Non-alcoholic fatty liver disease other diagnostic studies
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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.
- Requires dexterity and skill
- 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]
Histopathalogical 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.