I met Isaiah Abraham Wagler the way I meet all my patients, cocooned in glass. A slide containing a small slice of his liver lay before me. I positioned it on the cool black stage of the microscope. Tinted blue and red to reveal the delicate cellular structures, the tissue looked like the tortuous flow of a red river. From what I could see, the overall structure of Mr. Wagler's liver seemed sound, but there were faint strands of gray, the first signs of long-term damage. The gray strands told me his liver was slightly scarred. Something was awry.
About a month before, Mr. Wagler had complained of a dull pain in his belly after meals. His family doctor had ordered an ultrasound, which revealed hard clumps of cholesterol, called stones, in his gallbladder. Stones can form when the liver isn't producing the right ratio of chemicals in the digestive fluid called bile. After a preliminary blood workup, Mr. Wagler's gallbladder was removed. During the operation the surgeon, Dr. Evans, noted a slight grayish brown discoloration of the liver, and he took a snippet and sent it to me, the pathologist.
I switched the microscope to medium power and began to scan the red field. The liver is laid out, like a vast honeycomb, in a series of hexagons called lobules. The nutrients and blood from the gut enter at the edges of the lobule and pass through hepatocytes, or liver cells, on their way to the central vein of each lobule. There the blood collects and enters the venous system, on the way to the heart. I could see that the overall lobular structure of the liver was still preserved. There was a little scarring at the edges but no sign of cirrhosis, the medical term for scarring so severe that the liver cannot function normally-or heal.
I began searching for other clues. There were none-no clumps of search-and-rescue immune cells, no tissue reaction, no signs of injured or dying cells. If Mr. Wagler's liver was scarred from alcoholism, I would expect the cells to look blurry, the intricate cellular scaffolding to be in ruins. Or if the virus that causes hepatitis had invaded the cell, the nucleus would look broken up, as if a bomb had gone off inside. But I saw nothing but a little scarring. These scars, though, were the gravestones of dead hepatocytes.
