Non-alcoholic fatty liver disease other diagnostic studies: Difference between revisions

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Latest revision as of 16:23, 27 December 2017

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

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 Perisinusoidal fibrosis Portal/ periportal 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.

Template:WS Template:WH

[1] Angula P. Nonalcoholic Fatty Liver Disease. NEJM. 2002 346(16):1221-31

[2] 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

[3] 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

[pmid28507929-4] 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.

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[2]

[3]

[4]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Non alcoholic fatty liver disease}}
-'''Editor in Chief''': Elliot Tapper, M.D., Beth Israel Deaconess Medical Center, [[User:C Michael Gibson |C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]
+{{CMG}} ; {{AE}} {{ADG}}
 ==Overview==
-A biopsy of the liver is still considered the gold standard in diagnosis. This is especially true for those patients with elevated liver enzymes for whom a non-invasive workup is inconclusive; 34% of these patients, in one series, were found to have NASH.<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
+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]].
-</ref> Classically, biopsy reveals macrovesicular steatosis, inflammation, ballooning degeneration, zone 3 perivenular/periportal/perisinusoidal fibrosis and, finally, mallory bodies.<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> Unfortunately, however, a standard biopsy is only able to sample a volume that is 1/50,000th of the liver, underscoring substantial room for sampling error.
+==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|clotting abnormalities]] due to hepatic disease.
+===Complications===
+Complications of liver biopsy are rare but include
+*[[Pain]]
+*[[Hypotension]]
+*[[Peritonitis]]
+*[[Internal bleeding|Intraperitoneal hemorrhage]]
+*Biliary injury
+===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>
+*[[Steatosis|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 cells|inflammatory cell infiltration]], mostly lobular, and liver injury.
+*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]].
+*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]].
+*[[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>
+===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.<ref name="pmid28507929">{{cite journal |vauthors=Vizuete J, Camero A, Malakouti M, Garapati K, Gutierrez J |title=Perspectives on Nonalcoholic Fatty Liver Disease: An Overview of Present and Future Therapies |journal=J Clin Transl Hepatol |volume=5 |issue=1 |pages=67–75 |year=2017 |pmid=28507929 |pmc=5411359 |doi=10.14218/JCTH.2016.00061 |url=}}</ref>
+{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
+! style="background:#efefef;" |Component
+! style="background:#efefef;" |Range
+! style="background:#efefef;" |Score
+|-
+| rowspan="4" |Steatosis
+|<5%
+|0
+|-
+|5-33%
+|1
+|-
+|34-66%
+|2
+|-
+|>66%
+|3
+|-
+| rowspan="4" |Lobular Inflammation
+|None
+|0
+|-
+|<2 focci
+|1
+|-
+|2-4
+|2
+|-
+|>4
+|3
+|-
+| rowspan="3" |Hepatocyte  Balloning
+|None
+|0
+|-
+|Few ballooned cells
+|1
+|-
+|Many ballooned cells
+|2
+|-
+| rowspan="3" style="background:#efefef;" |Interpretation
+| style="background:#efefef;" |0-2
+| style="background:#efefef;" |Non-diagnostic
+|-
+| style="background:#efefef;" |3-4
+| style="background:#efefef;" |Borderline
+|-
+| style="background:#efefef;" |5-8
+| style="background:#efefef;" |Diagnostic
+|}
+===Staging===
+Based on the degree of fibrosis on biospy NASH can be classified into 4 stages.
+{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
+! colspan="2" style="background:#efefef;" |Staging
+|-
+|Stage 1
+|
+Zone 3 [[fibrosis]]<br>
+Perisinusoidal fibrosis<br>
+Portal/ periportal fibrosis
+|-
+|Stage 2
+|Perisinusoidal and portal/periportal [[fibrosis]]
+|-
+|Stage 3
+|Bridging [[fibrosis]]
+|-
+|Stage 4
+|[[Cirrhosis]]
+|}
 ==References==
 {{reflist|2}}
-{{WH}}
-{{WS}}
 [[Category:Gastroenterology]]
-[[Category:Hepatitis]]
 [[Category:Hepatology]]
+[[Category:Disease]]
+[[Category:Needs content]]
+{{WS}}
+{{WH}}