Autoimmune Hepatitis chronic and progressive hepatitis of unknown etiology hepatocyte injury is caused by IFN- produced by CD4+ and

+ and CD8+ T cells and by CD8+ T-cellmediated cytotoxicity. A defect in regulatory T-cells may underlie the uncontrolled activation of pathogenic, self-reactive lymphocytes. Genetic factors likely play a role in the autoimmunity The injurious immune reaction may be triggered by viral infections, certain drugs such as minocycline, atorvastatin, simvastatin, methyldopa, interferons, nitrofurantoin, and pemoline, and herbal products (such as black cohosh).

Clinicopathologic Features. The disease may run an indolent or severe course (including fulminant hepatitis). There is a female predominance (78%), particularly in young and perimenopausal women. The annual incidence is highest among white northern Europeans The salient features include the absence of serologic markers of viral infection, elevated serum IgG and -globulin levels (1.2 to 3.0 times normal), and high serum titers of autoantibodies. Autoimmune hepatitis is classified into types 1 and 2, based on the patterns of circulating antibodies. Type 1 is characterized by the presence of antinuclear (ANA), antismooth muscle (SMA), antiactin (AAA), and anti soluble liver antigen/liver-pancreas antigen (anti-SLA/LP) antibodies. Type 2 autoimmune hepatitis are antiliver kidney microsome-1 (ALKM-1) antibodies, which are mostly directed against CYP2D6, and antiliver cytosol-1 (ACL-1). Type 1 is much more common than Type 2 in the United States and is associated with the HLA-DR3 serotype. There is a female predominance, but the disease occurs in children and adults of both sexes. The entire histologic spectrum of chronic hepatitis may be seen, but it is marked by prominent inflammatory infiltrates of lymphocytes and plasma cells. Clusters of plasma cells in the interface of portal tracts and hepatic lobules are fairly characteristic for autoimmune hepatitis An acute appearance of clinical illness is common (40%), and a fulminant presentation with onset of hepatic encephalopathy within 8 weeks of disease onset is possible. In a small subset of patients, autoimmune hepatitis diagnosed clinically may show histologic destruction of bile ducts (autoimmune cholangitis), making distinction from primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC) quite difficult. The mortality of patients with severe untreated autoimmune hepatitis is approximately 40% within 6 months of diagnosis, and cirrhosis develops in at least 40% of survivors. Prednisone alone or in combination with azathioprine is the mainstay of therapy. The ten-year survival rate after transplantation is 75%, but the disease recurs in 22% to 42% of transplanted patients.

Drug- and Toxin-Induced Liver Disease Drug-induced liver injury accounts for about 10% of adverse drug reactions, and is the most common cause of fulminant hepatitis in the United States. Genetic variability is a critical factor that influences the susceptibility to drug-induced injury. Injury may result (1) from direct toxicity to hepatocytes or biliary epithelial cells, causing necrosis, apoptosis, or disruption of cellular function; (2) through hepatic conversion of a xenobiotic to an active toxin; or (3) through immune mechanisms, usually by a drug or a metabolite acting as a hapten to convert a cellular protein into an immunogen. [40] drug reactions may be predictable (intrinsic) or unpredictable (idiosyncratic). Predictable drug reactions can occur in anyone who receives a sufficient dose of an agent. Unpredictable reactions depend on idiosyncracies of the host, particularly the rate at which the host metabolizes the agent, and the intensity of the immune response. Idiosyncratic drug reaction , adults are more susceptible than children, and women are affected more than men. Important examples include chlorpromazine, an agent that causes cholestasis in patients who are slow to metabolize it to an innocuous byproduct, and halothane, which can cause a fatal immune-mediated hepatitis It may take the form of hepatocyte necrosis, cholestasis, or insidious onset of liver dysfunction. Drug-induced chronic hepatitis is clinically and histologically indistinguishable from chronic viral hepatitis; hence, serologic markers of viral infection are critical for making the distinction.

TABLE 18-5 -- Patterns of Injury in Drug- and Toxin-Induced Hepatic Injury Pattern of Injury Morphologic Findings Examples of Associated Agents Cholestatic Bland hepatocellular cholestasis, without inflammation Contraceptive and anabolic steroids; estrogen

Pattern of Injury

Morphologic Findings

Examples of Associated Agents replacement therapy

Cholestatic hepatitis Hepatocellular necrosis

Cholestasis with lobular necroinflammatory activity; may Numerous antibiotics; phenothiazines show bile duct destruction Spotty hepatocyte necrosis Submassive necrosis, zone 3 Massive necrosis Methyldopa, phenytoin Acetaminophen, halothane Isoniazid, phenytoin Ethanol, methotrexate, corticosteroids, total parenteral nutrition Amiodarone, ethanol Methotrexate, isoniazid, enalapril Sulfonamides, numerous other agents

Steatosis Steatohepatitis Fibrosis cirrhosis Granulomas Vascular lesions

Macrovesicular Microvesicular, Mallory bodies and Periportal and pericellular fibrosis Noncaseating epithelioid granulomas

Sinusoidal obstruction syndrome (veno-occlusive disease): High-dose chemotherapy, bush teas obliteration of central veins Budd-Chiari syndrome Sinusoidal dilatation Oral contraceptives Oral contraceptives, numerous other agents

Peliosis hepatis: blood-filled cavities, not lined by endothelial Anabolic steroids, tamoxifen cells Neoplasms Hepatic adenoma Hepatocellular carcinoma Cholangiocarcinoma Angiosarcoma Oral contraceptives, anabolic steroids Thorotrast Thorotrast Thorotrast, vinyl chloride

hepatic injury is considered predictable with overdoses of acetaminophen, exposure to Amanita phalloides toxin, carbon tetrachloride, and, to a certain extent, alcohol. Many other xenobiotics, such as sulfonamides, -methyldopa, and allopurinol, cause idiosyncratic reactions. acetaminophen is the leading cause of drug-induced acute liver failure. The most common prescription drugs causing idiosyncratic injury (that is, drug toxicity unrelated to drug dosage) include antibiotics and, in particular, isonazid, nonsteroidal analgesics, and anti-seizure medications. Idiosyncratic reactions evolve with a subacute course and are usually characterized by high bilirubin levels. Herbal preparations can be responsible for both predictable and idiosyncratic liver damage. Reye syndrome, a rare and potentially fatal syndrome of mitochondrial dysfunction in liver, brain, and elsewhere, occurs predominantly in children and is characterized morphologically by extensive accumulation of fat droplets within hepatocytes (microvesicular steatosis). Its development has been associated with the administration of acetylsalicylic acid (aspirin) for the relief of fever methotrexate administration, an effective treatment for moderate to severe psoriasis, can cause liver injury, including hepatic steatosis and fibrosis.[41] Exposure to a toxin or therapeutic agent should always be included in the differential diagnosis of liver disease.

ALCOHOLIC LIVER DISEASE Excessive alcohol (ethanol) consumption is the leading cause of liver disease in most Western countries. forms of alcoholic liver disease: (1) hepatic steatosis (fatty liver disease), (2) alcoholic hepatitis, and (3) cirrhosis

Morphology Hepatic Steatosis (Fatty Liver).

Moderate alcohol - microvesicular lipid droplets accumulate in hepatocytes. With chronic intake of alcohol - clear macrovesicular globules displace the hepatocyte nucleus Macroscopically, the fatty liver of chronic alcoholism is a large (as heavy as 4 to 6 kg), soft organ that is yellow and greasy little or no fibrosis at the outset, with continued alcohol intake fibrous tissue develops around the terminal hepatic veins and extends into the adjacent sinusoids. The fatty change is completely reversible if there is abstention from further intake of alcohol.

Alcoholic Hepatitis (Alcoholic Steatohepatitis). Alcoholic hepatitis is characterized by: 1. 2. Hepatocyte swelling and necrosis: swelling results from the accumulation of fat and water & proteins In some cases there is cholestasis in surviving hepatocytes and mild deposition of hemosiderin (iron) in hepatocytes and Kupffer cells. Mallory bodies: Scattered hepatocytes accumulate tangled skeins of cytokeratin intermediate filaments such as cytokeratin 8 and 18, in complex with other proteins such as ubiquitin. Mallory bodies are visible as eosinophilic cytoplasmic clumps in hepatocytes). These inclusions are a characteristic but not specific feature of alcoholic liver disease, since they also present in NAFLD, PBC, Wilson disease, chronic cholestatic syndromes, and hepatocellular tumors. Neutrophilic reaction: accumulate around degenerating hepatocytes, particularly those having Mallory bodies. Lymphocytes and macrophages also enter portal tracts and spill into the parenchyma. Fibrosis: activation of sinusoidal stellate cells and portal tract fibroblasts, giving rise to fibrosis. Most frequently fibrosis is sinusoidal and perivenular, separating parenchymal cells; occasionally, periportal fibrosis may predominate, particularly with repeated bouts of heavy alcohol intake.

3. 4.

Cirrhosis. The final and irreversible form of alcoholic liver disease usually evolves slowly and insidiously but may develop in 1 or 2 years in some cases. At first the cirrhotic liver is yellow tan, fatty, and enlarged, usually weighing over 2 kg. Over the span of years, it is transformed into a brown, shrunken, nonfatty organ, sometimes less than 1 kg in weight. Initially the developing fibrous septa are delicate and extend through sinusoids from central to portal regions as well as from portal tract to portal tract. Regenerative activity of entrapped parenchymal hepatocytes generates uniform micronodules. With time the nodularity becomes more prominent; scattered larger nodules create a hobnail appearance on the surface of the liver Parenchymal islands are engulfed by wider bands of fibrous tissue, and the liver is converted into a mixed micronodular and macronodular pattern Ischemic necrosis and fibrous obliteration of nodules eventually create broad expanses of tough, pale scar tissue (Laennec cirrhosis). Bile stasis(greenish0 often develops; Mallory bodies are only rarely evident at this stage. Thus, end-stage alcoholic cirrhosis comes to resemble, both macroscopically and microscopically, the cirrhosis developing from viral hepatitis and other causes.

Pathogenesis. Short-term ingestion of as much as 80 gm of alcohol (six beers or 8 ounces of 80-proof liquor) over one to several days generally produces mild, reversible hepatic steatosis. Daily intake of 80 gm or more of ethanol generates significant risk for severe hepatic injury daily ingestion of 160 gm or more for 10 to 20 years is associated more consistently with severe injury. Only 10% to 15% of alcoholics, however, develop cirrhosis.

Thus, other factors must also influence the development and severity of alcoholic liver disease. These factors include: Gender. Women seem to be more susceptible to hepatic injury R/T the estrogen-dependent response to gut-derived endotoxin (LPS) in the liver. Estrogen increases gut permeability to endotoxins, which, in turn, increase the expression of the LPS receptor CD14 in Kupffer cells. This predisposes to increased production of pro-inflammatory cytokines and chemokines. Ethnic differences. higher for African Americans than for white Americans

Genetic factors. Current attention is being given to genetic polymorphisms in detoxifying enzymes and some cytokine promoters. ALDH*2, a genetic variant of aldehyde-dehydrogenase (ALDH), found in 50% of Asians, has a very low activity. Individuals who are homozygous for ALDH*2 are unable to oxidize acetaldehyde and do not tolerate alcohol. Co-morbid conditions. Iron overload and infections with HCV and HBV increase the severity of alcoholic liver disease.

Exposure to alcohol causes steatosis, dysfunction of mitochondrial and cellular membranes, hypoxia, and oxidative stress. At millimolar concentrations, alcohol directly affects microtubular and mitochondrial function and membrane fluidity. Hepatocellular steatosis results from (1) shunting of normal substrates away from catabolism and toward lipid biosynthesis, as a result of generation of excess reduced nicotinamide adenine dinucleotide (NADH + H+) by the two major enzymes of alcohol metabolism, alcohol dehydrogenase and acetaldehyde dehydrogenase; (2) impaired assembly and secretion of lipoproteins; and (3) increased peripheral catabolism of fat. Acetaldehyde (the major intermediate metabolite of alcohol) induces lipid peroxidation and acetaldehyde-protein adduct formation, further disrupting cytoskeletal and membrane function. Cytochrome P-450 metabolism produces reactive oxygen species (ROS) that react with cellular proteins, damage membranes, and alter hepatocellular function. In addition, alcohol-induced impaired hepatic metabolism of methionine leads to decreased intrahepatic glutathione levels, thereby sensitizing the liver to oxidative injury. The induction of CYP2E1 and other cytochrome P-450 enzymes in the liver by alcohol increases alcohol catabolism in the endoplasmic reticulum and enhances the conversion of other drugs (e.g., acetaminophen) to toxic metabolites. Alcohol can become a major source of calories in the diet of an alcoholic, displacing other nutrients and leading to malnutrition and deficiencies of vitamins (such as thiamine). Alcohol causes the release of bacterial endotoxin from the gut into the portal circulation, inducing inflammatory responses in the liver, such as the activation of NF-B, and release of TNF, IL-6, and TGF-. In addition, alcohol stimulates the release of endothelins from sinusoidal endothelial cells, causing vasoconstriction and the contraction of activated stellate cells (myofibroblasts), leading to a decrease in hepatic sinusoidal perfusion In summary, alcoholic liver disease is a chronic disorder featuring steatosis, hepatitis, progressive fibrosis, cirrhosis, and marked derangement of vascular perfusion. For some unknown reason, cirrhosis develops in only a small fraction of chronic alcoholics. Clinical Features. Hepatic steatosis (fatty liver) may become evident as hepatomegaly, with mild elevation of serum bilirubin and alkaline phosphatase levels. Severe hepatic dysfunction is unusual. Alcohol withdrawal and the provision of an adequate diet are sufficient treatment. Alcoholic hepatitis tends to appear acutely, usually following a bout of heavy drinking. Symptoms and laboratory manifestations may range from minimal to fulminant hepatic failure. Between these two extremes are the nonspecific symptoms of malaise, anorexia, weight loss, upper abdominal discomfort, tender hepatomegaly, and the laboratory findings of hyperbilirubinemia, elevated alkaline phosphatase, and often a neutrophilic leukocytosis. An acute cholestatic syndrome may appear, resembling large bile duct obstruction. The outlook is unpredictable; each bout of hepatitis incurs about a 10% to 20% risk of death.. The manifestations of alcoholic cirrhosis are similar to those of other forms of cirrhosis. Laboratory findings reflect the hepatic dysfunction, with elevated serum aminotransferase, hyperbilirubinemia, variable elevation of serum alkaline phosphatase, hypoproteinemia (globulins, albumin, and clotting factors), and anemia. In some instances, liver biopsy may be indicated, since in about 10% to 20% of cases of presumed alcoholic cirrhosis, another disease process is found. Finally, cirrhosis may be clinically silent, discovered only at autopsy or when stress such as infection or trauma tips the balance toward hepatic insufficiency. The long-term outlook for alcoholics with liver disease is variable. Five-year survival approaches 90% in abstainers who are free of jaundice, ascites, or hematemesis; it drops to 50% to 60% in those who continue to imbibe. In the end-stage alcoholic the proximate causes of death are (1) hepatic coma, (2) massive gastrointestinal hemorrhage, (3) intercurrent infection (to which these patients are predisposed), (4) hepatorenal syndrome following a bout of alcoholic hepatitis, and (5) hepatocellular carcinoma (the risk of developing this tumor in alcoholic cirrhosis is 1% to 6% of cases annually). Metabolic Liver Disease The most common acquired metabolic disorder is non-alcoholic fatty liver disease. Among inherited metabolic diseases, hemochromatosis, Wilson disease, and 1-antitrypsin deficiency are most prominent. Also included among liver metabolic diseases is neonatal hepatitis, a broad disease category encompassing rare inherited diseases and neonatal infections. NONALCOHOLIC FATTY LIVER DISEASE (NAFLD) NAFLD is a group of conditions that have in common the presence of hepatic steatosis (fatty liver), in individuals who do not consume alcohol, or do so in very small quantities (less than 20 g of ethanol/week).

It has become the most common cause of chronic liver disease in the United States, and in its various forms, probably affects more than 30% of the population. fatty liver without other complications may not be detected clinically. NAFLD includes simple hepatic steatosis, steatosis accompanied by minor, non-specific inflammation, and non-alcoholic steatohepatitis (NASH). Steatosis with or without non-specific inflammation is generally a stable condition without significant clinical problems. In contrast, NASH is a condition in which there is hepatocyte injury that may progress to cirrhosis in 10% to 20% of cases. The main components of NASH are hepatocyte ballooning, lobular inflammation, and steatosis.[44] With progressive disease fibrosis occurs. NASH affects men and women equally and the condition is strongly associated with obesity and the other components of the metabolic syndrome, such as dyslipidemia, hyperinsulinemia and insulin resistance. It is estimated that more than 70% of obese individuals have some form of NAFLD. It is the most common cause of so-called cryptogenic cirrhosis, namely cirrhosis of unknown origin. NAFLD contributes to the progression of other liver diseases such as HCV infection and HCC. The epidemic of obesity in the United States heightens concern that NAFLD will increase in prevalence. genetics and environment play a role in the pathogenesis. A two-hit model of pathogenesis has been proposed, encompassing two sequential events: (1) hepatic fat accumulation and, (2) hepatic oxidative stress.[

Clinical Features. Individuals with simple steatosis are generally asymptomatic. liver biopsy is the most reliable diagnostic tool for NASH and helps determine the extent of steatosis, presence of steatohepatitis, and degree of fibrosis. Serum AST and ALT are elevated in about 90% of patients with NASH. The AST/ALT ratio is usually less than 1, in contrast to alcoholic steatohepatitis in which the ratio is generally above 2.0 to 2.5 association between NASH and the metabolic syndrome, cardiovascular disease is a frequent cause of death in patients with NASH. The goal of treating individuals with NASH is to reverse the steatosis and prevent cirrhosis.

Morphology. Steatosis usually involves more than 5% of the hepatocytes and sometimes more than 90%. Large (macrovesicular) and small (microvesicular) droplets of fat, predominantly triglycerides, accumulate within hepatocytes At the most clinically benign end of the spectrum, there is no appreciable hepatic inflammation, hepatocyte death, or scarring, despite persistent elevation of serum liver enzymes. Steatohepatitis (NASH) is characterized by steatosis and multifocal parenchymal inflammation, mainly neutrophils, Mallory bodies, hepatocyte death (both ballooning degeneration and apoptosis), and sinusoidal fibrosis. Fibrosis also occurs within portal tracts and around terminal hepatic venules. These histological changes are similar to those of alcoholic steatohepatitis. When cirrhosis is established, the steatosis or steatohepatitis tends to be reduced and sometimes is not identifiable.

HEMOCHROMATOSIS I. Hemochromatosis was first described by von Recklinghausen in 1889. It is characterized by the excessive accumulation of body iron, most of which is deposited in parenchymal organs such as the liver and pancreas. Iron can also accumulate in the heart, joints, or endocrine organs. hemochromatosis for the hereditary disease and hemosiderosis for the acquired deposition of iron HEREDITARY HEMOCHROMATOSIS/ PRIMARY-homozygous recessive,due to excess Iron absorption Mutations of genes encoding HFE, transferrin receptor 2 (TfR2), or hepcidin Mutations of genes encoding HJV (hemojuvelin: juvenile hemochromatosis) (Neonatal hemochromatosis)[*] II. HEMOSIDEROSIS (SECONDARY HEMOCHROMATOSIS/ACQUIRED)

A.

Parenteral iron overload Transfusions Long-term hemodialysis Aplastic anemia Sickle cell disease Myelodysplastic syndromes Leukemias Iron-dextran injections

B.

Ineffective erythropoiesis with increased erythroid activity -Thalassemia Sideroblastic anemia Pyruvate kinase deficiency

C.

Increased oral intake of iron African iron overload (Bantu siderosis)

D. E.

Congenital atransferrinemia Chronic liver disease Chronic alcoholic liver disease Porphyria cutanea tarda

F.
*

Neonatal hemochromatosis

Neonatal hemochromatosis develops in utero and does not appear to be a hereditary condition.

Total body iron pool- 2 to 6 gm in normal adults; about 0.5 gm is stored in the liver, 98% of which is in hepatocytes. In hemochromatosis - >50 gm, over one third of which accumulates in the liver. The following features characterize this disease: Fully developed cases exhibit (1) micronodular cirrhosis in all patients; (2) diabetes mellitus in 75% to 80% of patients; and (3) skin pigmentation in 75% to 80% of patients. Iron accumulation is lifelong but the injury caused by excessive iron is slow and progressive; hence symptoms usually first appear in the fifth to sixth decades of life. Males predominate (5 to 7 : 1) with slightly earlier clinical presentation, partly because physiologic iron loss (menstruation, pregnancy) delays iron accumulation in women. In hemochromatosis, regulation of intestinal absorption of dietary iron is abnormal, leading to net iron accumulation of 0.5 to 1.0 gm/year, mainly in the liver. The disease manifests itself typically after 20 gm of stored iron have accumulated. Excessive iron appears to be directly toxic to host tissues, by the following mechanisms: (1) lipid peroxidation via ironcatalyzed free radical reactions, (2) stimulation of collagen formation by activation of hepatic stellate cells, and (3) interaction of reactive oxygen species and of iron itself with DNA, leading to lethal cell injury or predisposition to hepatocellular carcinoma. The actions of iron are reversible in cells that are not fatally injured, and removal of excess iron with therapy promotes recovery of tissue function. The main regulator of iron absorption is the protein hepcidin (also known as liver expressed antimicrobial peptide or LEAP1), encoded by the HAMP gene. Hepcidin, which also has antibacterial activity, is produced in hepatocytes as an 84 amino acid propeptide that is cleaved into a mature form of 25 amino acids and smaller circulating forms of 20 and 23 amino acids. Transcription of hepcidin is increased by inflammatory cytokines and iron, and decreased by iron deficiency, hypoxia and ineffective erythropoiesis.

Hepcidin binds to the cellular iron efflux channel ferroportin (FPN), causing internalization and proteolysis of the channel. This prevents the release of iron from intestinal cells and macrophages; thus hepcidin lowers plasma iron levels. Conversely, a deficiency in hepcidin causes iron overload.

Other proteins involved in iron metabolism, do so by regulating hepcidin levels. (1) hemojuvelin (HJV), which is expressed in the liver, heart, and skeletal muscle (2) transferrin receptor 2 (TfR2), which is highly expressed in hepatocytes, where it mediates the uptake of transferrin-bound iron (3) HFE, the product of the hemochromatosis gene. Lack of hepcidin expression caused by mutations in hepcidin, HJV, TfR2, and HFE cause hemochromatosis. Of these mutations, those in HFE are the most common, as discussed below. Mutations of HAMP and HJV cause a severe form of hereditary hemochromatosis, known as juvenile hemochromatosis. Mutations of HFE and TfR2 cause the classic form of hereditary adult hemochromatosis, a milder disease than the juvenile form. Mutations of ferroportin cause a distinctive iron storage disease that is different from hereditary hemochromatosis. A serine protease (TMPRSS6) was recently identified as an iron sensor that suppresses HAMP expression.[48] The adult form of hemochromatosis is almost always caused by mutations of HFE.It encodes an HLA class I-like molecule that regulates intestinal absorption of dietary iron. The most common HFE mutation is a cysteine-to-tyrosine substitution at amino acid 282 (called C282Y), due to a single G to A transition at nucleotide 845 (G845A). This mutation, which causes inactivation of the protein, is present in 70% to 100% of the patients diagnosed with hereditary hemochromatosis. The other common mutation is H63D (histidine at position 63 to aspartate). The H63D homozygous state and C282Y/H63D compound heterozygous mutations often cause only mild iron accumulation. The C282Y mutation is largely confined to white populations of European origin, while the H63D has a worldwide distribution. The frequency of C282Y homozygosity is 0.45% (1 of every 220 persons), and the heterozygous frequency is 11%, making hereditary hemochromatosis one of the most common genetic disorders in humans. However, the penetrance of this disorder is low in patients with the homozygous C282Y mutation, so the genetic condition does not lead to clinical disease in all individuals.

The morphologic changes in hereditary hemochromatosis are characterized principally by: deposition of hemosiderin in the following organs (in decreasing order of severity): liver, pancreas, myocardium, pituitary gland, adrenal gland, thyroid and parathyroid glands, joints, and skin (detected by the Prussian blue histologic reaction or by atomic absorption analysis of tissue); cirrhosis pancreatic fibrosis. In the liver, iron becomes evident first as golden-yellow hemosiderin granules in the cytoplasm of periportal hepatocytes, which stain blue with the Prussian blue stain With increasing iron load, there is progressive involvement of the rest of the lobule, along with bile duct epithelium and Kupffer cell pigmentation. Iron is a direct hepatotoxin, and inflammation is characteristically absent. At this stage, the liver is typically slightly larger than normal, dense, and chocolate brown. Fibrous septa develop slowly, leading ultimately to a micronodular pattern of cirrhosis in an intensely pigmented liver. Biochemical determination of hepatic tissue iron concentration is the standard for quantitating hepatic iron content. Normal iron content of liver tissue is less than 1000 g per gram dry weight of liver. Hereditary hemochromatosis exhibit over 10,000 g iron per gram dry weight hepatic iron concentrations in excess of 22,000 g per gram dry weight - fibrosis and cirrhosis. Pancreas becomes intensely pigmented, has diffuse interstitial fibrosis, and may exhibit some parenchymal atrophy. The heart is often enlarged and has hemosiderin granules within the myocardial fibers, producing a striking brown coloration to the myocardium. A delicate interstitial fibrosis may appear. hemosiderin deposition in dermal macrophages and fibroblasts, most of the pigmentation results from increased epidermal melanin production- slate-gray color to the skin. With hemosiderin deposition in the joint synovial linings, an acute synovitis may develop. Excessive deposition of calcium pyrophosphate - pseudo-gout.

The testes may be small and atrophic but are not usually significantly pigmented. It is thought that the atrophy is secondary to a derangement in the hypothalamic-pituitary axis resulting in reduced gonadotropin and testosterone levels.

Clinical Features. Classical hemochromatosis is more often a disease of males and rarely becomes evident before age 40. The principal manifestations include hepatomegaly, abdominal pain, skin pigmentation (particularly in sun-exposed areas), deranged glucose homeostasis or frank diabetes mellitus due to destruction of pancreatic islets, cardiac dysfunction (arrhythmias, cardiomyopathy), and atypical arthritis. In some patients, the presenting complaint is hypogonadism (e.g., amenorrhea in the female, impotence and loss of libido in the male). The classic triad of pigment cirrhosis with hepatomegaly, skin pigmentation, and diabetes mellitus might not develop until late in the course of the disease. Death may result from cirrhosis or cardiac disease. A significant cause of death is hepatocellular carcinoma; the risk is 200-fold greater than in the general population, and treatment for iron overload does not remove the risk for this tumor. Fortunately, hemochromatosis can be diagnosed long before irreversible tissue damage has occurred. Screening involves demonstration of very high levels of serum iron and ferritin, exclusion of secondary causes of iron overload, and liver biopsy if indicated. Screening of family members of probands is important. Heterozygotes also accumulate excessive iron, but not to a level that causes significant tissue damage.

Neonatal hemochromatosis (also called congenital hemochromatosis) is a disease of unknown origin manifested by severe liver disease and extrahepatic hemosiderin deposition. not an inherited disease; liver injury, leading to hemosiderin accumulation, occurs in utero, and might be related to maternal alloimmune injury to the fetal liver. Extrahepatic hemosiderin deposition, detected by buccal biopsy, needs to be documented for the correct diagnosis. There is no specific treatment, except for supportive care, and liver transplantation in severe cases. The most common causes of hemosiderosis are disorders associated with ineffective erythropoiesis, such as severe forms of thalassemia and myelodysplastic syndromes . In these disorders, the excess iron results not only from transfusions, but also from increased absorption. Alcoholic cirrhosis is often associated with a modest increase in stainable iron within liver cells. However, this represents alcohol-induced redistribution of iron, since total body iron is not significantly increased. A rather unusual form of iron overload resembling hereditary hemochromatosis occurs in sub-Saharan Africa, the result of ingesting large quantities of alcoholic beverages fermented in iron utensils (Bantu siderosis). Home brewing in steel drums continues to this day, and genetic susceptibility to this disease, such as mutations of ferroportin has been proposed in these populations. Lastly, chronic HBV and HCV infection may increase iron storage within hepatocytes.

WILSON DISEASE Autosomal recessive disorder caused by mutation of the ATP7B gene, resulting in impaired copper excretion into bile and a failure to incorporate copper into ceruloplasmin. This disorder is marked by the accumulation of toxic levels of copper in many tissues and organs, principally the liver, brain, and eye. Normally, 40% to 60% of ingested copper (2 to 5 mg/day) is absorbed in the duodenum and proximal small intestine, and is transported to the portal circulation complexed with albumin and histidine. Free copper dissociates and is taken up by hepatocytes. Copper is incorporated into enzymes and also binds to a 2-globulin (apoceruloplasmin) to form ceruloplasmin, which is secreted into the blood. Excess copper is transported into the bile. Ceruloplasmin accounts for 90% to 95% of plasma copper. Circulating ceruloplasmin is eventually desialylated, endocytosed by the liver, and degraded within lysosomes, after which the released copper is excreted into bile. The estimated total body copper is only 50 to 150 mg. The ATP7B gene, located on chromosome 13, encodes a transmembrane copper-transporting ATPase, expressed on the hepatocyte canalicular membrane. More than 300 mutations in the ATP7B gene have been identified, but not all genes cause the disease. The overwhelming majority of patients are compound heterozygotes containing different mutations on each ATP7B allele. Deficiency in the ATP7B protein causes a decrease in copper transport into bile, impairs its incorporation into ceruloplasmin, and inhibits ceruloplasmin secretion into the blood. T

hese changes cause copper accumulation in the liver and a decrease in circulating ceruloplasmin. The copper causes toxic liver injury, through the production of ROS by the Fenton Specifically, non-ceruloplasminbound copper spills over from the liver into the circulation, causing hemolysis and pathologic changes at other sites such as the brain, corneas, kidneys, bones, joints, and parathyroids. Morphology. The liver often bears the brunt of injury, but the disease may also present as a neurologic disorder. Fatty change (steatosis) may be mild to moderate, with vacuolated nuclei (glycogen or water) and occasionally, focal hepatocyte necrosis. An acute hepatitis can show features mimicking acute viral hepatitis, except possibly for the accompanying fatty change. The chronic hepatitis of Wilson disease exhibits moderate to severe inflammation and hepatocyte necrosis, with the particular features of macrovesicular steatosis, vacuolated hepatocellular nuclei, and Mallory bodies. With progression of chronic hepatitis, cirrhosis will develop. Massive liver necrosis is a rare manifestation that is indistinguishable from that caused by viruses or drugs. Excess copper deposition can often be demonstrated by special stains (rhodamine stain for copper, orcein stain for copper-associated protein). Because copper also accumulates in chronic obstructive cholestasis and because histology cannot reliably distinguish Wilson disease from viral- and drug-induced hepatitis, demonstration of hepatic copper content in excess of 250 g per gram dry weight is most helpful for making a diagnosis. In the brain, toxic injury primarily affects the basal ganglia, particularly the putamen, which shows atrophy and even cavitation. Nearly all patients with neurologic involvement develop eye lesions called Kayser-Fleischer rings, green to brown deposits of copper in Desemet's membrane in the limbus of the cornea.

Clinical Features. The age at onset average age is 11.4 years, but usually manifests between 6 and 40 years of age. The most common presentation is acute or chronic liver disease. Neuropsychiatric manifestations, including mild behavioral changes, frank psychosis, or a Parkinson diseaselike syndrome (such as tremor), are the initial features in most of the remaining cases. The biochemical diagnosis of Wilson disease is based on a decrease in serum ceruloplasmin, an increase in hepatic copper content (the most sensitive and accurate test), and increased urinary excretion of copper (the most specific screening test). Serum copper levels are of no diagnostic value, since they may be low, normal, or elevated, depending on the stage of evolution of the disease. Early recognition and long-term copper chelation therapy (as with D-penicillamine, or Trientine) or zinc-based therapy has dramatically altered the usual progressive downhill course.

1-ANTITRYPSIN DEFICIENCY autosomal recessive disorder marked by very low levels of 1-antitrypsin. The major function of this protein is the inhibition of proteases, particularly neutrophil elastase, cathepsin G, and proteinase 3, which are normally released from neutrophils at sites of inflammation. 1-Antitrypsin deficiency leads to the development of pulmonary emphysema, because the activity of destructive proteases is not inhibited. It also causes liver disease, as a consequence of the accumulation of this protein in hepatocytes. In addition, cutaneous panniculitis, arterial aneurysm, bronchiectasis, and Wegener's granulomatosis can occur in 1antitrypsin deficiency. 1-Antitrypsin is a small 394amino acid plasma glycoprotein synthesized predominantly by hepatocytes, member of the serine protease inhibitor (serpin) family, located on chromosome 14 at least 75 1-antitrypsin forms have been identified, denoted alphabetically by their relative migration on an isoelectric gel. The general notation is Pi for protease inhibitor and an alphabetic letter for the position on the gel; two letters denote the genotype of the two alleles. The most common genotype is PiMM, occurring in 90% of individuals (in the traditional sense, this would be the wild-type genotype). Most allelic variants show substitutions in the polypeptide chain but produce normal levels of functional 1-antitrypsin. Some deficiency variants, including the PiS variant, result in a moderate reduction in serum concentrations of 1-antitrypsin without clinical manifestations. Rare variants termed Pi-null have no detectable serum 1-antitrypsin. The most common clinically significant mutation is PiZ; homozygotes for the PiZZ protein have circulating 1-antitrypsin levels that are only 10% of normal. These individuals are at high risk for developing clinical disease. Expression of alleles is autosomal codominant, and consequently, PiMZ heterozygotes have intermediate plasma levels of 1antitrypsin. Among people of northern European descent the PiS frequency is 6% and the PiZ frequency is 4%; the PiZZ state

affects 1 in 1800 live births. Because of its occasionally early presentation for liver disease, 1-antitrypsin deficiency is the most commonly diagnosed genetic hepatic disorder in infants and children. Pathogenesis. With most allelic variants, the mRNA is transcribed, and the protein is synthesized and secreted normally. Deficiency variants show a selective defect in migration of this secretory protein from the endoplasmic reticulum to Golgi apparatus; this is most marked for the PiZ polypeptide, attributable to a single amino acid substitution of Glu342 to Lys342. The mutant polypeptide (1AT-Z) is abnormally folded and polymerizes, creating endoplasmic reticulum stress and leading to apoptosis ( Chapter 1 ; see Fig. 1-27 ). The precise mechanisms of liver disease with 1AT-Z are not well defined. The accumulated 1AT-Z in the endoplasmic reticulum triggers a series of events, including an autophagocytic response, mitochondrial dysfunction, and possible activation of pro-inflammatory NFB, causing hepatocyte damage.[53] All individuals with the PiZZ genotype accumulate 1AT-Z in the endoplasmic reticulum of hepatocytes, but only 10% to 15% of PiZZ individuals develop overt clinical liver disease. Other genetic factors or environmental factors are thus posited to play a role in the development of liver disease. Morphology. 1-Antitrypsin deficiency is characterized by the presence of round-to-oval cytoplasmic globular inclusions in hepatocytes, which in routine H&E stains are acidophilic and indistinctly demarcated from the surrounding cytoplasm. They are strongly periodic acidSchiff (PAS)-positive and diastase-resistant ( Fig. 18-27 ). The globules are also present but in diminished size and number in the PiMZ and PiSZ genotypes. For unknown reasons most of the globules are in hepatocytes surrounding the portal tracts. Moreover, the number of globule-containing hepatocytes in a patient's liver is not correlated with the severity of pathologic findings. The hepatic pathology associated with PiZZ homozygosity is extremely varied, ranging from neonatal hepatitis ( Fig. 18-28 ) without or with cholestasis and fibrosis (discussed below), to childhood cirrhosis, to a smoldering chronic inflammatory hepatitis or cirrhosis that becomes apparent only late in life. For the most part the only distinctive feature of the hepatic disease is the PAS-positive globules; infrequently, fatty change and Mallory bodies are present. The diagnostic 1antitrypsin globules may be absent in the young infant; steatosis may be present as a tip-off to the possibility of 1-antitrypsin deficiency. Clinical Features. Neonatal hepatitis with cholestatic jaundice appears in 10% to 20% of newborns with the deficiency. In adolescence, presenting symptoms may be related to hepatitis or cirrhosis. Attacks of hepatitis may subside with apparent complete recovery, or they may become chronic and lead progressively to cirrhosis. Finally, the disease may remain silent until cirrhosis appears in middle to later life. HCC develops in 2% to 3% of PiZZ adults, usually but not always in the setting of cirrhosis. The treatment, and the cure, for severe hepatic disease is orthotopic liver transplantation. In patients with pulmonary disease the single most important treatment is avoidance of cigarette smoking, because smoking markedly accelerates emphysema and the destructive lung disease associated with 1antitrypsin deficiency. NEONATAL CHOLESTASIS Prolonged conjugated hyperbilirubinemia in the neonate, termed neonatal cholestasis, affects approximately 1 in 2500 live births. The major conditions causing it are (1) cholangiopathies, primarily biliary atresia (discussed later), and (2) a variety of disorders causing conjugated hyperbilirubinemia in the neonate, collectively referred to as neonatal hepatitis. Neonatal cholestasis and hepatitis are not specific entities, nor are the disorders necessarily inflammatory. Instead, the finding of neonatal cholestasis should evoke a diligent search for recognizable toxic, metabolic, and infectious liver diseases, the more common of which are listed in Table 18-7 . Once identifiable causes have been excluded, one is left with the syndrome of idiopathic neonatal hepatitis, which shows considerable clinical overlap with biliary atresia. Despite the long list of disorders associated with neonatal cholestasis, most are quite rare. Idiopathic neonatal hepatitis represents as many as 50% of cases, biliary atresia represents another 20%, and 1-antitrypsin deficiency represents 15%. Differentiation of biliary atresia from nonobstructive neonatal cholestasis assumes great importance, since definitive treatment of biliary atresia requires surgical intervention (Kasai procedure), whereas surgery may adversely affect the clinical course of a child with other disorders. Fortunately, discrimination can be made with clinical data in about 90% of cases, with or without liver biopsy. Affected infants have jaundice, dark urine, light or acholic stools, and hepatomegaly. Variable degrees of hepatic synthetic dysfunction may be identified, such as hypoprothrombinemia. Thus, liver biopsy is critical in distinguishing neonatal hepatitis from an identifiable cholangiopathy.

TABLE 18-7 -- Major Causes of Neonatal Cholestasis

Bile duct obstruction Extrahepatic biliary atresia Neonatal infection Cytomegalovirus Bacterial sepsis Urinary tract infection Syphilis

1-Antitrypsin deficiency Cystic fibrosis Miscellaneous Shock/hypoperfusion Indian childhood cirrhosis Alagille syndrome (paucity of bile ducts) Idiopathic neonatal hepatitis

Toxic Drugs Parenteral nutrition Metabolic disease Tyrosinemia Niemann-Pick disease Galactosemia Defective bile acid synthetic pathways

Morphology. The morphologic features of neonatal hepatitis include lobular disarray with focal liver cell apoptosis and necrosis, panlobular giant-cell transformation of hepatocytes ( Fig. 18-29 ), prominent hepatocellular and canalicular cholestasis, mild mononuclear infiltration of the portal areas, reactive changes in Kupffer cells, and extramedullary hematopoiesis. This predominantly parenchymal pattern of injury may blend imperceptibly into a ductal pattern of injury, with bile ductular proliferation and fibrosis of portal tracts. In these cases distinction from an obstructive biliary atresia may therefore be difficult.