be identified in liver biopsies. K e y words: Histology; Chronic hepatitis; HBV; HDV; HCV; Autoimmune
Conceptually, chronic hepatitis is an inflammatory primary disease of the liver with persistent biologic abnormalities for more than 6 months, and etiologically related to B, delta, C hepatitis viruses and autoimmune factors. The aims of histopathological studies of liver biopsies are to evaluate the degree of necroinflammatory activity, to determine the severity of the disease, to define a histological diagnosis and to evaluate the effect of therapy. The histological features in liver biopsies in relation to the etiology will be reviewed here. The histological hallmark of chronic infection with the hepatitis B virus in the liver is the presence of ground-glass hepatocytes. It is a frequent change, easy to recognize in haematoxylin-eosin stained histological sections. The number of liver cells affected varies considerably in inverse relation to the degree of inflammatory activity. On the basis of several previous studies (1-3), we know that the natural history of chronic hepatitis B infection begins with a high viral replicative phase with HBeAg and HBV-DNA in the serum and is histologically characterized by a scarce necroinflammatory change usually corresponding to chronic persistent or mild chronic active hepatitis. Generally scattered ground-glass cells expressing cytoplasmic and membranous HBsAg antigen (Fig. 1) and abundant nuclear
HBcAg are observed. This initial period is followed by seroconversion (from HBeAg to anti-HBe) with a marked increase in necroinflammatory activity during that phase (2,4). Immunostaining usually reveals nuclear and cytoplasmic HBcAg which are focally distributed. In the subsequent non-replicative phase, as the disease progresses the hepatitis activity subsides and finally disappears. Groups of ground-glass cells, showing an intense positive staining for HBsAg, become prominent, and inversely, the HbcAg positivity disappears. The inflammatory activity is of low degree or absent (5). Scattered hyperplastic rounded areas are intermingled with polymorphic hepatocytes and 'ground-glass' fields, producing distortion and irregularity of the laminar pattern. The hepatitis delta agent is an mRNA defective virus with ! 700 bases and it is a frequent cause of reactivation of chronic hepatitis B. Delta superinfection causes activation and worsening of the liver disease (6). Thus, chronic delta hepatitis usually shows a severe histological picture with marked lobular inflammatory activity and piecemeal necrosis, frequently associated with bridging and multilobular necrosis or cirrhosis. Liver lesions experiment variations in different histological fields of the same biopsy specimen. Thus, areas severely involved coexist with more quiescent areas sometimes showing ground-glass cells or prominent nuclear dysplasia (7).
Correspondence to: Dr. Alberto Moreno, Fundaci6n para el Estudio de las Hepatitis Virales, C/Guzm~n el Bueno,72. Bajo, 28015 Madrid, Spain.
LIVER B1OPSY FOR DIAGNOSIS OF CHRONIC HEPATITIS
SI 15
Occasionally, sanded nuclei, a virtually p a t h o g n o m o n i c feature of delta infection, are observed (Fig. 2) (8). In our experience, these nuclei are relatively c o m m o n in patients co-infected with h u m a n immunodeficiency virus. I m m u nohistochemical demonstration of tissue delta antigen, usually nuclear, is indicative of active viral replication (9). Chronic hepatitis C is a c o m m o n liver disease caused by a persistent infection with a single-stranded R N A hepatotropic virus (10). F r o m a histological point of view, the C antigens cannot yet be detected by standard techniques; and some recent reports need further study and confirmation (I 1). The histopathological picture of chronic hepatitis C is highly characteristic although it is not p a t h o g n o m o n i c (Fig. 3) (12). The features include sinusoidal lymphocytosis, acidophilic r h o m b o i d degeneration and lymphoid follicles with or without bile duct damage (16). These features taken single m a y be observed in m a n y different etiologies, but their coexistence in the same specimen makes the histologic diagnosis of C viral hepatitis highly possible. At least two characteristic pictures m a y be observed. In most cases chronic hepatitis C presents a mild histological picture, showing laminar m o n o m o r p h i s m , slight periportal piecemeal necrosis, a few lobular acidophilic bodies and prominent portal lymphoid follicles. However, in the acute stages and in the early stages of the chronic phase a prominent lobular sinusoidal lymphocytosis and a moderate acidophilic degeneration, without significant lobular disarray, m a y
be observed. This peculiar picture of chronic iobular hepatitis is frequent and characteristic of hepatitis C virus-induced liver disease (13). A u t o i m m u n e chronic hepatitis is another type of chronic hepatitis that courses with severe polyclonal hypergammaglobulinemia and several n o n - o r g a n o specific autoantibodies detected in the serum (14). The histopathoiogy of a u t o i m m u n e chronic hepatitis is heterogeneous, but in most cases a severe type of chronic active hepatitis with bridging hepatic necrosis and disturbed lobular architecture is present (15). In addition to this basic picture, at least 3 different types of histological pattern can be found superimposed. One pattern is characterized by confluent lytic necrosis, zonal, paravenular or intervenular, with cell 'drop-out'. A second, and highly characteristic, pattern shows extensive laminar rosetting involving several acini (Fig. 4) ('multilobular') usually with clusters of plasma cells. This diffuse rosetting is virtually absent in chronic hepatitis C and is rarely observed at this intensity in hepatitis B or delta. Finally in other cases of a u t o i m m u n e chronic hepatitis, the most significant histological finding is multinucleate giant hepatocytes with severe lytic confluent .lesions and fibrosis. In summary, n o w a d a y s in most cases of chronic hepatitis it is possible to make a precise diagnosis of the various etiologic forms by using histological parameters a n d / o r immunohistochemical techniques, together with serological studies.
References
8 Moreno A, Ram6n y Cajal S, Marazuela M, et al. Sanded nuclei in delta patients. Liver 1989; 9: 367-71. 9 Lau JYN, Hansen LJ, Bain VG, et al. Expression of intrahepatic hepatitis D viral antigen in chronic hepatitis D virus infection. J Clin Pathol 1991;44: 549-53. 10 Choo Q-L, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. Science 1989; 244: 1-3. 11 Infantolino D, Bonino F, Zanetti AR, Lesniewski RR, Barbazza R, Chiaramonte M. Localization of hepatitis C virus (HCV) antigen by immunohistochemistry on fixed-embedded liver tissue, ital J Gastroenterol 1990;22: 198-9. 12 Scheuer PJ, Ashrafzadeh P, Sherlock S, Brown D, Dusheiko GM. The pathology of hepatitis C. Hepatology 1992; 15: 567-71. 13 Moreno A, Bfircena R, Erdozain JC, Martinez J, Quiroga JA, Carrefio V. A clinico-pathological prospective study of posttransfusion hepatitis C. Submitted for publication. 14 Johnson PJ, Mcfarlane JG, Eddelston ALWF. The natural course and heterogeneity of autoimmune-type chronic active hepatitis. Semin Liver Dis 1991;44: 187-96. 15 Bach N, Thung SN, Schaffner F. The histology of chronic hepatitis C and autoimmune chronic hepatitis: a comparative analysis. Hepatology 1992; 15: 572-7. 16 Gerber M, Chronic hepatitis C: The beginning of the end of a time-honored nomenclature? Hepatology 1992; 15: 733-4.
1 Chu C-M, Karayiannis P, Fowler MJF, Monjardino J, Liaw Y-F, Thomas HC. Natural history of chronic hepatitis B virus infection ,n Taiwan: studies of hepatitis B virus DNA in serum. Hepatology 1985; 5: 431-4. 2 Desmet VJ. lmmunopathology of chronic viral hepatitis. Hepatogastroenterology 1991; 38: 14-21. 3 Franca STM, Kiyosawa K, Imai Y, et al. Change of intrahepatic expression of hepatitis-B core antigen during the clinical course of type-B chronic hepatitis. Scand J Gastroenterol 1989, 24: 454-60. 4 Liaw YF, Chu C-M, Su I-H, Huang M-J, Lind DY, Chang-Chien CS. Clinical and histological events preceding hepatitis B 'e' antigen seroconversion in chronic type B hepatitis. Gastroenterology 1983; 84:216-9. 5 Liaw YF, Pao C, Chu CM, Sheen IS, Huang MJ. Changes of sei-um hepatitis B virus DNA in two types of clinical events preceding spontaneous hepatitis B e antigen seroconversion in chronic type B hepatitis. Hepatology 1987; 7: I-3. 6 Lok ASF, Lindsay I, Scheuer P J, Thomas HC. Clinical and histological features of delta infection in chronic hepatitis B virus carriers. J Clin Pathol 1985; 38: 530-3. 7 Kanel GC, Govindarajan S, Peters RL. Chronic delta infection and liver biopsy changes in chronic active hepatitis B. Ann Intern Med 1984; 10h 51-4.