2016 Annual Meeting

Secrets from the Consult Files: Great Liver Cases with Key Teaching Points

Room CC Ballroom 6 C - March 15 2016 - 7:30pm to 9:30pm

Moderators:
Michael Torbenson, MD and Rish Pai, MD, PhD
Panelists:
Taofic Mounajjed, MD, Matthew M. Yeh, MD, PhD, Cynthia D. Guy, MD, Maha Guindi, MD, Andrew Clouston, MD

Pre-Meeting Materials

Case 1

Faculty:
Taofic Mounajjed, MD

Clinical History:

A 68 year old man with no prior history of liver disease was found to have elevated liver biochemistries. The patient’s past medical history includes multiple myeloma, end stage renal disease, and congestive heart failure.

Pertinent Laboratory Data:

The patient's liver biochemistries are as follows: alkaline phosphatase: 304 U/L (normal: 45-115 U/L) and AST: 51 (normal: 8-48 U/L). ALT and bilirubin were normal. Viral hepatitis serology was negative.

Morphological Findings (click to enlarge):

Figure 1 H&E
Figure 2 PAS-D
Figure 3 Trichrome
Figure 4 Congo Red

Case 2

Faculty:
Matthew M. Yeh, MD, PhD,

Clinical History:

A 65 year-old man presents with a CT scan of the abdomen revealing a liver mass.

Morphological Findings (click to enlarge):

Figure 1 100x
Figure 2 200x
Figure 3 200x
Figure 4 200x
Figure 5 200x

Case 3

Faculty:
Cynthia D. Guy, MD

Clinical History:

Case history: This 67 year old Caucasian woman presented to her local emergency room with complaint of right upper quadrant abdominal pain. She underwent cholecystectomy. At the time of cholecystectomy, the liver looked nodular and a needle core biopsy was obtained.

Past medical history and physical examination: The patient has systemic hypertension and hyperlipidemia. Her height is 5’ 4”, her weight is 155 lbs and her BMI is 26. The patient denies alcohol consumption.

Pertinent Laboratory Data:

Laboratory values at presentation:
AST 75 (normal range 15-41 IU/L)
ALT 46 (normal range, 14-54 IU/L)
Alkaline phosphatase 118 (normal range 24-110 IU/L)
Total bilirubin 1.1 (normal range 0.4-1.5 mg/dL)
Conjugated bilirubin 0.6 (normal range 0.1-0.6 mg/dL)
Ceruloplasmin 21 (normal range 20-35 mg/dL)
Platelets 89 (normal range 150-450)
Anti-nuclear antibody (ANA) screen was positive
ANA titer 1:2560
Anti-smooth muscle antibody screen negative.
IgG level 1730 (normal range 588-1573 mg/dL)
IgM level 114 (normal range 57-237 mg/dL)
IgA level 457 (normal range 46-287 mg/dL)
Anti-mitochondrial antibody screen is negative

Morphological Findings (click to enlarge):

Figure 1 H&E
Figure 2 H&E
Figure 3 H&E
Figure 4 H&E
Figure 5 H&E
Figure 6 H&E
Figure 7 H&E
Figure 8 H&E
Figure 9 H&E
Figure 10 H&E
Figure 11 Trichrome
Figure 12 Trichrome
Figure 13 Trichrome

Case 4

Faculty:
Maha Guindi, MD

Clinical History:

47-year-old Caucasian male with a history of long standing ileal Crohn's disease. S/p small bowel resection in 1998 and ileocecal resection in 2006, on Mercaptopurine. Presented with low grade fever, LLQ abdominal pain, and fatigue. Labs showed acute liver injury,and lymphopenia. Hospitalized 7-14-2015 and given •piperacillin-tazobactam (ZOSYN) with continued fevers and uptrending of liver tests. Liver tests peaked on 07-17-2015. Doxycycline added. Mercaptopurine held.

Liver workup including hepatitis serology, CMV, and EBV PCR were unremarkable. CMV seropositive, IgM neg. MRCP found mild hepatosplenomegaly with no focal lesions or fatty infiltration, and normal intra and extrahepatic bile ducts. Abdominal CT did not show evidence of perforation or abscess. The patient underwent transjugular liver biopsy on 07-21-2015. There was no portal pressure gradient.

Pertinent Laboratory Data:

On admission 7-14-2015?: ALT 344, AST 234, ALP 247,and total bilirubin of 1.1.
Peak liver tests 07-17-2015: ALT 496, AST 293, ALP 379, BILIDIR 0.8.

Morphological Findings (click to enlarge):

Figure 1 H&E
Figure 2 H&E
Figure 3 H&E
Figure 4 H&E
Figure 5 H&E
Figure 6 H&E
Figure 7 H&E

Case 5

Faculty:
Andrew Clouston, MD

Clinical History:

The liver biopsy is from an 18 year old female who developed itch when she commenced taking the oral contraceptive pill. Her LFTs were elevated with a mixed picture – ALP 440 IU/L, GGT 759 IU/L, ALT 214 IU/L and AST 93 IU/L. On further questioning, her mother had a history of cholecystectomy in her teens. A liver biopsy was taken.

Morphological Findings (click to enlarge):

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6 Keratin 7
Figure 7 Keratin 7
Figure 8 Keratin 7

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