steatosis & steatosis & steatohepatitissteatohepatitis

By Dr. Osman BukhariBy Dr. Osman Bukhari

-Mild steatosis involving less than 10% of -Mild steatosis involving less than 10% of hepatocytes is common hepatocytes is common

-Dtected icidentally & clinical manifestations -Dtected icidentally & clinical manifestations are variableare variable

Causes:Causes:

1-Macrovesicular steatosis & st /hep\atitis:1-Macrovesicular steatosis & st /hep\atitis: (Alcohol , obesity, D.M. , starvation ,(Alcohol , obesity, D.M. , starvation , malabsorption , drugs.)malabsorption , drugs.)

2-Microvesicular steatosis:2-Microvesicular steatosis: (fatty liver of (fatty liver of

pergnancy , Reyes syndr. ,drugs.)pergnancy , Reyes syndr. ,drugs.)

*Macrovesic.st. is generally bengin.*Macrovesic.st. is generally bengin.

*Microvesic. St. occurs in more serious*Microvesic. St. occurs in more serious

conditions.conditions.

*Steatosis usually occurs alone , in some*Steatosis usually occurs alone , in some

pats. Macrovesic. St. is associated with pats. Macrovesic. St. is associated with

hepatitis (steatohepatitis).hepatitis (steatohepatitis).

*Steatohepatitis is either alcoholic or *Steatohepatitis is either alcoholic or non alcoholic (NASH).non alcoholic (NASH).

Clinic. Features &management:Clinic. Features &management: 1-Macrovesic. St:1-Macrovesic. St: -Often asymtomatic & found incidentally.-Often asymtomatic & found incidentally. -Clinical features of the cause.-Clinical features of the cause. -Tender hepatopmegally.-Tender hepatopmegally.

--Mild changes in LFT.Mild changes in LFT. -US :Bright liver.-US :Bright liver. -Treatment is that of the cause.-Treatment is that of the cause. -Ursodeoxycholic acid improves liver LFT-Ursodeoxycholic acid improves liver LFT and histology in NASHand histology in NASH..

2-2-Microvesic. St.:Microvesic. St.: -Associated with acute onset of fatigue &-Associated with acute onset of fatigue &vomitting & progressing if severe to vomitting & progressing if severe to encephalopathy &coma.encephalopathy &coma. -Jaundice with fatty liver of pregnancy , -Jaundice with fatty liver of pregnancy , alcohols .& drug induced steatosis. alcohols .& drug induced steatosis. jaundice is absent in Reyes;jaundice is absent in Reyes; -Acute hepatic failure : ICU.support &-Acute hepatic failure : ICU.support & liver transplant.liver transplant.

Prognosis: Prognosis: Excellent in most cases.Excellent in most cases.

Alcohol Liver DiseaseAlcohol Liver Disease -Alcohol is the most common preventable -Alcohol is the most common preventable

disease in the west. disease in the west. -Alcohol is exclusively metabolized in-Alcohol is exclusively metabolized in the liver.the liver. -Alcohol is metabolised to acetaldehyde-Alcohol is metabolised to acetaldehyde by alcohol dehydrogenase (mitochondrialby alcohol dehydrogenase (mitochondrial enzyme) & mixed function oxidase enzymeenzyme) & mixed function oxidase enzyme

((smooth endoplasmic reticulin ) & then tosmooth endoplasmic reticulin ) & then to

acetate by acetaldehyde dehydrogenase whichacetate by acetaldehyde dehydrogenase which

enters Krebs cycle with production of toxicenters Krebs cycle with production of toxic

metabolites (adducts)metabolites (adducts)

-Acohol is a powerful inducer of mixed-Acohol is a powerful inducer of mixed

function oxidases.function oxidases.

Pathogenesis:Pathogenesis: -Depends on the amount & duration of -Depends on the amount & duration of

consumption. Amount is less in females.consumption. Amount is less in females.

--Steady daily intake is more hazardadous.Steady daily intake is more hazardadous.

-Only 10-20% develop alcohol liver (?genetic)-Only 10-20% develop alcohol liver (?genetic)

-fatty changes are due to increased production-fatty changes are due to increased production

& impaired excretion of triacyl glycerolby & impaired excretion of triacyl glycerolby

the liver.the liver.

-centrilobular necrosis & cirrhosis are -centrilobular necrosis & cirrhosis are attributed to toxic metabolites produced attributed to toxic metabolites produced

during alcohol metab. (adducts) & immune during alcohol metab. (adducts) & immune

reaction.reaction.

PathologyPathology::

1-1-Mitochondrial swelling & proliferation ofMitochondrial swelling & proliferation of

endoplasmic reticulum.endoplasmic reticulum.

2-Steatosis (reversible)2-Steatosis (reversible)

3-Mallroy hyaline bodies.3-Mallroy hyaline bodies.

4-Siderosis4-Siderosis

5-Autoimmune hepatitis.5-Autoimmune hepatitis.

6-Central hyaline necrosis6-Central hyaline necrosis

7-Fbirosis & cirrhosis.7-Fbirosis & cirrhosis.

8-HCC.8-HCC.

Clinical features:Clinical features:

1-Fatty liver1-Fatty liver: : asymtomatic or non specific asymtomatic or non specific

symptoms & hepatopmegally.symptoms & hepatopmegally.

2-Hepatitis: severe illness with malnutrition ;2-Hepatitis: severe illness with malnutrition ;

jaundice, hepatopmegally , ascitis & encephalopathy.jaundice, hepatopmegally , ascitis & encephalopathy.

3-Cholestasis: abdomenal pain , jaundice &3-Cholestasis: abdomenal pain , jaundice & hepatopmegally. hepatopmegally. 4-Cirrrohsis.4-Cirrrohsis. 5-HCC.5-HCC.

Investigation:Investigation: aimed at: aimed at:

1-Establishing alcohol abuse.1-Establishing alcohol abuse. 2-Exclding other causes of liver disease.2-Exclding other causes of liver disease. 3-Assessing severity of liver disease.3-Assessing severity of liver disease.

*Biological evidence of alcohol abuse include:*Biological evidence of alcohol abuse include:

1-Peripheral macrocytosis in the absence of1-Peripheral macrocytosis in the absence of

anaemia.anaemia.

2-Increased plasma GTT.2-Increased plasma GTT.

3-Unexplained rib fracture.3-Unexplained rib fracture.

*LFT& investigations to exclude other causes*LFT& investigations to exclude other causes

liver disease including liver biopsy.liver disease including liver biopsy.

*Imaging.*Imaging.

Management & Prognosis:Management & Prognosis: 1- 1- Stop alcohol intake (delirium tremens.)Stop alcohol intake (delirium tremens.) 2-Protien rich diet & Vit supplements.2-Protien rich diet & Vit supplements. 3- Treat complication of liver cirrhosis.3- Treat complication of liver cirrhosis. 4-Liver transplantation in advanced disease4-Liver transplantation in advanced disease with hepatic failure.with hepatic failure. 5- Prognosis is good with fatty liver (reversible) & 5- Prognosis is good with fatty liver (reversible) &

worst with hepatitis.worst with hepatitis. 6-Cirrohsis may present with complication6-Cirrohsis may present with complication 7-HCC may complicate.7-HCC may complicate.