Native liver xanthogranulomatous cholangiopathy in primary sclerosing cholangitis: impact on posttransplant outcome

Xanthogranulomatous cholecystitis in a patient with ulcerative colitis and primary sclerosing cholangitis: A case report

Chronic gallbladder disease due to xanthogranulomatous cholecystitis is uncommon, and its symptoms are generally vague. While there is no firm evidence to link xanthogranulomatous cholecystitis to primary sclerosing cholangitis or ulcerative colitis. The patient is a 41-year-old male with a history of ulcerative colitis, primary sclerosing cholangitis, and biliary stenting who complained of symptoms of anorexia, jaundice, and pruritus. In the initial ultrasound exam, there was evidence of intrahepatic and extra-hepatic bile duct dilation along with a significant and mass-like circumferential thickening of the gallbladder wall. Magnetic resonance cholangiopancreatography was performed for further evaluation, which indicated increased gallbladder wall thickness, containing multiple T2 hyper-signal nodules while the mucosal layer was intact. There was also a filling defect in the common bile duct's distal portion. These findings matched a xanthogranulomatous cholecystitis diagnosis and a possibly malignant lesion in the distal of the common bile duct. The patient ultimately had a cholecystectomy, and pathology findings confirmed the diagnosis of xanthogranulomatous cholecystitis. Biopsy specimens obtained from the distal of the common bile duct lesion were microscopically identified as intramucosal adenocarcinoma. In patients with a history of primary sclerosing cholangitis who present with nonspecific symptoms suggesting chronic gallbladder disease and radiologic evidence of circumferential gallbladder wall thickening containing intramural nodules and intact mucosa, xanthogranulomatous cholecystitis should be kept in mind.

Frequent overlap of active hepatitis in recurrent primary sclerosing cholangitis after living-donor liver transplantation relates to its rapidly progressive course

Recurrence of primary sclerosing cholangitis after liver transplantation is a challenging issue. Liver pathologies of recurrent primary sclerosing cholangitis after living-donor liver transplantation have not been reported. Here, liver pathologies of explanted grafts and biopsies of 9 patients who underwent retransplantation for recurrent primary sclerosing cholangitis were compared with those of native livers. Recurrence was diagnosed in 13 of 36 patients for primary sclerosing cholangitis post-living-donor liver transplantation, and 9 of them underwent retransplantation. All explanted grafts revealed biliary cirrhosis with sclerosing cholangitis, and 6 patients had additional features of active hepatitis. Liver biopsies showed that 3 had active hepatitis in addition to fibrous cholangitis at recurrence of primary sclerosing cholangitis. Two developed active hepatitis later after the diagnosis of recurrence. In explanted grafts, in addition to extensive hilar lymphoplasmacytic cholangitis, 4 cases showed hilar xanthogranulomatous cholangitis. The latter was not evident in 7 native livers. Ductopenia was extensive in all native livers, although such changes were relatively mild in explanted grafts at retransplantation. Patients with recurrent primary sclerosing cholangitis developed progressive graft failure, and the interval between diagnosis of recurrence and retransplantation (mean, 3.2 years) was shorter than that between diagnosis of primary sclerosing cholangitis and first transplantation (mean, 7.7 years). The rather rapid deterioration of recurrent primary sclerosing cholangitis after liver transplantation may be related to the frequent overlap of active hepatitis.

Radiofrequency ablation of hepatocellular carcinoma in patients with decompensated cirrhosis: evaluation of therapeutic efficacy and safety

OBJECTIVE

Our objective was to determine the therapeutic efficacy and safety of radiofrequency ablation in the treatment of hepatocellular carcinoma (HCC) in patients with decompensated cirrhosis.

SUBJECTS AND METHODS

Nineteen patients with 26 HCC nodules (range, 0.8-5 cm; mean, 1.96 cm) and decompensated liver cirrhosis (mean Child score, 10.7) were treated with radiofrequency ablation using cooled-tip electrodes and a 200-W generator. Radiofrequency ablation was performed under the guidance of sonography or CT. Procedure-related complications, therapeutic efficacy, each patient's survival, changes in blood test results--that is, serum aminotransferase and bilirubin--and changes in the Child score before and after ablation therapy were analyzed. To assess the therapeutic response of the tumor to radiofrequency ablation, we performed contrast-enhanced CT after the procedure and during follow-up.

RESULTS

Complete necrosis without marginal recurrence at the 6-month follow-up was attained in 23 lesions (88.5%). During follow-up (mean, 13.3 months), one patient experienced a remote tumor recurrence in the liver. The median survival time was 12.0 +/- 1.7 months. Two patients died of liver failure--one at 2 months and one at 4 months after treatment. The other patients were followed for at least 6 months (range, 6-28 months; mean, 12 months). The first and second weeks after therapy, the serum aminotransferase and bilirubin levels were significantly higher than were pretreatment levels (p < 0.05). However, 3 weeks after therapy, those figures were nearly restored to the pretreatment levels. The mean Child scores 3 weeks after radiofrequency ablation (10.8) were similar to those before treatment (10.7).

CONCLUSION

Radiofrequency ablation can be used selectively for treatment of HCC in patients with decompensated cirrhosis but has the potential to aggravate the preexisting hepatic dysfunction.

Multicystic biliary hamartoma

In this report, we presented 3 cases of unusual hamartomatous nodules of the liver. These nodules were located around hepatic capsule of the left hepatic lobe and characteristically protruded from the liver. Histologically, these nodular lesions consisted of ductal structures, periductal glands, and fibrous connective tissues containing blood vessels. Smooth muscle bundles focally surrounded ductal structures. Bile-like materials were observed within some ducts. Two cases were associated with xanthogranulomatous inflammation around bile-like materials, and this inflammatory process extended from ductal lumens to periductal connective tissues. In contrast, the remaining case, which was not associated with inflammation, showed a honeycomb appearance. Ductal epithelium and periductal glands resembled biliary epithelium and peribiliary glands, respectively, and they also expressed biliary-type cytokeratins such as cytokeratins 7 and 19. These nodules shared pathologic characteristics of ciliated hepatic foregut cysts, such as their location (around the falciform ligament) and periductal smooth muscle bundles, but did not fulfill the diagnostic criteria (no ciliated cells and multilocular lesions). These hamartomatous nodules of the liver did not fit into any of the described categories of hepatic nodular lesions. At present, we speculate that these lesions might be related to developmental abnormalities of the biliary tract or embryonal foregut.

A case of Papillon-Lefevre syndrome associated with xanthogranulomatous pyelonephritis and hepatitis

Papillon-Lefevre syndrome (PLS) is an autosomally recessive palmoplantar keratoderma accompanied by psoriasiform plaques on the extensor surfaces of extremities and leading to premature loss of deciduous and permanent teeth by progressive periodontitis. Patients with PLS may exhibit mental retardation, intracranial ectopic calcifications, nail dystrophies and a tendency to various infectious disorders, in addition to skin and oral findings. Herein, we report a 26-year-old man with PLS, who had experienced xanthogranulomatous pyelonephritis and hepatitis during childhood and adolescence. To the best of our knowledge, this is the first report of PLS associated with xanthogranulomatous inflammation.

Hepatobiliary pathology

PURPOSE OF REVIEW

This review highlights recent publications on hepatobiliary pathology concerning several unusual types of hepatitis, fatty liver disease, disorders of the biliary tree and other topics that have a substantial impact on liver biopsy interpretation.

RECENT FINDINGS

In the outbreak of severe acute respiratory syndrome (SARS), many patients had abnormalities in liver function tests. Liver biopsy findings in three cases were reported that showed a generic picture of hepatitis, with exceptionally increased mitotic activity. The role of portal myofibroblasts in cirrhosis was examined in several studies. A newly described lesion, isolated ductular hyperplasia (IDH) was found in patients with prolonged abnormalities of liver function tests of uncertain origin. Hyperplastic, well-differentiated bile ductules were seen on liver biopsy in the absence of any identifiable biliary disease. Hereditary hemochromatosis is now a complex entity with various clinicopathological forms based on mutations in the HFE gene and other iron-homeostatic genes such as transferrin receptor 2 and ferroportin 1. In some of these heritable forms of primary iron overload, stainable iron is present in both hepatocytes and Kupffer cells. After liver transplantation, differentiating recurrent HCV infection from acute rejection on liver biopsy is problematic, with exceptionally low inter- and intra-observer reliability shown in one study.

SUMMARY

The hepatitis associated with the SARS coronavirus, Isolated Ductular Hyperplasia in patients with liver function test abnormalities and other topics with pathologic relevance are reviewed.