Patomorfologija chronic hepatitises at children and teenagers.

Histological criteria HG are a combination vospalitelnoyokletochnoj infiltrations, various forms of a hepatocellular degeneration and a necrosis, and also a fibrosis [63, 101, 134, 388].

At a lesion of hepatocytes a virus, at patients HG, distinguish two types of structural changes of a cell:

• a serious dystrophia up to a necrobiosis of hepatocytes (at continuously recurring a disease current);

• parallel development in a cell of processes of a dystrophia and intracellular neogenesis (at alternating of clinico-laboratory exacerbations and remissions).

1.3.1. Slabovyrazhennyj a chronic hepatitis

Morphological substrate slabovyrazhennogo a chronic hepatitis was characterised by rather small volume of inflammatory changes in limits of portal tracts, safety of a boundary plate of lobes, the big number of not amazed hepatocytes, small volume of necrotic changes, domination of easy forms of a dystrophia over serious, a focal hyperplasia zvezdchatyh retikuloendoteliotsitov. [204, 230].

1.3.2. A moderate chronic hepatitis

The chronic hepatitis of moderate activity possesses following morphological features: involving and destruction of a boundary plate, augmentation of volume of infiltrates and diffusion of those to peripheric departments of lobes, a gain of necrotic changes and, accordingly, reduction of number of not changed hepatocytes. [204, 208, 215, 230]

1.3.3. A serious chronic hepatitis

Massiveness of a lesion of portal both periportal zones and penetration of infiltrates into the centres of lobes is inherent in this variant of a chronic hepatitis. Among infiltrates lymphoid elements and plasmocytes which were diffusively distributed both in portal tracts, and among hepatocytes prevailed. Presence of continuous fields of lymphocytes in a depth sept, with formation of microfollicular structures was characteristic. Both in regional hepatocytes, and in lobes the necrotic changes which had focal character often became perceptible. Fall sinusoidov was expressed. As a result the most authentic morfometricheskimi the signs allowing

To differentiate a serious chronic hepatitis from moderated, have appeared: a volume gain lizisa kernels, change of their configuration, a necrosis of hepatocytes, prevalence of a balloon and hyaline dystrophia, sharp narrowing sinusoidov,
The big prevalence of infiltrates, mainly from lymphocytes and plasmocytes [134, 204, 230].

Differences in a histological picture at children and adults become perceptible. Easy changes in a liver, classified as it is less or peerly 4 points it is observed at 80-90 % of children, whereas at adults - on the average no more, than at half of patients. Expression of an inflammation on histological index Scheuer at children makes 0,6+0,7 against 3,2+1,1 at adults, fibrosis degree 0,5±0,5 against 2,6+1,2 accordingly.

Researches have shown, that inflammatory activity of process at children, the highest in the first years of a current of an infection, further gradually decreases [7, 10, 218, 219].

1.3.4. A chronic hepatitis, a cirrhosis.

The cirrhosis arising in outcome HVG, concerns a postnecrotic cirrhosis. Morfologicheski it is characterised:

• the big loss of hepatic cells;

• a collapse of a stroma and a fibrosis, the fibrous tissue expands in the form of wide strips in which that remains from hepatic triads is quite often concluded;

• randomly scattered nodules of neogenesis of hepatocytes which vary in sizes from microscopical to several centimetres in diameter.

This type Xr was characterised by growth of a connecting tissue which together with infiltrates got into depth of a parenchyma, formed bridges between the central veins, and also between veins and portal tracts and by that caused diskompleksatsiju a lobular structure of a liver [7, 10, 161, 204].

1.3.5. Patomorfologija a hepatitis of Century

Presence and level of markers HBV accurately correlates with gravity gistoloyogicheskih inflammatory changes in a liver [85, 420], that is bound to intensifying of an expression of virus fibers and larger activity cytotoxic T -

Lymphocytes. At an exacerbation of a hepatitis the quantity cytotoxic T-limfotsitov (CD8 +) in a parenchyma was enlarged, associating with zones of necrosises of hepatocytes. In zones of confluent necrosises defined raised maintenance HBsAg in hepatocytes [252, 329, 347, 379, 420]. From serumal markers reflect histological activity of an IgM-antibody to HBcAg which maintenance correlates with lobuljarnymi and step necrosises [85, 399] is better.

Semiquantitative studying bioptatov a liver at children suffering HGV, has taped in 74 % of cases minimum and slabovyrazhennuju degree, and in 26 % moderate degree of histological activity (HECTARES). At an estimation of a histological index of a stage of synchronisation (GISH) in 41 % it is found out minimum, in 54 % of cases - moderated and only in 5 % of observations - a serious stage [160, 399].

Recently there were reports about HGV with steatosis implications, earlier was considered, that for a HBV-infection it is a condition is not characteristic [462, 412].

1.3.6. Patomorfologija a hepatitis With.

Is inflammatory-necrotic changes, dystrophia, fibrosis, implications of neogenesis, disturbance of a circulation, an iron exchange are observed in various combinations. The inflammation is shown by mononuclear infiltration of portal tracts with step necrosises or without them. [85, 63, 250, 255, 292]. Fibrous changes are characteristic for HGS, and consist in various degree of expression of a fibrosis of portal tracts and periportal zones. Except these, to some extent characteristic changes for all hepatitises, the majority of authors describe a triad of signs: damage of an epithelium of cholic canaliculuses mononuklearami, lymphoid units/follicles in portal tracts and small/krupnokapelnaja fatty dystrophia of hepatocytes [85, 114, 135, 177, 236, 297, 342, 366]. All components of this triad seldom simultaneously meet at a hepatitis In, an autoimmune hepatitis and accurately speak well HGS. Presence of lymphoid units back correlates with a fibrosis stage [114, 185].

The second element - a fatty dystrophia of hepatocytes meets in 40 - 70 %
Cases [296, 449]. Between steatosis level at HGS and an index of histological activity observed return correlation. Thus, the steatosis is a marker of virus process, associating with the lowered immunoreactivity] and inactive phase HGS [148, 149, 150, 160, 191, 211, 281, 449].

Steatosis at HGS 3 viruses, an index of mass of the body, proceeding abusing of alcohol, age [228, 423, 424] are independent assotsiirovan with a fibrosis, a genotype.

The third element of a morphological triad at HGS - inflammatory poyovrezhdenie cholic ducts in portal tracts. In an epithelium of cholic ducts find out HCV. At the same time it is noted any communication between damage of cholic ducts and presence of an autoimmune component at HGS [426]. For HGS as a whole it is characteristic low, but constant activity vospayolenija in a liver, with periodic exacerbations, and about activation and plazmotsitarnaja infiltration of portal tracts, and step necrosises testify to an inactive phase - portal lymphoid units and a steatosis [160, 177, 429, 330, 366]. Despite presence or absence of clinical and biochemical implications, practically at all patients find a hepatitis at morphological research [278]. The analysis morfometricheskih indicators bioptatov, taken of a liver at children with chronic hepatitises, has taped authentic prevalence in inflammatory infiltrates of lymphocytes at HGV and fibroblasts at HGS. The last testifies to larger sclerosing potential at patients with a HCV-infection and possibilities development in them of a fibrosis in the first 10 years of disease. [177, 194, 330].

1.3.7. Morphology sochetannyh virus hepatitises.

Sochetannaja HCV/HBV the infection is characterised by an appreciable variety of results replikativnoj activity, immunohistochemical revealing of antigens of viruses In and With, and also microscopical data, that not always coincides with results of molekuljarno-biological research. It testifies to various variants of activity of each virus [85, 109, 260].

Combination HGV and HGS leads to weighting clinical and
Morphological implications of illness [346, 448]. Morphological changes also reflect effects replitsirujushchegosja a virus. So, in sochetannyh infections В+С at sick DNA HBV (+) above volume of step necrosises and a fibrosis, than at DNA HBV (-) [85]. Viruses In and With, and also iron accumulation, lead sinergichnomu to damage of a liver [85]. Comparing morphology of hepatitises In, With and В+С, В+D. Have found out, that "is matte-steklovidnye" gepato-tsity met only at HGV and ХГВ+С, and at ХГВ+С and HGS - lymphoid follicles and damage of cholic ducts [97, 207, 208].

1.3.8. The "latent" infection.

The latent HBV-infection (anti-HbcAg) have found at half of patients with HGS, in the presence of a cancer of a liver markers HBV taped more often [85, 132, 181]. Virus DNA find at research of a liver, Serum, mononuklearov bloods in many years after recover from OGV. The infection reactivation also can be observed, how is spontaneous, and at immunosupressii [387, 424, 460].