Reply To: Make cytology great again!

Hi Scott,

There’s a lot of information you’ve given us here!

Bloods:
-Neutrophilia:Most likely an inflammatory response (due to infection/inflammation etc)
-HCT: Low end of normal, but still within normal limits.

-Mild increase in ALP: Causes could be secondary (GI, pancreatitis, endocrinopathies, cholestasis (GB disease, bile duct neoplasia, cholelithiasis) etc) or primary hepatic (hepatitis, cholangiohep, neoplasia)
-Marked ALT elevation: Primary hepatic disease (hepatitis, hepatic toxicity, hepatic trauma, neoplasia (adenocarcinoma),) or extra hepatic causes including cholestasis will cause an increase in ALT, but I would expect ALP to be higher than ALT if the primary pathology was due to cholestasis.

So I would be suspicious of primary hepatic disease, the degree of elevation doesn’t give me any information about severity of damage and so I would want to follow the trend of ALT and consider re-testing in 5-7days to see if its trending up or down.

-Marked Tbil elevation: I think pre-hepatic causes are unlikely based on the current HCT levels and the degree of hyperbilirubinaemia and so this elevation is either due to primary hepatic disease or secondary EHBO (could be due to cholelithiasis if obstructing the CBD but a dilated CBD would be noticed on ultrasound) or could be due to pancreatitis.

-Amylase is a non-specific test so I wouldn’t read too much into this.
-In light of the hyperbilirubinaemia the bile acids are not useful.

Ultrasound:
-Hepatomegaly is non-specific, differentials could include hepatitis, steroid hepatopathy, vaculolar hepatopathy,lipidosis, neoplastic infiltration (round cell: lymphoma/MCT or diffuse adenocarcinoma), amyloidosis
-Localised lymphadenopathy could be due to inflammatory changes or neoplastic infiltration.
-Splenomegaly: Sedation, EMH, lymphoid hyperplasia, neoplastic infiltration and unlikely splenic torsion (as you would expect to see other changes, lack of Doppler, hyperechoic mesentery and change in splenic echogenicity).
-Splenic infarct is likely an incidental finding, however underlying disease creating a hypercoagulable state is possible.
-Splenic nodule: Likely incidental finding ddx include EMH,benign lymphoid hyperplasia, haematoma, granuloma, neoplasia.
-Gallbladder sludge is an incidental finding if gravity dependent. Cholelithiasis could be incidental or clinically significant depending on location etc, could be associated with cholangitis, cholangiohep, cholestasis.

Cytology:
I’m rubbish at cytology so will attempt these

First image I think is a vaculolar hepatopathy, lipid type.
Second image: Hepatocytes with bile casts indicative of cholestasis.
Third: Are these hepatocytes and some spindle cells. I don’t think I see any criteria of malignancy so maybe it’s fibrosis…But I could be completely wrong.

Based on all of the above I would be suspicious that there was pancreatitis present (CPLi would be nice to add info), but I would also wonder about a primary hepatic process going on because of the degree of ALT elevation (but I think cytology report might help give more information on this compared to my guess)and your bile aspirate may shed light on if there is any infectious/inflammatory process within the GB too.