Liver and intrahepatic bile ducts - nontumor
Hepatitis (acute and chronic)
Chronic hepatitis


Topic Completed: 29 August 2019

Revised: 29 August 2019

Copyright: 2012-2019, PathologyOutlines.com, Inc.

PubMed Search: Chronic hepatitis[TI] general[TI]


Jordon March, M.D.
Kimberley J. Evason, M.D., Ph.D.
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Cite this page: March J, Evason KJ. Chronic hepatitis. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/liverchronichepgeneral.html. Accessed September 20th, 2019.
Definition / general
  • Liver fibrosis occurring as a result of hepatocyte based injury and inflammation, most commonly due to viral or autoimmune hepatitis or alcoholic or non-alcoholic fatty liver disease
Essential features
  • Progressive fibrosis that ultimately leads to liver cirrhosis
  • Morphologically characterized by portal inflammation with interface activity, lobular necroinflammatory activity and fibrosis
Terminology
ICD coding
ICD-10 coding:
  • B18.0 - chronic viral hepatitis B with delta-agent
  • B18.1 - chronic viral hepatitis B without delta-agent
  • B18.2 - chronic viral hepatitis C
  • B18.8 - other chronic viral hepatitis
  • B18.9 - chronic viral hepatitis, unspecified
  • K73.0 - chronic persistent hepatitis, not elsewhere classified
  • K73.1 - chronic lobular hepatitis, not elsewhere classified
  • K73.2 - chronic active hepatitis, not elsewhere classified
  • K73.8 - other chronic hepatitis, not elsewhere classified
  • K73.9 - chronic hepatitis, unspecified
  • Sites
    • Liver parenchyma
    Pathophysiology
    • Hepatocytes are injured by viral infection, drugs, deregulated inflammatory cells or abnormal accumulation of metabolites, leading to activation of hepatic stellate cells, which produce increased extracellular matrix resulting in fibrosis (Middle East J Dig Dis 2016;8:166, Physiol Rev 2008;88:125)
    Clinical features
    • May lack symptoms until end stage (cirrhosis)
    • Associated signs and symptoms include:
      • General: fatigue (most common), malaise, mild discomfort in the right upper quadrant, anorexia
      • Impaired biliary tract function: jaundice, pruritus
      • Portal hypertension: gastroesophageal varices, ascites, edema, splenomegaly
      • Impaired hepatocyte metabolism: spider angiomata, hepatic encephalopathy, easy bleeding / bruising
    Diagnosis
    Laboratory
    Radiology description
    • MRI and CT findings in cirrhosis
      • Surface and parenchymal nodularity
      • Hypertrophy of the caudate lobe and lateral segments of the left lobe
      • Atrophy of the posterior segments of the right lobe
    • Ultrasound findings in cirrhosis
    Radiology images

    Image hosted on other servers:
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    Nodular liver in patient with hepatitis B

    Prognostic factors
    Case reports
    Treatment
    • Dependent on underlying etiology
    Gross description
    • In cirrhosis, the liver is generally firm and demonstrates a micronodular or macronodular pattern
    • Color ranges from beefy red (normal) to dark green (cholestasis) or yellow (steatosis) (World J Gastroenterol 2016;22:1357)
    Gross images

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    Cirrhotic liver is diffusely nodular

    Microscopic (histologic) description
    • Fibrosis
      • Required for pathologic diagnosis of chronic hepatitis
      • Progressive fibrosis of limiting plate leads to enlargement of portal tracts and stellate periportal fibrous extension
      • May lead to portal - portal or portal - central fibrous bridging, culminating in cirrhosis, which is usually micronodular (nodules < 3 mm in diameter) or mixed micronodular and macronodular type
    • Portal inflammation
      • Mononuclear infiltration of portal tracts (mostly CD4+ T lymphocytes with some plasma cells)
      • Lymphoid aggregates or follicles may be present (most common in hepatitis C infection)
    • Interface hepatitis
      • Previously called “piecemeal necrosis”
      • Hepatocyte apoptosis and inflammation at the stromal-parenchymal interface (interface of portal tract and lobule)
      • Mononuclear infiltrate (mostly CD8+ T lymphocytes)
    • Lobular hepatitis
      • Mononuclear infiltrate of the hepatic parenchyma (lobules)
      • Apoptotic / necrotic hepatocytes (Councilman bodies) in zones 2 and 3
    Microscopic (histologic) images

    Contributed by Kimberley J. Evason, M.D., Ph.D.
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    Chronic hepatitis C

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    Fibrosis in chronic hepatitis C

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    Cirrhosis (end stage)

    Positive stains
    • Trichrome stain can help with the assessment of the amount of scarring and fibrosis present (stage)
    Sample pathology report
    • Liver, core biopsy:
      • Chronic hepatitis with mild activity (grade 2, scale 0-4, Batts-Ludwig methodology) and periportal fibrosis with septae formation (stage 2, scale 0-4, Batts-Ludwig methodology), consistent with clinical history of chronic hepatitis C
    Differential diagnosis
    • Primary biliary cirrhosis (PBC)
      • Can have portal based inflammation with interface activity and lobular activity
      • Florid duct lesions not seen in chronic hepatitis
      • Clinical history may include elevated alkaline phosphatase, gamma-glutamyl transpeptidase, serum IgM and antimitochondrial autoantibodies
    • Lymphoma or leukemia infiltrating into the liver
      • Can have portal lymphocytic inflammation
      • Lacks interface hepatitis and portal based fibrosis
      • May have monomorphism and marked atypia of the infiltrating cells
    • Active hepatitis with bridging necrosis
      • Has portal inflammation with interface activity and lobular inflammation
      • Bridging necrosis can cause a nodular appearance from low power, mimicking bridging fibrosis or cirrhosis
      • Trichrome staining is paler in zones of dropout / necrosis than in fibrous areas
    Board review question #1

      An asymptomatic 35 year old woman has elevated serum aminotransferases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]). A liver biopsy was performed. What is the most likely underlying etiology of these findings?

    1. Alcoholic liver disease would be expected to show steatohepatitis. There is no fat in this biopsy
    2. Infection with hepatitis C causes chronic hepatitis, which is characterized by fibrosis and periportal lymphocytic inflammation
    3. Oxaliplatin induced liver injury is characterized by a vascular injury pattern including sinusoidal dilatation, congestion, and centrizonal necrosis
    4. Tylenol associated liver injury is associated with centrizonal necrosis
    5. Valproic acid-associated liver injury is characterized by microvesicular steatosis
    Board review answer #1
    B. Infection with hepatitis C causes chronic hepatitis, which is characterized by fibrosis and periportal lymphocytic inflammation

    Comment Here

    Reference: Chronic hepatitis - general
    Board review question #2

      A liver biopsy from a 54 year old man is shown below. What feature, required for the diagnosis of chronic hepatitis, is shown in the image?

    1. Bridging necrosis is not required for the diagnosis of chronic hepatitis. This biopsy shows bridging fibrosis, not bridging necrosis. Bridging necrosis would appear pale blue-gray on trichrome stain
    2. There is extensive fibrosis in this biopsy. Fibrosis is required for the histologic diagnosis of chronic hepatitis
    3. Interface hepatitis is often present in chronic viral hepatitis, but is not required for the diagnosis of chronic hepatitis
    4. Nodule formation is seen here and is required for the diagnosis of cirrhosis, but is not required for the diagnosis of chronic hepatitis
    5. Portal inflammation is often present in chronic viral hepatitis, but is not required for the diagnosis of chronic hepatitis
    Board review answer #2
    B. There is extensive fibrosis in this biopsy. Fibrosis is required for the histologic diagnosis of chronic hepatitis

    Comment Here

    Reference: Chronic hepatitis - general
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