The ancient Greeks considered the liver to be the seat of the soul and source of courage. This view persisted for centuries, fascinating physicians, philosophers, and playwrights alike. References to the liver in Shakespeare's works highlight the perceived importance of this organ to one's strength of character. A pale or dysfunctional liver was thought to impart cowardice, and in Macbeth, Shakespeare uses the term lily-livered to insult a frightened servant. However, unlike Shakespeare and the ancient Greeks, not all modern pathologists are enamored of the liver, and some may even consider themselves lily-livered when confronted with hepatic biopsies. In this issue, we seek to demystify certain topics in medical and transplant liver pathology.
The issue begins with a comprehensive review of acquired cholestatic diseases of the liver, a broad and challenging group of disorders encompassing bile duct obstruction, primary biliary cholangitis, primary sclerosing cholangitis, and drug-induced liver injury. Dr Jessurun provides a thoughtful and practical approach to liver biopsy interpretation, separating the histologic patterns of cholestasis into 4 categories: (1) ductular reaction, (2) pure canalicular cholestasis, (3) cholestasis with intrahepatic bile duct disease, and (4) cholestatic hepatitis. The following 2 articles complement this review by discussing cases of cholestasis due to a rare genetic disorder or posttransplantation complication; De Michele et al present the first published report of neonatal intrahepatic cholestasis due to citrin deficiency in an American infant of Ashkenazi Jewish descent, whereas Dr Stashek presents a case of fibrosing cholestatic hepatitis and, in doing so, discusses the difficult differential diagnosis of hyperbilirubinemia following orthotopic liver transplantation.
Like hyperbilirubinemia, transaminitis is common in the posttransplant setting and raises a broad differential diagnosis, including disorders unique to transplant or immunocompromised patients as well as those that may affect the general population. The histologic findings in liver biopsy specimens performed for posttransplant transaminitis are often nonspecific. Dr Twaddell presents an interesting case of hepatitis E viral infection in a patient who underwent liver transplantation for cirrhosis due to hepatitis C virus, illustrating the importance of clinical and serologic correlation to avoid mistakenly attributing nonspecific findings to the underlying condition. Another pitfall of transplant hepatology is attributing end-stage liver disease to only 1 cause. Dr Twaddell's second article highlights this pitfall with a case of unexpected α1 antitrypsin deficiency in an explant performed for nonalcoholic steatohepatitis.
The issue continues with an excellent review of hepatic Budd-Chiari syndrome. Dr Pittman discusses the clinical, radiographic, and histologic features of both the acute and chronic forms of this disorder, using 2 cases to illustrate the variation in presentations. In the next article, Dr Weidner examines the morphologic classification and differential diagnosis of hepatic granulomas before focusing on the clinical and histologic manifestations of hepatic sarcoidosis. In the last article in the issue, Mounajjed et al report the findings, including vascular abnormalities, in a series of resected accessory hepatic lobes.
We have enjoyed compiling this issue and hope our readers will find these articles relevant and useful to their daily practice.© 2018 Lippincott Williams & Wilkins, Inc.