Non-alcoholic fatty liver disease other diagnostic studies: Difference between revisions
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==Overview== | ==Overview== | ||
Liver biopsy may be helpful in the diagnosis of non-alcoholic fatty liver disease. Findings on biopsy include macrovesicular steatosis, inflammation, ballooning degeneration, zone 3 perivenular/periportal/perisinusoidal fibrosis and, finally, mallory bodies. | Liver biopsy may be helpful in the diagnosis of non-alcoholic fatty liver disease. Findings on biopsy include [[Steatosis|macrovesicular steatosis]], [[inflammation]], ballooning degeneration, zone 3 perivenular/periportal/perisinusoidal fibrosis and, finally, [[mallory bodies]]. | ||
==Other Diagnostic Studies== | ==Other Diagnostic Studies== | ||
*Liver biopsy is considered as a gold-standard for diagnosing, grading, and staging NAFLD. | *Liver biopsy is considered as a gold-standard for diagnosing, grading, and staging NAFLD. | ||
*Invasive test | *Invasive test | ||
*Associated with significant bleeding risk in patients with clotting abnormalities due to hepatic disease. | *Associated with significant bleeding risk in patients with [[Clotting|clotting abnormalities]] due to hepatic disease. | ||
===Complications=== | ===Complications=== | ||
Complications of liver biopsy are rare but include | Complications of liver biopsy are rare but include | ||
*Pain | *[[Pain]] | ||
*Hypotension | *[[Hypotension]] | ||
*Peritonitis | *[[Peritonitis]] | ||
*Intraperitoneal hemorrhage | *[[Internal bleeding|Intraperitoneal hemorrhage]] | ||
*Biliary injury | *Biliary injury | ||
===Findings=== | ===Findings=== | ||
Classically, biopsy reveals:<ref>Angula P. Nonalcoholic Fatty Liver Disease. NEJM. 2002 346(16):1221-31</ref><ref>Brunt EM, Janney CG, Di Bisceglie AM et al. Nonalcoholic steatohepatitis: A proposal for grading and staging the histological lesions. Am. J. Gastroenterol. 1999; 94(9):2467-2474</ref> | Classically, biopsy reveals:<ref>Angula P. Nonalcoholic Fatty Liver Disease. NEJM. 2002 346(16):1221-31</ref><ref>Brunt EM, Janney CG, Di Bisceglie AM et al. Nonalcoholic steatohepatitis: A proposal for grading and staging the histological lesions. Am. J. Gastroenterol. 1999; 94(9):2467-2474</ref> | ||
*Macrovesicular steatosis | *[[Steatosis|Macrovesicular steatosis]] | ||
*Inflammatory cells | *[[Inflammatory cells]] | ||
*Ballooning degeneration | *Ballooning degeneration | ||
*Zone 3 perivenular/periportal/perisinusoidal fibrosis | *Zone 3 perivenular/periportal/perisinusoidal [[fibrosis]] | ||
*Mallory bodies | *[[Mallory bodies]] | ||
===Interpretation=== | ===Interpretation=== | ||
*Histologic changes in NAFLD are very similar to those in alcoholic hepatitis and may also mimic those seen in chronic HCV infection | *Histologic changes in NAFLD are very similar to those in [[alcoholic hepatitis]] and may also mimic those seen in chronic [[HCV infection]]. | ||
*The spectrum of abnormalities varies from simple bland steatosis to NASH, in which steatosis is associated with mixed inflammatory cell infiltration, mostly lobular, and liver injury. | *The spectrum of abnormalities varies from simple bland [[steatosis]] to [[NASH]], in which [[steatosis]] is associated with mixed [[Inflammatory cells|inflammatory cell infiltration]], mostly lobular, and liver injury. | ||
*Cell injury is manifested by hepatocyte ballooning as well as by Mallory hyaline and acidophilic bodies. | *Cell injury is manifested by hepatocyte ballooning as well as by Mallory hyaline and [[Acidophilic|acidophilic bodies]]. | ||
*Fibrosis is classically perisinusoidal/perivenular and may lead to bridging fibrosis and cirrhosis. | *[[Fibrosis]] is classically perisinusoidal/perivenular and may lead to bridging [[fibrosis]] and [[cirrhosis]]. | ||
*Although portal tracts are relatively spared in adult NAFLD, children with this condition may have a predominance of portal inflammation and fibrosis as opposed to lobular involvement. | *Although [[Portal system|portal tracts]] are relatively spared in adult NAFLD, children with this condition may have a predominance of portal [[inflammation]] and [[fibrosis]] as opposed to lobular involvement. | ||
*Compared with alcoholic hepatitis, NASH is associated with a higher prevalence of nuclear vacuoles and steatosis, while alcoholic hepatitis tends to produce periportal and pericellular fibrosis. | *Compared with [[alcoholic hepatitis]], NASH is associated with a higher prevalence of nuclear vacuoles and [[steatosis]], while [[alcoholic hepatitis]] tends to produce periportal and pericellular [[fibrosis]]. | ||
*Alcoholic hepatitis presents with identical histology but patient history and/or biochemistry will indicate prolonged, excessive alcohol intake.<ref>Skelly et al. Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology. J Hepatol 2001;35:195-9 | *[[Alcoholic hepatitis]] presents with identical [[histology]] but patient history and/or biochemistry will indicate prolonged, excessive [[alcohol]] intake.<ref>Skelly et al. Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology. J Hepatol 2001;35:195-9 | ||
</ref> | </ref> | ||
=== | ===Histo-pathological classification=== | ||
Depending on degree of steatosis, necroinflammatory activity, and degree of fibrosis non-alcoholic liver disease can be classified as follows: | Depending on degree of steatosis, necroinflammatory activity, and degree of fibrosis non-alcoholic liver disease can be classified as follows: | ||
| Line 97: | Line 96: | ||
|Stage 1 | |Stage 1 | ||
| | | | ||
Zone 3 fibrosis<br> | Zone 3 [[fibrosis]]<br> | ||
Perisinusoidal fibrosis<br> | Perisinusoidal fibrosis<br> | ||
Portal/ periportal fibrosis | Portal/ periportal fibrosis | ||
|- | |- | ||
|Stage 2 | |Stage 2 | ||
|Perisinusoidal and portal/periportal fibrosis | |Perisinusoidal and portal/periportal [[fibrosis]] | ||
|- | |- | ||
|Stage 3 | |Stage 3 | ||
|Bridging fibrosis | |Bridging [[fibrosis]] | ||
|- | |- | ||
|Stage 4 | |Stage 4 | ||
|Cirrhosis | |[[Cirrhosis]] | ||
|} | |} | ||
Latest revision as of 16:23, 27 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Liver biopsy may be helpful in the diagnosis of non-alcoholic fatty liver disease. Findings on biopsy include macrovesicular steatosis, inflammation, ballooning degeneration, zone 3 perivenular/periportal/perisinusoidal fibrosis and, finally, mallory bodies.
Other Diagnostic Studies
- Liver biopsy is considered as a gold-standard for diagnosing, grading, and staging NAFLD.
- Invasive test
- Associated with significant bleeding risk in patients with clotting abnormalities due to hepatic disease.
Complications
Complications of liver biopsy are rare but include
- Pain
- Hypotension
- Peritonitis
- Intraperitoneal hemorrhage
- Biliary injury
Findings
Classically, biopsy reveals:[1][2]
- Macrovesicular steatosis
- Inflammatory cells
- Ballooning degeneration
- Zone 3 perivenular/periportal/perisinusoidal fibrosis
- Mallory bodies
Interpretation
- Histologic changes in NAFLD are very similar to those in alcoholic hepatitis and may also mimic those seen in chronic HCV infection.
- The spectrum of abnormalities varies from simple bland steatosis to NASH, in which steatosis is associated with mixed inflammatory cell infiltration, mostly lobular, and liver injury.
- Cell injury is manifested by hepatocyte ballooning as well as by Mallory hyaline and acidophilic bodies.
- Fibrosis is classically perisinusoidal/perivenular and may lead to bridging fibrosis and cirrhosis.
- Although portal tracts are relatively spared in adult NAFLD, children with this condition may have a predominance of portal inflammation and fibrosis as opposed to lobular involvement.
- Compared with alcoholic hepatitis, NASH is associated with a higher prevalence of nuclear vacuoles and steatosis, while alcoholic hepatitis tends to produce periportal and pericellular fibrosis.
- Alcoholic hepatitis presents with identical histology but patient history and/or biochemistry will indicate prolonged, excessive alcohol intake.[3]
Histo-pathological classification
Depending on degree of steatosis, necroinflammatory activity, and degree of fibrosis non-alcoholic liver disease can be classified as follows:
Grading
NAFLD activity score is employed for grading steatohepatitis of NASH. NAS represents the sum of scores for steatosis, lobular inflammation, and ballooning.[4]
| Component | Range | Score |
|---|---|---|
| Steatosis | <5% | 0 |
| 5-33% | 1 | |
| 34-66% | 2 | |
| >66% | 3 | |
| Lobular Inflammation | None | 0 |
| <2 focci | 1 | |
| 2-4 | 2 | |
| >4 | 3 | |
| Hepatocyte Balloning | None | 0 |
| Few ballooned cells | 1 | |
| Many ballooned cells | 2 | |
| Interpretation | 0-2 | Non-diagnostic |
| 3-4 | Borderline | |
| 5-8 | Diagnostic |
Staging
Based on the degree of fibrosis on biospy NASH can be classified into 4 stages.
| Staging | |
|---|---|
| Stage 1 |
Zone 3 fibrosis |
| Stage 2 | Perisinusoidal and portal/periportal fibrosis |
| Stage 3 | Bridging fibrosis |
| Stage 4 | Cirrhosis |
References
- ↑ Angula P. Nonalcoholic Fatty Liver Disease. NEJM. 2002 346(16):1221-31
- ↑ Brunt EM, Janney CG, Di Bisceglie AM et al. Nonalcoholic steatohepatitis: A proposal for grading and staging the histological lesions. Am. J. Gastroenterol. 1999; 94(9):2467-2474
- ↑ Skelly et al. Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology. J Hepatol 2001;35:195-9
- ↑ Vizuete J, Camero A, Malakouti M, Garapati K, Gutierrez J (2017). "Perspectives on Nonalcoholic Fatty Liver Disease: An Overview of Present and Future Therapies". J Clin Transl Hepatol. 5 (1): 67–75. doi:10.14218/JCTH.2016.00061. PMC 5411359. PMID 28507929.