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Steatohepatitis: more important in 2018!JOHN HART, M.D.SURGICAL PATHOLOGY & HEPATOLOGYUNIVERSITY OF CHICAGO MEDICAL CENTERjohn.hart@uchospitals.edu

Topics to be Covered

• Microvesicular vs macrovesicular steatosis

• Natural history of NASH

• Risk factors in the development of NASH

• Diagnosis of NASH

• Histologic features of NASH

• Grading and staging NASH

• NAFLD in chronic HCV

• Other conditions associated with NAFLD

Topics Not Covered

• Alcoholic steatohepatitis (ASH)

• Distinction between NASH and ASH

• Pediatric NASH (slides at the end)

• Treatment of NASH

• NASH as a cause of cryptogenic fibrosis

• Regression of fibrosis/cirrhosis in NASH

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Macrovesicular

Steatosis

• Common finding

• Patients ambulatory,

outpatient

• Due to long-standing,

chronic conditions or

metabolic states

• Risk of fibrosis and

cirrhosis

Microvesicular

Steatosis

• Rare condition

• Patients critically ill in ICU

• Due to severe

mitochondrial injury

• Acute hepatic dysfunction

Macrovesicular Microvesicular

H&E Stain Oil Red O Stain

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Differential Diagnosis for Diffuse Microvesicular Steatosis

• Acute fatty liver of pregnancy

• Drugs & toxins (e.g., valproic acid)

• Alcoholic foamy degeneration

• Inherited disorders of fatty acid metabolism

• Inherited urea cycle disorders

• Mitochondrial cytopathies

• Wolman disease

• Cholesterol ester storage disease

• Reye syndrome

MacSween's Pathology of the Liver, 6th Edition

S. Romeo at al. Nat. Genet 40, 1461

E.K Spelites et at PloS Genet. 7, e1001324

KF Petersen et al N Engl. J Med, 362, 1082

Genetic risk factors for hepatic steatosis

Triglyceride accumulation leads to steatosis

Fatty Liver

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?

• lysophosphatidylcholines• ceramides • phosphatidic acids• diacylglycerol

↑ FFA

↑ lipotoxic intermediates

Proinflammatory cytokines• TNF-α• IL-6

Mitochondria dysfunction

ER stress

G.S.Hotamisligil, Cell 140,900 (2011)A.E. Feldstein. Semin Liver Dis. 30, 391

Hepatocellular injuryInflammation

What Causes Steatohepatitis?

Non-Alcoholic Fatty Liver Disease (NAFLD)

Steatosis Steatohepatitis

Most common

chronic liver disease in

the United States

Inflammation

Hepatocyte injury

Fibrosis

This is a Key Distinction !

Why Diagnose NASH?

• Potential interventions:

– Lifestyle modification

– Several ongoing medication trials

– Bariatric surgery

• Prognosis:

– NASH is progressive

– Cirrhosis and its complications in some patients

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Healthy diet

ExerciseWeight loss

Improved diabetic control

Promrat et al., Hepatology 2010.

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Steatohepatitis?Jaundice?

Cirrhosis?

*

* Liver transplantation also effective in selected cases

Fatty Liver Disease (FLD)

NAFLD patients N = 132 Cirrhosis ( X = 8.3 yrs f/u)

Steatosis 49 (37%) 2 (4%)

Steatosis +

lobular inflammation

10 (8%) 0 (0%)

Steatosis +

hepatocyte ballooning

19 (14%) 4 (21%)

Steatosis + ballooning +

Mallory-Denk or fibrosis

54 (41%) 14 (26%)

Matteoni et al., Gastroenterology 1999.

Normal LiverSimple

Steatosis

Steatohepatitis

Cirrhosis

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• 41 patients undergoing bariatric surgery• BMI median = 50 (34.5 to 69.8)• Intra-operative liver biopsy:

• 43.8% normal• 29.3% steatosis• 26.9% NASH

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Histologic Features of NASH

(and ASH)

• Steatosis - predominantly macrovesicular

• Inflammation - neutrophilic and lymphocytic

• Hepatocyte injury - +/- Mallory-Denk bodies

• + / - fibrosis – centrilobular and/or portal/periportal

Brunt EM, Clin Liv Dis 2009

Histologic Features of Steatohepatitis Steatosis

• Extent > 5% (by definition)

• Macrovesicular >> microvesicular:

– Pure microvesicular steatosis is not a feature in NAFLD

– Focal microvesicular steatosis is not clinically significant

• Zonal distribution:

– Often zone 3 predominant in adults

– Panacinar or azonal distribution can be seen

– Can be zone 1 predominant in children

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Macrovesicular steatosis

Macrovesicular steatosis with focal microvesicular steatosis

zone 3 (centrilobular) steatosis

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panacinar steatosis

zone 1 (periportal) steatosis in pediatric NAFLD

azonal steatosis

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Histologic Features of Steatohepatitis Inflammation

• Lobular inflammation:

– Clusters of neutrophils, esp. surrounding Mallory-Denk bodies

– Clusters of lymphocytes

– Clusters of macrophages / Kupffer cells (microgranulomas)

• Portal inflammation:

– Mostly seen in pediatric NAFLD, resolving NASH, and in severe disease

– Dense inflammation suggests superimposed AIH / chronic viral hepatitis

– Autoantibodies (ANA, SMA) present in 40% of patients with NAFLD

lobular inflammation

lobular inflammation

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portal inflammation

Histologic Features of Steatohepatitis Hepatocyte injury

• Hepatocyte ballooning degeneration:

– Most difficult and subjective feature of steatohepatitis

– Enlarged hepatocytes with wispy or clumped cytoplasm and a centrally placed nucleus

– Most prominent in zone 3 in areas of perisinusoidal fibrosis, and sometimes easier to see in the trichrome stained section

– Can contain Mallory-Denk bodies

– Loss of cytokeratin 8/18 IHC can aid identification

– Not common in pediatric NAFLD

• Acidophil bodies

Acidophil Bodies

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hepatocyte ballooning degeneration

hepatocyte ballooning degeneration

hepatocyte ballooning degeneration

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Histologic Features of Steaohepatitisoften present, but not required

• Mallory-Denk bodies

• Glycogenated hepatocyte nuclei

• Lobular lipogranulomas

Brunt Clin Liver Dis 2009

Mallory-Denk Bodies

• Located in zone 3

• Denatured cytokeratin filaments

• Associated with ubiquitin

• Occur in ballooned hepatocytes

• CK7, CK18, CK19, p62 +

• Sometimes cuffed by neutrophils

• Also seen in zone 3 in ASH and

amiodarone toxicity

Mallory Body George Mallory

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Mallory-Denk Body Helmut Denk

Mallory-Denk bodyMallory-Denk body

Histologic Features Unusual for Steatohepatitis Consider other liver diseases

• Pure or predominant microvesicular steatosis

• Portal > lobular inflammation*

• Portal > centrilobular fibrosis*

• Prominent hepatocyte ballooning with minimal

steatosis (consider amiodarone toxicity)

• Epithelioid granulomas

• Conspicuous plasma cells

• Chronic cholestatic features

* Except pediatric NASH

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Grading of NASH*EM Brunt. Sem Liver Dis 2001; 21:3-16.

GRADE SteatosisHepatocyteBallooning

LobularInflammation

PortalInflammation

MILDUp to 66%;

mostly

macrovesic.

Zone 3;

occasional

cells

Scattered polys and

mononuclear cellsNone or mild

MODUp to 66%;

usually

mixed

Zone 3;

obvious

Polys with ballooned

cells & areas of

pericellular fibrosis

Mild to

Moderate

SEVERE> 66%;

usually

mixed

Predom.

Zone 3;

marked

Polys with ballooned

cells & areas of

pericellular fibrosis

Mild to

Moderate

*modified version

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American Journal of Gastroenterology (1999) 94, 2467–2474;

• Nine study pathologists (NIDDK consortium)

• 32 adult and 18 pediatric biopsies

• 14 histologic features scored:

– Degree of macrovesicular steatosis (0-3)

– Degree of lobular inflammation (0-3)

– Degree of hepatocyte ballooning (0-2)

– Degree of fibrosis (0-4)

• NAFLD Activity Score (NAS):

– Score ≥ 5 correlated with diagnosis of NASH

– Score < 3 correlated with diagnosis of not NASH

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►

►►

►

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grade 1 hepatocyte ballooningclusters of ballooned hepatocytes

grade 2 hepatocyte ballooningenlarged ballooned hepatocytes

grade 1 lobular inflammation<2 foci per lobule

grade 2 lobular inflammation> 2 foci per lobule

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American Journal of Physiology - Gastrointestinal and Liver Physiology May 2011

Necroinflammatory Activity Leads to Fibrosis

Stage 1:zone 3

(perivenular) pericellular

Stage 2: As in Stage I

+portal /

periportalfibrosis

Stage 3:bridgingfibrosis

Stage 4:Cirrhosis

Staging for NASHEM Brunt. Sem Liver Dis 2001; 21:3-16.

trichrome: normal central vein

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perivenular and sinusoidal fibrosis

Case 45 S07-23911 (grade 2 / stage 2)

GLUTAMINE SYNTHETASE Cytokeratin 7

centrilobular and portal fibrosis

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central-to-portal bridging fibrosis

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• 58 y.o. M with increased LCTs on routine testing

• TB = 0.5, AST = 49, ALT = 56, alk phos = 124

• Obese (BMI = 30.85), hypercholesterolemia, HTN

• HBV, HCV negative; ANA negative

• Social drinker

• U/S reveals fatty liver disease

• Seen at U of C in consultation:– TB = 0.4, AST = 45, ALT = 54, alk phos = 117

– Serum ferritin = 382, alpha-1-antitrypsin PiMM

– ANA = 1:160

– FIBROSpect II = 9 (consistent with stage 0-1)

Clinical History*13-30422

*from the electronic medical record

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grade 2 ballooning and lobular inflammation

extensive centrilobular fibrosis – stage 1b

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How to Sign Out This Case?Steatohepatitis, grade 2, stage 1

Macrovesicular Steatosis• Inherited disorders:

– Glycogen storage disease types I and III – Urea cycle defects– Hereditary fructose intolerance– Abetalipoproteinemia– Cystic fibrosis– Wilson disease

• Drugs:– L-asparaginase– Amiodarone– Methotrexate– Cortisone– Tamoxifen

• Other diseases:– Kwashiorkor– Polycystic ovarian syndrome – Celiac disease– Chronic HCV hepatitis

Chronic HCV hepatitis and NAFLD

• NAFLD 2.5X more common in HCV than in general population

• Hepatitis C virus can cause steatosis

– Genotype 3 virus is steatogenic and degree of steatosis

associated with viral load

– Non-genotype 3 HCV a/w insulin resistance and Type 2 DM

• Insulin resistance and steatosis may regress with viral

eradication, return with recurrent infection

Machado M et al. Ann Hepatol 2009

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• 55 year old healthy female found to be serum HCV Ab+ at the time of her first blood donation

• Received blood transfusions during thoracic surgery in 1972

• No other risk factors for HCV infection

• Genotype 1a and 1b; IL28b genotype C/T

• AST = 111, ALT = 95

• Liver biopsy prior to consideration of clinical trial

Clinical History11-22155

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portal and periportal fibrosis

centrilobular fibrosis

central – portal bridging

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chronic HCV hepatitis, grade 2

lobular necroinflammatory activity

hepatocyte ballooning

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centrilobular fibrosis

How To Sign Out This Case ?

• Diagnosis:

– Chronic HCV hepatitis (grade 2)

– Steatohepatitis (grade 2)

– Periportal and centrilobular fibrosis

• Comment: Both the steatohepatitis and the

chronic HCV hepatitis appear to be

contributing to the development of fibrosis

• 33 year old female with a history of mildly elevated LCTs since the age of 20

• TB = 0.5, AST = 150, ALT = 153, alk phos = 50

• HAV, HBV, HCV negative

• ANA = 1:80; anti-SMA negative

• Alpha-1-antitrypsin PiMM; iron studies normal

• No medications or alcohol

• Recent diagnosis of polycystic ovarian syndrome:

– BMI = 39.7

– Hyperlipidemia

– Abdominal U/S reveals fatty liver

Clinical History09-24093

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Steatosis vs. Steatohepatitis

no lobular inflammation

no fibrosis

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grade 1 hepatocyte ballooning

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• 45 y.o. F s/p bilateral mastectomy for breast cancer

• Currently on Tamoxifen

• Obese; social drinker

• TB = 0.7, AST = 182, ALT = 127, alk phos = 62

• Albumin = 4.7, PLT = 350K,

• HAV, HBV, HCV negative

• ANA = 1:80; anti-SMA = < 1:25

• Heterozygous H63D; C282Y not detected

• Ceruloplasmin = 24.8, alpha-1-antitrypsin PiMM

Clinical History11-12809

13-28786

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centrilobular fibrosis (stage 1a)

grade 2 lobular inflammation

grade 2 hepatocyte ballooning

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Steatohepatitis (grade 2, stage 1a)

Clinical Follow-up

• Seen again two years later

• Still on Tamoxifen (until 2016)

• TB = 0.7, AST = 113, ALT = 79, alk phos = 73

• Hyperlipidemia, obesity, DM (metformin)

• PE reveals mild hepatomegaly

• U/S reveals fatty liver disease

• FIBROSPECT = 89

• Repeat liver bx – progression to stage 2

BMJ, doi:10.1136/bmj.38391.663287.E0 (published 21 March 2005)

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Clinical History

• 47 year old male with dilated cardiomyopathy diagnosed in 2006

• Undergoes liver biopsy to evaluate for heart transplantation

• Physical exam reveals hepatomegaly• TB = 1.2, DB = 0.5, AST = 54, ALT = 38, Alk phos = 154

09-932

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14 y.o. female with hepatomegaly

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Cystic FibrosisCystic Fibrosis

29 y.o. obese female

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sister with Wilson disease !

Clinical History• A 17 year old Inuit Eskimo male from Alaska

has a history of Blau’s syndrome.

• A recent UGI to evaluate dysphagia revealed

grade I esophageal varices.

• The patient is status post splenectomy to treat

anemia.

• TB = 0.7, AST = 121, ALT = 86, Alk Phos = 147

• Serologic tests for HAV, HBV, HCV negative

• Medications: multi-vitamin

No evidence of fibrosis

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Ito Cell Hyperplasia

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Take Home Points• Macrovesicular steatosis:

– Don’t forget about Wilson disease in young patients

– Adverse reaction for a few drugs

• Steatohepatitis:– Don’t forget about Wilson disease in young patients

– Minimal criteria require refinement

– Pediatric variant with atypical histopathology

– Drug therapy trials ongoing

– 10% of chronic HCV hepatitis patients have NASH

– Grade and stage appropriately

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Pediatric NAFLD

• Schwimmer JB et al. Hepatology 2005; 42:641-9.– Greater level of obesity, male gender, Hispanic ethnicity

– Greater portal inflammation & fibrosis

– Less hepatocyte ballooning & inflammation

• Xanthakos S et al. Clin Gastroenterol Hepatol 2006; 4:226-32.– Biopsies from 41 adolescents undergoing bariatric surgery

– 24% steatosis

– 7% steatosis & portal fibrosis

– 32% steatosis & portal inflammation

– 20% NASH (adult type)

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Ballooning Degeneration + + – –

Perisinusoidal Fibrosis – + + –

Adult Pediatric

Steatosis + +

NASH

Portal Inflammation – + + –

Portal fibrosis – – + –

Adapted from Schwimmer JB et al. Hepatology 2005; 42:641-9.

+ / –

+ / –

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Schwimmer JB et al.

Histopathology of Pediatric NAFLD

Hepatology 2005; 42:641-9.