Cholestasis

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Definition
Bile accumulation in the liver. Could be mechanical or functional.

Clinical Features
• May be acute or chronic
• Acute:
o usually:
 complete
 due to either:
 total functional exocrine secretory failure of hepatocytes
e.g.:
 drug-induced cholestasis
 complete obstruction of extrahepatic bile ducts e.g.:
 impacted gallstone
• Chronic:
o indicates longer duration cholestatic condition (weeks, months, years)
o may be:
 complete e.g.:
 chronic total extrahepatic bile duct obstruction by
carcinoma of pancreas or
 variably incomplete e.g.:
 primary biliary cirrhosis
 primary sclerosing cholangitis).
o if incomplete may remain anicteric for long periods

Pathogenesis
• Arrest or marked reduction in bile secretion and bile flow due to:
 o functional secretory disturbances of hepatic parenchymal cells1
o obstruction at any level in excretory pathways of bile, from canaliculi to
papilla of Vater2

Intrahepatic Cholestasis

• Cause:
o primary focus inside liver:
 diseases of:
 parenchymal cells
 intrahepatic bile ducts
 sometimes both parenchymal cells and intrahepatic bile
ducts1

Extrahepatic Cholestasis

• Cause:
o bile excretory block in larger ducts:
 outside liver along extrahepatic bile ducts e.g.:
 gallstones
 bile duct tumors
 bile duct strictures
 in larger hilar intrahepatic ducts

Combined Intra- And Extrahepatic Cholestasis

• Involves both:
o intrahepatic segments of biliary tree
o extrahepatic segments of biliary tree
• Examples:
o extrahepatic bile duct atresia in neonates
o primary sclerosing cholangitis in adults and children
• Block in bile secretion:
o may be:
 complete:
 total arrest of bile secretion
 retention of:
 bile salts
 bilirubin
 functional or obstructive
 incomplete
 usually incomplete or partial obstruction of:
 intrahepatic bile ducts:
 mostly due to destructive diseases of
intrahepatic bile ducts (vanishing bile duct
diseases) such as:
  primary biliary cirrhosis
 primary sclerosing cholangitis
 extrahepatic bile ducts:
 incomplete obstruction (narrowing or
strictures) of segments of larger bile ducts
 retention of:
 bile salts (but not bilirubin)

Histopathology
Acute Complete Cholestasis

• Changes in:
o lobular parenchyma
o portal tracts
• Bilirubin accumulation in liver lobule (Fig. 1

Fig. 1: Marked bilirubin stasis in hepatocytes, canaliculi, and Kupffer cells in

neonate with extrahepatic bile duct atresia. (H&E)

):

o starts in centrilobular zone

o pigment granules in parenchymal cells:
 hepatocellular bilirubin stasis
o inspissated bilirubin-stained bile plugs in dilated intercellular canaliculi:
 canalicular bilirubin stasis
• Hypertrophic Kupffer cells:
o phagocytose debris resulting from hepatocellular damage and death due to
retention of detergent bile acids, i.e.:
 dying parenchymal cells
 liberated canalicular bile plugs
o Kupffer cell bilirubin stasis indicates at least several days' duration3
• Edema of portal tract connective tissue:
o especially if extrahepatic obstructive origin
o results in:
  some rounding of portal contours
 incipient ‘ductular reaction’

Chronic Complete Cholestasis

• Parenchymal changes appear with time superimposed on early bilirubin stasis

• Bilirubin stasis:
o gradually extends toward periportal parenchyma
• Lymphocytic inflammatory infiltrate:
o restricted to area with bilirubin stasis
o mild
o in most forms lasting for weeks
o apparently secondary to cholestatic changes

Chronic Incomplete Cholestasis

• Bilirubin stasis not a feature:

o except if:
 terminal decompensating phase
 superimposed pathologic changes:
 e.g. drug-induced liver damage

Histopathologic Diagnosis of Chronic Cholestasis

• Applies to both complete and incomplete chronic cholestasis

• Parenchymal, portal, and periportal alterations as outlined below

Parenchymal Changes

• Include:
o cholate stasis
o cholestatic liver cell rosettes
o feathery degeneration
o xanthomatous cells
o bile infarcts

Cholate Stasis

• Periportal hepatocyte lesion:

o thought to be due to membrane-damaging effect of retained bile acids4
• Hepatocytes:
o swollen (Fig. 2
 Fig. 2: Cholate stasis in periphery of parenchymal nodule in cirrhotic liver
of patient with end stage primary sclerosing cholangitis. The hepatocytes
near the fibrous septum (lower part) show hydropic swelling, clumping of
the cytoplasm, and Mallory bodies. (H&E)

o pale
o coarsely granular:
 contain granules of lysosomal copper, complexed with copper-
binding protein (metallothionein):
 stainable with:
 rhodanine (copper) (Fig. 3

Fig. 3: Cholate stasis in periphery of cirrhotic

nodule in patient with stage 4 primary biliary
cirrhosis. Lysosomal copper–metallothionein
complexes appear as red-stained granules in the
copper-specific rhodanine stain.

 orcein (metallothionein) (Fig. 4

 Fig. 4: Cholate stasis in periportal parenchyma in
patient with primary sclerosing cholangitis. The
picture shows orcein-positive granules in periportal
hepatocytes, representing lysosomal localization of
copper binding protein (metallothionein). (Orcein
stain)

o with time:
 contain Mallory bodies
o very late stages:
 may be bilirubin inclusions

Cholestatic Liver Cell Rosettes

• Useful diagnostic feature5

• Tubular rearrangement of liver cell plates that are normally one cell thick
• Glandular or tubular structures:
o lined by four or more hepatocytes:
 may show feathery degeneration
o central lumen:
 may:
 vary greatly in diameter (Fig. 5
 Fig. 5: Cholestatic liver cell rosettes. Liver biopsy of
patient with primary sclerosing cholangitis. The involved
hepatocytes appear in tubular arrangement. (H&E)

 appear empty
 be filled with eosinophilic or bilirubin-stained material in
variable degrees of inspissation
Feathery Degeneration

• Hydropic swelling of:

o single cells
o groups of parenchymal cells
• May be some bilirubin impregnation of remaining visible cytoplasm in chronic
complete cholestasis
Xanthomatous Cells

• Feature of longstanding incomplete and complete cholestasis

• Lipid-laden histiocytes with foamy cytoplasm:
o accumulate in:
 parenchyma
 portal tracts
o single or in clusters
o represent tissular expression of hyperlipidemia that accompanies chronic
cholestasis
Bile Infarcts

• So-called Charcot–Gombault infarcts

• Late parenchymal lesion in severe cholestasis of long duration
• Mainly in large duct obstruction
• Lesions consist of necrotic hepatocytes:
o mostly paraportal
o possibly bilirubin impregnation of central necrotic area
o gradually replaced by organizing mesenchymal tissue
o finally result in fibrous scars

Two Further Characteristic Changes In Neonatal Cholestatic Liver Diseases

Parenchymal Multinucleated Giant Cells

• Due to syncytial fusion of several mononucleated hepatocytes

• Variable:
o number of nuclei
o location
 • Often contain pigment granules corresponding to:
o bilirubin
o lipofuscin
o hemosiderin
• May:
o appear necrotic
o surrounded by neutrophil polymorphs6

Extramedullary Hematopoiesis

• Foci comprising clusters of:

o erythrocyte precursor cells
o myeloid precursor cells
o megakaryocytes
• Common

Periportal And Architectural Changes

• Comprise:
o ductular reaction
o ductular reabsorption
o periductular fibrosis
o biliary fibrosis
o final stage of biliary cirrhosis

Ductular Reaction

• Increased number of ductular profiles in periphery of portal tract:

o gradually extend into periportal parenchyma toward neighboring portal
tracts in periphery of liver lobule
o accompanied by:
 edema
 neutrophil infiltration (Fig. 6

Fig. 6: Ductular reaction in chronic cholestasis. Liver biopsy from

patient with primary sclerosing cholangitis. The picture shows a
mildly inflamed portal tract (upper part) with (at 8 o'clock) a focus
 of ‘ductular reaction’ composed of bile ductules, edematous
stroma, and some neutrophil infiltration. (H&E)

)7

• If obstruction of extrahepatic bile ducts:

o mainly due to increased bile pressure8,9
o involves elongation of pre-existing bile ductules9
o has been described as ‘marginal bile duct proliferation’10
• In other cholestatic diseases, not necessarily obstructive:
o proinflammatory cytokines may be predominant triggers11,12
o cholangiocytes lining ductules may show signs of reabsorption:
 reflected in vacuolization of cytoplasm
 accumulation of bilirubin and lipofuscin
• Biliary piecemeal necrosis describes:13
o irregular portal–parenchymal interface due to:
 wedge-shaped periportal extension
 accompanying inflammation into periportal parenchyma
 possibly features of cholate stasis

Periductular Fibrosis

• Accompanies ductular reaction

Biliary Fibrosis

• Progressive ductular reaction with periductular fibrosis eventually results in

fibrous linkage of adjacent portal tracts:
o i.e. portal–portal septal fibrosis
o potentially reversible14 because basic angioarchitectural pattern of liver
preserved15
Biliary Cirrhosis

• Final stage in disturbance of lobular architecture

• Characterized – like any cirrhosis – by:
o additional portal–central fibrous septa
o nodular parenchymal regeneration
• Ongoing cholestasis:
o characterized by:
 persistence of ductular reaction
 edema
 periductular inflammation
 fibrosis
o together with lesions of cholate stasis in nodular periphery creates at low
magnification impression of clear halo between cirrhotic nodules and
fibrous septa:
  indicates actively progressing disease in its cirrhotic stage

Special Stains and Immunohistochemistry

Cholate Stasis

• Earliest stages:
o may be revealed by immunostaining for cytokeratin 7:
 reveals a phenotypic switch to a biliary type of intermediate
filament cytoskeleton in periportal hepatocytes (Fig. 7

Fig. 7: Primary biliary cirrhosis. Detail of portal tract and

surrounding parenchyma. This cytokeratin 7 immunostain
highlights an increase in the number of ductular structures at the
portal tract periphery; expression of cytokeratin 7 in periportal
hepatocytes (early stage of cholate stasis), and a few scattered,
small cytokeratin 7 positive cells at some distance from the portal
tract (presumed hepatic progenitor cells). (Immunostain for
cytokeratin 7)

• With time:
o cytokeratin 7 expression extends with decreasing gradient from limiting
plate toward center of the lobule over a distance of several cells16

Cholestatic Liver Cell Rosettes

• Some or all lining hepatocytes may

o express bile duct-type cytokeratin i.e.:
 cytokeratin 7
 tissue polypeptide antigen (TPA):
 indicates partial shift toward bile duct cell phenotype (Fig.
8
 Fig. 8: Cholestatic liver cell rosettes. Immunostaining for
cytokeratin 7 reveals cholestatic liver cell rosettes to better
advantage. Normal hepatocytes do not express cytokeratin
7, whereas cells in cholestatic rosettes express this
intermediate filament to variable extent.

)16–18

 should not be misinterpreted as expression of

hepatocellular regeneration

Diagnosis
• If incomplete and anicteric:
o no microscopically visible accumulation of bilirubin in liver tissue
sections
o underscores usefulness of distinguishing between:
 bilirubin stasis
 cholate stasis
 either separately or in combination may constitute picture
of histologic cholestasis19
• Basic differences between chronic complete and incomplete cholestasis are:
o absence of bilirubin stasis in incomplete category
o occasionally more pronounced expression of lesions in complete variety

Giant Cell Transformation Of Parenchymal Cells

• Occurs in a variety of conditions

• Appear to be more specific for age than disease:
o nonspecific reaction of infant's hepatocytes to various types of injury:
o occasionally in adults

Absent Ductular Reaction

• Chronic states of cholestasis sometimes lack obvious ductular reaction e.g. may
be absent in:
 o Alagille's syndrome
o some cases of:
 primary sclerosing cholangitis
 chronic liver allograft rejection

Differential Diagnosis
Select up to 2 differential diagnoses to compare with Cholestasis

Paucity of Interlobular Bile Ducts [Liver] (View full diagnosis)

Neonatal Giant Cell Hepatitis [Liver]
Primary Sclerosing Cholangitis [Liver] (View full diagnosis)
Primary Biliary Cirrhosis [Liver] (View full diagnosis)
Drug Induced and Toxic Liver Injury [Liver] (View full diagnosis)

Bilirubin Stasis

• Dark brown to black deposits (in hepatocytes, canaliculi, Kupffer cells, and
ductules) in erythropoietic protoporphyria:
o easily identified by polarized light:
 protoporphyrin deposits have a red to yellow birefringence with a
Maltese cross configuration in coarser (ductular) deposits (Figs 9
and 10

Fig. 9: Erythropoietic protoporphyria. Dark brownish-black

deposits of protoporphyrin in hepatocytes, canaliculi, Kupffer
cells, and ductules. (H&E)
 Fig. 10: Erythropoietic protoporphyria. The deposits are
birefringent, and show a Maltese cross picture of red birefringence
in the larger deposits. (Polarized light)

)20

Extramedullary Hematopoiesis

• Not a reliable criterion for differentiation between various cholestatic diseases

such as biliary atresia and neonatal hepatitis

Biliary Fibrosis

• Distinguish from true biliary cirrhosis

Staging/grading
Staging In Chronic Cholestatic Liver Diseases

• Based on periportal and architectural changes

• Stage 1:
o portal
• Stage 2:
o periportal
• Stage 3:
o septal
• Stage 4:
o cirrhotic21

References
1 Trauner M, Meier PJ, Boyer JL. Molecular regulation of hepatocellular transport
systems in cholestasis. J Hepatol. 1999;31:165–178.
2 Desmet VJ. Cholestasis: extrahepatic obstruction and secondary biliary cirrhosis.
MacSween RNM, Anthony PP, Scheuer PJ, Burt AD, Portmann BC editor. Pathology of
the liver. ed. 3. Edinburgh: Churchill Livingstone; 1994.

3 Desmet VJ, Roskams T. Histological features. In: Bircher J, Benhamou JP, McIntyre N,
Rizzetto M, Rodes J editor. Oxford Textbook of clinical hepatology, ed. 2. vol. 1:Oxford:
Oxford University Press; 1999.

4 Desmet VJ. Current problems in diagnosis of biliary disease and cholestasis. Semin
Liver Dis. 1986;6:233–245.

5 Nagore N, Howe S, Scheuer PJ. The three-dimensional liver. In: Popper H, Schaffner F
editor. Progress in liver diseases. vol. IX:Philadelphia: W.B. Saunders; 1990.

6 Thaler H. Leberkrankheiten. Histopathologie. Pathophysiologie. Klinik. Berlin:

Springer; 1982;.

7 Desmet V, Roskams T, Van Eyken P. Ductular reaction in the liver. Path Res Pract.
1995;191:513–524.

8 James J, Lygidakis NJ, Van Eyken P, Tanka AKF, Bosch KS, Ramaekers FCS, et al.
Application of keratin immunocytochemistry and Sirius red staining in evaluating
intrahepatic changes with acute extrahepatic cholestasis due to hepatic duct carcinoma.
Hepatogastroenterology. 1989;36:151–155.

9 Slott PA, Liu MH, Tavoloni N. Origin, pattern and mechanism of bile duct proliferation
following biliary obstruction in the rat. Gastroenterology. 1990;99:466–477.

10 Matzen P, Junge J, Christoffersen P, Poulsen H. Reproducibility and accuracy of liver

biopsy findings suggestive of an obstructive cause of jaundice. Brunner H, Thaler H
editor. Hepatology. A Festschrift for Hans Popper. New York: Raven Press; 1985.

11 Desmet VJ, Roskams T, Van Eyken P. Pathology of the biliary tree in cholestasis:
ductular reaction. Manns MP, et al. editor. Cholestatic liver diseases. Lancaster: Kluwer
Academic Publishers; 1998.

12 Matsumoto K, Fuji H, Michalopoulos G, Fung JJ, Demetris AJ. Human biliary

epithelial cells secrete and respond to cytokines and hepatocyte growth factors in vitro:
interleukin-6, hepatocyte growth factor promote DNA synthesis in vitro. Hepatology.
1994;20:376–382.

13 Ludwig J. New concepts in biliary cirrhosis. Semin Liver Dis. 1987;7:293–301.

14 Hammel P, Couvelard A, O'Toole D, Ratouis A, Sauvanet A, Flejou JF, et al.

Regression of liver fibrosis after biliary drainage in patients with chronic pancreatitis and
stenosis of the common bile duct. N Engl J Med. 2001;344:418–423.
15 Desmet VJ. Cirrhosis: Aetiology and pathogenesis: cholestasis. Boyer JL, Bianchi L
editor. Liver cirrhosis. Falk Symposium 44. Lancaster: MTP Press; 1987.

16 Van Eyken P. Cytokeratin immunohistochemistry in liver histopathology. Adv Clin

Pathol. 2000;4:201–211.

17 Van Eyken P, Desmet VJ. Cytokeratins and the liver. Liver. 1993;13:113–122.

18 Van Eyken P, Sciot R, Desmet VJ. A cytokeratin immunohistochemical study of

cholestatic liver disease: evidence that hepatocytes can express “bile duct-type”
cytokeratins. Histopathology. 1989;15:125–135.

19 Desmet VJ. Chronic cholestasis. Hoofnagle JH, Goodman Z editor. Liver biopsy.
Interpretation for the 1990's. Thorofare: Slack Incorporated; 1991.

20 Bloomer JR. The liver in protoporphyria. Hepatology. 1988;8:402–407.

21 Ludwig J, La Russo NF, Wiesner RH. The syndrome of primary sclerosing

cholangitis. In: Popper H, Schaffner F editor. Progress in liver diseases. vol.
IX:Philadelphia: W.B. Saunders; 1990.

Last updated: 23 Nov 2006