fatty liver disease





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  • NAFLD = most common

    • middle aged, but can be younger
    • mild AST ALT elevation
    • 20-30% can have low titer ANA, anti sm muscle
    • association with metabolic syndrome (central obesity, dyslipidemia, hypertension, hyperglycemia/insulin resistance)
    • neutrophils rare (vs AFLD)

  • Alcohol liver disease = striking cellular injury, PMNs

    • central vein sclerosis
    • striking balloon cells, mallory hyaline
    • neutrophils in lobules
    • diffuse pericellular fibrosis

  • Steatosis = fat

    • macrovesicular: EtOH, obesity, DM, HLD, steroids
    • microvesicular: Alcoholic foamy liver degeneration, HAART, pregnancy, Reye syndrome, tetracycline, valproic acid, malnutrition, other metabolic/genetic conditions
    • 10% of NAFLD can have small circumscribe patches of microvesicular steatosis
    • no risk of fibrosis

  • Steatohepatitis = fat + lobular inflammation + balloon cell

    • ddx surgical hepatitis in wedge/resections
    • ddx hepatitis C if too much inflammation
    • 30% develop fibrosis, 15% cirrhosis

  • Other features

    • lipogranuloma: histiocytic aggregates w lipid droplets
    • megamitochondria: more common in steatohepatitis
    • glycogenated nuclei in 45-65%, assoc diabetes

  • Fibrosis Staging

    • 1a: mild pericellular on trichrome
    • 1b: moderate pericellular on H&E
    • 1c: portal fibrosis only
    • 2: portal fibrosis and pericellular fibrosis
    • 3: briding fibrosis
    • 4: cirrhosis

  • NAFLD activity score

    • fat
      • 0: minimal < 5%
      • 1: mild <= 33%
      • 2: moderate <= 66%
      • 3: marked 67+
    • balloon cells
      • 0: none
      • 1: few
      • 2: many
    • lobular inflammation
      • 0: none
      • 1: 1 foci per 20x field
      • 2: 2-4 foci per 20x field
      • 3: 5+ foci per 20x field
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