Can you drink alcohol while taking pure garcinia cambogia
If anyone gets hold of accurate studies supporting the above claim about Garcinia, please feel free to send me the link.
Alex Soft Releases Garcinia Cambogia Games
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From Flab to Fab With Weight Loss Pills
Who doesn’t want to look fab? You’d be able to wear whatever you want and still look damn fabulous. It is not that easy, though, unless you are skinny and fit, which happens to be just a small fraction of the population these days. Obesity is a growing concern and it is not just a medical issue but a psychological problem too as it brings with it various concerns on self-image, insecurity, and even self-harm. A body full of flab isn’t attractive. If you are using weight loss pills- be sure to study what it is inside them. Let us all acknowledge the obvious. However, we should not demean another person because of the way they look because not all the time it is of their own doing.
Being fat may be the result of poor lifestyle choices or utter laziness. The majority live a sedentary lifestyle and rarely go out anymore to exercise. We are so obsessed with tech gadgets that all we do all day is to lie down in bed and tinker with our smart gadgets or sit down on the couch and watch TV all day when we have nothing better to do. It slows down our metabolism and makes us more prone to gaining weight and staying fat. Even though we know this, we still don’t do something about it despite it being the cause of obesity that many of you are all complaining about. Being fat may also be a medical issue such as hormones running wild, which you have little control over and needs medical intervention.
Diet pills are a great way to get this off to a great start for yourself.
You don’t get fat overnight. Sure, you gain a pound or two and feel that your body suddenly expanded a little but it won’t leave a permanent damage. You get fat because of unhealthy habits that cause you to stay bloated forever, unless you do something about it. Regularly eating fastfood, junks, processed foods, sugary beverages and soda daily among others are just a few of the reasons you get fat and stay fat. It takes an iron will to resist temptation and resist your cravings. It is not an easy feat, which is why many people give up early on and just accept their fate of being overweight and obese than just constantly see their efforts go down the drain and start from scratch over and over again.
Most fitness supplements are great for this purpose.
What they fail to realize is that getting fit and weight loss can’t be achieved in a day or two, similar to how you don’t easily put on weight after just one eating binge. It is making those same mistakes over and over again just like procrastinators do. If you want to shed all your excess fats and start sporting a slimmer and healthier figure, you need to be up for the challenge and commit yourself to weight loss no matter what the odds are. The first obstacles you will likely face is your own self-doubt. You will doubt the efforts you are putting in and your own capability to commit to your goals. But once you do believe in yourself, know that nothing is impossible and you can achieve whatever you have set your mind and heart into.
Weight loss pills can be used for many different things.
http://thetopweightlosspills.com.au is a great place to tons of diet supplement reviews and info on related topics.
There are weight loss success stories you’d come across social media from time to time. The common denominator among them is that they usually had to make the ultimate decision of losing weight in the face of a life or health crisis. They usually decide to take charge of their lives again and looking fab from flabby is just a bonus. You have to commit to daily exercise routines. You don’t just exercise today and skip tomorrow because you just do not feel like it. Discipline is the key. You need to force yourself to commit to your goals regardless of how you feel that day. Put your emotions aside and visualize yourself 10, 20, 30, 40, 50, 60 pounds lighter. Imagine how lighter and healthier you will feel in your ideal weight. That should be inspiration enough.
A lot of diet pills simply are too expensive for the average person to afford.
Remember that it is not all about physical appearance. Some try to lose weight because of health reasons. Overweight and obese individuals are at higher risk f developing chronic, deadly and debilitating conditions like heart disease, stroke, diabetes, and many others. You don’t want to shorten your lifespan just because you are too lazy to move around and eat right. Don’t forget that while exercise is a big factor when it comes to weight loss, the food and amount of food you eat weighs just as much. After all, you are what you eat and it’s not just a cliché but a sad reality of life.
If you try to live healthy, you’ll soon notice that your appearance improves. So, let that be your focus. Do not obsess over weight loss because you’ll just get frustrated that you are not seeing the results you wanted fast enough. Invest in healthy habits because that will not only help you lose weight but even save your life. Try to transform your life by changing your life perspectives and behavior. If you adopt healthy eating habits and an active lifestyle, it will become second nature to you and you won’t have to exert that much effort the next time around. Little by little, you gradually stray away from your bad habits and are taking baby steps to the best version you can ever be. You’ll soon realize that you look and feel differently sooner rather than later. The importance of supplements and pills is increasingly becoming a priority all over the world. And the best thing about getting fit, you not only achieve your goals of dropping the excess pounds but turn your life around too. It’s all about being healthy. When you are healthy, you look and feel healthy. You may still be several pounds off the weighing scale but it won’t bother you nor mess with your confidence or self-image because you know better now.
Comparing Green Coffee Bean Extract With Garcinia Cambogia
If you look around you now, it is common to see overweight and obese people. In fact, their population is growing by the months and years that pass by. And it is not surprising at all considering how much fast food many of us eat on a daily basis. These people have proven, without a doubt, that you are what you eat. So, what do they usually do once they get wind of the problem? They go crash diet. Well, it works for a while but you do not really see long-term results, nor is it a solution in the first place. You only mess up with your digestion consequently making you crave and eat more than usual.
Green Coffee is a great way to get started.
These fad diets promise the world to you. But you soon realize that none of these so-called crash diets have helped you at all. Fad diets claim to work and promote weight loss when you avoid eating several types of food or strictly reduce your daily food intake. This is why Garcinia Cambogia is so popular. They probably have even made your problem worse because you starved yourself for a while and now your body is asking for more food to compensate. Everyone who tried any crash diet will likely agree that it is hard to follow no matter what type of fad diet you have decided to try. You may be able to see a little weight loss at first but it is only temporary. People also lose interest soon enough, making them regain any lost weight or gain even more after.
Many outlets have done research comparing Green Coffee vs. Garcinia Cambogia– which both have similar properties for weight loss.
These extracts are absolutely amazing in so many ways.
Garcinia Cambogia is even better than the other ones.
What you need are long-term solutions that you have been trying to ignore all along such as eating right and taking doctor-approved weight loss supplements. The experts suggest a healthy weight loss of ½ to 2 pounds weekly through improved nutrition and more active physical activity. Small frequent meals are better than three big ones daily. Add to that the beauty and value of exercise and you can very well see a new you in no time. Not only can these health habits help you lose weight, they also improve your over-all health and help build up healthy habits that reduces your risk of having Diabetes, high blood pressure, or heart disease. These silent killers attributes to the high mortality rate among the obese population. Phentermine and Garcinia Cambogia are great diet pills you can use for this as well.
Reducing your daily caloric intake is also a good practice to promoting weight loss. Your body can only burn so much throughout the day and anything that is in excess will likely end up as stored fats. Your body needs stored fats, though, in cases of emergency that serves as extra fuel to help you survive difficult situations. However, metabolism slows down as you age, which makes it harder for your body to burn what you eat. By restricting calories to just what your body needs to last you an entire day, you no longer store excess fats which is exactly what you need. So, make the ultimate sacrifice of cutting back on food and resist temptation if you have weight issues.
If you crash diet, you may be able to see sudden weight loss. That is true because you would likely limit or remove carbohydrates in your diet since it is one of the root causes of weight gain. But the problem is that weight loss is just temporary, as mentioned earlier. Starving yourself is never a good solution too because your body will have a hard time coping with such a drastic measure. You will start craving for food because your body does not have the energy it needs to fuel important daily biologic processes. We have been using Garcinia Cambogia for quite some time with good results.
How can you lose weight safely and effectively then? The answer is plain and simple. Change the way you live and the way you eat. But many people find it hard to stick to this lifestyle change because results take too long to be seen that many gets discouraged and go back to their old ways before they even achieve the results they want. Hence, take a weight loss supplement to boost your weight loss effects. Different diet pills have different effects. Some can burn fats while others suppress the appetite. Others work better and provide multiple effects but may be priced a little higher than regular weight loss pills. It won’t hurt if you take one because most diet pills are made using natural ingredients that have been found to lead to weight loss. You can avoid bothersome side effects when you take the right dose and take it properly. These annoying side effects are usually the most common complaints among diet pill users.
If you want to make the most of a diet pill’s weight loss properties, always consult your doctor first so he/she can prescribe you the one best suited for your needs and your body. Aside from that, you can be properly assessed and have everything taken into consideration before suggesting any brand in particular. After all, it is better to be safe than to be sorry. These weight loss pills are sure to work if that is what you are trying to do.
Your excess weight may be a constant cause of stress and worry but never ever try anything that can put your health and your life at risk. It all starts with yourself and your will to turn your life around. Learn to love your body and take good care of it because no one else will do it for you. If you need a little nudge – like a diet pill perhaps – do not be afraid to acknowledge it too and act on it because that’s when you can make things happen.
A Weight Loss Pill With Success Stores(Full Guide On Meridia)
Weight loss has never been so fast and easy.
No matter how much we try to deny it, or ignore, we can’t help but be drawn to people who fit the perfect image. It means that they look cool, cool enough to strut the latest fashion trends without being bothered by jiggly fats and annoying bulges. Unfortunately, not all of us are blessed with the metabolism of our youth, right when puberty just hit us and our metabolism is up to par with our raging hormones. This is a great way to get started with meridia. Imagine that, those were the days. Sadly, gravity sets in and everything goes down. There goes your life as well, especially your social life. It is such a shame that people get bullied and ridiculed because they are fat. We don’t want to be labeled as discriminatory but deep down inside, we often pass judgment to the next person just because he or she is overweight or obese. There’s little we can do about these people, it takes a whole lot more initiative to change an entire society’s mindset. But there is something we can do with our weight. It does not have to be purely for aesthetic reasons, but for a healthy and long quality life in the years to come.
Consult your doctor first and tell him about your plans of supplementing your weight loss regimen with such a drug. If he tells you it is okay, go ahead and start transforming your body and your life right before your very eyes. But before that, you need to be wary of the following considerations:
• Stay away from the drug if you are taking or have taken a MAO inhibitor or if you are allergic to its component, sibutramine.
• Inform your doctor about these conditions:
o high blood pressure
o kidney or liver disease
o underactive thyroid
o history of gallstones
o bleeding disorder
o 16 years old or younger and 65 years old or older
• Inform your doctor about other drugs you are taking like cold or allergy drugs, antidepressants, or painkillers.
• Tell your doctor if the drug was not effective because you fail to lose the minimum four pounds since you started taking the drug or 4-weeks into the added supplementation. These are great diet supplements.
Aside from taking MAO inhibitors, the following conditions also rule out any chances of you ever being allowed to take this drug:
• High blood pressure
• History of coronary artery disease
• An eating disorder
• History of stroke or heart attack
• Taking stimulant diet supplements
• Pregnant or lactating
If you are wondering how to start taking Meridia, of course, seek your doctor first. With his go signal, take it orally once a day.
Why This Weight Loss Pill Is So Effective
And you can take it regardless if you have eaten something or not. It is expected to lose around four pounds during the first month. If you didn’t lose at least that weight, it is best to have a little talk with your doctor once more. Make it a point that you get to have your pulse and blood pressure checked regularly too. You can only continuously take Meridia for two years, not any longer than that. When storing, ensure that you put it somewhere away from heat, light and moisture. This little weight loss pill has been gaining fame precisely for that reason- it helps people slim down(plain and simple). In case you miss a dose, take it at once. But if it is almost time for the next dose, just skip the previous dose. Never take another dose to make up for the one you have missed.
Things to Avoid
• Do not drive or operate machineries.
• Avoid other similar weight loss pills.
• Refrain from taking any cold, cough or allergy drugs.
• Stay away from alcohol all the time.
Remember that the following are the common side effects you’ll experience while you are on Meridia:
• Upset stomach and dry mouth
• Stomach pain and constipation
• Changes in appetite
• Headache, joint pain, and back pain
• Flu symptoms like sore throat, stuffy or runny nose, and cough
• Feeling depressed, dizzy or nervous
• Redness, warmth or a tingly feeling underneath your skin
• Sleeping issues (insomnia)
But if you experience the following more serious side effects, be ready to seek emergency medical assistance such as these signs of an allergy: difficulty in breathing, hives, and swelling of the face, lips, throat or tongue.
• shortness of breath
• fast, uneven or pounding heartbeats
• hallucinations, agitations, tremor, fever, nausea, vomiting, overactive reflexes, loss of coordination, diarrhea, and dilated pupils
• rigid muscles, sweating, high fever, confusion, andfainting
• easy bruising and nosebleeds
• high blood pressure
• sudden numbness or weakness
• chest pain or a heavy feeling on your chest radiating to your shoulder or arms
Like any other drug, Meridia has its pros and cons. You can only tell if it is safe for you after consulting with your doctor. If it is okay for you to take it, then good for you. Losing weight will no longer be that impossible feat that seems to elude you for as long as you can remember.
Are Weight Loss Pills The Answer To Real Obesity? Read This To Find out…
Weight issues are common among people who loves to eat. After all, your body does not need all that food to fuel your daily body functions. What happens is that they end up as stored fats. And once it does, it won’t be that easy to lose them off common problem areas such as your arms, belly, and thighs.
These are the best diet pills you will find.
Among the famous diet supplements out in the market today, Garcinia Cambogia is the most promising one when it comes to getting rid of stubborn fats and achieving a slimmer physique. Reducing your appetite is pretty simple when you know how to do it. That is why we are choosing people like you to participate in this.
If you actually needdiet pills in Canada, make sure you are reading into their contents to see what they contain for ingredients.
This miracle diet pill is well-known for its dual fat action buster properties as well as its ability to curb your appetite. You no longer have to rely on food to make you feel better, or depend on sugar and simple carbohydrates to instantly provide you with an energy boost. Garcinia Cambogia is rich in hydroxycitric acid or HCA. It is related to the citric acid found in lemons and oranges. HCA is a potent fat buster and appetite suppressor. It burns fats by blocking Citrate Lyase, the enzyme responsible in making and storing fats. Also, it puts a break on your desire to eat by increasing serotonin levels, otherwise known as the body’s happy hormone. Emotional eaters can greatly benefit from this effect since they no longer have to eat to cope with the various life stresses they face each day. Moreover, it increases a person’s satiety level, making them feel full earlier so they no longer fall to the pitfalls of overeating.
Weight loss pills have always been popular.
People struggling with their weight understands all the difficulties associated with weight loss. But if there’s something that promises to aid their weight loss journey by making things easier for them and helping them reach their goal faster, that’s no other supplement than the pure Garcina Cambogia extract. Garcinia Cambogia have millions of satisfied users over the years, and promises of more in the years to come, more slimmer bellies, more happy people, more leaner arms and thighs, more active lifestyle, and more lives changed by this amazing pill.
This Weight Loss Pill Supports your Passion for Fashion
We all want to look good, if possible, all the time. That means you need to have a killer bod along with some really fashionable clothes. However, just getting that jaw-dropping figure is a major feat on its own, add to that the fact that most trendy clothes nowadays are geared toward the slim and fit population. I mean, just look at those mannequins. They’re actually quite intimidating. And only a handful of shops and brands carry a plus-size selection. And if they do, the options aren’t that promising.
So, if you want to lose inches off your belly or maintain that slim figure, take Garcinia Cambogia. Garcinia Cambogia happens to be the ‘holy grail’ of weight loss, if that’s not enough to make you do a double-take on this supplement. Simply popping the Garcinia Cambogia pill can do wonders on your body, even let you wear clothes you never thought you could now fit in. It is a bit vain if you look at it without understanding the effect of weight loss in a person. In reality, it actually boosts your morale and confidence in yourself. No matter how much we try to deny it, outside appearance does matter when it comes to socializing with others, getting jobs or promotions, meeting new friends, and generally feeling good about yourself among others.
Weight loss pills like that are great for health.
You just can’t imagine how bad a person feels when they are constantly being ridiculed for their weight and other ugly features exacerbated by their heavy frame. With the help of Garcinia Cambogia, you literally transform your life by physically transforming your body. You now get to wear all the fashionable pieces of clothing you’ve been dying to try for so long. And best of all, you not only became healthier but feel better too. You don’t need to be a rocket scientist to know how powerful the Garcinia Cambogia supplement is. It is evident with everybody who gave it a try and are now sporting a new and undoubtedly cool look from now on.
Why Garcinia Cambogia Is Now Going To Facebook
We always had the notion that whatever is being shown on TV is legitimate and lives up to its name. In short, that specific move to feature and endorse Garcinia had its place securely planted on people’s mind. It also gave people who are battling with weight issues another option to address their problem. This product may just be what they are looking for. Maybe it really work, famous personalities will not stick their head out for it if they were not convinced of its potential. They have presented studies and clinical trials that Garcinia Cambogia has been through as proof of its claim. TV has made it possible for people to know about this great product.
This is always true regardless of what you may have been told.
Why Pure Garcinia Cambogia Is Great For Health
What would you say if somebody told you that you could lose all the excessive weight in a couple of weeks just by doing three easy steps? Maybe it’s hard to believe, but it’s not impossible!
The first step would be to buy one of the Nato Garcinia Cambogia supplements. Garcinia Cambogia is the main ingredient of many pills and powders, and its main function is to prevent your body from producing so much fat. It also has the added benefit of making you less hungry on an everyday basis. The second step would be to eliminate all the sugars and starches. You want be able to continue doing this, since it would be very hard on your body, but that’s why we’re talking short-term weight-loss measures. Sugars and starches are the food that stimulates the secretion of insulin in your body.
When you lower your levels of insulin, you make it easier for the fat to leave your system. Along with taking Garcinia Cambogia extract, this should significantly improve the way you lose weight. Lowering insulin has another benefit – it will reduce the amount of water your body retains, and by doing that, eliminate the excess of weight that’s caused by it. The third step of this programme would be to eat more vegetables, protein and fat. You should include at least one protein source in your every meal, as well as a portion of vegetables that are low on carbs, such as broccoli, spinach, cauliflower, kale, cabbage and cucumber. Always make sure the Nato Training Mission is remembered when you are doing this.
The second and the third step will make you lose a significant amount of weight, but Garcinia Cambogia will help you maintain the new number. That’s why it’s important to combine them. By doing all three of them, you should transform into a much thinner person in a matter of weeks. Where To Buy Garcinia Cambogia In South Africa (New Choices). In South Africa, Garcinia Cambogia is very well known by its effectiveness as a dietary supplement. The pumpkin-shaped fruit is native to rain forests of Asia and Africa. It has been used to prepare curries and as a souring ingredient, as well as a natural digestive. As you might’ve supposed, those are not the reasons for its being so popular across the globe. Buying Garcinia Cambogia is a great way to get started.
Purchasing it may be tough for those who are uninformed. Be sure to read up on where to buy Garcinia Cambogia if you want to have the best choices. Hydroxycitric acid, or HCA is the main active ingredient, as well as the main reason for Garcinia Cambogia’s reputation as a weight-loss miracle. It’s a substance whose effect on the human body is twofold. The most important function of HCA is the blocking of another substance called citrate lyase. By blocking the thing that makes it possible for your body to turn carbs into fat, HCA prevents you from storing it. That’s why they say that this supplement will make you lose so much weight.
The second effect that HCA has on your body is the suppressing of the appetite. Find more diet tips at garciniacambogiapure.ca. By increasing the levels of serotonin in your brain, HCA makes you happier and less prone to emotional eating. The two functions put together make Garcinia Cambogia an almost miraculous dietary supplement that could make all your dreams come true, without harming you in any way. Unfortunately, the claims that the supplement has no side effects are simply not true. Various symptoms related to it have been reported. The list includes the following: nausea, diarrhoea, fatty stool, restlessness, headache and rash. Most reported side effects are harmless, although there have been exceptions, such as documented hospitalizations because of liver toxicity.
The most effective garcinia cambogia routines
We always tend to dream big. And we also apply it when we make goals when we are trying to lose weight. But it does not work that way. Anyone who is fat or has been fat knows how hard it is to lose weight. And one of the biggest mistakes an obese person can ever do to sabotage his weight loss attempts is to do everything all at once and expect a miracle to happen overnight. Setting a high expectation on yourself can put a lot of unintended pressure and eventually wear you out.
Among the most effective techniques for getting in shape is to reduce weight securely. Losing a lot of pounds is simple and can be quite rewarding. This has been the verdict of many physicians that examine this topic of diet plan professionally. The reason you must make use of risk-free methods is straightforward. Weight loss pills are essential. Unsafe diet regimen drugs need to be stayed away from and they are not the best types of conditions for the ordinary person. If you believe you can do these things well, you must most definitely check out the most recent diet supplements on the market. These are called weight loss pills.
That is why so many are flocking in droves to garciniacambogia.org.nz.
The cravings decrease approaches they have are very powerful. They additionally induce the metabolic process and raise it to make sure that your body burns fat deposits and gets rid of excess calories.
This is a vital part of lessening the poisons in your body and burning excess fat deposits. If you are thinking about slimming down today, you should acquire a container of these diet plan nutritional supplements so you could obtain your objectives promptly. You do not wish to stand by up until it is far too late. Working out often could help you get a truly fantastic body. Nevertheless, this is usually something that most people are too lazy to do. You wish to be sure you are doing everything in your power to burn fat securely and not need to make use of bad supplements that are dangerous to your physical body. The obestiy epidemic is at http://www.cdc.gov/cdctv/diseaseandconditions/lifestyle/obesity-epidemic.html.
Garcinia Cambogia, a plant that is included in the herbal state is a flowering plant that remains green throughout the year. Although it is native to South East Asia, central and west Africa and India, it is used in almost all the corners of the world for various purposes. The extract from the fruit of this plant is renowned worldwide for its numerous health benefits. In some parts of the world, the fruit of this plant is used in the preparation of curries. Many people across the world today are either using this product or considering using it to lose weight in a healthy way.
Our South African Garcinia Cambogia Supplier Is Fully Stocked
The average person does not take the recommended 10,000 steps per day. The average person does NOT have the time to hit the gym up 5 days a week. The average person does not have time to fuss with food. They have to eat on the run because they are constantly on the run. In a perfect world we all would be able to slow down and spend more time taking steps, hitting up the gym and pondering our food choices.
Since the 1960s when Garcinia Cambogia’s weight loss properties were discovered, it has never left the mainstream market and continues to have a cult following among the weight loss obsessed.
It is not a perfect world.
Here is our favorite site for getting pure Garcinia Cambogia extract.
So what do you do when you have packed on the pounds and need to rid yourself of them? Well you take the one thing that will speed things up for you to keep up with your busy lifestyle. Garcinia Cambogia is the one thing that has been proven to help peel away the pounds and that will fit in with your hectic lifestyle.Garcinia Cambogia is an easy to take supplement that is available in pill form that will help to keep your appetite down and your metabolism up. In this fast paced we need fast paced weight loss methods and this method is an all natural method straight from nature! There is no way to go wrong with this option. You do not have to starve yourself and drink your meals. You do not have to pay the high cost of replacement meals or specialized meals.
Garcinia Cambogia is affordable and available. It is an easy solution to your dieting needs. If your in a hurry and you need an easy solution. GC is a quick weight loss method that can fit in nicely with your busy lifestyle. You do not have to worry about taking those ten thousand steps or trying to make it to the gym everyday. You have your answer. Losing weight is no picnic. It is difficult and stressful. Stress is one of the worst things for weight control. Stress is known to pile on the pounds especially around your belly area. It really is a vicious circle of events. You are stressed about your weight and then the stress causes you to gain weight. Breaking the cycle is the only way to lose the weight. Garcinia Cambogia can be the one thing that can help you to break the cycle. Why? This wonderful compound can take the stress out of dieting. When you know that you are taking a pill that has been proven time and time again in clinical trials to help people lose weight it takes the stress out of losing weight. Most people worry about dieting. They worry about the food that they are eating. They have to deal with the guilt of the slip ups when they eat something they should not.
GC will help you to avoid the slip ups because it is a potent appetite control method. Garcinia Cambogia also helps to improve the way your body burns fat.
It’s meant to educate you about one central concept: The effectiveness of Garcinia cambogia depends entirely on how you take it.
Once you know that you are taking aproven supplement it takes the worry and stress right out of dieting. Garcinia Cambogia is the key to successful dieting. Get rid of the stress and get rid of the belly fat! Get rid of the stress and slim down. Get rid of the stress by taking a proven winner in the battle against extra pounds! When you are done with “go nowhere diets” and done with the guilt of not being able to take offthe weight you will be able to recognize the true value in this all natural weight loss measure. Give yourself a break and add this supplement to your dieting arsenal.
Australia Now Has The Best Version of Garcinia Cambogia
It is a small fruit of tropical origin that can be described as resembling a smaller pumpkin. The color of the fruit varies depending on the area and the stage of growth, but it is mostly green and yellow. It is used in both traditional medicine and cuisine because it is tasty and healthy. It can be prepared in many ways, but the most common one includes mixing it into curry paste.
The fruit has been discovered by us Westerners not so long ago. Most of us know it for the beneficial effect that it has on the process of losing weight. Although these claims have not yet been proven, GC is allegedly a fruit that has such an effect that it prevents you from gaining weight. As an ingredient of many dietary supplements, it serves two main purposes. Its active ingredient blocks a substance that causes you to stop accumulating weight in your body.
This is the function that most people know of, and also one of the biggest reasons why it is so popular. The second most important function is preventing you from regaining the weight you already lost. Many people recommend using these products, but there are differences depending on the manufacturer. Some put a lot less HCA in their products, causing them to be less effective in the weight loss process.
When deciding which of the products you should buy, always refer to the ingredient list and check the percentage of HCA it contains. That should help you make the right choice. Here is our best version of Garcinia Cambogia. If you are looking for the best way to lose weight, look no further. You will find that the solution is a quite simple mix of the already existing ones. The thing about weight loss is that it inevitably implies a healthy lifestyle.
Like with so many other things, you cannot get permanent results without committing to your goals. This is why you will need to start exercising, eating healthier and living happier if you seriously want to get rid of all that fat that has been accumulating on your hips, waist, thighs, arms and legs. You could, of course, try to let the supplements do all your dirty work.
Taking Garcinia Cambogia pills to magically lose weight sounds amazing, but it just won’t work, and you know it. If you are one of those people who believe everything that is being said on TV, then you might even think that Garcinia Cambogia is really that great. On the other hand, if you have some common sense, you will know that life just isn’t that perfect. Nothing, not even Garcinia Cambogia, can solve your problems that easily.
If you just try to make some positive changes in your lifestyle, you will eventually see the difference. Introducing a regular exercise regime is a significant factor in the weight loss process. Working out on a regular basis will help you lose weight, reduce your stress levels and maintain a good figure. The most important factor of them all is healthy eating. It involves resisting your cravings, even when it is really tough to do so.
This takes a lot of effort and strong willpower, but you shouldn’t get discouraged because it is far from being impossible. Unlike taking supplements like GC, the combination of a healthy diet and exercise will make you thinner and happier. Having a bunch of obligations, a full life and a great figure often seems like an impossible mission. However, like with many other things that are a big part of your life, this issue can be resolved by taking a shortcut.
Not Losing Weight Eating Low Carb?
If you have been eating low carb but you’re not losing weight, or not experiencing the success you expected, you’ll want to read this.
This topic arose out of several discussions in the low carb group.
There are quite a few people struggling, and through those conversations I’ve narrowed it down to four possible culprits that may be causing your weight loss stall (or EEK!! – weight gain). This may just be the one thing you read that turns everything around for you, starting today! 😀
4 Reasons You May Not Be Losing Weight Eating Low Carb
I encourage you to read all four points and everything on this page, start to end, as there may be more than one issue causing your stall – or your personal frustration with the low carb diet…
1. Are You Tracking Your Carbs & Fat/Protein Ratios Properly?
First, make sure you are tracking your meals properly. I highly recommend you use MyFitnessPal with this Net Carb Hack. It’s very easy to set up, and so many people who were struggling found it VERY eye opening (myself included!).
If you’re just “eyeballing it” or writing down your carbs on paper, you’re not getting the whole picture. It’s VERY easy for carbs to creep up on you or into your diet.
Everyone I know that started tracking was shocked at what they thought was accurate vs what they discovered via tracking. 😉
Tracking is GREAT for personal accountability. It forces you to be more conscious of every single thing you put in your mouth. It’s also a great way to keep up with your weight loss progress, track your fat & protein ratios, and keep an eye on your calories.
Potential culprits include: carb creep, eating too much protein, not eating enough healthy fats (eating too lean), not eating enough (calories too low), or perhaps needing to lower your calories. We don’t usually watch calories on a low carb diet, it doesn’t hurt to keep an eye on your overall stats when you’re trying to determine what may be affecting your weight loss.
The most common culprit though is your fat/protein ratio…
There is a science to the way a low carb diet works, and healthy fats are critical. When you eat super low carb, you go into ketosis where your body burns fat for energy instead of carbs/sugar. If you eat too lean, your weight loss WILL STALL as your body won’t know what to burn for energy.
* Your goal is 20 net carbs per day (max), with at least 70% of your daily calories coming from healthy fats.
2. Your Body Is Adjusting. Don’t Do Anything Drastic!
When you first start eating low carb, or get back on track, you generally experience great weight loss in the first week or two. It’s very common to experience a brief “hold”, or even slight fluctuations on the scale, after this initial weight loss.
THIS IS TOTALLY NORMAL. It’s your body adjusting.
This “stall” usually happens during week two or week three. Unfortunately this is when most people sabotage their diet. You might get discouraged after a few days of not seeing the scales move, and decide “screw it” and just eat whatever you want.
Or you might try something drastic like lowering your calories, doing an egg fast, etc to try to get the scales moving again. That is NOT recommended…
Instead, wait it out! Keep doing what was obviously working the first week or two when you were losing weight easily. 😉
3. Common Culprits That Stall Weight Loss
Common “stall” culprits include: cheese, cream cheese, artificial sweeteners, sugar free & processed foods, bars & shakes, and complicated recipes. When you are tracking closely it’s easy to look back over your daily journals and see what you may be doing differently that could be causing your weight loss progress to stall.
Note: Cheese is low carb, but you should only eat 4 ounces a day max.
My advice: go back to simple, whole foods. Stick to meat & greens with plenty of healthy fats. Make healthy “real food” choices. Here’s an example of a simple low carb dinner. Pecan halves make a great snack, and they are easy to grab ‘n go. 1/3 cup of pecans is a great replacement for a bar or shake. See: 3IMAX
You should be getting 12-15 net carbs a day in low carb vegetables.
If you are making complex multi-ingredient recipes, make sure you are tracking every single ingredient AND portions/servings. You can do this easily using the Recipe Calculator in MyFitnessPal.
4. Don’t Compare Your Weight Loss To Other People’s Results
Don’t compare yourself to others. This is a surefire way to get yourself discouraged! People who have more weight to lose will lose faster than someone who doesn’t. For example, someone that needs to lose 200 pounds may lose 20 pounds the first month, where someone who needs to lose 20 pounds may lose 4 pounds the first month.
Those last 20-40 pounds are the hardest to lose, by the way! 😛
There are many other variables at play too, such as how big a lifestyle change it was for one person over another. Let’s say one person quit drinking sodas when they started the low carb diet. They will lose a lot of weight upfront, compared to someone that didn’t drink soda at all to begin with.
Men lose weight faster than women. Younger people lose weight faster. First-time low-carbers lose weight faster. Yo-Yo Dieters will lose weight slower in the beginning.
Your body and lifestyle are unique to you, and your weight loss journey is yours. Variables include age, medications, health issues, lifestyle, stress levels, etc.
Focus On Making A Healthy Lifestyle Change
Scale fluctuations and brief “stalls” are totally normal on your weight loss journey. The key is to eat healthy not just for “instant gratification” (ie, fast weight loss) but also as a means of reaping ALL of the health benefits of a healthy low carb / ketogenic diet.
This includes your heart health, controlling diabetes, reducing or eliminating arthritis and fibromyalgia symptoms, controlling your blood sugar, etc.
Keep your goal in mind, and commit to a healthy lifestyle change that will naturally take the weight off your body over time.
You may lose inches even when the scales say you’re not losing pounds.
You should measure yourself and track your progress in both inches AND pounds. There have been amazing stories from people that lost several sizes and many inches – without seeing a noticeable difference on the scale. Crazy but true!
Are You Weighing Yourself Properly?
Your weight will fluctuate five pounds or more throughout a single day. You should always weigh yourself at the same time of day, on the same scales, wearing the same amount of clothes (or none). The ideal time to weigh yourself is first thing in the morning after you pee. This is the only way to get an accurate reading.
(This is why you always weigh more at the doctor’s office. 😉 )
They now include a FREE EatSmart Body Tape Measure with their scale:
I absolutely LOVE my EatSmart Digital Scale! 😀
If you already have a great scale, make sure you also have a way to measure. I already had the Eatsmart scale before they started including a free body tape measure so I just ordered the Fit & Fresh Body Tape Measure, Locking Pin and Push-Button Retraction from Amazon this week myself.
It’s inexpensive, and an easy way to take your own body measurements (without needing an extra hand to hold the tape or look at the numbers!).
Tracking your foods, drinks, pounds lost AND inches lost in MFP is a great way to keep close track of your overall weight loss journey. You’ll feel GREAT seeing the progress you’re making, and being IN TOTAL CONTROL of your health!
Spend your 20 net carbs each day VERY wisely. Consider what will have the highest nutritional value or be the healthiest food choices. 😉
I hope this helps you tweak your low carb diet to see better success.
If you have any questions, or want to share your personal experience on some of these points, leave a comment! I would love to hear from you. 😀
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Human Pathology Digital Image Gallery
CONJUGATED BILIRUBIN: Bilirubin that has been conjugated to glucuronic acid, making it water-soluble
CONFLUENT-LYTIC NECROSIS: Death of clusters of hepatocytes (* attributed in the current literature to humoral immunity)
COUNCILMAN (ACIDOPHIL) BODY: Single-cell necrosis (apoptosis) of a hepatocyte, typically in hepatitis as a result of attack by a T-killer cell.
* CYTOPLASMIC DISSOCIATION means edema at the edges of a hepatocyte, granular cytoplasm around its nucleus. The cell is injured.
FOCAL NECROSIS: Death of individual cells, evidenced either by Councilman bodies or lytic necrosis (i.e., collapse seen on reticulin stain). Inside the lobule, it's "focal lobular necrosis", as in smoldering hepatitis from any cause.
* FEATHERY DEGENERATION: A pattern seen when a liver cell retains both bile salts and water. Ask a physical chemist how the detergent effect of bile salts causes it. When the bile actually digests a group of liver cells, it's called a BILE INFARCT (misnomer, of course). Leave recognizing these to us.
GIANT MITOCHONDRIA (megamitochondria): Monsters seen in hepatocytes in alcoholism (sometimes NASH). They are d-PAS negative (lets you distinguish them from alpha-1 antitrypsin). See J. Clin. Path. 45: 412, 1992.
* "Yokoo bodies." These mitochondria may have suffered a characteristic loss of DNA due to alcohol-induced free-oxygen-radical damage or something; the deletion makes it harder for the liver cell to burn fat, and so forth (Gastroent. 108: 193, 1995.)
GROUND GLASS HEPATOCYTES: Distinctive hepatocytes seen in chronic (not acute) hepatitis B infection. The "ground glass" cytoplasm is an unusual accumulation of a cytokeratin (Hepatology 28: 347, 1998).
HEPATOCELLULAR JAUNDICE: Jaundice due primarily to failure of hepatocytes to properly take up / conjugate bilirubin.
HEMOLYTIC JAUNDICE: Jaundice due to excessive destruction of red cells or their precursors at any site
* HELLP SYNDROME: Hemolysis, elevated liver enzymes, low platelets. A poorly-understood and very serious complication of pregnancy. Seizure and hypertension management, glucocorticoids, and/or exchange transfusions may be required. More about this later.
INTERFACE HEPATITIS: Necrosis of groups of hepatocytes within the limiting plate. The term has replaced "piecemeal necrosis", to prevent confusion with focal necrosis deeper within the lobule. Often the only evidence of "necrosis" that you see is a little area with collapsed architecture (reticulin stain shows the collapse); if you're lucky, you may spot a Councilman body.
INTERLOBULAR BILE DUCT: The big bile duct in the portal tract. It runs with the branch of the hepatic artery.
JAUNDICE: Too much bilirubin (conjugated or not) in the bloodstream, for any reason
LIMITING PLATE: The row of hepatocytes immediately adjacent to the portal tract. It should be smooth and uniform.
* NONSPECIFIC REACTIVE HEPATITIS ("liver cell unrest"): Increased prominence of Kupffer cells and increased ploidy of many hepatocytes. This is a non-specific finding, common to many (if not most) serious illnesses affecting the entire body.
LOBULAR DISARRAY: Loss of the normal radial arrangement of liver plates within the lobule, typically with severe distortion of the sinusoids. The hallmark of acute hepatitis.
LUPOID HEPATITIS: An unfortunate term for the several kinds of non-viral (?), autoimmune hepatitis in which the histology is that of chronic hepatitis, usually with a lot more plasma cells than in the viral forms (worth remembering).
LYTIC NECROSIS: The hepatocytes in a region (large or small) are gone, leaving behind collapsed stroma. Older references call this "dropout necrosis".
MALLORY'S HYALINE: Masses ("rope-like", "cottage cheese", "Mallory-Denk bodies") of altered cytokeratin and cell stress proteins (ubiquitin, others: Arch. Path. Lab. Med. 114: 589, 1990). Usually (but not always) a marker for alcoholic hepatitis / severe NASH.
MASSIVE NECROSIS: Most of the hepatocytes on the slide are dead. Due to poisoning, viruses, medication reactions, or ischemia. SUBMASSIVE NECROSIS means that at least some entire lobules are destroyed, but in other lobules, enough cells are alive.
MACROVESICULAR FAT: One large lipid drop in a hepatocyte, pushing the nucleus to one side
MICROVESICULAR FAT: Several lipid drops in a hepatocyte; the nucleus stays in the center
OBSTRUCTIVE JAUNDICE: Cholestatic jaundice caused by mechanical obstruction of the common bile duct or hepatic ducts. Also called SURGICAL / SURGEON'S JAUNDICE; all other forms of jaundice are MEDICAL / INTERNIST'S JAUNDICE.
* ONCOCYTIC HEPATOCYTES (oxyphilic hepatocytes, i.e., mitochondrion-packed) are common in many livers, especially where there's been a lot of regeneration, i.e., cirrhosis, which has let mutant mitochondria overgrow (Virch. Arch. 432: 349, 1998). Fibrolamellar hepatocellular carcinomas are also mitochondrion-packed.
Is life worth living? It depends on the liver!
The liver is usually our heaviest internal organ, and the most durable. Unlike lungs, kidneys, heart, and brain, the livers of most 100-year-olds are morphologically and functionally normal.
Liver pathology includes only a few common diseases. The terminology and morphology of these lesions are notoriously confusing for beginners. Further, you'll have to know them, because liver biopsy is fairly common, especially in this era of managing chronic hepatitis by biopsy results.
It would be best for you to start by learning the definitions in the "Glossary", and making note of the material under "For Future Liver Pathologists".
You already know that the liver is the great chemical plant of the body. You remember its location, its anatomic relationships, its blood supply, and its essential architecture.
Worth mentioning: The STELLATE CELLS ("Ito cells", "perisinusoidal cells") sit in the space of Disse, store vitamin A, and turn on to carry out fibrosis of the hepatic lobule in developing cirrhosis.
* Future pathologists: See them with CRBP-1 or alpha-SMA.
* Possbly the most interesting recent work on liver pathology is the finding that signals from hepatocytes in their death-throes stimulate both hepatocyte progenitors and myofibroblsts / stellate cells / laminin producers to handle the re-growth (Gut 59: 645 & 655, 2010) The new hope is that natural killer cells can be activated by biotech products to destroy the proliferating stellate cells (Gut 60: 90, 2011) or at least suppress them (Dig. Dis. Sci. 55: 261, 2010; Gastroenterology 138: 347, 2010).
Normal adult livers weigh 1400-1600 gm. Liver weight is widely variable at autopsy. I've autopsied an end-stage cirrhotic with a 700 gm liver, and an alcoholic with a 7000 gm liver. The liver HURTS when, and only when, its capsule is stretched.
Despite the discussion in "Big Robbins", the normal liver may or may not be palpable, depending on its shape. Maybe 1% of livers have a "Riedel's lobe" easily felt on the right side; this is simply an anatomic variant of no importance to one's health. Others have a small right lobe and a large left lobe, while still others have random grooves across the organ ("hepar lobatum", or one variant). The hyperinflated lungs of the emphysema patient usually push the liver downward and make the edge palpable, but again, this is not reliable; "rib marks" (really from muscle pressure) in emphysema produce the familiar LEIBERMEISTER GROOVES. Remember that a newborn's liver edge is usually easily palpable 1-2 cm below the costal arch.
The histology of the liver is worth reviewing. Remember that the METABOLIC LOBULE ("ACINUS") is centered on the portal areas, and the CLASSICAL LOBULE is centered on the central vein. Whichever system you use, ZONE 1 is the hepatocytes near the portal areas, ZONE 2 is the hepatocytes midway between the portal areas and central veins, and ZONE 3 is the hepatocytes around the central veins.
The familiar polyhedral, pink-staining hepatocytes are often (maybe 10%) binucleate or tetraploid / octoploid. This is normal. You remember the architecture of the liver plates and sinusoids, the passage of bile from canaliculi to canals of Hering to bile ducts, and the appearance and function of the hepatic endothelium and Kupffer cells.
* Prominent Kupffer cells and increased hepatocyte polyploidy is LIVER CELL UNREST, common in people who are sick for a variety of reasons. Its diagnostic significance is nil.
* Future pathologists: You can stain the healthy canaliculi using your CEA stain.
You will learn about biopsying the liver (the open "wedge" biopsy, the classic through-the-skin cutting-neecle techniques, the tiny-pieces transjugular approach for the very-sick) on rotations (Gut 55: 1789, 2006). Lately, a liver cutting-needle biopsy has come to be considered "adequate" if it is 20 mm long and/or contains 11 or more complete portal tracts (Am. J. Clin. Path. 125: 710, 2006).
The Greek titan Prometheus had his liver devoured each day by a monster bird, but it always grew right back.
If individual hepatocytes are destroyed but the architecture of the lobule is NOT destroyed, the remaining hepatocytes will totally regenerate the liver parenchyma.
If whole lobules are destroyed, the remaining lobules will expand. They will function normally, though bile may not be drained quite so well.
Of course, if scar tissue alters the flow of blood through the liver (i.e., cirrhosis has occurred), regeneration will only produce less-than-fully-perfused nodules of liver cells. (This will disappoint well-read problem drinkers who understood that their hepatocytes had unlimited capacity to regenerate. )
* Liver biopsies are not always easy to read, especially if the community hospital pathologist isn't focused on liver. The value of a second opinion: Arch. Path. Lab. Med. 125: 736, 2001.
* Incredible as it may seem, your lecturer got his first exposure to pathology as freshman advisee of the dean of experimental liver pathology, Brown's Nelson Fausto, whose focus was and is liver regeneration. ("All right. You say you want to be a doctor. How serious are you?") Turned out to be a fantastic man and teacher. After years of bragging about this, I was delighted to see him as third author of the new "Big Robbins".
Increased bilirubin in the bloodstream is JAUNDICE.
There's no reason to review bilirubin production and metabolism here. You can check "Big Robbins" if you need refreshing.
Here's a simple review, similar to the one in "Big Robbins", of the various causes of jaundice:
TOO MUCH BILIRUBIN BEING PRODUCED ("hemolytic jaundice")
"Ineffective hematopoiesis", i.e., normoblasts dying in the bone marrow
Thalassemias (even mild ones like beta-thal minor)
Intravascular hemolysis (many, many reasons for this; IgG-mediated hemolysis of red cells is listed here as well though technically not "intravascular")
LIVER FAILS TO TAKE UP AND/OR CONJUGATE BILIRUBIN ("hepatocellular jaundice")
Hepatitis (many causes)
Cirrhosis (many causes)
Gilbert's non-disease and the Crigler-Najjar syndromes
NOTE: From "Biochemistry". Gilbert's (officially pronounced as French Zheeel-BEAR's) is a forme fruste of Crigler-Najjar (Lancet 346: 314, 1995; Lancet 345: 958, 1995). Both result from mutations of the glucuronyl transferase that solubilizes bilirubin. Crigler-Najjar (two subtypes) is always recessive, Gilbert's can be dominant (interference with normal function) or (more often) recessive (mild loss-of function alleles).
Gilbert's is extremely common (several % of the population) and usually a non-problem. One tipoff is that the bilirubin levels, which usually will stay below 6 mg/dL, increase during fasting. Some folks do find it troublesome. Gilbert's may be exacerbated by other illnesses or medications, in particular G6PD deficiency and/or the protease inhibitors used in anti-retroviral therapy (J. Inf. Dis. 192: 1381, 2005).
LIVER DOESN'T SEND BILIRUBIN TO THE RIGHT PLACE ("cholestatic jaundice")
Problems with the liver cells
Drugs (estrogen, anabolic steroids)
Dubin-Johnson (pigmented) non-disease
The hepatocytes are rich in a brown pigment (dPAS positive)
* These people lack a pump, which is coded by, of all things, the gene ABCC2 for the hated MRP2 multidrug-resistance protein (Gastroent. 117: 653, 1999) that pumps cancer chemotherapy agents out of cancer cells.
* A specialist can diagnose Dubin-Johnson without biopsy by its effect on different urinary coproporphyrin levels. Don't worry about it.
Rotor (non-pigmented) non-disease.
* Making the call is easy because the liver refuses to take up the Tc 99 m-DIPA biliary scan radionuclide (Clin. Nuc. Med. 22: 635, 1997). Autosomal recessive; the gene awaits discovery..
* Byler's disease ("FIC-1/ATP8B1" and at least two other loci; familial intrahepatic cholestasis). This is a family of autosomal recessive illnesses in which there are problems with the bile transport proteins. There is a problem with bile transport in the liver, and sometimes "Byler bile" is appears coarsely granular. The Byler family from which all the index patients came is Amish and highly inbred; See Hepatology 26: 155, 1997. There is a Byler-like illness at BSEP, the bile salt export pump, and another at the multidrug-resistance protein 3 site).
"Benign familial recurrent intrahepatic cholestasis", the forme-fruste of Byler at FIC-1. Patients have intermittent cholestasis and elevated alkaline phosphatase. On biopsy during an attack, you will see bile in the canaliculi, and only in the canaliculi. Second locus Gastroent. 127: 379, 2004.
Really bad cases of other liver diseases (hepatitis, cirrhosis, alcoholism; i.e., when the liver fails, the picture is likely to be mixed).
Problems with the bile ducts in the liver
* Alagille's (dysmorphic child, intrahepatic bile ducts in the portal areas vanish over time; autosomal dominant, gene Jagged1 (Circulation 109: 1354, 2004, the variable liver disease itself Gut 49: 431, 2001; molecular biology Am. J. Path. 171: 641, 2007)
Normally, more than 70% of portal areas should contain a visible bile duct; if there are fewer than 50%, consider Alagille's.
Problems with the bile ducts beyond the liver (call a surgeon)
Gallstone in the common duct
Cancer (i.e., biliary, pancreatic, ampullary)
Traumatic / Iatrogenic (i.e., the surgeon nicked the common bile duct)
Note that in all but hemolytic jaundice, bile production will be diminished. Stools may become light-colored (gray if the bile is completely obstructed), and there will be diminished intestinal absorption of fat (pee-yew!) and fat-soluble vitamins.
Lab tests are of considerable help in distinguishing these entities.
Obviously, in the first two categories, the serum unconjugated bilirubin will be elevated.
In the third category, only the conjugated bilirubin will be elevated until the liver cells themselves are damaged. Serum BILE ACIDS ("bile salts") will also be increased from the onset, producing the troublesome itching seen in these syndromes. Conjugated (but not unconjugated) bilirubin in the bloodstream spills into the urine. You'll study other markers for cholestasis in the unit on lab testing.
On biopsy, obstructive jaundice presents the familiar BILE PLUGS, which begin as dilatations of the canaliculi and end up forming BILE LAKES when the canaliculi rupture.
* As the liver cells become damaged, they fill with soap bubbles (i.e., bile salts and water), producing FEATHERY DEGENERATION. You won't need to recognize this. Later, you'll see necrotic cells surrounding bile lakes.
WHEN THE LIVER FAILS
Regardless of cause, when the liver can no longer function as chemical plant, several unwholesome things happen.
JAUNDICE is usual. When the liver is really scrambled, hyperbilirubinemia is mostly the conjugated sort, i.e., the cells remember how to conjugate, but not what to do with, the bile. There is usually some unconjugated hyperbilirubinemia, too.
HYPOALBUMINEMIA is usual, since the liver isn't making albumin. Without albumin in the bloodstream, ascites and edema develop. By the way, HYPOCHOLESTEROLEMIA is usual in liver disease too (unless the primary problem is obstruction of bile flow -- why?), since the liver isn't producing LDL's.
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(This is part of the reason for the silly myth that "too low cholesterol is bad for you".)
COAGULOPATHY of liver disease (NEJM 365: 147, 2011) results from diminished hepatic synthesis of factors II, V, VII (first to go), IX, and X. (Note that absent vitamin K from malabsorption also prevents synthesis of II, VII, IX, and X.) Monitor all this by following the prothrombin times (rather than PTT, since factor VII is first to go and to return).
The anti-clotting factors are also diminished, and people talk about the clotting system in liver failure being "rebalanced".
Further, as the liver fails to clear factors that have become activated in the course of living, low-grade DIC is likely to develop. This is probably why PT and the classic measures correlate poorly with intractability of bleeding from varices / bleeding during liver transplantation.
As liver cells fail, detoxification of nasty compounds fails and HYPERAMMONEMIA and FETOR HEPATICUS (a distinctive mercaptan-based odor to the breath). Other side-effects are reddening of the thenar and hypothenar eminences ("palmar erythema"), spider "angiomas" (you'll learn about these in physical diagnosis), and (in men) gynecomastia and testicular atrophy. In longstanding liver failure, the parotid glands often enlarge for some reason (still completely unknown as of 2014).
THROMBOCYTOPENIA is due to lack of thrombopoietin: Am. J. Gast. 94: 1918, 1999.
HEPATORENAL SYNDROME is a syndrome of kidney failure.
We used to precipitate this by "lasixing" cirrhotics with ascites.
The pathophysiology, once obscure, is now clear. First, liver failure interferes with the breakdown of the vasodilator nitric oxide. Second, portal hypertension itself forces the splanchnic arteries to open wider at the expense of circulation to the rest of the body. Third, bacteria from the gut find their way into the mesenteric lymph nodes, where they cause all sorts of havoc with cytokines (NEJM 361: 1279, 2009). We now manage all but the worst cases by giving plasma expanders and vasopressin analogues (Gastroent. 122: 923, 2002) (to constrict the splanchnic circulation) plus dopamine (to open the renal microcirculation) helps (Hepatology 27: 35, 1998; Am. J. Gastroent. 92: 2113, 1997; Clin. Sci. 92: 433, 1997; Mayo. Clin. Proc. 71: 874, 1996; Lancet 362: 1819, 2003). When there is massive tense ascites, tapping and draining it ("large volume paracentesis") is helpful in the short-run. Unless the liver disease is reversible (i.e., alcoholic hepatitis or a drug allergy), this is just buying time while waiting for a liver transplant. Update South. Med. J. 103: 654, 2010.
- Type 1 hepatorenal syndrome is acute renal failure during a medical catastrophe, most often spontaneous bacterial peritonitis
HEPATOPULMONARY SYNDROME is seen when the liver fails. The small arterioles and capillaries of the lungs dilate preposterously causing V/Q mismatching (i.e., the oxygen cannot reach the centers of the vessels, and there are some shunts opening that bypass the alveoli altogether). There is no current remedy apart from curing the liver disease. See Gastroent 113: 606, 1997; Surg. Clin. N.A. 79: 23, 1999; Mayo Clin. Proc. 79: 42, 2004; Lancet 363: 1461, 2004 ("notoriously underdiagnosed"); NEJM 358: 2378, 2008; Med. Clin. N.A. 93: 871, 2009.
* One factor may be increased endothelin 1, either not cleared by the liver or actually manufactured in proliferating cholangiocytes (Dig. Dis. Sci. 57: 516, 2012).
* Future clinicians: In contrast to congestive heart failure, dyspnea in hepatopulmonary syndrome improves when lying flat ("platypnea"), since the V/Q mismatching is worst in the lung bases. Any idea why?
* Future clinicians: PORTOPULMONARY HYPERTENSION is the other lung problem caused by liver disease, and often coexists with hepatopulmonary syndrome. It's probably mediated by factors that aren't being cleared from the blood, and the histopathology is as for idiopathic pulmonary hypertension. Patients must have portal hypertension and/or bad liver disease, plus mean pulmonary arterial pressure above 25 mmHg at rest and a few other criteria. Update Hosp. Pract. 41(2): 62, April 2013.
HEPATIC ENCEPHALOPATHY is not a pretty sight, and probably results from a combination of factors, including nitrogen-containing false neurotransmitters (supposedly including octopamine -- remember that from "Biochemistry"? -- and some others) produced by the gut flora.
* Fatigue in liver failure may respond to ondansetron: Lancet 354: 397, 1999. The antibiotic rifaximin seems to help (NEJM 362: 1071, 2010).
Early in the process, there's a curious distortion of spatial perception. (The stereotype of accelerated confusion in the problem drinker is all too familiar -- he pours the whiskey onto his lap, rather than into the glass in his other hand; he cannot find his way home even when he sobers up. Whatever the cause, hepatic encephalopathy makes life far more difficult.) The first change on physical exam is ASTERIXIS, a curious flappy falling-asleep-and-waking-back-up of the fingers-hands-arms-whole body. Clinicians monitor hepatic encephalopathy by measuring blood ammonia.
<01383> Alzheimer II glia in hepatic encephalopathy (best one is in the center of the field; it appears as a swollen, pale nucleus)
In acute massive liver failure, cerebral edema is the pathway out of life in about 50% of cases (Lancet 351: 719, 1998). We're still making educated guesses about the mechanism.
When the liver finally gives up completely, REFRACTORY HYPOTENSION supervenes from total-body vascular relaxation (which we can suppose is due to the failure of the liver to metabolize some vasodilator, most likely one that's not yet been discovered.) Nothing you can do will save the patient.
Reminder: Serum liver enzyme (transaminases, lactate dehydrogenase) concentrations become elevated when liver cells are acutely injured. Note that in burned-out cirrhosis when drinking is stopped, liver enzymes will be normal.
Cirrhosis ("roaches of the liver", etc.) is scarring of the whole liver sufficient to permanently interfere with circulation of blood to the hepatocytes, no matter what the cause. You will see
NOTE: The development of fibrosis is still quite mysterious; we know the stellate cells are the ones responsible, but nobody really understands it or what we might do to stop it. Sometimes, you can see layer upon layer of reticulin fibers being laid down as liver cells die in waves; this is the sign of irreversible (?) damage in chronic hepatitis, and probably is how scars build up, at least in part.
<08846> cirrhosis, trichrome stain (fibrous tissue is blue, of course); micronodular
<39710> cirrhosis after hepatitis, gross photo showing uneven involvement of the liver lobules. Just recognize cirrhosis.
MICRONODULAR CIRRHOSIS: Most of the nodules are smaller than 0.3 cm, and the fibrous-scar bands are relatively thin.
Think of alcoholism, hemochromatosis (since alcohol and iron will involve all lobules equally), primary-autoimmune biliary cirrhosis (since portal areas tend to link to adjacent portal areas), or biliary infection/obstruction (same reason, "secondary biliary cirrhosis"; remember cystic fibrosis).
* The inborn errors of metabolism worth remembering are the bad kind of galactosemia, tyrosenemia, type IV glycogen storage disease, and hereditary fructose intolerance.
<08285> micronodular cirrhosis (this happens to have been a case of primary biliary cirrhosis); liver on left is normal
Urbana Atlas of Pathology
small nodular liver
Small liver with cirrhosis
Urbana Atlas of Pathology
MACRONODULAR CIRRHOSIS: Most of the nodules are larger than 0.3 cm, and the fibrous-scar bands are relatively thin.
Think of chronic hepatitis, with its uneven pattern of inflammation, progressed to cirrhosis (since viral disease is generally patchy and will not involve all lobules equally).
Wilson's disease, galactosemia, and alpha-1 antitrypsin deficiency may supposedly produce either pattern, though they probably begin involving lobules evenly; since they are accumulations and cell death releases the storage product, perhaps this explains the unevenness. As a matter of fact, a rehabilitated alcoholic's micronodular liver will, after a few years of sobriety, exhibit enough large regenerative nodules to qualify as macronodular.
* Pathologists only: "Incomplete septal cirrhosis" is stabilized (regressing?) macronodular cirrhosis with only thin fibrous bands and really no nodules. Liver function tests are better, but portal hypertension may be is more severe -- hence the tendency to say "cirrhosis" despite no nodules. See Gastroent. 106: 459, 1994.
* In an era in which regression of fibrosis is now well-recognized, just how useful the term "cirrhosis" is might be questioned (Am. J. Clin. Path. 137: 5, 2012). Your lecturer believes that the appearance of a cirrhotic liver is so distinctive that the term will always be with us. Please do remember that a diagnosis of "cirrhosis" is no longer a death sentence.
Necrosis and fibrosis
POST-NECROTIC CIRRHOSIS ("end-stage liver"): Macronodular cirrhosis with really big, thick fibrous-scar bands. Usually results either from submassive necrosis (i.e., whole lobules were destroyed), or (much more often) progression of another type of cirrhosis to the end stage (micronodular and macronodular no long mean anything as nodules coalesce).
<25659> macronodular cirrhosis (some big scars show progression to postnecrotic cirrhosis)
The traditional wisdom has been that the fibrosis in cirrhosis does not regress. Only recently have we begun to recognize that there may be regression, though not complete reversal, if the underlying process goes quiet.
Look for thin septa with holes in them, lone thick fibers (i.e., the surrounding thin stuff is gone), and other stuff that's harder to see why it means regression. See Arch. Path. Lab. Med. 124: 1599, 2000; update Hum. Path. 37: 1519, 2006 (the underlying problem must be corrected, and healing is incomplete and unpredictable, with only a minority showing convincing healing).
Especially in kids cured of thalassemia by marrow transplantation, extensive reversal of cirrhosis is now known to take place (Ann. Int. Med. 136: 667, 2002); there is often some regression when hepatitis C virus is eradicated from a long-time patient (Dig. Dis. Sci. 43: 2573, 1998; Ann. Int. Med. 149: 399, 2008); the new treatments for chronic hepatitis B cause a majority of patients with cirrhosis to revert to non-cirrhosis on histology (Lancet 381: 468, 2013), and when autoimmune hepatitis is controlled (Ann. Int. Med. 127: 981, 1997)
There are now animal models for stem cell work in partially-repairing the damaged liver (as is already in use for the damaged heart). Stay tuned: Gastroent. 135: 438, 2008.
* Death rates from cirrhosis (age-corrected) have run a curious pattern over the past 100 years. Between 1900 and 1934, deaths dropped by about 2/3; this coincided with the temperance movement and the massive decline in alcohol consumption. The end of Prohibition and the Great Depression resulted in a tremendous resurgence of alcohol overindulgence, and the rate of death from cirrhosis skyrocketed, peaking in 1970. Since then, they've dropped dramatically; I suspect the explanation is better nutrition and the recovery movement (Postgrad. Med. 115: 13, Jan 2004.)
CONGESTION of the liver receives excessive attention. There's no mystery; if the right side of the heart isn't pumping well enough, blood pools in the liver.
Except in the most sudden violent deaths, the central areas of the liver will be more or less congested. (If you're at an autopsy and someone asks, "Is that a nutmeg liver?", you can safely guess "Yes!")
Clinicians enjoy showing the hepatojugular reflux of those with congested livers, especially behind failing right ventricles. Pathologists enjoy exhibiting their cut nutmegs, which have light-and-dark areas that resemble congested liver.
* If you want to get fancy. instead of demonstrating hepatojugular reflux, you can now use a high-tech device to assess the "stiffness" of the liver, which is of course increased in the living when they have congestive heart failure in the absence of co-existing cirrhosis (Radiology 257: 872, 2010).
Someone really had fun
making this photo!
Slide from Andrea McCollum MD
Cuyahoga County Coroner's Office
Slide from Andrea McCollum MD
Cuyahoga County Coroner's Office
If death has been preceded by a few hours of inadequate circulation (heart failure, shock), count on seeing some hepatocyte necrosis in the centers of lobules. (This is CENTRAL HEMORRHAGIC NECROSIS. Why the liver? Why in the centers? Think about it!)
This isn't "due to the congestion", but merely results from inadequate perfusion with oxygenated blood.
Clinicians may have noted "elevated liver transaminases" ("ISCHEMIC HEPATITIS"), and even mild jaundice. You can experience the transaminase elevations yourself by running a marathon. Don't worry, the liver will completely regenerate (since its connective tissue framework is still intact.)
If hepatic congestion and underperfusion have been extreme and longstanding, the rare CARDIAC SCLEROSIS may supervene. This is substantial fibrosis in the central areas of the lobule. (Grossly, the liver surface looks like a football, since scar contracts in the centers of the lobules.)
In extreme cases (i.e., tricuspid insufficiency, certain congenital heart surgeries), the fibrous tissue may bridge adjoining lobules -- true CARIAC CIRRHOSIS.
* That cardiac cirrhosis is real has recently been demonstrated by a study of people who have undergone the Fontan procedure, in which the right ventriclar pulse is transmitted directly to the hepatic veins. See J. Thorac. Card. Surg. 129: 1348, 2005.
* In cardiac cirrhosis, the central veins may become connected to one another, leaving "reverse lobulation", each with a single portal tract in the middle.
Otherwise, cardiac sclerosis is usually just an anatomic pathologist's curiosity.
The liver has a dual blood supply and, while hepatocytes are vulnerable to hypoxia, the stroma is very resistant and hepatocytes regenerate easily. This makes it difficult to truly arterially infarct the liver.
When a branch of the portal vein is compromised, the worst that usually happens is atrophy of hepatocytes in a region ("Zahn's infarct"; fresh lesions have much stasis of blood in the sinusoids and thus look blue).
HEPATIC VEIN THROMBOSIS ("Budd-Chiari")
<49262> Budd-Chiari; liver is engorged with blood and you can see the clots;
Sounds serious, and is. The most common cause is polycythemia vera. Most any other cause of hypercoagulable blood can produce "Budd-Chiari". Another important cause is invasion of the hepatic veins by hepatocellular carcinoma.
* We've long been puzzled by the link to polycythemia vera; now it seems that the JAK2 mutation that causes it is somehow key to these thrombi as well (Blood 117: 3968, 2011).
As you'd expect, in the acute case, the liver swells (ouch!), ascites develops rapidly, and the patient usually dies of venous infarction of the liver unless surgery or thrombolysis are performed.
In some foreign countries, "chronic Budd-Chiari" is a common problem. Nobody knows why. At autopsy, look for fibrous "webs" in the hepatic veins.
* Diabetic micro-angiopathy occasionally produces non-cirrhotic fibrosis (like hyaline arteriolar sclerosis) of the sinusoids. The entity is newly-named "diabetic hepatosclerosis" (Arch. Path. Lab. Med. 130: 27, 2006; update Am. J. Clin. Path. 132: 494, 2009). Probably it is common but under-recognized. Ordinarily the hepatic sinusoids have no basement membrane; if you see one, it's probably diabetic hepatosclerosis.
HEPATIC VENO-OCCLUSIVE DISEASE, clinically a Budd-Chiari mimic but with no thrombus, results from intimal thickening of the veins (onion-skinning, etc.). Think of Jamaican bush-tea (as in the lung: terrible health problem West. Ind. Med. J. 64: 60, 1997), comfrey, graft-vs.-host, radiation effect. Older review, emphasizing the "herbal tea" connection: Arch. Surg. 125: 525, 1990). Several high-power medications (sirolimus, thioguanine, oxaliplatin) have probably caused veno-occlusive disease. And it's one of the most serious complications of hematopoietic stem-cell transplantation (Lancet 379: 1301, 2012 -- * defibronate study).
Joel K. Greenson MD
* Sickle-cell patients often have chronic venous outflow obstruction (why?). Be careful about biopsying these people. Blood 101: 101, 2003.
PORTAL VEIN THROMBOSIS
Again, this is serious. It results from hypercoagulable blood, invasion by hepatocellular carcinoma, pancreatitis, or cirrhosis.
The major problems are ascites and venous infarction of the bowel.
NECROSIS OF THE LIVER
Infections tend to produce random areas of necrosis ("focal", "spotty"), ranging from tiny (most cases of viral hepatitis) to massive ("acute yellow atrophy" / "acute liver failure").
Poisons and other noxious things, on the other hand, tend to damage distinctive portions of the lobule (why?) More about this later.
CENTRAL NECROSIS: Ischemia, carbon tetrachloride, chloroform, acetaminophen
* Test-takers: Notice that all three of these famous poisons do their work by generating free radicals; perhaps this is rougher on the central areas because of the lower concentrations of oxygen found there. And please remember too that we usually see the livers of poisoning victims after they've been in shock -- which damages the central areas, anyway.
<07020> carbon tetrachloride, gross; note the necrosis (yellow, of course)
MIDZONAL NECROSIS: Yellow fever and dengue. (Think about why. It is in the virus's interest to have regenerating hepatocytes on both sides.)
PERIPHERAL NECROSIS: Acute iron poisoning (J. Tox. 39: 721, 2001), phosphorus, eclampsia/HELLP (in eclampsia/HELLP, fibrin microthrombi should be visible in the sinusoids near the portal areas).
<07023> liver showing phosphorus poisoning; note periportal necrosis
PELIOSIS HEPATIS ("blood cysts", a misnomer)
Lakes of blood among the hepatocytes. Usually a non-problem found on imaging or autopsy. On section, the liver features many easily visible holes filled with blood.
The pathology has recently been reviewed in depth (For. Sci. Int. 149: 25, 2005.)
Sometimes it is due to dilated veins ("phlebectatic peliosis"); in this case, the lesions are round and lined by endothelium and/or fibrosis, and the liver looks like swiss cheese.
In the more familiar sort of peliosis the lakes are lined only by hepatocytes ("parenchymal peliosis"); in this case, the lesions are irregularly-shaped.
Anabolic steroid use is the best-known cause (generally parenchymal), but many others are known (oral contraceptives, cachexia) or suspected (hemangiomas, congestion in people with mild weakness of the veins).
A blow to (or biopsy of) the involved organ may cause these to rupture, with serious hemorrhage.
VIRAL HEPATITIS: GENERAL CONSIDERATIONS
The hepatitis family is an alphabet-soup of viruses. However, the anatomic pathology is generally similar. Some viruses are better at producing different patterns than are others.
You can get each of these infections only once. But B can linger, and C usually does linger, as a minor or major problem.
As with most viral diseases, infectivity peaks just before symptoms appear. Acute hepatitis is heralded by the blahs. As the immune system gears up, joint pains and rash can occur. Appetite vanishes, and the patient typically becomes utterly revolted by tobacco. (Smoking cessation is a redeeming feature of the acute hepatitis family.)
In the acute disease, the liver swells and becomes tender, jaundice often appears (mild cases are "anicteric"), and (with influx of bile into the bloodstream) the patient starts to itch and to pass brown urine (why?) Serum transaminases go sky-high, and other lab evidence of liver disease may become apparent.
The best treatment your lecturer knows for the acute phase is masterful inactivity for all but C, intensive therapy for C. Educate the patient, find out who else needs to be checked for hepatitis or get prophylactic gamma globulin, and give clotting factors if you must.
ACUTE VIRAL HEPATITIS: You will see
Note that in hepatitis, the cells may die either by lysis or apoptosis, or both. Probably the lysis is due to the viruses and/or to antibodies, while the apoptosis is caused by instructions to self-destruct delivered by the T-cells.
<05961> acute viral hepatitis with Councilman body
<08834> acute viral hepatitis; sinusoids are not visible, lots of inflammatory cells
<11787> acute viral hepatitis, great bile plugging
<12770> acute viral hepatitis (do you see a Councilman body?)
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
Necrosis and lobular collapse
MASSIVE NECROSIS ("FULMINANT HEPATITIS"; "ACUTE YELLOW ATROPHY") may supervene on any kind of acute hepatitis, and often kills the patient in short order. Update Lancet 376: 190, 2010.
Causes range from medicines (idiosyndratic responses to real medicines; adulterants in quack medicines, really bad hepatitis B, D, or E; mushroom poisoning; rare complications of pregnancy; the worst cases of typhoid; extreme vascular disease; rarely hepatitis A, maybe not hepatitis C)
Grossly, as you would expect, the liver is shrunken, red-to-yellow, soft, and flabby, with a wrinkled capsule.
Histologically, the hepatocytes are almost all gone (lytic necrosis and/or apoptosis), leaving a collapsed fibrous tissue framework. Don't expect to see much inflammation.
SUB-MASSIVE NECROSIS is a little less striking histologically and lasts a little longer, killing the patient in a few months. (Or the patient may recover after being super-sick for a few months.)
If a patient survives either process, the parenchyma is usually intact, and recovery should be complete, without cirrhosis. Rarely, the collapsed reticulin meshwork of the liver turns into broad scars (instant "post-necrotic cirrhosis").
<13320> massive necrosis after hepatitis, gross (nothing left but the reticulin and endothelial framework!)
<13321> massive necrosis after hepatitis, histology
<13322> massive necrosis after hepatitis, histology
Pittsburgh Pathology Cases
CHRONIC HEPATITIS: Inflammation of the liver for more than six months.
You will see a dense, mostly-lymphocytic inflammatory infiltrate in the portal areas, with or without spill-over into the parenchyma.
There may be some smoldering changes resembling acute hepatitis in the parenchyma.
In mild cases, the limiting plate is intact (i.e., there is no interface hepatitis). We used to call this "chronic persistent hepatitis".
<12788> mild chronic hepatitis, reticulin stain (see the limiting plate intact); you don't need to tell this isn't normal liver;
<12791> mild chronic hepatitis, trichrome (again, see the limiting plate intact); again, you can't tell this isn't normal liver;
These findings are more ominous when the patient has chronic hepatitis clinically:
Drug-induced liver disease (most notably methotrexate), Wilson's, alpha-1 antitrypsin deficiency, and the autoimmune "lupoid" hepatitis family also typically pass through a "chronic active hepatitis" histopathology stage on their way to cirrhosis.
<12800> severe chronic hepatitis, piecemeal necrosis
<20328> severe chronic hepatitis; almost to cirrhosis (the nodules are not yet completely separate)
<40279> severe chronic hepatitis, note the necrotic cells
<20183> severe chronic hepatitis with good bridging necrosis; the hepatocytes are stained orange and the bridge is an area of lytic necrosis
Joel K. Greenson MD
Future pathologists please note: Any and all of these patterns (from acute hepatitis to post-necrotic cirrhosis) can be mimicked by idiosyncratic reactions to various drugs. Chronic hepatitis and its sequelae are often caused by autoimmunity.
HEPATITIS A ("infectious hepatitis")
This is an unpleasant but almost always self-limited disease caused by a tiny RNA enterovirus (* picornavirus; "pico-" means "tiny", and "rna" you can figure out).
Hepatitis A is transmitted by the fecal-oral route, i.e., poor sanitation, small kids (i.e., day-care or institutions), hands (J. Clin. Micro. 30: 757, 1992, note that there are countries where toilet paper isn't used), raw oysters (be sure to ask), some gay male sexual practices (JAMA 267: 1587, 1992), others. Hepatitis A is more common overseas but is no rarity in the U.S.
Hepatitis A, until recently an endemic scourge on many Indian reservations (MMWR 46: 600, 1997) has become much less common thanks to the recommendation to immunize all these children (Am. J. Pub. Health 94: 996, 2004).
* The 1998 strawberry outbreak: NEJM 340: 595, 1999.
The incubation period is about two weeks, and this is the time when virus is shed in the feces. The infection in kids is usually asymptomatic. Adults who get symptoms at all suffer jaundice and discomfort for a few weeks. Once in a while, the disease is fatal.
You'll hear different versions of whether the virus itself damages hepatocytes (the other enteroviruses are cytotoxic), or whether the liver damage is actually wrought by the body's immune response.
Immune response is exactly what you'd expect:
IgM ANTI-HAV appears in the blood when the symptoms begin, clears the infection (which may wax and wane clinically for a few months), and usually disappears within 12 months.
Actually, IgM often sticks around indefinitely. Don't draw any conclusions from its presence if the person's not sick (Arch. Path. Lab. Med. 137: 90, 2013).
IgG ANTI-HAV appears in the blood during the symptomatic period, and usually stays around for life, rendering the patient immune.
Occasionally the disease causes acute yellow atrophy and death/transplantation (Am.
Update February 2018: You may see a 2 year anniversary maintenance video above.
J. Gastro. 98: 448, 2003).
Hepatitis A very seldom becomes chronic or leads directly to cirrhosis. There is probably no carrier state. At worst, the disease might be a trigger for autoimmune chronic hepatitis, but the virus won't stay around.
* How the vaccine came about: Lancet 343: 321 & 322, 1994; J. Inf. Dis. 169: 996, 1994; JAMA 271: 1328, 1994; JAMA 273: 906, 1995 (now classic). Hepatitis A vaccine for post-exposure prophylaxis seems to work about as well as immune globulin: NEJM 357: 1685, 2007.
HEPATITIS B ("serum hepatitis"; update NEJM 359: 1486, 2008; Lancet 373: 582, 2009)
The world's most serious DNA-virus-related health problem. The reservoir for the virus ("HBV", "Dane particle") is the world's 300 million (Proc. Nat. Acad. Sci. 93: 6542, 1996) or 350 million (WHO 2009) or 400 million (ASCP) carriers, most of whom are asymptomatic and probably have histologically normal or near-normal livers.
Perhaps one person in three worldwide has met the hepatitis B virus; most people cure themselves.
<10532> hepatitis B, * orcein stain (stains the virus)
<11708> hepatitis B, core antigen stained in nuclei
Even an infinitesimal amount of infected blood, when introduced into another person's tissues, is highly effective in transmitting the infection.
- transfusions (of course, we check donor units)
People born uninfected in the poor nations also frequently turn positive during their childhood. This has been blamed on bedbugs; probably this isn't the main problem (Lancet 343: 761, 1994).
In the U.S. underclass, infection is also rampant, with around 25% of forensic-service deaths being core-antibody positive (J. For. Sci. 38: 1075, 1993).
* Hepatitis B immunization has resulted in a triumphant reduction in the prevalence of carriage in Taiwan and the rate of hepatocellular carcinomas (JAMA 276: 906, 1996).
* In 1997, I predicted the 1998-9 media hype that the vaccine causes multiple sclerosis. The activists don't have the numbers, but even after the claim was already totally discredited, many lawsuits still got filed (Science 281: 630, 1998).
* Catching hepatitis B from the surgeon, even when e-antigen-negative ("low-risk"): NEJM 336: 178, 1997.
HBsAg ("Australia antigen"): Surface antigen. Envelope protein. During the productive infection, the liver cells make considerable excess non-infectious HBsAg, facilitating diagnosis.
HBcAg: Core antigen. Nucleocapsid.
* Not surprisingly, several genetic variants exist, which affect both the progress of the hepatitis, and the prognosis of any hepatocellular carcinomas that arise here. This will affect you by the time you are in practice. See Gastroent. 137: 1687, 2009.
HBeAg: Another nucleocapsid antigen, which means the virus is being replicated.
* Interestingly, entry of the virus into the hepatocyte is by means of binding to polymerized serum albumin.
After a person first meets the virus, the incubation period is usually 1-4 months.
Antigens and antibodies:
HBsAg first appears in the blood shortly before symptoms begin (if they are to begin -- maybe 70% of infections are asymptomatic). It remains in the blood for the duration of the infection, whether it is acutely symptomatic, slowly-progressive / subclinical, or merely the carrier state.
HBeAg appears in the blood just after HBsAg, and before symptoms start. It remains as long as there is acute viral replication (you're VERY contagious. ), and disappears if (and only if) viral replication stops. The patient is still sick when HBeAg disappears, but can take comfort in the good news.
Anti-HBeAg appears soon after viral replication and HBeAg production stop (if they stop). The patient can still be sick, but this is another piece of good news.
If HBeAb stays around, it's a marker for the person being very contagious -- bad enough that the NCAA forbids sports participation for a chronic carrier.
Don't ask for an assay of HBcAg, the core antigen in the blood. It's an intranuclear protein and there's almost none in the blood. However, Anti-HBcAg, in its IgM form, appears in the blood typically before symptoms begin, and generally remains present for years (IgG anti-HBcAg will eventually take over, maybe). If a person with clinical hepatitis has cleared his blood of HBsAg, but has not yet developed detectable anti-HBsAg, the presence of IgM anti-HBcAg confirms that the infection is, indeed, hepatitis B and is in the CORE WINDOW.
Anti-HBsAg is generally present when the infection is pretty much over, and is a good sign of recovery.
NOTE: Now that we use viral DNA to discover hepatitis B infection, we're discovering quite a few folks who never mount an antibody response. These folks seem to fail to expand their clone of HBV-specific T-cells (Gastroent 134: 1470, 2008).
"Occult hepatitis B" has undetectable HBsAg, positve anti-HBc, and positive anti-HBs, but there's sometimes viral DNA detectable in the blood, and the virus is still hiding in the liver. Its true frequency is of course unknown. These people will have the disease flare when they get immunosuppressed by chemotherapy, infamously by rituximab. Overall, about 1/3 of patients who are HBsAg-positive will reactivate (i.e., the virus reappears in the blood), and of these, maybe a quarter will get very sick, especially if they were not given lamivudine to prevent it. People with occult infection (i.e, anti-HBs negative, anti-HBc positive) may serorevert (HBsAg reappears in the blood) during chemotherapy.
BEWARE! During the time between disappearance of HBsAg and appearance of anti-HBsAg, the patient may experience a potentially-lethal type III systemic vasculitis. (Why?)
If your patient is anti-HBsAg positive and anti-HBcAg negative, probably this person has had the hepatitis B vaccine (why?)
* Well, maybe it's not a SURE sign of recovery; the Scripps crew has found viral DNA up to five years after appearance of the antibody, but the patients don't seem sick or catching (J. Clin. Inv. 93: 230, 1994).
Symptoms begin in hepatitis B infection only when T-cells become angry with HBsAg and HBcAg and start killing the hepatocytes that produce them. Histopathologists find T-cytotoxic cells where the hepatocytes are dying. Eventually, the only surviving liver cells are the ones that won't continue making viruses, and these replenish the liver.
The acute disease may be subclinical, or can cause weeks of jaundice and misery, or can cause fulminant hepatitis and death (this used to kill a few percent of patients with acute hepatitis B before we had effective antiviral medications), or sub-massive hepatic necrosis with resolution or cirrhosis.
Survivors (and 99% of people survive the acute episode) usually clear themselves of the virus, but maybe 10% fail to do so. These can become healthy carriers, develop chronic hepatitis that may remit or progress to cirrhosis if untreated. Rule of thumb: The more severe the initial illness, the less chance of remaining chronically infected (why?) Terminology: Chronic hepatitis B means HBsAg has been present in the bloodstream for 6 months or more.
NOTE: Carrying hepatitis B, with or without ongoing liver disease, is an important cause of cryoglobulinemia and/or "polyarteritis nodosa of hepatitis B" (both immune complex, type III immune injury problems).
NOTE: People who become carriers are those who mount a poor immune response. Men (weaker immune response) are more at risk than women; different HLA types differ in susceptibility (Lancet 344: 1194, 1994).
NOTE: Quite a few patients with hepatitis B in the blood but persistently normal transaminases do indeed go on to fibrosis and cirrhosis (Gastroent. 134: 1376, 2008).
Further, anyone who carries around the virus for a long time is at substantial risk for hepatocellular carcinoma. (Hepatitis B and/or hepatitis C contribute to most cases of this cancer, which worldwide is one of the most common fatal diseases. In the case of hepatitis B, the virus may be acting as a mitogen that allows Nowell's law to act, and/or mutating genes at or near its insertion sites: J. Virol. 65: 6761, 1991; there is no doubt that insertion of the virus can and does scramble chromosomes: Proc. Nat. Acad. Sci. 88: 9248, 1991.)
People who continue to harbor the virus are probably those that are not especially good at making interferon (the chronically sick, the immunocompromised, little kids, the unlucky, men much more often than women). Alpha-interferon was the original the mainstay of therapy for chronic hepatitis B infections, and the results are encouraging, with maybe half of people going into remission. Of course, interferon therapy was expensive and produces 'flu-like symptoms, but it was better than dying or infecting your spouse. And thankfully the risk for hepatocellular carcinoma also dropped greatly (Cancer 66: 2395, 1990 was the first big one).
Future histopathologists: You can stain for HBsAg in the cytoplasm, or core antigen in the nucleus. "GROUND GLASS HEPATOCYTES", with greatly increased smooth endoplasmic reticulum suggest chronic hepatitis B infection.
* Don't worry about the "sanded nuclei", full of core antigen, that are classically described in hepatitis B. This is subtle and of no use clinically, and we won't ask you to recognize them.
We may hope that the hepatitis B vaccine will eventually make this infection, and its dread sequelae, a thing of the past. Gambia institutes HBV vaccination of its population (Lancet 341: 1129, 1993). Kids in the U.S. should get immunized, too (Pediatrics 93: 747, 1994). Please be sure you, too, are immune, Doc.
A few mutant viruses that can affect the immunized are now appearing (Epid. & Inf. 124: 295, 2000).
HEPATITIS D (Lancet 378: 73, 2011)
"Delta hepatitis virus" (HDV) is an incomplete RNA virus that can replicate only while synthesis of HBsAg is also taking place. Unlike HBV, delta is directly cytopathic to hepatocytes. About 15 million people are infected worldwide.
Delta may CO-INFECT (i.e., arrive under a person's skin at the same time as the HBV particle) or SUPERINFECT (i.e., arrive under the skin of a person already infected with HBV). Fortunately, delta is relatively hard to transmit (somewhere between HBV and HIV in infectivity), and hepatitis D is most common in gay men and (in the developed world, especially ) IV-drug-abusers.
The results are grim. In co-infections, fulminant disease is common (maybe 5%). In a superinfection, the victim experiences a second round of acute hepatitis, which tends (maybe 50% of the time) to turn chronic and progressive. Treating chronic hepatitis D with alpha-IF: NEJM 330: 88, 1994 (it helps around half of them while being treated; half of these relapse.) If the virus continues replicating, death is near-certain after a few decades (Gastroenterology 136: 1629, 2009).
Fortunately, carriers of delta are probably uncommon. Delta kills maybe 1000 people a year in the USA.
* Disturbingly, there's a fair amount of hepatitis D in school children in Mongolia, and it seems to be acquired through dirty needles in the health care setting (Am. J. Trop. Med. Hyg. 75: 365, 2006).
* LABREA HEPATITIS, noted in the western parts of the Amazon region, is a fulminant, deadly hepatitis of children and young adults caused by hepatitis B and D. There is microvesicular steatosis, and inflammation of the portal and central veins, and "morula cells", macrophages loaded with virus (Trans. Royal Soc. Trop. Med. 101: 831, 2007).
HEPATITIS C (the vast majority of the old non-A, non-B hepatitis cases) updates Ann. Int. Med. 132: 296, 2000; Mayo Clin. Proc. 73: 355, 1998; Lancet 362: 2095, 2003.
This flavivirus (HCV) and its related disease spectrum are now well-characterized. Worldwide, about 170 million people carry the virus (Gut 58: 846, 2009). In the U.S., 1% of asymptomatic people are positive for HCV (maybe more than this among swingers and MUCH more among IV drug users; maybe 0.3% in those not in these risk groups; health care workers aren't at increased risk: Lancet 343: 1618, 1994; ear-piercing is a risk factor: NEJM 334: 1691, 1996; 19% positive for inner-city forensic-pathology service deaths J. For. Sci. 38: 1075, 1993); in the 2000's, intravenous drug use was the most common cause in the USA, with 98% of junkies positive in some communities; in the poor nations, it's around 5%; worldwide 3%; the highest known prevalence is around 20% in Egypt (see below). At least 170 million people are infected worldwide (Science 288: 339, 2000), at least 3 million in the USA, with about 10000 deaths yearly (that mortality figure is conservative and is going to increase: JAMA 297: 784, 2007).
Hepatitis C virus is transmitted by the same routes as hepatitis B, but is clearly not nearly so catching. The best route seems to be blood transfusion or needle-sharing (J. Inf. Dis. 162: 823, 1990; hemophiliacs Blood 84: 1020, 1994).
Needlesticks from infected blood carry about a 6% chance of infection (Br. Med. J. 315: 333, 1997) and prophylactic treatment with anti-hepatitis C medicines is now administered routinely after such events.
Strangely, nobody yet knows the prevalence of perinatally-transmitted hepatitis C, but it can declare itself later in life as a fulminant illness: Arch. Dis. Child. 88: 160, 2003.
Thankfully, with changing lifestyles (maybe) and surveillance in the hospital (certainly), the transmission rate of hepatitis C is only about 1/5 what it was in the 1980's (Sci. Am. 280(3): 17, March 1999.)
The risk from a transfusion is now about 1 in 2 million (Lancet 361: 161, 2003).
* Among several hundred Irish women infected in the '70's by bad RhoGam, half still had demonstrable virus, most of these had some inflammation, many had some fibrosis, but only two had cirrhosis (NEJM 340: 1228, 1999).
Hepatitis C transmission by acupuncture is now so well-known that you'd do well to warn your patients to be sure they know who's doing it (Can. Fam. Phys. 49: 985, 2003).
Sexual transmission is very rare but it probably occurs (JAMA 269: 361 and 392, 1993; Gut 45: 7, 1999; the risk to MSM's seems very low Am. J. Pub. Health 95: 502, 2005); older studies suggest that around a quarter of spouses do eventually catch it (Ann. Int. Med. 120: 748, 1994). Vertical transmission from Mom is common, especially if Mom has lots of virus on board: NEJM 330: 744, 1994. In some communities -- in striking contrast to HIV, hepatitis B, and so forth -- around 40% of people who carry the virus haven't got a clue how they got it.
* Maybe from the barber (?! the macho man's horror; see Lancet 345: 658, 1995). Nothing further.
In the US, if you're living clean enough to donate blood, your chance of coming down with hepatitis C is very low (BMJ 316: 1413, 1998; NEJM 341: 556, 1999).
A majority of people with the antibody do have detectable virus by PCR in the blood.
* Unlike hepatitis B and D, to date there is no reliable stain for hepatitis C.
The presence of the virus's RNA in the blood (or liver tissue, which is harder to obtain) is today's standard for proving infection. The exact specificity of a positive antibody depends on the test (the cheap first-generation assays were infamously nonspecific) and of course the population screened (clean-living people's positive screens are more likely to be false than needle-drug-user's positive screens). For an update on the difficult subject of who to screen and how, see Am. J. Gastro. 100: 607, 2005.
We used to teach that only a few folks do clear the virus quickly after being infected (Science 288: 333, 2000); with newer methods of detecting acute infection, some folks say that around 67% clear themselves without treatment within 8 weeks (Hepatology 37: 60, 2003), though it's also known that many people's viral levels simply become undetectable and the infection does recur. There's still a question of whether to treat immediately or wait-and-see. And some people who are chronically infected have viremia only intermittently, and in some studies, rates of spontaneous clearance over the years are relatively high (Irish J. Med. Sci. 174: 37, 2005 gives a surprising 31%, perhaps just the luck o' the Irish.)
* Children exposed from blood transfusion do much better, often clearing themselves (NEJM 341: 912, 1999).
Egypt, with around 20% of its people infected, has the highest rate. Probably because of needles (used to administer antimony in the treatment of schistosomiasis ) not being sterilized between patients during one of the aggressive "eradicate schistosomiasis" campaigns (Lancet 355: 887, 2000).
Incubation period is a week to six months; texts give the average as 8 weeks. The acute infection is more likely to be subclinical (or cause minor "belly trouble"), and massive necrosis does not occur. However, infection usually becomes progressive. Nobody knows the rate of subclinical infections, so nobody truly knows how many people clear themselves of the infection in the acute phase. If you don't clear it, fortunately, progression is slow, and severe liver failure results in only about 10-30% of people and usually only after decades.
* Miraversin, an antisense oligonucleotide for hepatitis C (miravirsen): NEJM 368: 1685, 2013.
You can get sick several times if you get a big dose of the bug several times (Lancet 343: 388, 1994). After acquiring the virus via blood transfusion, chronic infection with abnormal liver histology happens more often than not (Ann. Int. Med. 137: 961, 2002). The impact on overall length of life is usually small (NEJM 327: 1906, 1992; Gut 47: 845, 2000) but the infection is still a serious business. Patients who are treated for their illness cost third-party payers much less than those who do not (lost productivity, advanced disease): Dig. Dis. Sci. 57: 2995, 2012.
Around a third of hepatitis C virus carriers have aggressive-looking chronic hepatitis or cirrhosis (Br. Med. J. 308: 695, 1994). Unlike the other viral diseases, there is often quite a bit of fatty change (correlates with severity: J. Inf. Dis. 192: 1943, 2005 -- some strains produce random fat-laden cells, others cause the metabolic syndrome itself with most cells in zone 3) and/or regenerative change in the bile ducts, rather few inflammatory cells (maybe just lymphoid aggregates) in the parenchyma, and a portal infiltrate that's all lymphocytes (no plasma cells or eosinophils, and perhaps even making a "nice lymphoid aggregate" or even a "nice lymphoid follicle / germinal center") suggests hepatitis C. The progression to fibrosis is steady and usually takes decades; if you're male, a drinker, older, and/or unlucky, it may take only a decade or so (Lancet 349: 825, 1997.)
NOTE: As with hepatitis B, carrying hepatitis C, with or without ongoing liver disease, is an important cause of cryoglobulinemia (Am. J. Med. 96: 124, 1994; NEJM 330: 751, 1994 for the success of alpha-IF therapy). The cryoglobulins are immune complexes made of the virus and the antibodies.
* How does hepatitis C virus produce fibrosis? There is often remarkably little inflammation. In one model, the virally-infected hepatocytes produce huge amounts of transforming growth factor beta, causing stellate cells to produce collagen. Stay tuned; this may become the basis for a novel anti-fibrogenic therapy (Gastroenterology 129: 246, 2005).
* NOTE: Hepatitis C virus tends to drive out hepatitis B virus over the long-term in patients infected with both (Gastroent. 106: 1048, 1994, others).
* As with hepatiis B, quite a few of these people never have elevated transaminases, even as they progress to cirrhosis. We have to wonder how these people's infections were detected (Am. J. Gastro. 98: 1588, 2003).
We now eliminate about half of chronic infections using a combination of pegylated interferon and ribavirin. This is one of the most important triumphs of late-20th_century medicine in the last decade. More about this on your gastroenterology rotation.
* Future pathologists only:
Metavir fibrosis score:
F1 = portal fibrosis, no septa
F2 = portal fibrosas, a few septa
F3 = portal fibrosis, lots of septa, no cirrhosis
A1 = mild activity
A2 = moderate activity
A3 = severe activity
Ishak fibrosis score:
0 = no fibrosis 1-2 = portal fibrosis, no bridging 3-4 = bridging, no cirrhosis 5-6 = cirrhosis
For the harder-to-treat HCV genotypes, a metavir score of F2 or less (few or no septa) or a Ishak score of 2 or less (no bridging) may justify following but not treating the patient.
Like hepatitis B, longstanding infection with hepatitis C places a person at grave risk for hepatocellular carcinoma (Lancet 345: 413, 1995).
Nowadays, hepatitis&C infections are treated aggressively with the hope of cure. The difficult genotype 1 seems to respond well to the regimen with added boceprevir (NEJM 364: 1195 & 1207, 2011 -- now there are reports of most patients having their infections cleared with ABT-450 -- protease inhibitor -- plus retonavir NEJM 370: 222, 2014). For people with genotypes 1, 2 or 3 even with previous treatment failures, the combination of daclatasvir and sofobuvir seems to clear most infections NEJM 370: 211, 2014. Ledipasvir and sofosbuvir: NEJM 370: 1483, 1879 & 1889, 2014. Ombitasvir, dasabuvir and ribavirin: NEJM 270: 1594 and 1604, 2014. Oral regimen: Daclatasvir, asunaprevir, and beclabuvir: JAMA 313: 1728, 2015. More about the emerging regimens, which can work even for the hard-to-treat genetype 1 strain: Lancet 385: 1107, 2015. You can read about a variety of other current studies.
* Transgenic mice carrying only the core protein develop steatosis, adenomas, and then hepatocellular carcinomas (Nat. Med. 4: 1065, 1998).
In contrast to hepatitis B, the presence of ANTI-HCV usually indicates the persistent presence of hepatitis C virus in the body. The original work found that around 60% of people found to be positive with the first-generation antibody assay did indeed have virus detectable by PCR. The newer assays (RIBA) are much more specific, and are used if the screening is positive but no virus is present in the blood -- if these are positive, the person has probably self-cured.
* There's hope that we'll have a hepatitis C vaccine, but it's a long way off. Like HIV, the virus is notorious for mutating rapidly, even in the same patient, and this isn't good for vaccine-makers. And like HIV, antibodies aren't very protective. Updates J. Imm. 176: 6065, 2006; Gastroenterology 130: 453, 2006.
HEPATITIS G and the HEPATITIS GC family are hepatitis-C-like flaviviruses.
Hepatitis G virus and its cousin GB virus C are relatively common infectious agents that produces a chronic viremia. They're now considered two isolates of the same virus "GB Virus C". They are known to be transmitted by blood products, sex, needles, and mother-to-child (Arch. Dis. Child. 80: F72, 1999). There's an antibody test (Lancet 349: 318, 1997).
Whether these critters ever make anybody sick has been under study for two decades There doesn't seem to be an acute illness (NEJM 336: 741 & 747, 1997). More studies failing to show any evidence that they make you sick: Gut 103: 103, 1998; Arch. Dis. Child. 80: F72, 1999; Ann. Int. Med. 126: 874, 1997.
A person may clear the virus, or have persistent virus infection. Around 85% of hepatitis C patients have evidence of past or present infection (J. Inf. Dis. 194: 410, 2006).
The virus also multiplies in B- and T-lymphocytes (J. Inf. Dis. 193: 451, 2006). It inhibits HIV replication in vitro (J. Inf. Dis. 192: 2147, 2005; Lancet 363: 2040, 2004), and it is claimed that persistent GB virus C coinfection slows the rate of progression of HIV disease (J. Inf. Dis. 194: 410, 2006; NEJM 350: 981, 2004), Stay tuned.
* People who study these things say that C, G, and the GC's all evolved from yellow fever or dengue fairly recently.
* TTV ("transfusion transmitted virus") is a DNA virus that's very common (10% of folks) in Japan, less common in the West. It elevates transaminases after a transfusion, but nobody's found anyone sick from it yet (Lancet 352: 164, 1998).
HEPATITIS E: An important, epidemic calicivirus (now hepevirus) infection in the poor nations (Lancet 379: 2477, 2012; NEJM 367: 1237, 2012).
* This disease produced at least one major outbreak (New Delhi monsoon floods, 1955) but was officially discovered when it caused an outbreak at a Soviet military camp in Afghanistan in 1983. Dr. Mikhail S. Balayan, who knew he was immune to hepatitis A, mixed "a pooled faecal extract from affected soldiers" with his yogurt, went back to Moscow, and when he got sick found the new virus (named HEV) in his stool by electron microscopy Dr. Balayan won the Order of Lenin.
It's usually mild, but there are around 70,000 deaths worldwide each year from massive hepatic necrosis. For some reason, pregnant women (or those taking oral contraceptives: Am. J. Trop. Med. 82: 12, 2010) are likely to be severely affected, and may die. It never becomes chronic in healthy folks. There is no specific treatment. In outbreaks, mortality can be as high as 25%.
In the poor nations, it's waterborne. The developed world has different strains and probably these are from contaminated, poorly-cooked meat. In 2009, the fact that this infection is fairly common in France was linked to the practice of eating raw pig livers. I am not making this up (Emerg. Inf. Dis. 15: 110, 2009).
You'll make the diagnosis on the presence of IgM antibodies. Around 25% of people from the Middle East have had it, but it is less prevalent in the rest of the world (J. Inf. Dis. 16: 801, 1994). Review from the CDC in Inf. Dis. Clin. N.A. 14: 669, 2000.
The first cases of chronic hepatitis E, progressing to cirrhosis, were reported in transplant recipients in 2008 (NEJM 358: 811 & 859, 2008).
Vaccine NEJM 356: 895, 2007; Lancet 376: 849, 2010; NEJM 372: 899 & 914, 2015.
YELLOW FEVER: The reservoir is monkeys (South America and Africa) and it is transmitted monkey-to-human or human-to-human by the Aedes mosquito. The diagnosis is clinical. A relatively mild febrile illness with viremia lasts 3-6 days; in a minority, a fulminant hepatitis follows after initial remission. Pathologists see Councilman bodies, necrosis especially in the mid-zone of the lobule, and a surprising lack of inflammatory response (still the pattern: Trans. Royal. Soc. Trop. Med. 101: 831, 2007). Yellow fever today in Bolivia: Lancet 353: 1558, 1999. Death from yellow fever is probably not so much due to liver failure as to overactivation of cytokines, much as in sepsis: J. Inf. Dis. 190: 1821, 2004. The live yellow-fever vaccine is one of the oldest and most effective but kills some of the recipients; a new inactivated vaccine shows promise (NEJM 364: 1326, 2011). Yellow fever outbreak in the Darfur region of the Sudan: NEJM 368: 689, 2013.
CHRONIC HEPATITIS NOT CAUSED BY VIRUSES
AUTOIMMUNE ("lupoid"; "plasmacytic") HEPATITIS: Chronic hepatitis progressing to cirrhosis, without chronic virus infection but with evidence of immune injury. Reviews NEJM 354: 54, 2006; Lancet 382: 1433, 2013.
Poorly understood, but fairly common (prevalence of around 16 people in 100,000, much higher in some groups especially the Eskimo / Inuit), and deadly if missed (3/4 dead in ten years if untreated).
Many weight loss drugs pose potential hidden dangers and are “associated with hepatotoxicity and acute liver injury.” (7) In the case of garcinia cambogia, it can easily be overused and is not very well-regulated.
We'll distinguish the different types (which bear little relationship to real lupus) when we discuss liver function testing. The most common type ("type I") features autoantibodies against smooth muscle / filamentous actin / F-actin. Other types are distinguished by other antibodies (anti-LKM-1 for the much more severe type II; anti-SLA/soluble liver antigen/LP/liver-pancreas once defined "type III" but now are a variant of type I: Gastroent. 135: 2107, 2008), but the havoc is wrought by the T-cells.
* Despite its reputation as a slow, chronic illness, it may be acute and even fulminant (Dig. Dis. Sci. 58: 897, 2013).
* Leave the diagnosis of the uncommon "autoantibody-negative autoimmune hepatitis" to the gastroenterologists. There may be an unknown autoantigen, or the familiar antibodies may show up later (Dig. Dis. Sci. 57: 610, 2012).
Current thinking is that something first damages the liver (probably one of the viral hepatitis family, or some drug or poison, or whatever), and patients then get sensitized to their livers and start destroying them over the long haul. More about this later.
Drugs that trigger "lupoid hepatitis" include some of the older ones, and today minocycline (Br. Med. J. 312: 169, 1996) and the infamous herbal remedy "dai-taiko-so".
Future pathologists: Autoimmune chronic hepatitis usually features a lot more plasma cells than does viral chronic hepatitis.
* F-actin antibodies plus a histologic picture of autoimmune plasmacytic hepatitis is fairly common in chronic hepatitis C infection and HCV/HIV coinfection (Am. J. Clin. Path. 314: 228, 2012). If you are serious about this being autoimmune hepatitis, ask for the ELISA (very sensitive, now will perhaps define the disease) rather than immunofluorescence.
Unlike in viral infection, the response to immunosuppression (i.e., glucocorticoids and for the long haul azathioprine) is generally good and the illness generally remits after a few years. (Anti-LMK-1 disease is less likely to respond and often does not remit and often relapses, requiring long-term maintenance). The common protocol, which often cures, is based on azathioprine (NEJM 333: 958 & 1004, 1995; update on why some patients tolerate it poorly: Dig. Dis. Sci. 51: 968, 2006).
We suggest following the course of the disease with biopsy, since liver enzymes correlate rather poorly with histologic progression.
* Future pathologists! Here's your scoring system (J. Hep. 31: 929, 1999)
- +2 if you're a female patient
About 85% of these people can achieve remission with today's treatments. Transplantation may eventually be necessary. After ten years, the transplant has about a 50/50 chance of being involved by recurrent disease (Gut 52: 893, 2003; update on the natural history of recurrent autoimmune hepatitis Dig. Dis. Sci. 57: 2248, 2012).
PRIMARY BILIARY CIRRHOSIS: An autoimmune disease caused (we don't know exactly how) by antibodies against pyruvate dehydrogenase ("anti-mitochondrial antibodies"). Lancet 362: 53, 2003. We'll talk more about this under "Liver Testing".
The bile ducts are selectively attacked by the immune system, eventually resulting in severe obstructive jaundice.
For some reason, the biliary epithelial cells express pyruvate dehydrogenase, or something very much like it, on their luminal surfaces (J. Clin. Invest. 91: 2653, 1993). This is evidently the target.
* The anti-nuclear antibodies often seen in primary biliary cirrhosis are usually directed at glycoprotein 210 and/or nucleoporin 62, on the nuclear surface pores.
* There are several known associations with HLA and Interleukin 12 genes: NEJM 360: 2544, 2009.
The histopathology begins with chronic inflammation (mostly portal, sometimes some interface hepatitis), and progresses through bile-duct obliteration and collateral formation to micronodular (why?) cirrhosis. For the details see Mayo Clin. Proc. 73: 179, 1998.
Less easy to explain are the frequent appearance of granulomas and Mallory's hyaline.
* Patients typically complain of severe fatigue, even early in the disease. One group attributes this to retained manganese (Gut 53: 587, 2004).
* Pitfall: Sarcoidosis can look exactly like PBC-with-granulomas, but the AMA is negative.
* Copper is likely to accumulate. Don't confuse it with Wilson's.
<24568> primary biliary cirrhosis, early; cirrhosis has not really developed yet, but portal areas are inflamed; you could not tell at this magnification that this is primary biliary cirrhosis
<24569> primary biliary cirrhosis, histology (i.e., the bile duct is gone)
Joel K. Greenson MD
Chronic inflammatory infiltrate
Primary biliary cirrhosis was found in the 1990's to be considerably more common than we had once thought, and to responds to therapy with bile salt analogues such as ursodeoxycholic acid (nobody knows why; Br. Med. J. 312: 1181, 1996) -- most cases get fairly good response; if more is needed, methotrexate and colchicine are helpful (Dig. Dis. Sci. 55: 3291, 2010).
* "Primary autoimmune cholangitis" looks something like primary biliary cirrhosis, but has high ANA titers and no anti-mitochondrial antibodies. See Am. J. Surg. Path. 18: 91, 1994; update on sorting out the autoimmune hepatitis family histologically Am. J. Clin. Path. 114: 705, 2000.
* IDIOPATHIC ADULTHOOD DUCTOPENIA is disappearance of the interlobular bile ducts; it may be asymptomatic (elevated GGT prompts its discovery) or progress to cirrhosis (NEJM 336: 835, 1997). More often, this is the result of drug-induced cholestasis that isn't recognized in time.
"Secondary biliary cirrhosis" is more likely to be just fibrosis, due to obstruction of the common bile duct, usually in chronic pancreatitis. If the stenosis is relieved, the fibrosis often regresses some (NEJM 344: 452, 2001).
DRUGS AND POISONS (a problem easily overlooked; reviews Gut 44: 731, 1999, NEJM 354: 731, 2006; including how to establish the relationship and warnings about what will happen if you leave the patient on the medication that's causing the liver disease)
As before, "all poisons are drugs, all drugs are poisons".
Drug-induced liver disease is a medicolegal nightmare. Since it is caused by hypersensitivity to medication, and since only a very few people are vulnerable to a particular drug, it's often missed in clinical trials.
To make the call, you want to see one of these:
- SGPT/ALT three times the upper limit of normal
Especially rough on the liver:
Any of these can produce massive hepatic necrosis. The toadstool and the acetaminophen overdose will produce massive hepatic necrosis; "Ecstasy" in recreational amounts is famous for the same (Transplant. Proc. 33: 2743, 2001). The others are more likely to produce a hepatitis-like picture.
ACETAMINOPHEN OVERDOSE is very common.
The drug is metabolized by two different pathways, one "safe", the other productive of noxious free radicals. Ordinarily, we use only the "safe" pathway, but when that is overloaded, the drug gets shunted into the bad pathway.
* We've already seen the "two-pathway" concept in our discussions of atherosclerosis and Alzheimer's disease. Stay tuned for the discovery of more "two-pathway diseases".
Three or four days after the overdose, the patient gets sick and lapses into hepatic failure. By this time, the drug itself may be mostly gone.
Future emergency room specialists: You can block the "bad" pathway using good old N-acetyl-cysteine, or "Mucomist", from the respiratory care department.
On biopsy or at autopsy, the necrosis is most obvious in the central areas. There's little or no inflammation.
* In England and Wales, acetaminophen is the popular method of suicide. Clever legislators required selling acetaminophen ("paracetamol") in smaller packages that required folks to unwrap each tablet. The suicide rate dropped dramatically (BMJ 346: f403, 2013).
BACTERIAL CHOLANGITIS ("ascending cholangitis", etc.) is suppuration involving bile ducts.
Joel K. Greenson MD
The underlying cause is almost always obstruction. Pretty much any gut bacterium can be the opportunist. E. coli is most common; clostridial gas gangrene of the liver is ultra-deadly.
As you would expect, patients are super-sick with the acute infection. Call a surgeon, since the bile has to be drained.
"Charcot's triad" is jaundice, right upper quadrant pain, and a bad fever.
The give-away on histologic exam is neutrophils within the bile ducts. Since there's obstruction, look for bile plugs, too.
LIVER ABSCESSES, in the U.S. are usually of bacterial origin, spreading either up the bile ducts ("cholangitis abscess" -- ascending cholangitis) or via the portal vein ("pyelophlebitic abscess" -- appendicitis, diverticulitis), or from septic emboli (bacterial endocarditis), or following a dirty wound.
Naturally, patients are super-sick, as with ascending cholangitis.
"Amebic abscesses", a misnomer, are areas of "anchovy paste" necrosis without much inflammation. Hydatid cysts can become infected, forming real abscesses.
* PERICHOLANGITIS has been discarded as a term in pathology. Inflammation AROUND the bile ducts, typically extra lymphocytes, is very common at autopsy and no one knows what it means, if anything.
One could conjecture that the liver clears the blood of foul products of fatal disease, and that these are excreted in the bile and attract inflammatory cells.
Patients with ulcerative colitis and Crohn's generally have fibrosis around the bile ducts (SCLEROSING CHOLANGITIS) and often biliary obstruction / biliary cirrhosis.
Or one can have idiopathic PRIMARY SCLEROSING CHOLANGITIS, a curious, probably-immune-mediated entity. The extra-hepatic bile ducts in these diseases come to look like uneven strings of beads. Under the microscope, there is onionskin fibrosis around the intrahepatic bile ducts. Review Lancet 382: 1587, 2013.
* The majority of these patients have positive p-ANCA, often with curious specificities (Am. J. Med. 105: 393, 1998; Gut 44: 886, 1999.)
More recently, there are claims that there are distinctive autoantibodies against biliary epithelium (Gastroent. 132: 1504, 2007), and this seems to be holding up.
Medical therapy does not slow the progression of this disease. Many of these people need liver transplants, and the disease tends to recur in the transplanted organ.
* Sclerosis of the bile ducts is one feature of IgG4 sclerosing disease. More about this when we understand it.
* Perhaps 20% of folks go on to develop cholangiocarcinoma.
No inflammation, just no ducts
Onion-skinning around bile duct
Malaria can load the Kupffer cells with pigment, but seldom causes hepatic dysfunction.
KALA-AZAR (a vicious form of leishmaniasis ) packs Kupffer cells with organisms but does not interfere with liver function.
INFECTIOUS MONO from any of the usual causes can produce elevated transaminases and/or mild hepatocyte failure.
SECONDARY SYPHILIS can give an acute hepatitis, while TERTIARY and especially CONGENITAL syphilis are noted causes of hepar lobatum, due to scar contraction.
Don't forget LEPTOSPIRA in unexplained jaundice, especially if there is hemolysis.
* PENICILLIUM MARNEFFEI is an opportunist in AIDS, especially in Southeast Asia (Arch. Path. Lab. Med. 128: 191, 2004).
Increased pressure in the portal venous system, for whatever reason (usually increased resistance to flow and/or increased anastomoses with the arterial circulation).
Portal vein obstruction / compression
Thrombus (typically from tumor invasion, hypercoagulability, or polycythemia vera)
Tumors (hepatic, biliary, pancreatic)
Really bad pancreatitis
Cirrhosis (both fibrosis of the vasculature, especially hepatic veins, and AV-shunting contribute)
* Central hyaline sclerosis without cirrhosis
Really bad fatty change
Alcoholism / "alcoholic hepatitis", etc.
Schistosomiasis (eggs plug portal vein radicles, leading to the infamous "pipestem fibrosis")
* Congenital hepatic fibrosis (a thankfully-rare birth defect, with very few veins in the expanded portal areas; one known locus is a variant autosomal recessive polycystic kidney disease gene, and hepatic fibrosis is common in the fully-expressed condition as well: Medicine 85: 1, 2006)
Osler-Weber-Rendu telangiectasisa (abnormal vascular communications: NEJM 343: 931, 2000).
Really bad right-sided heart failure
Regardless of cause, portal hypertension is troublesome.
Patients get ASCITES, or large accumulations of fluid in the abdomen. This is troublesome. Mechanisms of formation include
(1) the obvious increase in hydrostatic pressure in the venules;
(2) the increase (most mechanisms) in hydrostatic pressure within the hepatic sinusoids themselves (the "increased hepatic lymph formation" of "Big Robbins"; this stuff is likely to be rich in protein, since the hepatic sinusoidal "endothelium" is discontinuous)
(3) diminished circulatory volume due to low serum albumin, with a tendency of the kidneys to retain sodium and water. (BEWARE! If you give these patients a diuretic, you can send them into shock, kidney failure, "hepatorenal syndrome", etc., etc.)
Caused by cirrhosis
Dilated submucosal veins
(Ignore the "hyaline perisplenitis")
PORTO-SYSTEMIC SHUNTING results when blood from the guts finds other routes back to the right side of the heart.
This results in ESOPHAGEAL VARICES (which can bleed profusely), SEVERE HEMORRHOIDS ("anorectal varices", which can bleed profusely), and the distinctive CAPUT MEDUSAE around the belly-button.
* This also probably is the cause of the usually-mild IMMUNOGLOBULIN A NEPHROPATHY typical of cirrhotics (i.e., asymptomatic hematuria). IgA from the gut ends up in the kidneys, rather than being cleared by the liver.
FIBROCONGESTIVE SPLENOMEGALY produces big, firm spleens that often produce clinically significant hypersplenism (i.e., they make the person anemic, neutropenic, and/or thrombocytopenic). This is bad.
You can treat portal hypertension effectively by doing a porto-caval shunt operation. If the underlying problem is cirrhosis, this will result in blood flowing directly from the bowel to the systemic circulation, making hepatic encephalopathy much, much worse ("portosystemic encephalopathy"). But most people prefer this to dying of bleeding varices.
Sclerosing agents save the lives of patients during acute bleeds. Today, banding ("band ligation") is doing the same (Br. J. Surg. 86: 437, 1999.)
For lasting control, the patient is likely to have the shunt placed inside the liver itself, by the radiologist who passes a catheter down the jugular vein ("transjugular intrahepatic portosystemic shunt" -- now revolutionized by the development of the covered shunt which allows longer shunt patency AJR 199: 746, 2012).
* Old-fashioned "prophylactic sclerotherapy" of esophageal varices actually increased the risk of dying. Perhaps it just made whatever vein didn't get sclerosed into a bigger varix. NEJM 324: 1779, 1991.
Of course, portal hypertension isn't the only problem that the cirrhotic has. See "When the liver fails", above.
ALCOHOLIC LIVER DISEASE (Lancet 345: 227, 1995; Mayo Clin. Proc. 76: 1021, 2001)
Double normal weight
Joel K. Greenson MD
Alcohol vs. NASH
Woe to those who demand strong drink as soon as they rise in the morning, and linger into the night while wine inflames them!
Sir, I have known more old drunkards than old doctors.
"The Wine God's Procession"
Everybody knows alcohol is bad for the liver, but there is perennial confusion about the various patterns of liver injury and their outcome.
ALCOHOLIC STEATOSIS ("alcoholic fatty liver")
We've already reviewed why fat accumulates in liver cells damaged by alcohol.
To review: The drunken hepatocytes make too much fatty acid, make it into excess triglyceride instead of burning it, then can't complex the triglyceride to apolipoproteins, and can't export the lipoproteins they do make.
Current thinking supports popular wisdom that alcohol itself does the damage (in fatty change and the more severe forms of "alcoholic liver disease"). Poor nutrition doesn't help, either (i.e., few people make daily trips to the salad bar while on benders.)
If you've ever drunk a case of beer over a great football weekend, I bet you've had fatty liver. Did you notice? Probably not. The "disease" is usually just a pathology finding, unless:
Fatty liver is, by itself, completely reversible once the drinker sobers up. The same applies to fatty liver from other causes i.e., after bariatric surgery (Gastroenterology 130: 1617, 2006), in obesity, in ill-controlled adult-onset diabetes, in problem pregnancy, in galactosemia, in methotrexate toxicity, in Wilson's disease, and as a complication of a few rare disorders of lipid metabolism.
NOTE: "Microvesicular steatosis" (smaller vacuoles, usually several per cell) is typical of Reye's syndrome, problem pregnancies, mitochondrial problems (Gastroent. 108: 193, 1995), and toxicity from outdated-tetracycline poisoning, or some of the HAART drugs. It's also reversible; really, "microvesicular" steatosis can occur in any fatty liver.
* In my opinion, the "microvesicular vs. macrovesicular" distinction is of no value. I have seen only one Reye's autopsy, and it was pure macrovesicular fat. I've autopsied many, many problem drinkers, and the pattern is often mixed, and sometimes microvesicular-only. I addressed this question to the pathology on-line group in 1996, and there was no disagreement from a few hundred experienced pathologists.
NOTE: "Fatty change" confined to the stellate cells ("Ito cells") is vitamin A overdose. "Stellate cell lipidosis" is often due to vitamin A overdose or Retin-A: Am. J. Clin. Path. 119: 254, 2003.
* Of course, if you continue drinking, you're at serious risk to get cirrhosis, even if "you only had fatty change" on a biopsy. Bad prognostic indicators include giant mitochondria and mixed microvesicular and macrovesicular fat. See Lancet 346: 987, 1995.
ALCOHOLIC HEPATITIS (NEJM 360: 2758, 2009)
Much more serious. Here, we have inflamed liver cells with widespread liver cell death and some stranger things than fat in the liver cells. The process is worst in the centrilobular regions.
Alcoholic hepatitis comes on suddenly, usually after years of problem drinking. However, it's clearly a different entity from both common "fatty liver" and the all-too-familiar cirrhosis. The patient -- who may not even have had a drink for a few weeks -- suddenly comes in with jaundice (bilirubin 5 mg/dL or more), elevated transaminases, and signs of portal hypertension and liver failure. Typically there's also an increase in blood neutrophils.
The cause of alcoholic hepatitis -- the sudden appearance of a new disease after years of drinking -- has been a minor mystery of medicine for centuries. Today's thinking focuses on alteration of the permeability of the large bowel, allowing endotoxin to flow into the portal circulation. It activates Kupffer cells and causes them to produce TNF-α.
The process can kill a patient directly. If an anesthetic is required, this may precipitate liver failure. Or some Hippocrates who doesn't want to biposy the liver because of the known tendency to bleed will feel it to be enlarged and assign an erroneous diagnosis of cirrhosis.
On biopsy, surviving liver cells often bear MALLORY'S ALCOHOLIC HYALINE (not pathognomonic, but suggestive). This is masses of altered prekeratin fibers plus stress proteins. Free Mallory's hyaline is chemotactic for neutrophils.
Also look for GIANT MITOCHONDRIA, (* Yokoo bodies, after one of the professors who trained your lecturer), PAS-negative blobs in the cytoplasm.
* Mitochondria (giant or no) in alcoholics' livers often have genetic damage, presumably because alcohol generates toxic free radicals inside them (Gastroent. 108: 193, 1995). This is one more putative mechanism of fatty liver. How?
The process tends to be worse in the central regions, but no area is spared. Cholestasis is usual because of compromise of bile canaliculi, with bile lakes and bile plugs. At the same time, the bile ducts may proliferate within the portal areas.
As the liver cells die off, look for FIBROSIS, notably around the central veins ("central hyaline sclerosis"; see Virch. Archiv. 614: 11, 1989; Postgrad. Med. J. 76: 280, 2000). This won't go away, and seems to be a rapid route to cirrhosis. (* You may be told that alcoholic hepatitis always precedes alcoholic cirrhosis; there's no reason to think this is true.)
<39929> alcoholic hepatitis, good Mallory's hyaline
<26702> alcoholic hepatitis, good Mallory's hyaline
<08832> alcoholic hepatitis with fibrosis; there is no good hyaline; cells are becoming entrapped in the fibrous tissue
<21056> "alcoholic hepatitis", looks like early cirrhosis to me
<26693> "alcoholic hepatitis", looks like early cirrhosis to me
The treatment is sobriety, and perhaps medications or lactobacilli to alter the gut flora; watch for TNF-blockers.
Again, the histology is not pathognomonic for alcoholism. The heart-drug amiodarone in particular is infamous for producing the same histopathology, and post-ileal bypass hepatitis, Wilson's disease (shouldn't miss this one!), NASH, and * East Indian childhood cirrhosis (copper toxicity in the genetically-predisposed; J. Path. 195: 264, 2001) can be dead-ringers.
If you are actually in the hospital and your primary diagnosis is alcoholic hepatitis, you probably have it very, very bad. explaining why the mortality figures in some studies are so high (for example, J. Clin. Gastro. 40: 833, 2006).
Fortunately, if you sober up, all that will remain is whatever minor scarring has occurred. The liver cells will regenerate nicely, and your liver will probably be fine.
ALCOHOLIC CIRRHOSIS ("Laennec's cirrhosis", other names)
Exactly what causes the progression (if it is a progression) from reversible changes (fatty change, Mallory bodies, inflammation) to irreversible (?) disease (i.e., fibrosis-cirrhosis) is obscure.
Easy to remember -- if you drink less than six beers per day / four glasses of wine per day, cirrhosis is unlikely. In order to get cirrhosis, one needs at least 15 pint-years (i.e, a pint of the hard stuff per day for fifteen years, three pints a day for five years, or similar). Many cirrhotics have much more. Yet 2/3 of heavy drinkers die without cirrhosis. Nobody knows why.
At first, the liver is big because of widespread hepatocyte overgrowth and fatty change from ongoing drinking. Later, with advanced scarring and enforced sobriety, the liver becomes rather small.
Microscopically, you'll see fibrosis and nodules instead of the normal architecture and proliferated bile ducts in the scar tissue (a good sign of alcoholism).
Early Laennec's cirrhosis has fine bands and a micronodular pattern. Late, the pattern becomes post-necrotic. When the scar tissue starts seriously obstructing bile flow, clinicians see jaundice and the pathologist sees bile plugs.
<20163> alcoholic cirrhosis, histology; trichrome stain
<10535> "alcoholic cirrhosis" closeup of a lobule; note the Mallory's hyaline and the neutrophils attacking it. There may be fibrosis elsewhere, but this merely looks like alcoholic hepatitis.
<39593> alcoholic cirrhosis; lots of bile duct proliferation (as is usual in alcoholic cirrhosis); edge of a nodule on each side of the screen
The cirrhotic must decide what he or she wants out of life. Continuing drinking is overall as lethal as untreated AIDS. Sobriety gives maybe a 90% chance of not dying of the cirrhosis within the next five years.
* During the early 1990's, liver transplants for alcoholic liver disease got discussed as showcasing problems with our "no-guilt" / "you have a right" ideas. "Unconstitutional discrimination and a violation of the Americans with Disabilities Act" or not (the story of Mr. Bush's 1992 policy change is now history), good used livers and other resources are (as always) in limited supply. See Gastroent. 102: 1806, 1992 (the now-famous Pittsburgh study), JAMA 265: 1295, 1991; JAMA 266: 213, 1991; Br. Med. J. 299: 693, 1989. Half of alcoholics who receive liver transplants return to problem drinking within one year (Gut 43: 140, 1998), but the good news is that they seldom wreck their new livers in doing so (Gut 45: 421, 1999). In the late 20th century, a few philosophers continued to maintain that alcoholics "may justifiably be given lower priority than others in receiving these [limited] resources" (J. Med. Philos. 23: 31, 1998). However, the most recent article I could find was in Transplant International 14: 170, 2001 (essentially, lifelong alcoholics are no more responsible for their ruined livers than are babies with biliary atresia). Uh, sure. The "ethical debate" seems to be over and alcoholics are competing on an equal basis for liver transplants with the dying babies. The third-party payers now require six months of abstinence from alcohol, which is unverifiable and unenforcable (J. Med. Ethics 32: 263, 2006) -- and a large percentage return to alcohol abuse when they get their new liver. Update from the ethicists NEJM 365: 1836, 2011. ("We only transplant alcoholics who are sobered up, have a strong support network, and no major psychopathology.") Of course, an alcoholic might get some slight sympathy if someone who ruined their liver doing intravenous drugs or sexual promiscuity or taking medicines with suicidal intent (Liver Trans 17: 1111, 2011) gets priority. Especially if we continue to make it difficult to obtain organs for transplantation, this will eventually start getting media attention -- the truth is that I'm surprised it hasn't already.
This is one of the easiest ways to put yourself into an extreme calorie deficit for rapid weight loss.
Strangely, having been a marijuana smoker absolutely disqualifies people from receiving a liver transplant in most jurisdictions (Curr. Op. Org. Transpl. 15: 249, 2010) although there is evidence that this does not have any negative impact on people before or after transplant. Tobacco smokers may or may not be barred from receiving a liver; they do worse than non-smokers. Nowadays, anyone with enough money can go to China and come back with a new liver from an executed prisoner (Clin. Transp. 23: 831, 2009); a few "moral high ground" ethicists say it's immoral for US physicians to treat people who have done this (Am. J. Bioethics 10: 3, 2010) -- what do you think?
NON-ALCOHOLIC FATTY LIVER DISEASE -- non-alcoholic steatohepatitis, NASH, non-alcoholic fatty liver diseae, NAFLD (Am. Fam. Phys. 73: 1961, 2006; pathologists see Am. J. Clin. Path. 128: 837, 2007; J. Clin. Path. 60: 1384, 2007; Gastroent. 134: 1682, 2008; NEJM 363: 1341, 2010); BMJ 343: d3897, 2011; Gut 60: 1152, 2011 -- "what's new under the microscope"); JAMA 313: 2263, 2015.
NASH -- non-alcoholic steatohepatitis, fatty change into which acute inflammation, necrosis and fibrosis can creep -- is a poorly-understood but very real, very common condition that is only now getting the attention it deserves.
The JAMA article, cited above, claims that a majority of older obese and older diabetic folks have this and have fibrosis as a result; the pathology community is simply not seeing this at autopsy, but I don't doubt that NASH is at least a marker for bad health.
In countries where little alcohol is consumed and there is not much hepatitis or schistosomiasis , this is the most prevalent liver disease.
The anatomic pathology is much like alcoholic liver disease, with fatty change, often Mallory hyaline, and sometimes even cirrhosis (not so vicious as other forms of cirrhosis, but still sometimes requiring transplant -- Hepatology 43: 682, 2006).
* One tip-off that this is NASH is "chicken-wire" perisinusoidal fibrosis around hepatocytes in the central region. It is not pathognomonic, and to my eye is the hyalinization of the microvasculature already known to happen in the liver in diabetes.
There is always insulin resistance as well. Presently, discussions of pathophysiology emphasize the "adipokines" TNF-α and leptin, produced by bodyfat and causing insulin resistance. TNF-α is considered responsible for the cell injury, and leptin for fibrosis. The whole business is still very puzzling (Am. J. Path. 169: 846, 2006; Dig. Dis. Sci. 53: 1099, 2008); new players Gastroent. 134: 556, 2008; Am. J. Clin. Nutr. 89: 558, 2009.
The disease now easily the most common chronic liver disease in children and teens in the industrialized world, and many of these kids have fibrosis (Gastroent. 135: 1961, e2, 2008; Gastroent. 136: 160, 2009).
The mainstay of therapy has historically been weight loss and exercise in the overweight, masterful inactivity and perhaps metformin in the non-overweight (Med. Clin. N.A. 80: 1147, 1996; rationale for metformin Am. J. Gastro. 98: 2093, 2003). Exercise works for the mouse model (Diabetes 60: 2720, 2011). Betaine as a remedy: Am. J. Gastro. 96: 2534, 2001; Am. J. Gastro. +2 ), and not ferric (Fe +3 ) iron, is absorbed across the "mucosal barrier", mostly in the duodenum. It is complexed to a protein called NRAMP-2 (no diseases here yet) that transports much more efficiently when body iron stores are low. So the amount of iron absorbed varies inversely with the amount of ferritin already present in the duodenal epithelial cells, which in turn reflects total body iron stores. Iron absorption by the gut also increases when there is increased normoblastic activity. (The mechanism remains unknown; the latest stuff Blood 96: 4020, 2000.) Absorption is mildly increased in hemolytic anemias or after hemorrhage. Absorption is more markedly increased in "ineffective erythropoiesis", notably in severe sideroblastic anemia and thalassemias. Huge doses of dietary iron can override the regulatory mechanism.
Iron atoms are slowly released into the plasma, where they are bound to the globulin transferrin. The amount of transferrin present is also regulated, so that more will be present when more iron is required. The iron is then carried where it is needed. (* Transferrin will only carry ferric iron, while most of the other forms of iron are ferrous.) Likewise, when a red cell (or any other cell) is destroyed, its iron is carried away by transferrin. Extra iron is stored, mostly in the liver and bone marrow. In health, it is available for incorporation into RBC's or for transport by transferrin should a shortage develop.
Storage iron (somewhere in the range of 1 gm in most people) exists in two principal forms. (1) FERRITIN is a bit of iron at the center of a protein micelle. The protein shell explains the negative Prussian blue stain. This is the short-term storage form. It is the form found, for example, in bone marrow when it is soon to be incorporated into new RBC's. (2) HEMOSIDERIN is aggregates of ferritin with much of the protein gone. This is "Prussian blue positive" iron. It is a less labile storage form that accumulates when there is excess ferritin. (* "Hemosiderin" is an archaic name chosen by von Recklinghausen. "Exogenous hemosiderin" is an iron-protein complex that forms around sites of iron injection and foreign bodies composed of iron). Hemosiderin is the yellow pigment in the halo surrounding a bruise. Tip: If an injured area is pigmented yellow three months after bruising, the patient probably has iron overload.
Humans have no special mechanism for excreting excess absorbed iron. There is ordinarily a loss of 1 mg/day or so through GI and skin cell turnover and microhemorrhages into the gut and GU tracts. A typical menstrual period results in a loss of 10-20 mg of iron. During the course of a pregnancy, the fetus absorbs 500-1000 mg of iron from the mother's bloodstream. The fetus "gets priority" and often the mother becomes iron-deficient. Donating a 500 mL unit of blood removes approximately 250 mg of iron from the body.
Iron does harm to cells by generating free radicals. Primary iron storage problems are very common, under-diagnosed, easily and inexpensively detected, potentially fatal, and very treatable. And these patients are often considered hypochondriacs for many years before the diagnosis is finally made (Ann. Int. Med. 101: 707, 1984). During the early 1990's, it was finally appreciated that around 1 man in 200 is affected (NEJM 318: 1355, 1988). HEMOSIDEROSIS ("systemic siderosis", etc.): increased total body iron (as ferritin and hemosiderin), from any cause. Most of the excess iron is in the reticuloendothelial cells. Spill-over into parenchymal cells is what can cause trouble. It is now known that 13% of people carry an autosomal gene (HFE, within the HLA complex; update Arch. Int. Med. 166: 294, 2006) for excessive iron absorption via the gut and too-easy entry of iron into the liver cells. Homozygotes have worse problems; thankfully, we have finally come to recognize this as "the most common genetic disorder in populations of European ancestry": Am. J. Med. 119: 391, 2006; the vast majority of patients of Northern European stock have a C282Y mutation, and around 0.7 of people of Northern European ancestry are homozygous for the allele (update NEJM 358: 221, 2008; of these, one man in 4, and one woman in 10 is sick from it). H63D is common worldwide. Depending on diet and iron losses, these people may or may not express their PRIMARY HEMOSIDEROSIS.
HEMOCHROMATOSIS is hemosiderosis that has damaged parenchymal cells. Total body iron stores in excess of ten gm are very dangerous. In classic cases, total body iron stores often exceed 100 gm. PRIMARY HEMOCHROMATOSIS (formerly "idiopathic", now "familial", "genetic", "hereditary", or "HLA-linked"): in which the problem is greatly increased absorption of iron from the gut. These are "primary hemosiderosis" people in which the iron overload causes illness. Perhaps 1 man in 200 will be symptomatic with this during life, and thankfully we are diagnosing it more often. Review Am. Fam. Phys. 65: 853, 2002; Lancet 370: 1855, 2007. Update on screening (from the USPSTF): Ann. Int. Med. 145: 204, 2006. So do you screen using transferrin saturation (which is awfully sensitive and not very specific), the HFE gene (which is too expensive), or a serum ferritin (which picks up the people at risk for cirrhosis, albeit late, and is also up in acute or ongoing liver abuse/disease)? The case for ferritin: Blood 111: 3373, 2008. Expect continued disagreement.
* Other loci encode rare, severe forms. See below for an update.
SECONDARY HEMOCHROMATOSIS most often occurs in thalassemia major and in severe sideroblastic anemias. (Before it's symptomatic, of course, it's "secondary hemosiderosiss"). In these conditions, there is greatly increased iron absorption through the gut, and the patient requires many blood transfusions with no way of disposing of the iron load. Obviously you cannot treat these patients by bleeding (why not?) Deferoxamine is life-saving in thalassemia major: NEJM 331: 567, 1994.
So, in primary hemosiderosis and hemochromatosis, the problem is that iron is absorbed too easily through the gut. A patient homozygous for primary hemochromatosis who donates blood every eight weeks will remain iron-depleted. The tendency is encoded at HFE (Proc. Nat. Acad. Sci. 94: 2534, 1997 review, was HLA-H), discovered in 1996 in the HLA complex on chromosome 6, very closely linked to HLA-A and much like it; mouse hemochromatosis is caused by a bad beta2-microglobulin gene (Proc. Nat. Acad. Sci. 93: 1529, 1996) while the abnormal HLA-H doesn't bind properly to its microglobulin component. (* HLA-A3, B7, and B14 are often present, but the defect is linked with the chromosomes. Almost all B14 owners have the hemochromatosis gene, which is one reason (out of three) that your lecturer is confident that he carries it.) The frequency of the allele is about 14 out of every 100 chromosome 6's. Iron losses due to menstruation and pregnancies prevent expression primary hemochromatosis from ever developing in most women with the gene(s). Primary hemochromatosis is diagnosed nine times more frequently in men.
The classic hemochromatosis triad is liver trouble, diabetes mellitus, and skin discoloration. Today's list of major problems also includes cardiac rhythm disturbances, cardiac pump failure, and loss of sexuality. The liver may be enlarged on physical exam, or transaminases may be a bit high (South Med. J. 83: 1277, 1990). Around half of identified hemochromatosis patients develop overt diabetes mellitus. Since the 1990's, it has been considered good practice to screen everybody for iron overload (Gastroenterology 107: 453, 1994.) Most get the peculiar skin discoloration to some degree. The classic form of the disease is usually fully expressed around age 40-60 years. Patients, however, say their ill-health began during their 20's (Am. Fam. Physician 29: 55, March 1984).
LIVER DISEASE is the most serious problem in the majority of diagnosed hemochromatosis patients. The hepatocyte lysosomes and mitochondria are packed, and total liver iron stores are often more than one hundred times normal. There is often extensive fibrosis prior to the onset of symptoms (Arch. Int. Med. 166: 294, 2006), helping explain the classic observation that the liver enlarges even before cirrhosis develops. (The fibrosis reverses on iron removal unless cirrhosis is fully-developed.) The radiologist may notice it is unusually radio-dense. Micronodular cirrhosis (scarring that ruins the architecture of each lobule) is usually present by the time the diagnosis is made. When caused by hemochromatosis, this is called "pigment cirrhosis"). For the degree of fibrosis, the liver works surprisingly well, and clinical manifestations of cirrhosis are less severe than in alcoholic cirrhosis. However, cirrhosis is general considered irreversible and will finally kill the patient unless something else does first. (And something else usually does; only 25% of patients diagnosed to have primary hemochromatosis die of cirrhosis.) Once cirrhosis due to hemochromatosis has developed, the patient is at great risk for hepatocellular carcinoma (and to a lesser extent cholangiocarcinoma; histology Am. J. Clin. Path. 116: 738, 2001; hepatocellular carcinoma in iron overload without cirrhosis Am. J. Med. Sci. 334: 228, 2007). This is fatal and kills another 30% of patients diagnosed to have primary hemochromatosis.
Although more iron is deposited in the pancreatic acinar cells than in the ISLETS OF LANGERHANS, around 50% of patients have enough damage to their beta cells to develop symptomatic glucose intolerance.
CARDIAC INJURY is also caused by iron overload. Many hemochromatosis patients have pump failure and/or rhythm disturbances, either of which can be disabling or fatal. This is the other leading cause of death in iron-overloaded people. (How many of these deaths are assumed to be due to some other disease process? No one knows.)
ENDOCRINE INJURY is an additional problem. Patients are commonly troubled first by loss of libido, and eventually lose their secondary sex characteristics. Testicular atrophy secondary to pituitary failure with deposition in anterior lobe and Leydig cells too. It is quite reversible. Loss of testosterone in both men and women is now considered the explanation for the osteoporosis that develops in hemochromatosis patients (Ann. Int. Med. 110: 430, 1989). In addition, the adrenals, thyroid, and parathyroids are likely to be damaged, with various endocrine insufficiency syndromes. (* The role of "melanocyte stimulating hormone" in "bronze diabetes" is dubious.)
JOINT INJURY caused by iron overload (Arth. Rheum. 63: 286, 2011) is yet another major problem. Iron deposition in synovium results in synovial hyperplasia and erosion of bone and cartilage, eventually ruining the joint. In hemochromatosis, this usually affects the fingers, and is a problem for 50% of patients. In addition, the knees (and other weight-bearing joints) of hemochromatosis victims occasionally get accumulations of pyrophosphate crystals ("pseudogout", chondrocalcinosis).
SKIN PIGMENTATION in hemochromatosis is primarily due to increased melanin. (* Iron inhibits the enzyme that normally breaks down melanin.) Melanin imparts the "bronze" color; if there is enough hemosiderin in the skin, the combination looks "slate-gray".
Sepsis: For some unknown reason, Vibrio vulnificans (a raw seafood bug), Pasteurella pseudotuberculosis and Yersinia enterocolitica are much more pathogenic in the presence of iron overload. In 2011, the death of a CDC researcher from the relatively nonvirulent of plague with which he was working was attributed to his hemochromatosis (yes, they missed it even in a CDC worker -- NEJM 364: 2563, 2011). Even E. coli may get a boost in hemochromatosis (Am. J. Med. 87(3N): 40N, 1989).
You'll learn to make the diagnosis soon. In primary iron storage disease, it is important to make the diagnosis early. By the time the patient is obviously sick with hemochromatosis, he is 40 years old, has at least 20 grams of iron stored, has cirrhosis, and will probably be dead within ten years (though you can still help). If you find the tendency to accumulate iron, do this:
* "Why don't you give an iron chelator instead?" Retinal damage from deferoxamine is supposedly reversible. Some new iron chelator drugs are available now, but I'd still stick with the no-drug approach.
Secondary hemosiderosis and hemochromatosis: Nowadays, there is a tendency to transfuse sickle cell patients heavily in the hope of preventing stroke. Patients with severe thalassemia, Blackfan-Diamond, aplastic anemia and some of the myelodysplastic syndromes also become transfsion-dependent. The abnormal anatomy is similar to primary iron storage disorders, but more of the iron is usually in the Kupffer cells, not the hepatocytes until quite late. (People who overdo oral iron and make themselves sick tend to have a lot of hemosiderin in both hepatocytes and Kupffer cells.) Hemosiderosis due to red cell transfusions ("transfusional" or "iatrogenic siderosis") is unavoidable in patients with severe anemias of decreased production unless chelators are used (and these work well: Gastroent. 141: 1202, 1211). Remember, 100 red cell transfusions delivers 25 gm of iron! This is more than enough to produce hemochromatosis. These patients are now being treated with the new iron chelator drugs (update NEJM 364: 146, 2011) which are fairly well tolerated.
* Future pathologists: If you see lots of iron in both the Kupffer cells and the macrophages of the portal area, the patient has for whatever reason been taking a great deal of oral iron and is probably otherwise healthy, though they should stop the oral iron.
Hemosiderosis due to chronic alcohol abuse results from increased absorption of iron through the gut. The mechanisms are obscure, and this fact makes it hard to distinguish pigment cirrhosis from alcoholic cirrhosis. A few old-timers blame iron-rich wine for hemosiderosis in alcoholics. (A few wines are adulterated with iron, with up to 50 mg/mL. Most have much less). See Arch. Int. Med. 112: 184, 1963. Of course, if a hemochromatosis patient drinks heavily, the liver is doomed (Gastroent. 122: 281, 2002).
Vitamin-and-mineral faddists can occasionally make themselves chronically sick by iron-overloading themselves. (This is difficult to do and probably requires the genetic predisposition. See J. Roy. Soc. Med. 77: 690, 1984.) The Bantu people ingest 100 mg or more of iron daily from beer brewed in "iron pots" (really, discarded steel oil-drums). They tend to get hemosiderosis ("Bantu siderosis"), and a few get pigment cirrhosis. (Again, genes must be important; we now know that a Bantu beer-drinker with one dose of the hemochromatosis gene will probably get hemochromatosis; NEJM 326: 95, 1992.)
You'll screen for common hemochromatosis by checking the transferrin saturation levels, and confirm by serum ferritin levels. The current cutoffs ("transferrin saturation over 45% for women or 50% for men") probably miss too many people (Am. J. Med. 120: 999, e1-7, 2007). The actual iron assays on liver biopsy tissue will probably be replaced soon by MRI (Lancet 363: 341 & 357, 2004).
Hemosiderosis due to increased or ineffective erythropoiesis ("hematopoietic siderosis", typically when there is longstanding hemolysis), mild hemosiderosis is usual because of increased absorption of iron through the gut. In the severe thalassemias and sideroblastic anemias, red cell transfusions are required, erythropoiesis is ineffective, and absorption of iron through the gut is greatly increased. The iron overload progresses to fatal hemochromatosis. These are the patients who are most often treated experimentally with iron chelator drugs.
PORPHYRIA CUTANEA TARDA is a hereditary partial defect of uroporphyrin decarboxylase that is expressed best in the presence of iron overload. You'll encounter this if you keep your eyes open! Update Blood 95: 1565, 2000.
You'll diagnose hemochromatosis by labs, and confirm with genetic testing. Liver biopsy is still handy for judging the severity (Am. J. Clin. Path. 118: 73, 2002).
Here's a summary of the genes that are understood so far (Blood 106: 3710, 2005)
HFE: In the HLA class 1 locus. Hemochromatosis type 1. The protein is expressed throughout the body. To this day, we do not know exactly what it does; however, it's found complexed to transferrin receptor 1 in the duodenal crypts and it's reasonable to think it has to do with preventing overabsorption of iron through the duodenum. The healthy protein also apparently required in order to increase hepcidin levels when appropriate.
TFR2: Transferrin receptor 2. Hemochromatosis type 3. The protein is expressed by hepatocytes and interacts with transferrin. It's believed to sense the body's overall transferrin saturation. Mutation causes an uncommon illness identical to common HFE hemochromatosis but on the average more severe and earlier. It's also believed that a healthy TFR2 is required in order to increase hepcidin levels when required. Gastroent. 122: 1295, 2002.
HAMP: The gene for HEPCIDIN, expressed by liver and striated muscle. Hemochromatosis type 2B. The circulating hormone hepcidin controls absorption of iron through the duodenum and its release from macrophages. Deficiency is rare but causes a severe juvenile hemochromatosis. Hepcidin: Nat. Genet. 33: 21, 2003. Hepcidin rises in iron deficiency, falls in the iron-replete in health. It's inappropriately high in anemia of chronic disease (cytokine effects on the liver) and ineffective erythropoiesis (beta-thal major), promoting iron overload; exactly how it ties into common hemochromatosis is still being worked out.
HJV / HFE2: The gene for HEMOJUVELIN. This hormone binds to the protein NEOGENIN. Hemochromatosis type 2A. This seems to be the another hormone that inhibits absorption of iron through the duodenum. When normal, it's lowered by anemia, hypoxia, and iron deficiency, permitting a higher rate of iron absorption. Nat. Genet. 36: 77, 2004; mouse J. Clin. Inv. 115: 2187, 2005; hemojuvelin senses the amount of iron in the diet overall J. Clin Inv. 115 2180, 2005.
SLC40A1 (was SLC11A3): The gene for FERROPORTIN, which is the hepcidin receptor. Hemochromatosis type 4. Another protein expressed throughout the body. It seems to permit the exit of iron from cells -- its inhibition by hepcidin from angry macrophages and IL6-stimulated liver is the basis for anemia of chronic disease. Mutions here produce a dominant hemochromatosis with iron-overloading of body macrophages but not parenchymal cells, and normal or low transferrin saturation, and usually not the classic findings of hemochromatosis unless there is another gene. They do not give up their iron on phlebotomy, but develop "anemia of chronic disease". Autosomal dominant hemochromatosis ("ferroportin disease") is in fact most often due to deficiency in ferroportin (J. Clin. Inf. 108: 512 & 619, 2001; Blood 100: 692, 2002; Blood 106: 1092, 2005' update Gastroenterology 140: 1199, 2011).
CERULOPLASMIN: Aceruloplasminemia Gut 47: 858, 2000 (hepatocytes and Kupffer cells involved uniformly, no fibrosis, neurologic disease rather than liver failure; this is NOT Wilson's).
WILSON'S DISEASE ("hepatolenticular degeneration"; Mayo Clin. Proc. 78: 1126, 2003; Gastroent. 125: 1868, 2003; Lancet 369: 379, 2007)
Rare but very, very important. Don't miss this diagnosis. Untreated, it is lethal. Treated, it's harmless. You'll never diagnose it unless you think of it. And it ALWAYS masquerades as something else.
Wilson's disease is an autosomal-recessive problem in which the liver is unable to dispose of excess dietary copper via the bile.
The gene was cloned in 1997, and named ATP7B; it is (no surprise) a copper-transporting ATP-ase (Am. J. Hum. Genet. 61: 317, 1997).
* ATP7A is Menke's, an especially cruel X-linked neurodegenerative disease noted for producing "kinky hair."
Serum levels of ceruloplasmin, the copper transport protein, are often (but not always) low in Wilson's. This is probably because ceruloplasmin is ordinarily sent out of the liver cells bound to copper, and if it's unbound, it is degraded too rapidly.
More helpful for your workup, serum copper, not properly carried, spills copiously into the urine in Wilson's disease. This represents the only route of copper excretion, and it is inadequate.
Serum free copper (actually measured, not calculated) is an up-and-coming lab that seems sensitive and specific for Wilson's in the right setting (Am. J. Clin. Path. 131: 160, 2009).
Eventually, the copper accumulates, damaging liver, joints, brain (especially basal ganglia), proximal renal tubule (causing wasting of solutes) and red cells (mild ongoing hemolysis is the rule), and making the distinctive Keyser-Fleischer corneal ring (you probably won't see them without a slit lamp).
The copper itself probably damages the cells in which it accumulates, maybe by free radicals or inhibiting enzymes. * Future pathologists: Stain for copper using rhodaNine or rubeanic acid!
The histology in the liver passes through fatty change to a histopathology basically identical to alcoholic hepatitis to chronic hepatitis to micronodular cirrhosis to post-necrotic cirrhosis. At autopsy, you see an unforgettable bluish-coppery colored liver, and the same discoloration in the basal ganglia.
The treatment, of course, is to remove the copper with a metal chelator. Penicillamine works wonders, but it won't cure cirrhosis or restore dead neurons.
Lab diagnosis is treacherous. Serum ceruloplasmin is low more often than not, but this is a notoriously poor screening test. Staining the liver itself for copper is treacherous. Even assaying liver tissue for copper ("normal is less than 55 micrograms/gm of liver; Wilson's has more than 250") is unreliable because you may have sampled a regenerative nodule that's copper-poor, and copper is deposited near the portal areas whenever there is chronic cholestasis. I recommend a urinary copper assay.
Missing the diagnosis of Wilson's disease clinically is still a common blunder, especially when it presents as "mental illness" (update Gut 56: 115, 2007). The physician's mistake WILL cost the patient his/her long-term health or even life.
Joel K. Greenson MD
HEPATIC AMYLOIDOSIS: We cover this in "immuno". Amyloid accumulates in the vessels and space of Disse, and can eventually give a large, very firm liver that usually still functions acceptably. Past concerns about biopsying the liver in suspected amyloidosis seem to be groundless (Medicine 82: 291, 2003).
Joel K. Greenson MD
A host of drugs-poisons produce typical reactions in the liver. These range from predictable ("Take enough 'Tylenol' at once and your liver cells all die") to highly idiosyncratic ("Take 'Halothane' anesthesia a second time and there's a tiny chance that sensitivity will kill you.") "Inflammation" may mimic acute or chronic hepatitis.
Acetaminophen ("Tylenol"). Massive hepatic necrosis
Allopurinol. Granulomas (* infamous for looking like the ring granulomas of Q-fever)
Alpha-methyldopa. Inflammation, granulomas, massive necrosis (idiosyncratic)
Amiodarone. Inflammation, "alcoholic hepatitis" mimic, cirrhosis (idiosyncratic); kupffer cells loaded with phospholipid ("phospholipidosis")
Anabolic steroids. Cholestasis (at least)
Azathioprine. Fatty change, necrosis and regeneration in the central zones (Arch. Path. Lab. Med. 136: 618, 2012)
Chlorpromazine. Cholestasis (idiosyncratic)
Estrogens. Cholestasis (idiosyncratic), thrombosis (idiosyncratic)
Ethanol. Fatty change, alcoholic hepatitis, cirrhosis
Fenfluramine. Massive necrosis (idiosyncratic; a dozen Japanese find out what was really in their Red Chinese holistic-wholesome weight-loss pills beside lotus leaves and chrysanthemum petals: Ann. Int. Med. 139: 488, 2003)
Halothane. Massive hepatic necrosis (idiosyncratic)
<24392> "Halothane hepatitis" case; simply massive necrosis
* Hydrazine (a quack cancer remedy). liver necrosis (Ann. Int. Med. 133: 877, 2000).
Isoniazid. Looks like viral hepatitis (idiosyncratic) (especially >age 35)
*7nbsp;Lapitinib. for HER+ breast cancer; people with a certain HLA get liver toxicity.
Methotrexate. Necro-inflammation, cirrhosis (sometimes even at "safe" doses)
Oxyphenisatin (laxative). Inflammation ("lupoid hepatitis") (who'd abuse THAT?)
* Paraquat: Hepatocellular injury that resolves (early); necrosis of the bile duct cells (late)
Pennyroyal ("holistic herbal tonic" / amateur abortifacient) . simulates viral hepatitis (update on poisoning from Mayo's: Acad.