Preoperative Diagnosis

CHRONIC HEPATITIS C

 Postoperative Diagnosis:

CHRONIC HEPATITIS C

 Clinical History:

CHRONIC HEPATITIS C

 

 

 Specimen Received

	Right lobe of liver, NOS - ULTRASOUND GUIDED NEEDLE CORE BIOPSY

 

 

 Gross Examination

Submitted in formalin in a container labelled with the patient’s name only are three cores of soft reddish tan tissue, each measuring less than 0.5 mm in diameter.  They measure 2.0 mm, 4.0 mm, and 5.0 mm in length. They are wrapped and totally submitted in one cassette.  Trichrome and iron stains are obtained.

 

Dictated by: JOHN A WOLFE, MD

Entered: 01/06/06 - 1624 06RNORTON

 

FINAL DIAGNOSIS

RIGHT LOBE OF LIVER, NEEDLE CORE BIOPSIES:

:           CHRONIC HEPATITIS OF MILD ACTIVITY (GRADE 1) AND MILD PORTAL FIBROSIS (STAGE 1).

 

Comment

Examination of the biopsy material reveals hepatic parenchyma with overall intact lobular architecture.  Some reactive changes are noted and a few enlarged hepatocytes are noted.  The central vein areas are unremarkable and there is no evidence of congestion or areas of necrosis.  The portal areas are well defined and show benign bile ducts which show no evidence of inflammation.  The portal areas do show a mild increase in inflammatory cells consisting predominantly of activated lymphocytes.  There is no evidence of piecemeal necrosis.  The iron stain shows no hepatic parenchymal siderosis.  The trichrome stains shows mild portal fibrosis, but there is no periportal fibrosis or bridging fibrosis.

 

The control slides show the special stains to be working appropriately.

 

Grading of Chronic Hepatitis                                         Stage of Fibrosis

Grade		Portal/Periportal	Lobules	Stage		Degree of Fibrosis
	0	None or Mild	None		0	None
X	1	Portal Inflammation	Inflammation without necrosis	X	1	Minimal portal fibrosis
	2	Mild Periportal Inflammation	Focal or unicellular necrosis		2	Periportal fibrosis or portal-portal septa with intact architecture
	3	Moderate Periportal Inflammation	More extensive necrosis		3	Septal fibrosis with architectural distortion, no obvious cirrhosis
	4	Severe Periportal Inflammation	Necrosis includes bridging necrosis		4	Probable or definite cirrhosis

After Scheuer PJ: Classification of chronic viral hepatitis, A need for reassessment. J Hepatol 13:372-374,1991

 

Entered: 01/09/06 - 0722 06KSATTER

 

 

Signed: RICHARD R WILBER, MD 01/09/06                  

Original report read and signed