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Clinical scenario:  24-year old man.      

Liver, random needle core biopsy: 

-- Diffuse insoluable iron depositive in hepatocyte, pan-lobular pattern, grade 1 out of 3, highly indicative of hemochromatosis (see Note)

-- Minimal non-specific reactive changes (portal mononuclear inflammatory infiltrates and lobular disarray)

-- No significant portal or lobular inflammation, cholestasis, steatosis or fibrosis

-- Special stain for cytoplasmic hyaline globules is negative

Note:  Sections show three generous biopsy cores with an adequate number of portal tracts for evaluation. The changes in the liver biopsy borderline with mild abnormality and are non-specific. Special histochemical stain for iron show diffuse positive stain for cytoplasmic iron, grade 1 by Scheuer, indicative of heraditory hemochromatosis (in this age group). Of note, prior phlebotomy treatment can affect the histological grade of iron depositive. Quantitative iron analysis may be considered if the diagnosis can not be confirmed by genotypic study.

Reference:

Scheuer PJ, Williams R, Muir AR. Hepatic pathology in relatives of patients with hemochromatosis. J Pathol Bacteriol. 1962;84:53-64.

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:  47-year old woman       

Liver, random needle core biopsy: 

-- Moderate steatohepatitis, NAFLD score 6 (see NAFLD Score  and Note below)

-- No mallory hyalins, cholestasis, bile duct loss or granulomatous changes identified

-- Mild fibrosis.

-- prominent macrovesicular steatosis, lobular inflammation and hepatocyte ballooning degeneration, consistent with steatohepatitis, nafld score 5 out of 8 (see summary of findings and note)

-- no portal fibrosis, significant portal inflammation or cholestasis

-- trichrome stain reveals focal centrilobular sinusoidal fibrosis

-- pas stain reveals no cytoplasmic hyaline globule

NAFLD Histologic and Fibrosis Score

Steatosis Grade: 2 (>33 - 66%)

Hepatocyte Ballooning Injury Grade: 2

Lobular Inflammation Score: 2 (2-4 foci per 200/field)

NAFLD Activity Score (NAS): >5 (Diagnostic of steatohepatitis)

NAFLD Fibrosis Stage: 3 (bridging fibrosis)

Note: The etiology underlying observed steatosis and inflammation is not histologically apparent.  Both alcoholic and nonalcoholic etiologies should be considered.

The histological changes in this set of core biopsy are diagnostic of steatohepatitis.  The underlying etiology, however, is not histologically apparent.  Obesity, and chemical injury (drug and alcohol for example) are commonly encountered causes of the findings.  Correlation with clinical findings is recommended for a definitive etiological diagnosis.

Reference:

Kleiner DE, Brunt EM, et al (for the Nonalcoholic Steatohepatitis Clinical Research Network).  Design and validation of a histological scoring system for nonalcoholic fatty liver disease.  Hepatology 2005; 41:1313-1321. . 

Editor's comment:

Although alcohol abuse and obesity as the underlying etiology can often be revealed by the histologic changes, a conservative reporting approach is to list likely etiologic differential diagnosis since biopsy is frequently performed to evaluate the severity of the disease or to confirm liver injury. For the working NFLD Score schema, please visit Grading Schema 

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Clinical scenario: 9-yo boy with BMI of 32 and family history of obesity        

Liver, needle core biopsy: 

-- Diffuse moderate microvesicular steatosis, etiology uncertain (see Note and NAFLD score below)

-- No lobular inflammation, Mallory hyalines, cholestasis, bile duct loss or granulomatous changes identified).

Note: The etiology underlying the observed steatosis is not histologically apparent. Although hyperlipidemia and obesity are common causes, lysosomal acidic lipase (LAL) deficiency should also be considered in this case. (need ref here). 

Editor's comment:

Prominent microvesicular steatosis in this age group with family Hx of obesity should be worked up to exclude LAL deficiency

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Clinical scenario:  58-year old woman with liver cirrhosis of unknown cause         

Native liver (1460 grams), explant (total hepatectomy):   

-- End stage liver disease with extensive micronodular cirrhosis (see microscopic description and comment).

-- Extensive fibrosis with bile ductular proliferation, mononuclear inflammatory infiltrate.

-- Patchy paracellular cholestasis, confirmed by bile stain.

-- No granuloma, periductal fibrosis or dysplasia or carcinoma identified.

-- PAS-D stain for intracytoplasmic hyaline globule and Perl's stain for iron are negative.

-- Trichrome stain confirms the cirrhosis.

Note: Although the micronodular cirrhosis, active fibrosis with bile ductular proliferation and mononuclear inflammatory infiltrate are compatible with the patient's clinical history of type-C viral hepatitis, these changes are not pathognomonic.  It is difficult to render a definitive etiological diagnosis. The micronodular cirrhosis pattern and absence of significant periductal fibrosis do not support PSC.  Relative preservation of centrilobular zone is not compatible with cirrhosis 2nd to steatohepatitis.  Negative stain for intracytoplasmic hyaline globule can exclude alpha-1 antitrypsin deficiency as the underlying etiology.  Iron deposition can be seen in both end-stage liver disease and hemochromatosis.

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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