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Ultrastructure of the Liver in Non-Cirrhotic Portal Fibrosis

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Ultrastructure of the Liver in Non-Cirrhotic Portal Fibrosis Gut, 1970, 11, 905-910 Ultrastructure of the liver in non-cirrhotic Gut: first published as 10.1136/gut.11.11.905 on 1 November 1970. Downloaded from portal fibrosis with portal hypertension B. N. TANDON, R. LAKSHMINARAYANAN, S. BHARGAVA, N. C. NAYAK, AND S. K. SAMA From the All India Institute ofMedical Sciences, Department ofMedicine, Ansari Nagar, New Delhi-16, India SUMMARY The aetiology of the ultrastructural abnormalities of non-cirrhotic portal fibrosis is not known. In an attempt to elucidate the pathophysiology of this condition, the hepatic ultrastructure in nine cases of non-cirrhotic portal fibrosis with portal hypertension has been studied. A large series from Japan (Imanaga, Yamamoto, tation ofthe portal vein, the presence ofcollaterals, and Kuroyanagi, 1962) and several reports from and no evidence of any block. The intrahepatic the west (Tisdale, Klatskinn, and Glenn, 1959; pattern of the portal vein is not greatly disturbed Hallenbeck and Adson, 1961; Perez, 1961; Miller (Wig, 1966; Basu et al, 1967; Basu Mallick et al, and Brandt, 1962; Polish, Christie, Cohen, and 1967; Boyer et al, 1967; Datta, 1969). Haemo- Sullivan, 1962; Siderys and Vellios, 1964; dynamic studies show marked rise of splenic pulp http://gut.bmj.com/ Mikkelson, Edmondson, Peters, Redeker and pressure with normal or slight elevation of hepatic Reynolds, 1965) have described patients with idio- wedge pressure. The gradient between hepatic pathic portal hypertension, who had neither wedge pressure and splenic pulp pressure is cirrhosis of the liver nor portal or hepatic markedly increased (Boyer et al, 1967; Datta, venous obstruction. A lucid description of this 1969; Wig et al, 1969), hepatic blood flow is entity from North India (Ramalingaswami, Wig, normal (Boyer et al, 1967; Datta, 1969; Wig and Sama, 1962; Wig, 1966) stimulated several et al, 1969), and liver biopsies tend to be essenti- on September 30, 2021 by guest. Protected copyright. investigators to study the pathophysiology and ally normal or show minimal fibrosis (Ramalinga- aetiology of this disorder with the help of recent swami et al, 1962). Recently, a careful study has techniques (Basu, Boyer, Bhattacharya, Basu demonstrated subintimal thickening in the smaller Mallick, and Sen Gupta, 1967; Basu Mallick, intrahepatic radicles of the portal vein (Nayak Sen Gupta, Biswas, Pal, and Boyer, 1967; Boyer, and Ramalingaswami, 1969). The present study Sen Gupta, Biswas, Pal, Basu Mallick, Iber, of the hepatic ultrastructure is an attempt to and Basu, 1967; Datta, 1969; Wig, Tandon, elucidate the pathophysiology of portal hyper- Bhargava, Sama, and Nayak, 1969). It is suggested tension in non-cirrhotic portal fibrosis. that between 3% and 5 % of the cases of portal hypertension in the west may be idiopathic (Iber, 1969). The disease is probably more preva- lent in India and has been called 'non-cirrhotic' Method and Materials portal fibrosis (Basu et al, 1967; Basu Mallick et al, 1967; Boyer et al, 1967; Datta, 1969). Nine cases of non-cirrhotic portal fibrosis with Clinically the disease is characterized by spleno- portal hypertension were selected on the basis of megaly of long duration, repeated gastro- criteria previously described by us (Wig, 1966; intestinal bleeding with only minimal features of Nayak and Ramalingaswami, 1969). Serum hepatocellular failure (Wig, 1966; Basu et al, albumin, globulin, bilirubin, and alkaline phos- 1967: Boyer et al, 1967; Datta, 1969; Wig et al, phatase were estimated, and in each case a liver 1969). Splenoportovenograms show marked dila- biopsy was obtained using a Vim Silverman Received for publication 1 1 May 1970. needle. One part of the biopsy specimen was 906 B. N. Tandon, R. Lakshminarayanan, S. Bhargava, N. C. Nayak, and S. K. Sama studied by light microscopy; the other was Gut: first published as 10.1136/gut.11.11.905 on 1 November 1970. Downloaded from processed for electron microscopy. The specimen was fixed first in 3 % glutaraldehyde and then in 2% osmium tetraoxide (Karnovsky, 1965) and was embedded in epoxy resin (Luft, 1961). An LKB 4801 A ultratome was used to obtain thin sections (600A to 700A) which were stained with uranyl acetate (Watson, 1958) and lead citrate (Reynolds, 1963) and examined with a Hitachi Hu 1lA electron microscope. A section (one micron thick) was simultaneously examined for proper orientation of the tissue. Liver biopsies from two healthy control sub- jects were also studied. Results Splenomegaly with anaemia was a prominent feature in seven cases and two patients had haematemesis as the presenting symptom. No patient had ascites, jaundice, or any signs of hepatocellular failure. Oesophageal varices were demonstrated by barium swallow in eight of the nine cases. Splenoportovenography revealed patent, but dilated, portal and splenic veins. Collaterals were seen in all the cases. Serum bilirubin, albumin, alkaline phosphatase, and thymol turbidity were normal in all the cases. Liver histology was essentially normal with preservation of normal lobular architecture Fig. 1 Needle biopsy ofa patient with non-cirrhotic (Fig. 1). There was no evidence of cirrhosis and portal hypertension. The liver architecture and http://gut.bmj.com/ only in three cases was mild portal scarring structure appears normal. (H and E, x 110.) present. Silver stains revealed some increase in reticulum fibres in the portal areas in a few of the cases and a suggestion of increased argy- rophilia in the perisinusoidal framework. Discussion The ultrastructure of nuclei and nuclear mem- branes in non-cirrhotic portal fibrosis is normal. Non-cirrhotic portal fibrosis is characterized by No intranuclear bodies are observed. The mito- two ultrastructural findings: (1) normal nuclear on September 30, 2021 by guest. Protected copyright. chondria of hepatocytes are normal in size and and intracytoplasmic components of the hepato- shape. There is no evidence of mitochondrial cytes, and (2) abnormalities of the cell membrane swelling or degeneration and the double mem- and perisinusoidal space. These abnormalities brane and cristae are intact (Fig. 2). The rough include widening of the intercellular and Disse's endoplasmic reticulum is abundant while smooth spaces and fibrogenesis in the perisinusoidal endoplasmic reticulum is sparse. The hyaloplasm space which often extends into the intercellular is rich in glycogen bodies. Autophagic vacuoles space. These observations help in the understand- are occasionally seen (Fig. 3). ing of the pathophysiology of portal hypertension In this condition the cell membrane between in this disease. two hepatocytes shows widening with the develop- Previous haemodynamic studies have indicated ment of microvilli. The Disse's spaces are also raised splenic pulp pressure, normal or occasion- widened because of the laying down of collagen ally raised hepatic wedge pressure, and a notice- bundles, which occasionally extend into the inter- able increase in the gradient between hepatic cellular space, but most often spread into the wedge pressure and splenic pulp pressure (Boyer perisinusoidal space (Fig. 4). Mesenchymal cells et al, 1967; Datta, 1969; Wig et al, 1969). These are well developed close to collagen bundles. findings suggest a presinusoidal or a perisinu- Microvilli at the hepatocyte membranes which soidal block. The presence of large numbers of line sinusoids are abundant. An attempt at collagen bundles in the perisinusoidal area and capillary formation of sinusoids is occasionally the spaces ofDisse might possibly be the anatomi- shown by the development of endothelial lining cal lesion related to the portal hypertension in (Fig. 5). this disease. Formation of capillaries from sinu- 907 Ultrastructure of the liver in non-cirrhotic portalfibrosis with portal hypertension Gut: first published as 10.1136/gut.11.11.905 on 1 November 1970. Downloaded from Fig. 2 Ultrastructure ofhepatocytes in non- http://gut.bmj.com/ cirrhotic portalfibrosis. Nucleus and cytoplasmic organelles do not show any abnormality. (N, nucleus; Nu 2, nucleolus; NM, nuclear membrane; M, mito- chondria; ER, rough endoplasmic reticulum; SER, smooth endoplasmic reticalum; GI, glycogen.) x 24,oo. on September 30, 2021 by guest. Protected copyright. soids might aggravate portal hypertension. cirrhotic portal fibrosis. Even massive gastro- Presinusoidal block might also be localized to intestinal bleeding does not produce hepatic the smaller radicle of the portal vein (Nayak and encephalopathy in these patients (Wig, 1966). The Ramalingaswami, 1969), but such a localization normal ultrastructure ofhepatocytes corroborates would fail to explain the raised hepatic wedge these observations. The development of large pressure observed in some of these patients. The numbers of microvilli in the intercellular cell obliterative porto-venopathy described in this membrane seems to be an adaptive phenomenon disease (Nayak and Ramalingaswami, 1969) may which provides a wider area of contact between be secondary to the rise in portal pressure or sinusoidal fluid and the liver cell. The adaptation might result from perisinusoidal fibrosis. Alterna- may compensate for the barrier due to collagen tively the same aetiological factor might simul- bundles in the perisinusoidal space. Similar taneously produce the lesion in the smaller rad- observations have been recorded in cirrhosis of icle of the portal vein and in the perisinusoidal the liver (Philips and Steiner, 1965). area. It is important to note that perisinusoidal The aetiology of the ultrastructural
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