Hepatitis--a diagnostic approach to histopathologic interpretation of liver biopsy specimens

This paper discusses the differential diagnoses of "hepatitis" from a pathologist's point of view. An initial blind approach to the interpretation of liver biopsy specimens is recommended to avoid a biased diagnosis. The term "hepatitis" is subdivided into the following morphologic categories--lobular, portal, periportal and cholestatic hepatitis groups. In each group, the possible clinical diagnoses are discussed in order of likelihood. Salient histologic criteria, diagnostic histopathologic problems and pitfalls are highlighted. The final diagnosis should be based on a clinicopathologic correlation.

The spectrum of hepatic injury in enteric fever

Thirty six patients with culture-proven enteric fever and 15 patients of fever with etiology other than enteric fever as a control group were studied, with special reference to hepatic dysfunction and its relation to clinical features of the disease. Hepatomegaly was observed in 55% of enteric fever patients, and was slightly more common than splenomegaly (50%). Its incidence in typhoid fever (67%) was three times higher than in paratyphoid fever (22%). Hepatic dysfunction occurred in 55% of cases. Jaundice was noted in only 8% of the cases, whereas hyperbilirubinemia (serum bilirubin greater than 1.8 mg %) was present in 17%. Although hepatic manifestations of enteric fever were mild, a small but important group had sufficient hepatic involvement to mimick the clinical picture seen in viral hepatitis, amebic liver disease, and malaria with jaundice. It may be considered of clinical significance, since enteric hepatitis responds very well to specific therapy.

Immunoglobulin-containing plasma cells in acute hepatitis

Imunoglobulin(Ig)-containing plasma cells in human liver were investigated in different aetiological and histological forms of acute hepatitis. Liver specimens from 93 patients with acute hepatitis (A, B, non-A, non-B and drug-induced) were studied by conventional microscopy and by immunoperoxidase staining for IgG, IgA and IgM in paraffin sections. Plasma cells were found in 78 of 93 specimens and Ig-containing cells in 75. IgG-containing cells were significantly more abundant in acute hepatitis with bridging necrosis than in other forms (p less than 0.01), and there were more IgA-containing cells than in the classical and periportal forms (p less than 0.05). IgG-containing cells were more numerous in acute hepatitis with periportal or panacinar necrosis than in the classical form (p less than 0.05). IgG- and IgA-containing cells were less abundant in drug-induced hepatitis than in viral hepatitis (p less than 0.05). Among the viral groups the largest number of IgG-containing cells was found in non-A, non-B hepatitis, while IgA-containing cells were most abundant in type A. These differences were not statistically significant. IgM-containing cells were very scanty in all groups studied. It is concluded that Ig-producing plasma cells are common in acute viral hepatitis and presumably play a part in antibody-dependent immune reactions in this disease.

Fructose 1,6-bisphosphatase in the diagnosis of chronic hepatitis. II. Classification of chronic hepatitis based on fructose 1,6-bisphosphatase and other laboratory data

The histomorphology of typical liver cell necroses are here correlated with heterotope distributions of enzymes in liver parenchyma. A variety of findings indicate a congruence between gluconeogenetic areas of the liver and the typical pattern of 'piecemeal' necrosis. We therefore propose a diagnostic index based on fructose 1,6-bisphosphatase activity and the data from the clinical laboratory. This index makes it possible to distinguish between chronic persistent and chronic aggressive hepatitis.

Chronic hepatitis with nonspecific histological changes. Is it a distinct variant of chronic hepatitis?

A longitudinal follow-up study has been undertaken in 62 patients with clinicopathologically verified chronic hepatitis with non-specific reactive histological changes (NSRH) in comparison with 28 patients with chronic persistent hepatitis (CPH), the clinical features of which are quite similar to NSRH. In contrast to the stationary and non-progressive course of CPH, 45.2% of patients with NSRH, either HBsAg positive or negative, ran a fluctuating course with moderate to marked elevation of SGPT (greater than 200 IU/l) In HBsAg-positive patients, only those positive for HBeAg and a few negative for both HBeAg and anti-HBe had fluctuating courses. In addition, patients with apparent clinical and biochemical changes could show histological features of chronic lobular hepatitis (CLH). A few developed chronic active hepatitis and/or cirrhosis on follow-up biopsy. It is concluded that NSRH is a form of chronic hepatitis different from CPH, but similar to or representing a phase of CLH. It is suggested that NSRH should be categorized as CLH in the classification of chronic hepatitis.

[Classification of chronic hepatitis]

After an examination of the classifications of chronic hepatitis put forward between 1968 and the present a critical review of the subject is presented. On the basis of personal experience and in the light of recent developments, another classification is proposed which together with morphological criteria, haematochemical evaluation and particularly, statistically processed immunological data would permit adequate monitoring of possible therapeutic treatments.

[Humoral and histological correlations in chronic aggressive hepatitis without necrotic bridges]

By excluding the CALD complicated by B.H.N. we have been left with a range of C.A.H. patterns hardly distinguishable from C.P.H. on one side and from Cirrhosis on the other. We have tried to subdivide this range into three subgroups according to the extension of necrosis, fibrosis, inflammation, regeneration. Furthermore, we compared the biochemical parameters of activity of these subgroups in which we subdivided C.A.H. without B.H.N. to each other and with those of C.P.H. and C.L.H. Results shaw no statistical significative difference in the compared groups. Thus, we conclude for a priority of the histological patterns on biochemical parameters in the management of this disease.

[Epidemiology of hepatitis 1977-1979]

New serological tests allow one to classify the majority of patients with acute viral hepatitis into patients with hepatitis B, with hepatitis A or with hepatitis NonA/NonB. This breakdown was performed with 207 consecutive patients from the Zurich area in 1979. The data were compared with those obtained in patient series from 1977/78 (220 patients) and series published earlier (another 790 patients since 1972). Before 1979 only hepatitis B and hepatitis NonB could be differentiated. Since 1972 approximately 50% of all patients have had hepatitis B. In 1979 25% of the remaining patients had hepatitis A and 13% hepatitis NonA/NonB, while the others could not be classified. In all series so far analyzed slightly more men than women were affected, almost half of the patients were between 15 and 29 years old and no seasonal peaks were apparent. Sporadic disease is the rule, and clusters are extremely rare. However, there was a slight shift of risk situations which might have led to transmission of the virus. The percentage of patients with appropriately timed blood transfusions dropped from 12% in 1972 to 5% in 1979 and medical staff members from 18% to 6%, while the percentage of patients with histories of drug use increased from 4% to 11% and of travellers to foreign countries from 15% to 40%. Most of the travellers had hepatitis A, and the majority of transfused patients had hepatitis B, while drug users had either hepatitis B or NonA/NonB. Some background data on hepatitis viruses are summarized and possible prophylactic measures are discussed.

[Hepatitis: the problem of terminology (author's transl)]

Every case of hepatitis must be defined as far as possible on the basis of four reference criteria: aetiological, clinical presentation, histological and course. Each criterion offers information concerning the classification, severity and course of the disease. The use of these criteria makes it possible to avoid all errors of interpretation and to avoid imprecise terminology, a typical example of which is "subacute hepatitis" which for some implies severe acute hepatitis running a prolonged course and for others the existence of confluent necrosis without it being possible to say whether this should be classified amongst cases of acute hepatitis or chronic hepatitis. The terms acute and chronic should retain their clinical significance, the term aggressive should retain a histological significance and, insofar as the piecemeal necrosis which characterises it is seen in both types of hepatitis, it should be dissociated, in terms of classification, from chronic hepatitis.