Abstract
The diagnostic phenotype of nonalcoholic fatty liver disease (NAFLD)—in particular, the most significant form in terms of prognosis, nonalcoholic steatohepatitis (NASH)—continues to rely on liver tissue evaluation, in spite of remarkable advances in non-invasive algorithms developed from serum-based tests and imaging-based or sonographically-based tests for fibrosis or liver stiffness. The most common tissue evaluation remains percutaneous liver biopsy; considerations given to the needle size and the location of the biopsy have the potential to yield the most representative tissue for evaluation. The pathologist’s efforts are directed to not only global diagnosis, but also assessment of severity of injury. Just as in other forms of chronic liver disease, these assessments can be divided into necroinflammatory activity, and fibrosis with parenchymal remodeling, in order to separately analyze potentially reversible (grade) and non-reversible (stage) lesions. These concepts formed the bases for current methods of evaluating the lesions that collectively comprise the phenotypic spectra of NAFLD. Four extant methods have specific applications; there are pros and cons to each, and this forms the basis of the review.
Highlights
The value of liver biopsy evaluation for diagnosis in clinical care and effectiveness of intervention in clinical research in the field of nonalcoholic fatty liver disease (NAFLD) has remained unquestioned as knowledge in the field has continued to grow over the course of the last three and a half decades since the publication attributed as one of the early descriptions in humans [1]
Several clinical algorithms based on serum-based tests can be used to predict the likelihood of NAFLD, nonalcoholic steatohepatitis (NASH) or presence or severity of fibrosis, reviewed [2]
For the diagnosis of NASH, the most recognized form of injury in NAFLD with potential to progress to fibrosis and cirrhosis and its complications, there is a requirement for the steatosis and inflammation as described above, and for a particular form of hepatocyte injury known as ballooning
Summary
The value of liver biopsy evaluation for diagnosis in clinical care and effectiveness of intervention in clinical research in the field of nonalcoholic fatty liver disease (NAFLD) has remained unquestioned as knowledge in the field has continued to grow over the course of the last three and a half decades since the publication attributed as one of the early descriptions in humans [1]. As in most chronic liver diseases, this “error” is likely a reflection of the disease heterogeneity of NAFLD, and must be accounted for by providing sufficient numbers of subjects in clinical trials Another less well-known short-coming of liver biopsy, when done by radiologists, or in the setting of bariatric surgery, is the use of appropriately sized (i.e., large-bore) needles, [6], and potential differences between the right and left lobes of the liver. Once the decision for liver biopsy has been made, whether for clinical (i.e., diagnostic or prognostic) purposes, or for clinical trial protocol, the steps involve the histopathologic interpretation for diagnosis, and for semi-quantitative lesion evaluations, if requested, for protocol or study purposes Methods for these are the subjects of the remainder of this review
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