Liver Biopsies

[Laurie]

This will be a bit long and I ask for your forbearance.  Background:  hep c w/30 plus year duration, discovery 2 1/2 years ago, micronodular cirrhosis on biopsy, combo treatment for 20 weeks ended Oct 1st, 99 unsuccessful.  Went to Duke (my doc) to talk about maintenance as I had read that histology can improve with treatment.  He said unproven but another biopsy would be needed.  So, that's what we did and the following is the result:

First One:  9/97   benign hepatic parenchyma w/ abnormal architecture.  Trichrome stain demonstrates nodules surrounded by fibrous tissue.  Mild-moderate chronic inflammation w/piecemeal necrosis.  There is assoc mild fatty change.  No cholestasis, granulomatous finlammation or malignancy.  Iron stain focal trace to 1+ staining.  No iron staining of fibrous septa.  No PAS positive globules.  Diagnosis:  Chronic hepatitis C w/ mild-moderate inflammatory activity & micronodular cirrhosis.

The slides were available for comparison to

Second one:  1/00  Benign liver w/ mild fatty change & relatively prominent hepatitis.  Hepatitis is portal & periportal w/ relatively little inflammation in the lobule.  There is moderate inflammatory activity (piecemeal necrosis) & mild to  moderate  expansion of portal areas.  The portal inflammatory cells are misture of lymphocytes, neutrophils, plasma cells & eosinophils.  Bile ducts are present in normal numbers but occasionally show intraepithelial inflammation.  In several areas esosinophils are quite prominent in the portal infiltrate.  There are no granulomas.  PAS after diastase digestion - somewhat further into paraffin block & show more prominent inflammation in the portal regions particularly around bile ducts.  Occasional lymphoid nodules are present.  No PAS inclusions within hepatocytes.
Prussion blue - negative for stainable iron in hepatocytes.  Occasional Kupffer cells w/ stainable iron.
Trichrome - portal fibrosis is present as well as bridging fibrosis.  The extent of fibrosis DOES NOT suggest cirrhosis.
Diagnosis:  chronic hepatitis w/ moderate inflammatory activity
Portal fibrosis w/ bridging fibrosis
Mild fatty change, no granulomas
Comment:  Comparison - 1997 biopsy was quite fragmented whereas the current one is not.  Degree of inflammatory activity is similar in both.  Similar amount of fat present.  Less fibrosis in current than in the prior biopsy.

Duke does not recommend further treatment at this time.  Says the treatment is hard on the whole body (true) and the reduction in fibrosis is not proven.  But I went from cirrhosis, stage 4, to bridging fibrosis, stage 3.  What would account for this?  I do take herbs & supplements including Milk Thistle and have done so for 2 1/2 years, eat healthy organic, a rare glass of wine, etc. What would you tell your patient in this situation?  I am ecstatic about this, but would like to keep it if you know what I mean and if maintenance does indeed help, maybe I should do that.  Please advise.  Thank you so much in advance for your thoughtful reply.  Laurie