Table Of ContentPathology of Liver Diseases
Pathology of Liver Diseases
Gary C. Kanel, M.D.
Clinical Professor of Pathology
Keck Medical Center of USC
Department of Pathology and Laboratory Medicine
Los Angeles, CA, USA
This edition first published 2017
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Library of Congress Cataloging-in-Publication Data
Names: Kanel, Gary C., author.
Title: Pathology of liver diseases / Gary C. Kanel.
Description: Hoboken, NJ : John Wiley & Sons, Inc., 2017. | Includes
bibliographical references and index.
Identifiers: LCCN 2017001716 (print) | LCCN 2017002257 (ebook) | ISBN
9781118895030 (cloth) | ISBN 9781118895023 (pdf) | ISBN 9781118895009 (epub)
Subjects: | MESH: Liver Diseases—pathology
Classification: LCC RC845 (print) | LCC RC845 (ebook) | NLM WI 700 | DDC
616.3/62—dc23
LC record available at https://lccn.loc.gov/2017001716
Cover images: Courtesy of the author.
Set in 10/12pt Warnock Pro by Aptara Inc., New Delhi, India
10 9 8 7 6 5 4 3 2 1
v
Contents
Preface vi
About the companion website viii
Chapter 1 Normal Liver 1
Chapter 2 Viral Hepatitis 24
Chapter 3 Fatty Liver Diseases 50
Chapter 4 Diseases of the Biliary Tract 72
Chapter 5 Non-Viral Infectious Diseases 95
Chapter 6 Granulomatous Hepatitis 123
Chapter 7 Autoimmune Hepatitis 131
Chapter 8 Vascular Disorders 143
Chapter 9 Genetic and Metabolic Hepatic Diseases 162
Chapter 10 Developmental Hepatobiliary Disorders and Cystic Diseases 198
Chapter 11 Drug- and Toxin-Induced Liver Diseases 215
Chapter 12 Liver Transplantation 231
Chapter 13 Hepatic Tumors, Benign 266
Chapter 14 Hepatic Tumors, Malignant 289
Chapter 15 Miscellaneous Hepatic Disorders 337
Index 354
vi
Preface
With all of the advancements in hepatology, also remain the gold standard in the staging
including invasive and non-invasive imaging, and grading of chronic liver diseases to deter-
laboratory tests targeting specific diseases, mine the appropriate individual therapies. For
molecular biology, and genomics, one might all of these reasons, useful reference material, as
think that liver biopsy material in patients with presented in this book Pathology of Liver Dis-
suspected acute or chronic liver diseases or eases, is most helpful to the pathologist and the
hepatic tumors may not be as necessary in arriv- patients’ attending physicians in arriving at the
ing at a specific diagnosis as it was in the past; diagnosis or best possibilities that fit each indi-
however, what still persists is an inconsistency vidual patient.
oftentimes in the way patients clinically present Pathology of Liver Diseases uses both book
with laboratory tests and what in fact the biopsy and online material in the presentation of
shows. This therefore leads to the continued the whole range of liver diseases seen in both
importance of liver biopsy interpretation. the community hospitals as well as academic
The settings where liver biopsies are espe- medical centers. The book in fifteen chapters
cially crucial tools in patient care are numer- emphasizes not only the pathology seen in
ous, are discussed in more detail in Chapter 1, biopsy and surgically resected or transplanted
and include assessing patients who present and autopsy material, but also the most per-
with clinical signs of acute or chronic liver dis- tinent clinical and laboratory findings includ-
ease but with normal liver tests, patients with ing epidemiology and the various etiologic
abnormal liver tests inconsistent with the sus- and pathophysiologic concepts, imaging when
pected diagnosis (e.g., clinical diagnosis of acute appropriate, and the differential diagnostic
viral hepatitis with an unexpectedly high alka- possibilities with references.
line phosphatase value), and patients in acute Furthermore, what significantly adds to the
liver failure and those with transaminitis of overall usefulness of the book is the online
no known cause. Biopsies are often warranted material. An online Library Images that contains
in the evaluation of various space-occupying over 850 images of the various liver diseases is
lesions when imaging, cultures or fine needle offered that significantly adds to the over 540
aspirates are not conclusive. Biopsies are often images already in the book. Additional online
critical in specifically evaluating liver trans- Tables to those already in the book are added so
plant patients where the clinical presentation that the reader can have a more detailed refer-
and liver test abnormalities can hint at any of a ence to the grading and staging systems of fatty
whole range of possibilities including acute or liver diseases, viral and autoimmune hepatitis,
chronic rejection, biliary strictures, infections, and liver transplant rejection. In addition 140
or recurrent disease, all of which necessitate Case Examples from patients seen at the Keck
different treatment approaches. Lastly biopsies Medical Center of USC as well as from consult
Preface vii
case material are presented in PowerPoint for- the operating table of the step-by-step process
mat that demonstrate the various ways many of in liver transplantation.
these disease entities present clinically and the The amount of information targeting the
pathology seen, including both classic and com- numerous fields of medicine has exponentially
mon examples such as alcoholic hepatitis as well increased over recent years. The addition of this
as cases infrequently seen such as progressive book and online material will not only be most
familiar intrahepatic cholestasis. Finally, cour- valuable in enabling the viewer to have access to
tesy of Dr. Rick Selby, Professor of Surgery and the wealth of material in diagnostics but also in
Chief of Hepatobiliary, Pancreatic Surgery and gaining a better overall understanding of these
Abdominal Organ Transplantation at the Keck hepatic and hepatobiliary disorders.
Medical Center of USC, the PowerPoint pres-
entation Liver Transplantation – Surgical Pro- Gary C. Kanel,
cedure is also included with photographs from Los Angeles, 2017
viii
About the companion website
This book is accompanied by a companion website:
www.wiley.com/go/kanel/liverpathology
The website includes the following to supplement each chapter:
● A complete Reference List
● 140 Case Examples, which include over 420 images that demonstrate the various ways many of
these disease entities clinically present.
● A Library that contains over 860 images of the various liver diseases, which adds to over 540
images that are in the book itself.
There are also:
● Additional Tables that address in detail the grading and staging of various liver diseases such as viral
hepatitis and fatty liver diseases.
● A PowerPoint presentation entitled “Liver Transplantation – Surgical Procedure”, which includes
photographs from the operating table of the step-by-step process in liver transplantation.
To access the website, you will need to enter the password, which is the first word of the first para-
graph in Chapter 15.
1
1
Normal Liver
The liver is a unique organ that has numerous first seen as a hollow midline outgrowth stalk
structural and physiological functions. It is most (hepatic diverticulum) of the endodermal epi-
important when discussing liver pathology that thelium at the distal aspect of the foregut. By
one understands first the normal liver histology the fourth week, the diverticulum enlarges from
before one can best understand the basic patho- proliferation of the endodermal cell strands
physiologic concepts of the numerous liver dis- (hepatoblasts) and projects cranially into the
eases. The pathologist plays a fundamental role mesoderm of the septum transversum, eventu-
in assessing the various morphologic features ally giving rise to the liver hepatic parenchyma
seen in liver tissue, whether by fine needle aspi- and intrahepatic ducts. The cephalic end ulti-
rates, needle or wedge biopsies, partial hepatec- mately develops into the right and left hepatic
tomies, liver explants, or autopsy material. The lobes, while the stalk between the diverticulum
pathologist also has not only routine but also and foregut narrows and forms the extrahepatic
numerous special histochemical and immuno- biliary system and gallbladder.
histologic stains as well. Yet correlating the his- Solid cords are initially formed by proliferat-
tologic findings with the most pertinent clinical ing endodermal cells. These eventually anasto-
and laboratory data enables the pathologist to mose to form vesicles and cribriform tubules
better arrive at a diagnosis and the most perti- with centrally located lumenal structures (bil-
nent differential possibilities. iary canaliculi). The cords eventually merge and
This introductory chapter addresses all aspects develop small channels and capillaries that sub-
of the normal liver, reviewing the embryologic divide the cords to eventually form the hepatic
development, gross and microscopic features, sinusoids. The individual hepatoblasts are pro-
the pertinent intracytoplasmic components and genitor cells that develop into mature hepato-
how their function varies with their location cytes, with those immediately adjacent to the
within the hepatic lobule, and the importance of portal mesenchyme becoming the ductal plates.
stem cell function within the liver. Additionally The rapid growth rate of the hepatic cords ena-
the various useful stains and laboratory values bles the development of sheets of cells (mura-
will also be presented, as well as a brief outline lium multiplex) that persist until birth, after
of how best to organize pathologic readings and which the cell sheets narrow to two cells (mura-
signouts of liver biopsy specimens. lium duplex) and eventually evolve within the
first year of life into a one cell thick trabecular
cord (muralium simplex). The perisinusoidal
Embryology
cells and Kupffer cells appear by three months
gestation.
The hepatic primordium anlage initially appears The mesoderm from the septum transversum
at the end of the third week of gestation and is initially surrounds the liver and is directly in
Pathology of Liver Diseases, First Edition. Gary C. Kanel.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
Companion website: www.wiley.com/go/kanel/liverpathology
2 1 Normal Liver
contact with the lesser curvature of the stom- Additionally with time the left lobe diminishes in
ach, duodenum, and ventral body wall. The size, and the caudate and quadrate lobes develop
mesoderm eventually forms the lesser omen- as subdivisions of the right lobe.
tum, the falciform, coronary, and triangular lig- The vascular network, originally derived from
aments, with a portion developing into the liver the development of the vitelline and umbilical
(Glisson) capsule. The mesoderm on the liver veins, occurs at the same time as proliferation
surface is also in continuity with the perito- of the hepatoblasts, with the sinusoids forming
neum, and the portion that makes contact with from anastomosis of the hepatic cords and ves-
the future diaphragm remains uncovered (bare sels. By the fifth week of gestation most of the
area). The developing hepatic artery and vagus major vessels are present and include the right
nerve branches follow the mesoderm along and and left umbilical veins, the transverse portal
adjacent to the portal vein. sinus, and the ductus venosus, which shunts
The mesoderm is the main focus in the devel- blood from the umbilical vein into the inferior
opment of hematopoiesis, which begins at about vena cava. The portal vein initially develops
6 weeks and becomes most active during the from the vitelline vein and then subdivides into
fifth month of gestation. This process regresses the right and left branches. The hepatic and
with increase in bone marrow activity. The portal vein branches divide the parenchyma
erythroid precursors are most prominent during into the individual lobules and acini. At birth,
fetal development within the hepatic sinusoids a sphincter mechanism closes the ductus veno-
while the myeloid and megakaryocytic precur- sus, resulting in cessation of blood flow through
sors reside mostly within the portal structures the umbilical vein, with the liver now receiving
(Figure 1.1). This hematopoiesis is responsible blood from the left branch of the portal vein.
for the enlarged size of the liver (up to 10% body The biliary apparatus develops from mem-
weight by the tenth week of gestation, with the branous infoldings between the junctional com-
right and left lobes taking up an equal volume), plexes located between individual hepatoblasts
but this size significantly regresses at birth (5% and initially appears as intercellular spaces with
of body weight) at which time only rare small no distinct wall. The biliary canaliculi are first
clusters of normoblasts can be seen. By 4 weeks seen at 6 weeks of gestation, with synthesis of
of age hematopoietic activity has usually ceased. bile occurring by the ninth week and secretion
of bile by the twelfth week. The ductal plate,
which is initially two layers thick, is formed from
the periportal hepatoblasts. A lumen develops
by the third month (see Figure 1.1) with event-
ual formation of double-layered tubular (ductu-
lar) structures. The true interlobular bile ducts
occur immediately after birth from remodeling
of these ductular elements. This biliary network
receives its blood supply from a complex of arte-
rioles and capillaries formed from the peribiliary
plexus. The extrahepatic biliary tree develops
from the stalk of the original hepatic outgrowth.
Individual cell functions become apparent at
different stages of the embryologic develop-
Figure 1.1 Embryonic development. A developing
ment. α-Fetoprotein, found in high amounts at
bile ductule is seen at the border of the portal tract
and parenchyma. The portal tract and sinusoids birth, initially is seen within the hepatocytes by
contain hematopoietic precursors (extramedullary one month gestation and continues throughout
hematopoiesis). fetal development, with high serum levels at
Gross Anatomy 3
birth. Fatty change (steatosis), glycogen and gly- liver is larger compared with adjacent thoracic
cogen synthesis become most apparent by two and abdominal viscera and constitutes about
to three months gestation, with the glycogen 5–6% of the body weight.
eventually diminishing due to rapid glycogenol- Anatomically, the liver has four lobes: right,
ysis. Hemosiderin is usually seen early on but left, caudate, and quadrate. The right lobe
gradually decreases, with some often occurring accounts for one-half to two-thirds of the total
in the periportal hepatocytes at birth. liver volume and is divided from the left lobe
by the falciform ligament on gross inspection;
however, functionally the right and left lobes
Gross Anatomy
are of about equal size and are divided by a line
extending from the inferior vena cava superiorly
The adult liver weighs from 1200 to 1800 g, to the middle of the gallbladder fossa inferiorly.
dependent on the overall body size, takes up A total of eight functional segments are present,
the majority of the right upper abdominal cavity each having its own vascular supply and biliary
beneath the rib cage, and extends from the right drainage: the right posterolateral (VI and VII),
lateral aspect of the abdomen 15–20 cm trans- right anterolateral (V and VIII), left anterior (IV),
versely toward the xiphoid process. Although left posterior (II and III), and the caudate lobe (I),
the weight of the adult liver constitutes about the latter being a watershed area of both the right
1.8–3.1% of the total body weight, at birth the and left lobes blood supply (Figure 1.2).
Right posterolateral Right anterolateral Left anterior Left posterior
Middle hepatic vein
Right hepatic vein
Left hepatic vein
II
VII
VIII
I
IV
III
Umbilical vein
(remnant)
VI
V Inferior vena cava
Hepatic artery
Portal vein
Hepatic duct
Figure 1.2 Schematic anatomical vascular arrangements of the liver. The liver is divided into eight functional
anatomical segments, each having its own vascular supply and biliary drainage: the right posterolateral (VI and VII),
right anterolateral (V and VIII), left anterior (IV), left posterior (II and III), and the caudate lobe (I). Source: Wanless IR.
Physioanatomic considerations. In: Schiff’s Diseases of the Liver, 11th edn. Oxford: Wiley Blackwell, 2012. Reproduced
with permission of John Wiley & Sons.
