Liver biopsy in the post-hepatitis C virus era in Japan

In Japan,liver biopsies were previously crucial in evaluating the severity of hepatitis caused by the hepatitis C virus(HCV)and diagnosing HCV-related hepatocellular carcinoma(HCC).However,due to the development of effective antiviral treatments and advanced imaging,the necessity for biopsies has significantly decreased.This change has resulted in fewer chances for diagnosing liver disease,causing many general pathologists to feel less confident in making liver biopsy diagnoses.This article provides a comprehensive overview of the challenges and potential solutions related to liver biopsies in Japan.First,it highlights the importance of considering steatotic liver diseases as independent conditions that can coexist with other liver diseases due to their increasing prevalence.Second,it emphasizes the need to avoid hasty assumptions of HCC in nodular lesions,because clinically diagnosable HCCs are not targets for biopsy.Third,the importance of diagnosing hepatic immune-related adverse events caused by immune checkpoint inhibitors is increasing due to the anticipated widespread use of these drugs.In conclusion,pathologists should be attuned to the changing landscape of liver diseases and approach liver biopsies with care and attention to detail.

Optimal treatment strategies for hepatic portal venous gas:A retrospective assessment

BACKGROUND Hepatic portal venous gas(HPVG)generally indicates poor prognoses in patients with serious intestinal damage.Although surgical removal of the damaged portion is effective,some patients can recover with conservative treatments.AIM To establish an optimal treatment strategy for HPVG,we attempted to generate computed tomography(CT)-based criteria for determining surgical indication,and explored reliable prognostic factors in non-surgical cases.METHODS Thirty-four cases of HPVG(patients aged 34-99 years)were included.Necessity for surgery had been determined mainly by CT findings(i.e.free-air,embolism,lack of contrast enhancement of the intestinal wall,and intestinal pneumatosis).The clinical data,including treatment outcomes,were analyzed separately for the surgical cases and non-surgical cases.RESULTS Laparotomy was performed in eight cases(surgical cases).Seven patients(87.5%)survived but one(12.5%)died.In each case,severe intestinal damage was confirmed during surgery,and the necrotic portion,if present,was removed.Non-occlusive mesenteric ischemia was the most common cause(n=4).Twentysix cases were treated conservatively(non-surgical cases).Surgical treatments had been required for twelve but were abandoned because of the patients’poor general conditions.Surprisingly,however,three(25%)of the twelve inoperable patients survived.The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments,and only one patient(7%)died.Comparative analyses of the fatal(n=10)and recovery(n=16)cases revealed that ascites,peritoneal irritation signs,and shock were significantly more frequent in the fatal cases.The mortality was 90%if two or all of these three clinical findings were detected.CONCLUSION HPVG related to intestinal necrosis requires surgery,and our CT-based criteria are probably useful to determine the surgical indication.In non-surgical cases,ascites,peritoneal irritation signs and shock were closely associated with poor prognoses,and are applicable as predictors of patients’prognoses.

Transitions of histopathologic criteria for diagnosis of nonalcoholic fatty liver disease during the last three decades

Nonalcoholic fatty liver disease(NAFLD)is the hepatic manifestation of metabolic syndrome,and is the most common type of chronic liver diseases in the majority of developed countries.NAFLD shows a wide spectrum of disorders including simple steatosis,nonalcoholic steatohepatitis(NASH),and cirrhosis.While simple steatosis is recognized to be benign and stable,NASH is considered to be an aggressive form of the disease progressing to cirrhosis.Currently,differentiation between NASH and simple steatosis can be done only by liver biopsy.Despite many proposals and revisions,the histological criteria for the differentiation have not been perfected yet.In this review article,the changes in the histopathologic criteria of NAFLD during the last three decades are summarized,and perspectives of the future changes are demonstrated.The discussion focuses on how pathologists have been dealing with"hepatocellular ballooning".Loose criteria,in which hepatocellular ballooning was not required for the diagnosis of NASH,were applied in many clinical studies published in around 2000’s,whereas a strict criterion based on the presence/absence of hepatocellular ballooning was approved recently.Hence,simple and reliable methodsof identifying ballooned hepatocytes are being sought.Clinical and pathological predictors of NAFLD-related hepatocarcinogenesis will also be sought in the future.

Ruptured gastric artery aneurysm:An uncommon manifestation of microscopic polyangiitis

Gastric artery aneurysm is a rare and lethal condition,and is caused by inflammatory or degenerative vasculopathies.We describe herein the clinical course of a patient with a ruptured gastric artery aneurysm associated with microscopic polyangiitis.Absence of vasculitic changes in the aneurysm resected and negative results of autoantibodies interfered with our diagnostic process.We should have adopted an interventional radiology and initiated steroid therapy promptly to rescue the patient.

Changing common sense:Anti-platelet/coagulation therapy against cirrhosis

Until recently,anti-platelet/coagulation therapy had not been recommended for patients with cirrhosis.Although venous thrombosis is one of the representative complications of cirrhosis and ischemic disorders associated with atherosclerosis are not infrequent in cirrhotic patients,many clinicians have tended to hesitate to introduce anti-platelet/coagulation therapy to their patients.Undoubtedly,this is due to the increased risk of hemorrhagic diathesis in cirrhotic patients.However,accumulating evidence has revealed the benefits of anti-platelet/coagulation therapy for cirrhotic patients.In addition to the safety of the therapy carried out against cardiovascular diseases in cirrhotic patients,some clinical data have indicated its preventive effect on venous thrombosis.Moreover,the efficacy of antiplatelet/coagulation therapy against cirrhosis itself has been demonstrated both clinically and experimentally.The conceptual basis for application of anti-platelet/coagulation therapy against cirrhosis was constructed through two pathologic studies on intrahepatic thrombosis in cirrhotic livers.It may be better to use thrombopoietinreceptor agonists,which have been tested as a treatment for cirrhosis-related thrombocytopenia,in combination with anti-platelet drugs to reduce the risk of venous thrombosis.During the last decade,the World Journal of Gastroenterology,a sister journal of World Journal of Hepatology,has been one of the main platforms of active discussion of this theme.