Steatohepatitis - Revision history

Michael at 19:17, 16 May 2024

2024-05-16T19:17:21Z

← Older revision		Revision as of 19:17, 16 May 2024
Line 6:		Line 6:
	\| Synonyms =		\| Synonyms =
	\| Micro = [[liver steatosis\|steatosis]] (usually macrovesicular); hepatocyte injury -- [[ballooning degeneration]] (key feature), [[Mallory bodies]]; portal bridging (late stage)		\| Micro = [[liver steatosis\|steatosis]] (usually macrovesicular); hepatocyte injury -- [[ballooning degeneration]] (key feature), [[Mallory bodies]]; portal bridging (late stage)
	\| Subtypes = by etiology (classically): [[ASH]], [[~~NASH~~]] -- all almost histologically identical		\| Subtypes = by etiology (classically): [[ASH]], [[MASH]] -- all almost histologically identical
	\| LMDDx = [[liver steatosis\|steatosis]], [[Wilson disease]], [[hepatitis C]], [[drug-induced liver disease]]		\| LMDDx = [[liver steatosis\|steatosis]], [[Wilson disease]], [[hepatitis C]], [[drug-induced liver disease]]
	\| Stains =		\| Stains =
Line 39:		Line 39:
	Etiology:		Etiology:
	#Alcohol = alcoholic steatohepatitis (ASH).		#Alcohol = alcoholic steatohepatitis (ASH).
	#~~Not alcohol =~~ non-alcoholic steatohepatitis (NASH).		#Metabolic dysfunction-associated steatohepatitis (MASH).
			#*Previously ''non-alcoholic steatohepatitis'' (NASH).<ref name=pmid38692439>{{cite journal \|authors=Koda Y, Nagasaki Y \|title=Metabolic dysfunction-associated steatohepatitis treated by poly(ethylene glycol)-block-poly(cysteine) block copolymer-based self-assembling antioxidant nanoparticles \|journal=J Control Release \|volume=370 \|issue= \|pages=367–378 \|date=May 2024 \|pmid=38692439 \|doi=10.1016/j.jconrel.2024.04.050 \|url=}}</ref>
	#Drug/toxin.<ref name=pmid12016549>{{Cite journal \| last1 = Farrell \| first1 = GC. \| title = Drugs and steatohepatitis. \| journal = Semin Liver Dis \| volume = 22 \| issue = 2 \| pages = 185-94 \| month = \| year = 2002 \| doi = 10.1055/s-2002-30106 \| PMID = 12016549 }}</ref>		#Drug/toxin.<ref name=pmid12016549>{{Cite journal \| last1 = Farrell \| first1 = GC. \| title = Drugs and steatohepatitis. \| journal = Semin Liver Dis \| volume = 22 \| issue = 2 \| pages = 185-94 \| month = \| year = 2002 \| doi = 10.1055/s-2002-30106 \| PMID = 12016549 }}</ref>

Mitchell: /* Images */ Replaced a set of four images in thumbnail with large images. Updated pics to permit better use by iphone

2016-12-27T17:32:59Z

Images: Replaced a set of four images in thumbnail with large images. Updated pics to permit better use by iphone

← Older revision		Revision as of 17:32, 27 December 2016
Line 172:		Line 172:

	====Images====		====Images====
	{\|
	[[File:1 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		A. [[File:1 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	[[File:2 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		B. [[File:2 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	<br>		<br>
	[[File:3 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		C. [[File:3 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	[[File:4 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		D. [[File:4 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	<br>		<br>
	[[File:5 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		E. [[File:5 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	[[File:6 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		F. [[File:6 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	\|}
	Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads ~~(Row 1 Left 20X)~~. Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen ~~(Row 1 Right 400X)~~. A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen ~~(Row 2 Left 400X)~~. Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it ~~(Row 2 Right 400X)~~. Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis ~~(Row 3 Left 400X)~~. Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis ~~(Row 3 Right 400X)~~.
	{\|		Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. A. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads. B. Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen. C. A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen . D. Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it. E. Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis. F. Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis.
	[[File:1 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	[[File:2 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			A. [[File:1 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			B. [[File:2 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	<br>		<br>
	[[File:3 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		C. [[File:3 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	[[File:4 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		D. [[File:4 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	<br>		<br>
	[[File:5 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		E. [[File:5 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	[[File:6 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		F. [[File:6 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	\|}
	Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.		Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2. A. Steatosis is not pan-acinar, precluding grade 3. B. Cytoplasmic tufts [arrows] were commonly seen establishing frequent ballooning degeneration of grade 2. C. Trichrome shows periportal fibrosis [arrow] establishing fibrosis stage 2. D. PAS D shows a triad with mild damage, with an interlobular bile duct [green arrow] with luminal sheered epithelium, not neutrophils, a hepatic arteriole [red arrow], a hepatic venule [blue arrow], proliferating bile ductules [cyan arrows]; PAS-D macrophages [black arrows] in triad & sinusoid evidence damage; Neutrophils [magenta arrows] in proliferating bile ductules mean nothing, but in sinusoids indicate damage. E. Reticulin fibers in steatosis afflicted areas can appear abnormally lost, which should not be deemed evidence of hepatocellular carcinoma. F. Reticulin stain here shows hepatocyte acini [arrows], evidence of hepatocellular injury (Row 3 Right 400X).
	Steatosis is not pan-acinar, precluding grade 3 ~~(Row 1 Left 40X)~~. Cytoplasmic tufts [arrows] were commonly seen establishing frequent ballooning degeneration of grade 2 ~~(Row 1 Right 400X)~~. Trichrome shows periportal fibrosis [arrow] establishing fibrosis stage 2 ~~(Row 2 Left 400X)~~. PAS D shows a triad with mild damage, with an interlobular bile duct [green arrow] with luminal sheered epithelium, not neutrophils, a hepatic arteriole [red arrow], a hepatic venule [blue arrow], proliferating bile ductules [cyan arrows]; PAS-D macrophages [black arrows] in triad & sinusoid evidence damage; Neutrophils [magenta arrows] in proliferating bile ductules mean nothing, but in sinusoids indicate damage ~~(Row 2 Right 400X)~~. Reticulin fibers in steatosis afflicted areas can appear abnormally lost, which should not be deemed evidence of hepatocellular carcinoma ~~(Row 3 Left 400X)~~. Reticulin stain here shows hepatocyte acini [arrows], evidence of hepatocellular injury (Row 3 Right 400X).

	{\|		A. [[File:1 Steatohep 4 680x512px.tif\|Panacinar steatosis with unremarkable, small triads (40X).]]
	[[File:1 Steatohep 4 680x512px.tif\|Panacinar steatosis with unremarkable, small triads (40X).]]		B. [[File:2 Steatohep 4 680x512px.tif\|Ballooning degeneration, with cytoplasmic tufts (arrows) (400X).]]
	[[File:2 Steatohep 4 680x512px.tif\|Ballooning degeneration, with cytoplasmic tufts (arrows) (400X).]]
	<br>		<br>
	[[File:3 Steatohep 4 680x512px.tif\|Lipogranuloma (400X).]]		C. [[File:3 Steatohep 4 680x512px.tif\|Lipogranuloma (400X).]]
	[[File:4 Steatohep 4 680x512px.tif\|Triad with mild chronic inflammation without interface hepatitis (400X).]]		D. [[File:4 Steatohep 4 680x512px.tif\|Triad with mild chronic inflammation without interface hepatitis (400X).]]
	\|}
	Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1 ~~(not shown)~~. Panacinar steatosis with unremarkable, small triads ~~(Row 1 Left 40X)~~. Ballooning degeneration, with cytoplasmic tufts [arrows] ~~(Row 1 Right 400X)~~. Lipogranuloma ~~(Row 2 Left 400X)~~. Triad with mild chronic inflammation without interface hepatitis ~~(Row 2 Right 400X)~~.		Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1. A. Panacinar steatosis with unremarkable, small triads. B. Ballooning degeneration, with cytoplasmic tufts [arrows]. C. Lipogranuloma. D. Triad with mild chronic inflammation without interface hepatitis.
	{\|
	[[File:1 Steatohep 5 680x512px.tif\|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]
	[[File:2 Steatohep 5 680x512px.tif\|An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The patient had a normal bilirubin. (Row 1 Right 200X).]]		A. [[File:1 Steatohep 5 680x512px.tif\|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]
			B. [[File:2 Steatohep 5 680x512px.tif\|An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The patient had a normal bilirubin. (Row 1 Right 200X).]]
	<br>		<br>
	[[File:3 Steatohep 5 680x512px.tif\|Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X).]]		C. [[File:3 Steatohep 5 680x512px.tif\|Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X).]]
	[[File:4 Steatohep 5 680x512px.tif\|PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X).]]		D. [[File:4 Steatohep 5 680x512px.tif\|PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X).]]
	<br>		<br>
	[[File:5 Steatohep 5 680x512px.tif\|Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X).]]		E. [[File:5 Steatohep 5 680x512px.tif\|Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X).]]
	[[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]		F. [[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]
	\|}
	Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. Steatosis afflicts almost all hepatocytes (pan-acinar) ~~(Row 1 Left 40X)~~. An isolated septal duct with concentric fibrosis [arrow] should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. ~~(Row 1 Right 200X)~~. Cytoplasmic tufts [arrows] prove ballooning degeneration ~~(Row 2 Left 400X)~~. PAS with diastase shows PAS-D Kupffer cells (arrows) ~~(Row 2 Right 400X)~~. Reticulin shows thick black lines [red arrows] of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis [double head cyan arrow] should not be considered regeneration or hepatoma ~~(Row 3 Left 200X)~~. Trichrome shows a bridge [arrow] (~~Row 3 Right 200X~~).		Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. A. Steatosis afflicts almost all hepatocytes (pan-acinar). B. An isolated septal duct with concentric fibrosis [arrow] should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. C. Cytoplasmic tufts [arrows] prove ballooning degeneration. D. PAS with diastase shows PAS-D Kupffer cells (arrows). E. Reticulin shows thick black lines [red arrows] of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis [double head cyan arrow] should not be considered regeneration or hepatoma. F. Trichrome shows a bridge [arrow].

			[[File:4 99480485255889 sl 1.png\|Cirrhosis with steatohepatitis in a 54 year old man]]
			[[File:4 99480485255889 sl 2.png\|Cirrhosis with steatohepatitis in a 54 year old man]]
			[[File:4 99480485255889 sl 3.png\|Cirrhosis with steatohepatitis in a 54 year old man]]
			[[File:4 99480485255889 sl 4.png\|Cirrhosis with steatohepatitis in a 54 year old man]]

			Cirrhosis with steatohepatitis in a 54 year old man with type II diabetes, negative viral serologies, negative alcohol history, negative AMA/ANA, normal ceruloplasmin, low albumin/platelet count, and elevated bilirubin/alkaline phosphatase/transaminase, with hepatosplenomegaly. A. At lower power, no definite triads are seen, but there are potential bands (green arrows) and foci with steatosis (blue arrows). The low percent of hepatocytes afflicted by steatosis would indicate a Brunt necroinflammatory grade 1, here irrelevant as cirrhosis is present. B. Tufts (green arrows) prove ballooning degeneration needed for a diagnosis of steatohepatitis. Foamy macrophage-like hepatocytes (blue arrows) show feathery degeneration is also present. C. Reticulin shows two cell thick cords (green arrows) of regeneration. D. Trichrome shows blue bands and definite nodules (white arrows). At one time, 75% of the biopsy would have had to have been occupied to diagnose cirrhosis. Currently, under the Metavir system, one need only have extensive fibrosis, which would include developing cirrhosis of the HAI system, to obtain a grade IV status, acceptable for transplantation.



	{\| class="wikitable sortable"		{\| class="wikitable sortable"
Line 223:		Line 234:
	\| [[Image:Steatohepatitis Cases 03.tif \|thumb\| Fibrosis stage 1 Brunt necroinflammatory grade 2 (WC)]]		\| [[Image:Steatohepatitis Cases 03.tif \|thumb\| Fibrosis stage 1 Brunt necroinflammatory grade 2 (WC)]]
	\| Necroinflammatory grades Brunt 2, NAH 6. Fibrosis stage 1. About half the hepatocytes show macrovesicular steatosis (UL), with sparing of part of the acinus (UL, Black arrowhead), Lipogranulomas, acomar inflammatory collections, mostly macrophages, about steatosis/ballooning degeneration afflicted hepatocytes or adjacent to them (UR, green arrowheads) are present.Tufts/flocks of ballooning degeneration are readily found (LL, magenta arrowheads). Mild to moderate mononuclear inflammation of portal triads does not exclude steatohepatitis (LL, yellow arrowheads). Trichrome displays the blue thin lines that separate hepatocytes in stage 1 fibrosis (LR blue arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X , LR 10X		\| Necroinflammatory grades Brunt 2, NAH 6. Fibrosis stage 1. About half the hepatocytes show macrovesicular steatosis (UL), with sparing of part of the acinus (UL, Black arrowhead), Lipogranulomas, acomar inflammatory collections, mostly macrophages, about steatosis/ballooning degeneration afflicted hepatocytes or adjacent to them (UR, green arrowheads) are present.Tufts/flocks of ballooning degeneration are readily found (LL, magenta arrowheads). Mild to moderate mononuclear inflammation of portal triads does not exclude steatohepatitis (LL, yellow arrowheads). Trichrome displays the blue thin lines that separate hepatocytes in stage 1 fibrosis (LR blue arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X , LR 10X
	\|-
	~~\|[[Image:Steatohepatitis Cases 05.tif \|thumb\| Fibrosis stage 4 Brunt necroinflammatory grade 3 (WC)]]~~
	\|Necroinflammatory grades Brunt 3, NAH 8. Fibrosis stage 4. Steatosis is pan-acinar (UL). Acinar inflammatory aggregates More than 4 inflammatory aggregates are seen in a 20X field (UR black arrowheads). Many cells show ballooning degeneration, with tufts/flocks of material cytoplasm (LL yellow arrowheads) Trichrome limns regenerative nodules (LR magenta arrowheads). Original oculars UL 4X, UR 20X, LL 40X (higher pixel photograph), LR 10X
	\|}		\|}

Mitchell: /* Images */ added a case

2016-09-06T22:51:34Z

Images: added a case

← Older revision		Revision as of 22:51, 6 September 2016
Line 183:		Line 183:
	\|}		\|}
	Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads (Row 1 Left 20X). Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen (Row 1 Right 400X). A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen (Row 2 Left 400X). Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it (Row 2 Right 400X). Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis (Row 3 Left 400X). Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis (Row 3 Right 400X).		Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads (Row 1 Left 20X). Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen (Row 1 Right 400X). A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen (Row 2 Left 400X). Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it (Row 2 Right 400X). Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis (Row 3 Left 400X). Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis (Row 3 Right 400X).
			{\|
			[[File:1 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			[[File:2 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			<br>
			[[File:3 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			[[File:4 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			<br>
			[[File:5 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			[[File:6 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			\|}
			Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.
			Steatosis is not pan-acinar, precluding grade 3 (Row 1 Left 40X). Cytoplasmic tufts [arrows] were commonly seen establishing frequent ballooning degeneration of grade 2 (Row 1 Right 400X). Trichrome shows periportal fibrosis [arrow] establishing fibrosis stage 2 (Row 2 Left 400X). PAS D shows a triad with mild damage, with an interlobular bile duct [green arrow] with luminal sheered epithelium, not neutrophils, a hepatic arteriole [red arrow], a hepatic venule [blue arrow], proliferating bile ductules [cyan arrows]; PAS-D macrophages [black arrows] in triad & sinusoid evidence damage; Neutrophils [magenta arrows] in proliferating bile ductules mean nothing, but in sinusoids indicate damage (Row 2 Right 400X). Reticulin fibers in steatosis afflicted areas can appear abnormally lost, which should not be deemed evidence of hepatocellular carcinoma (Row 3 Left 400X). Reticulin stain here shows hepatocyte acini [arrows], evidence of hepatocellular injury (Row 3 Right 400X).

	{\|		{\|

Mitchell: /* Images */ Replaced a non-large image case with a large image case

2016-09-02T18:52:33Z

Images: Replaced a non-large image case with a large image case

← Older revision		Revision as of 18:52, 2 September 2016
Line 172:		Line 172:

	====Images====		====Images====
			{\|
			[[File:1 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
			[[File:2 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
			<br>
			[[File:3 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
			[[File:4 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
			<br>
			[[File:5 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
			[[File:6 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
			\|}
			Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads (Row 1 Left 20X). Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen (Row 1 Right 400X). A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen (Row 2 Left 400X). Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it (Row 2 Right 400X). Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis (Row 3 Left 400X). Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis (Row 3 Right 400X).

	{\|		{\|
	[[File:1 Steatohep 4 680x512px.tif\|Panacinar steatosis with unremarkable, small triads (40X).]]		[[File:1 Steatohep 4 680x512px.tif\|Panacinar steatosis with unremarkable, small triads (40X).]]
Line 179:		Line 191:
	[[File:4 Steatohep 4 680x512px.tif\|Triad with mild chronic inflammation without interface hepatitis (400X).]]		[[File:4 Steatohep 4 680x512px.tif\|Triad with mild chronic inflammation without interface hepatitis (400X).]]
	\|}		\|}
	Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1 (not shown). Panacinar steatosis with unremarkable, small triads (UL 40X). Ballooning degeneration, with cytoplasmic tufts (arrows) (UR 400X). Lipogranuloma (LL 400X). Triad with mild chronic inflammation without interface hepatitis (LR 400X).		Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1 (not shown). Panacinar steatosis with unremarkable, small triads (Row 1 Left 40X). Ballooning degeneration, with cytoplasmic tufts [arrows] (Row 1 Right 400X). Lipogranuloma (Row 2 Left 400X). Triad with mild chronic inflammation without interface hepatitis (Row 2 Right 400X).
	{\|		{\|
	[[File:1 Steatohep 5 680x512px.tif\|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]		[[File:1 Steatohep 5 680x512px.tif\|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]
Line 190:		Line 202:
	[[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]		[[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]
	\|}		\|}
	Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X). An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. (Row 1 Right 200X). Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X). PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X). Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X). Trichrome shows a bridge ~~(arrows)~~ (Row 3 Right 200X).		Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X). An isolated septal duct with concentric fibrosis [arrow] should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. (Row 1 Right 200X). Cytoplasmic tufts [arrows] prove ballooning degeneration (Row 2 Left 400X). PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X). Reticulin shows thick black lines [red arrows] of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis [double head cyan arrow] should not be considered regeneration or hepatoma (Row 3 Left 200X). Trichrome shows a bridge [arrow] (Row 3 Right 200X).

	{\| class="wikitable sortable"		{\| class="wikitable sortable"
Line 199:		Line 211:
	\| [[Image:Steatohepatitis Cases 03.tif \|thumb\| Fibrosis stage 1 Brunt necroinflammatory grade 2 (WC)]]		\| [[Image:Steatohepatitis Cases 03.tif \|thumb\| Fibrosis stage 1 Brunt necroinflammatory grade 2 (WC)]]
	\| Necroinflammatory grades Brunt 2, NAH 6. Fibrosis stage 1. About half the hepatocytes show macrovesicular steatosis (UL), with sparing of part of the acinus (UL, Black arrowhead), Lipogranulomas, acomar inflammatory collections, mostly macrophages, about steatosis/ballooning degeneration afflicted hepatocytes or adjacent to them (UR, green arrowheads) are present.Tufts/flocks of ballooning degeneration are readily found (LL, magenta arrowheads). Mild to moderate mononuclear inflammation of portal triads does not exclude steatohepatitis (LL, yellow arrowheads). Trichrome displays the blue thin lines that separate hepatocytes in stage 1 fibrosis (LR blue arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X , LR 10X		\| Necroinflammatory grades Brunt 2, NAH 6. Fibrosis stage 1. About half the hepatocytes show macrovesicular steatosis (UL), with sparing of part of the acinus (UL, Black arrowhead), Lipogranulomas, acomar inflammatory collections, mostly macrophages, about steatosis/ballooning degeneration afflicted hepatocytes or adjacent to them (UR, green arrowheads) are present.Tufts/flocks of ballooning degeneration are readily found (LL, magenta arrowheads). Mild to moderate mononuclear inflammation of portal triads does not exclude steatohepatitis (LL, yellow arrowheads). Trichrome displays the blue thin lines that separate hepatocytes in stage 1 fibrosis (LR blue arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X , LR 10X
	\|-
	~~\| [[Image:Steatohepatitis Cases 02.tif \|thumb\| Fibrosis stage 2 Brunt necroinflammatory grade 1 (WC)]]~~
	\| Necroinflammatory grades Brunt 1, NAH 3. Fibrosis stage 2. Overall, about a third of the biopsy shows mostly macrovesicular steatosis (UL). Rare inflammatory aggregates and ballooned hepatocytes were seen, but occasional linear/ropy Mallory hyalin was seen (UR blue arrowhead). Although trichrome can highlight Mallory hyalin (LL red arrowhead), the remainder of the image shows other cytoplasmic collections will also stain blue/blue-grey. The trichrome stain also showed peri-portal fibrosis (LR, yellow arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X (higher pixel photograph), LR 20X
	\|-		\|-
	\|[[Image:Steatohepatitis Cases 05.tif \|thumb\| Fibrosis stage 4 Brunt necroinflammatory grade 3 (WC)]]		\|[[Image:Steatohepatitis Cases 05.tif \|thumb\| Fibrosis stage 4 Brunt necroinflammatory grade 3 (WC)]]

Mitchell: /* Images */

2016-08-19T20:06:25Z

Images

← Older revision		Revision as of 20:06, 19 August 2016
Line 190:		Line 190:
	[[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]		[[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]
	\|}		\|}
	Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X). An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The ~~patient~~ had a normal bilirubin. (Row 1 Right 200X). Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X). PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X). Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X). Trichrome shows a bridge (arrows) (Row 3 Right 200X).		Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X). An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. (Row 1 Right 200X). Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X). PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X). Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X). Trichrome shows a bridge (arrows) (Row 3 Right 200X).

	{\| class="wikitable sortable"		{\| class="wikitable sortable"

Mitchell: /* Images */ Replaced a non-large image case with a large image case

2016-08-19T15:36:16Z

Images: Replaced a non-large image case with a large image case

← Older revision		Revision as of 15:36, 19 August 2016
Line 180:		Line 180:
	\|}		\|}
	Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1 (not shown). Panacinar steatosis with unremarkable, small triads (UL 40X). Ballooning degeneration, with cytoplasmic tufts (arrows) (UR 400X). Lipogranuloma (LL 400X). Triad with mild chronic inflammation without interface hepatitis (LR 400X).		Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1 (not shown). Panacinar steatosis with unremarkable, small triads (UL 40X). Ballooning degeneration, with cytoplasmic tufts (arrows) (UR 400X). Lipogranuloma (LL 400X). Triad with mild chronic inflammation without interface hepatitis (LR 400X).
			{\|
			[[File:1 Steatohep 5 680x512px.tif\|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]
			[[File:2 Steatohep 5 680x512px.tif\|An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The patient had a normal bilirubin. (Row 1 Right 200X).]]
			<br>
			[[File:3 Steatohep 5 680x512px.tif\|Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X).]]
			[[File:4 Steatohep 5 680x512px.tif\|PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X).]]
			<br>
			[[File:5 Steatohep 5 680x512px.tif\|Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X).]]
			[[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]
			\|}
			Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X). An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The patient had a normal bilirubin. (Row 1 Right 200X). Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X). PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X). Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X). Trichrome shows a bridge (arrows) (Row 3 Right 200X).

	{\| class="wikitable sortable"		{\| class="wikitable sortable"
Line 191:		Line 202:
	\| [[Image:Steatohepatitis Cases 02.tif \|thumb\| Fibrosis stage 2 Brunt necroinflammatory grade 1 (WC)]]		\| [[Image:Steatohepatitis Cases 02.tif \|thumb\| Fibrosis stage 2 Brunt necroinflammatory grade 1 (WC)]]
	\| Necroinflammatory grades Brunt 1, NAH 3. Fibrosis stage 2. Overall, about a third of the biopsy shows mostly macrovesicular steatosis (UL). Rare inflammatory aggregates and ballooned hepatocytes were seen, but occasional linear/ropy Mallory hyalin was seen (UR blue arrowhead). Although trichrome can highlight Mallory hyalin (LL red arrowhead), the remainder of the image shows other cytoplasmic collections will also stain blue/blue-grey. The trichrome stain also showed peri-portal fibrosis (LR, yellow arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X (higher pixel photograph), LR 20X		\| Necroinflammatory grades Brunt 1, NAH 3. Fibrosis stage 2. Overall, about a third of the biopsy shows mostly macrovesicular steatosis (UL). Rare inflammatory aggregates and ballooned hepatocytes were seen, but occasional linear/ropy Mallory hyalin was seen (UR blue arrowhead). Although trichrome can highlight Mallory hyalin (LL red arrowhead), the remainder of the image shows other cytoplasmic collections will also stain blue/blue-grey. The trichrome stain also showed peri-portal fibrosis (LR, yellow arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X (higher pixel photograph), LR 20X
	\|-
	~~\|[[Image:Steatohepatitis Cases 04.tif \|thumb\| Fibrosis stage 3 Brunt necroinflammatory grade 2 (WC)]]~~
	\| Necroinflammatory grades Brunt 2, NAH 7. Fibrosis stage 3. About 70% of hepatocytes are afflicted by steatosis (UL). Many ballooned cells are present, with their residual tufts/flocks (UR green arrowheads) demarcating multiple cells having formed apparent fat cysts. Two-three acinar inflammatory foci (UL magenta arrowheads) can be seen in a 20X field. The disorder is emphasized by a reticulin stain which shows the thin black lines (LL blue arrowheads) forming acinar circles, heading in irregular directions, and coming closer and separating from adjacent lines with great variability. The trichrome stain (RL) shows a bridge. Original oculars UL 4X, UR 20X, LL 20X, LR 10X
	\|-		\|-
	\|[[Image:Steatohepatitis Cases 05.tif \|thumb\| Fibrosis stage 4 Brunt necroinflammatory grade 3 (WC)]]		\|[[Image:Steatohepatitis Cases 05.tif \|thumb\| Fibrosis stage 4 Brunt necroinflammatory grade 3 (WC)]]

Mitchell: /* Images */ added case with big pictures

2016-08-17T16:53:39Z

Images: added case with big pictures

← Older revision		Revision as of 16:53, 17 August 2016
Line 172:		Line 172:

	====Images====		====Images====
			{\|
			[[File:1 Steatohep 4 680x512px.tif\|Panacinar steatosis with unremarkable, small triads (40X).]]
			[[File:2 Steatohep 4 680x512px.tif\|Ballooning degeneration, with cytoplasmic tufts (arrows) (400X).]]
			<br>
			[[File:3 Steatohep 4 680x512px.tif\|Lipogranuloma (400X).]]
			[[File:4 Steatohep 4 680x512px.tif\|Triad with mild chronic inflammation without interface hepatitis (400X).]]
			\|}
			Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1 (not shown). Panacinar steatosis with unremarkable, small triads (UL 40X). Ballooning degeneration, with cytoplasmic tufts (arrows) (UR 400X). Lipogranuloma (LL 400X). Triad with mild chronic inflammation without interface hepatitis (LR 400X).

	{\| class="wikitable sortable"		{\| class="wikitable sortable"
	\| [[Image:Steatohepatitis Cases 01.tif \|thumb\| Fibrosis stage 0 Brunt necroinflammatory grade 1 (WC)]]		\| [[Image:Steatohepatitis Cases 01.tif \|thumb\| Fibrosis stage 0 Brunt necroinflammatory grade 1 (WC)]]

Michael: /* Microscopic */

2016-06-17T04:09:09Z

Microscopic

← Older revision		Revision as of 04:09, 17 June 2016
Line 61:		Line 61:

	DDx:		DDx:
	*[[Steatosis]] - lacks ballooning degeneration.		*[[Steatosis]] - lacks ballooning degeneration and neutrophils.
	*[[Wilson disease]].		*[[Wilson disease]].
	*[[Hepatitis C]].		*[[Hepatitis C]].

Michael: /* General */

2016-06-17T04:07:17Z

General

← Older revision		Revision as of 04:07, 17 June 2016
Line 35:		Line 35:
	*''Steatohepatitis'' is a label for a set of histopathologic findings.		*''Steatohepatitis'' is a label for a set of histopathologic findings.
	*Fat accumulation (in hepatocytes) alone is [[liver steatosis]].		*Fat accumulation (in hepatocytes) alone is [[liver steatosis]].
	**It may be a pattern seen in drug toxicity, e.g. methotrexate toxicity.<ref>MG. ~~22 September 2009~~.</ref>		**It may be a pattern seen in drug toxicity, e.g. methotrexate toxicity.<ref name=pmid26344000>{{Cite journal \| last1 = Schumacher \| first1 = JD. \| last2 = Guo \| first2 = GL. \| title = Mechanistic review of drug-induced steatohepatitis. \| journal = Toxicol Appl Pharmacol \| volume = 289 \| issue = 1 \| pages = 40-7 \| month = Nov \| year = 2015 \| doi = 10.1016/j.taap.2015.08.022 \| PMID = 26344000 }}</ref>

	Etiology:		Etiology:

Michael: /* Clinical Research Network system */

2016-06-17T03:55:54Z

Clinical Research Network system

← Older revision		Revision as of 03:55, 17 June 2016
Line 120:		Line 120:
	! Score		! Score
	! Steatotic <br>hepatocytes (%)		! Steatotic <br>hepatocytes (%)
	! ~~Lobular~~ <br>lymphocytes		! Foci of lobular <br>lymphocytes
	! Ballooning <br>heptocytes		! Ballooning <br>heptocytes
	\|-		\|-

← Older revision		Revision as of 17:32, 27 December 2016
Line 172:		Line 172:

	====Images====		====Images====
	{\|
	[[File:1 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		A. [[File:1 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	[[File:2 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		B. [[File:2 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	<br>		<br>
	[[File:3 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		C. [[File:3 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	[[File:4 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		D. [[File:4 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	<br>		<br>
	[[File:5 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		E. [[File:5 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	[[File:6 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]		F. [[File:6 Nash 8 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1.]]
	\|}
	Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads ~~(Row 1 Left 20X)~~. Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen ~~(Row 1 Right 400X)~~. A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen ~~(Row 2 Left 400X)~~. Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it ~~(Row 2 Right 400X)~~. Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis ~~(Row 3 Left 400X)~~. Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis ~~(Row 3 Right 400X)~~.
	{\|		Steatohepatitis. Brunt necroinflammatory grade 1. Brunt fibrosis stage 1. A. Steatosis afflicts about 30% of hepatocytes; note the absence of visible triads. B. Cytoplasmic tufts of ballooning degeneration [violet arrows] were commonly found; a lymphohistiocytic aggregate [blue arrow], important for NAFLD, but not for Brunt, is seen. C. A triad shows a vein [green arrow], an artery [red arrow], an interlobular duct [blue arrow], and proliferating bile ductules [cyan arrows]; only a few lymphocytes are seen . D. Central vein shows only a few endothelial cells, with somewhat packed hepatocytes surrounding it. E. Trichrome shows mostly space of Disse fibrosis [black arrows], sometimes adjoining hepatocytes [green arrows] show this is a stage 1 fibrosis. F. Trichrome shows a central vein with a minimum of sclerosis; an interhepatocyte fibrous extension [arrow] displays the very beginning of fibrosis.
	[[File:1 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	[[File:2 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			A. [[File:1 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
			B. [[File:2 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	<br>		<br>
	[[File:3 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		C. [[File:3 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	[[File:4 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		D. [[File:4 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	<br>		<br>
	[[File:5 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		E. [[File:5 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	[[File:6 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]		F. [[File:6 NASH 09 680x512px.tif\| Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.]]
	\|}
	Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2.		Steatohepatitis. Brunt necroinflammatory grade 2. Brunt fibrosis stage 2. A. Steatosis is not pan-acinar, precluding grade 3. B. Cytoplasmic tufts [arrows] were commonly seen establishing frequent ballooning degeneration of grade 2. C. Trichrome shows periportal fibrosis [arrow] establishing fibrosis stage 2. D. PAS D shows a triad with mild damage, with an interlobular bile duct [green arrow] with luminal sheered epithelium, not neutrophils, a hepatic arteriole [red arrow], a hepatic venule [blue arrow], proliferating bile ductules [cyan arrows]; PAS-D macrophages [black arrows] in triad & sinusoid evidence damage; Neutrophils [magenta arrows] in proliferating bile ductules mean nothing, but in sinusoids indicate damage. E. Reticulin fibers in steatosis afflicted areas can appear abnormally lost, which should not be deemed evidence of hepatocellular carcinoma. F. Reticulin stain here shows hepatocyte acini [arrows], evidence of hepatocellular injury (Row 3 Right 400X).
	Steatosis is not pan-acinar, precluding grade 3 ~~(Row 1 Left 40X)~~. Cytoplasmic tufts [arrows] were commonly seen establishing frequent ballooning degeneration of grade 2 ~~(Row 1 Right 400X)~~. Trichrome shows periportal fibrosis [arrow] establishing fibrosis stage 2 ~~(Row 2 Left 400X)~~. PAS D shows a triad with mild damage, with an interlobular bile duct [green arrow] with luminal sheered epithelium, not neutrophils, a hepatic arteriole [red arrow], a hepatic venule [blue arrow], proliferating bile ductules [cyan arrows]; PAS-D macrophages [black arrows] in triad & sinusoid evidence damage; Neutrophils [magenta arrows] in proliferating bile ductules mean nothing, but in sinusoids indicate damage ~~(Row 2 Right 400X)~~. Reticulin fibers in steatosis afflicted areas can appear abnormally lost, which should not be deemed evidence of hepatocellular carcinoma ~~(Row 3 Left 400X)~~. Reticulin stain here shows hepatocyte acini [arrows], evidence of hepatocellular injury (Row 3 Right 400X).

	{\|		A. [[File:1 Steatohep 4 680x512px.tif\|Panacinar steatosis with unremarkable, small triads (40X).]]
	[[File:1 Steatohep 4 680x512px.tif\|Panacinar steatosis with unremarkable, small triads (40X).]]		B. [[File:2 Steatohep 4 680x512px.tif\|Ballooning degeneration, with cytoplasmic tufts (arrows) (400X).]]
	[[File:2 Steatohep 4 680x512px.tif\|Ballooning degeneration, with cytoplasmic tufts (arrows) (400X).]]
	<br>		<br>
	[[File:3 Steatohep 4 680x512px.tif\|Lipogranuloma (400X).]]		C. [[File:3 Steatohep 4 680x512px.tif\|Lipogranuloma (400X).]]
	[[File:4 Steatohep 4 680x512px.tif\|Triad with mild chronic inflammation without interface hepatitis (400X).]]		D. [[File:4 Steatohep 4 680x512px.tif\|Triad with mild chronic inflammation without interface hepatitis (400X).]]
	\|}
	Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1 ~~(not shown)~~. Panacinar steatosis with unremarkable, small triads ~~(Row 1 Left 40X)~~. Ballooning degeneration, with cytoplasmic tufts [arrows] ~~(Row 1 Right 400X)~~. Lipogranuloma ~~(Row 2 Left 400X)~~. Triad with mild chronic inflammation without interface hepatitis ~~(Row 2 Right 400X)~~.		Steatohepatitis Brunt necroinflammatory grade 3, Brunt fibrosis stage 1. A. Panacinar steatosis with unremarkable, small triads. B. Ballooning degeneration, with cytoplasmic tufts [arrows]. C. Lipogranuloma. D. Triad with mild chronic inflammation without interface hepatitis.
	{\|
	[[File:1 Steatohep 5 680x512px.tif\|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]
	[[File:2 Steatohep 5 680x512px.tif\|An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The patient had a normal bilirubin. (Row 1 Right 200X).]]		A. [[File:1 Steatohep 5 680x512px.tif\|Steatosis afflicts almost all hepatocytes (pan-acinar) (Row 1 Left 40X).]]
			B. [[File:2 Steatohep 5 680x512px.tif\|An isolated septal duct with concentric fibrosis (arrow) should not result in a diagnosis of primary sclerosing cholangitis. The patient had a normal bilirubin. (Row 1 Right 200X).]]
	<br>		<br>
	[[File:3 Steatohep 5 680x512px.tif\|Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X).]]		C. [[File:3 Steatohep 5 680x512px.tif\|Cytoplasmic tufts (arrows) prove ballooning degeneration (Row 2 Left 400X).]]
	[[File:4 Steatohep 5 680x512px.tif\|PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X).]]		D. [[File:4 Steatohep 5 680x512px.tif\|PAS with diastase shows PAS-D Kupffer cells (arrows) (Row 2 Right 400X).]]
	<br>		<br>
	[[File:5 Steatohep 5 680x512px.tif\|Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X).]]		E. [[File:5 Steatohep 5 680x512px.tif\|Reticulin shows thick black lines (red arrows) of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis (double head cyan arrow) should not be considered regeneration or hepatoma (Row 3 Left 200X).]]
	[[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]		F. [[File:6 Steatohep 5 680x512px.tif\|Trichrome shows a bridge (arrows) (Row 3 Right 200X).]]
	\|}
	Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. Steatosis afflicts almost all hepatocytes (pan-acinar) ~~(Row 1 Left 40X)~~. An isolated septal duct with concentric fibrosis [arrow] should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. ~~(Row 1 Right 200X)~~. Cytoplasmic tufts [arrows] prove ballooning degeneration ~~(Row 2 Left 400X)~~. PAS with diastase shows PAS-D Kupffer cells (arrows) ~~(Row 2 Right 400X)~~. Reticulin shows thick black lines [red arrows] of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis [double head cyan arrow] should not be considered regeneration or hepatoma ~~(Row 3 Left 200X)~~. Trichrome shows a bridge [arrow] (~~Row 3 Right 200X~~).		Steatohepatitis. Brunt necroinflammatory grade 3, Brunt fibrosis stage 3. A. Steatosis afflicts almost all hepatocytes (pan-acinar). B. An isolated septal duct with concentric fibrosis [arrow] should not result in a diagnosis of primary sclerosing cholangitis. The woman who underwent the biopsy had a normal bilirubin level, a normal alkaline phosphatase level, and only slightly elevated transaminase levels. C. Cytoplasmic tufts [arrows] prove ballooning degeneration. D. PAS with diastase shows PAS-D Kupffer cells (arrows). E. Reticulin shows thick black lines [red arrows] of collapse, without portal central bridging. The apparent loss of reticulin due to steatosis [double head cyan arrow] should not be considered regeneration or hepatoma. F. Trichrome shows a bridge [arrow].

			[[File:4 99480485255889 sl 1.png\|Cirrhosis with steatohepatitis in a 54 year old man]]
			[[File:4 99480485255889 sl 2.png\|Cirrhosis with steatohepatitis in a 54 year old man]]
			[[File:4 99480485255889 sl 3.png\|Cirrhosis with steatohepatitis in a 54 year old man]]
			[[File:4 99480485255889 sl 4.png\|Cirrhosis with steatohepatitis in a 54 year old man]]

			Cirrhosis with steatohepatitis in a 54 year old man with type II diabetes, negative viral serologies, negative alcohol history, negative AMA/ANA, normal ceruloplasmin, low albumin/platelet count, and elevated bilirubin/alkaline phosphatase/transaminase, with hepatosplenomegaly. A. At lower power, no definite triads are seen, but there are potential bands (green arrows) and foci with steatosis (blue arrows). The low percent of hepatocytes afflicted by steatosis would indicate a Brunt necroinflammatory grade 1, here irrelevant as cirrhosis is present. B. Tufts (green arrows) prove ballooning degeneration needed for a diagnosis of steatohepatitis. Foamy macrophage-like hepatocytes (blue arrows) show feathery degeneration is also present. C. Reticulin shows two cell thick cords (green arrows) of regeneration. D. Trichrome shows blue bands and definite nodules (white arrows). At one time, 75% of the biopsy would have had to have been occupied to diagnose cirrhosis. Currently, under the Metavir system, one need only have extensive fibrosis, which would include developing cirrhosis of the HAI system, to obtain a grade IV status, acceptable for transplantation.



	{\| class="wikitable sortable"		{\| class="wikitable sortable"
Line 223:		Line 234:
	\| [[Image:Steatohepatitis Cases 03.tif \|thumb\| Fibrosis stage 1 Brunt necroinflammatory grade 2 (WC)]]		\| [[Image:Steatohepatitis Cases 03.tif \|thumb\| Fibrosis stage 1 Brunt necroinflammatory grade 2 (WC)]]
	\| Necroinflammatory grades Brunt 2, NAH 6. Fibrosis stage 1. About half the hepatocytes show macrovesicular steatosis (UL), with sparing of part of the acinus (UL, Black arrowhead), Lipogranulomas, acomar inflammatory collections, mostly macrophages, about steatosis/ballooning degeneration afflicted hepatocytes or adjacent to them (UR, green arrowheads) are present.Tufts/flocks of ballooning degeneration are readily found (LL, magenta arrowheads). Mild to moderate mononuclear inflammation of portal triads does not exclude steatohepatitis (LL, yellow arrowheads). Trichrome displays the blue thin lines that separate hepatocytes in stage 1 fibrosis (LR blue arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X , LR 10X		\| Necroinflammatory grades Brunt 2, NAH 6. Fibrosis stage 1. About half the hepatocytes show macrovesicular steatosis (UL), with sparing of part of the acinus (UL, Black arrowhead), Lipogranulomas, acomar inflammatory collections, mostly macrophages, about steatosis/ballooning degeneration afflicted hepatocytes or adjacent to them (UR, green arrowheads) are present.Tufts/flocks of ballooning degeneration are readily found (LL, magenta arrowheads). Mild to moderate mononuclear inflammation of portal triads does not exclude steatohepatitis (LL, yellow arrowheads). Trichrome displays the blue thin lines that separate hepatocytes in stage 1 fibrosis (LR blue arrowheads). Original oculars UL 4X, UR 40X (higher pixel photograph), LL 40X , LR 10X
	\|-
	~~\|[[Image:Steatohepatitis Cases 05.tif \|thumb\| Fibrosis stage 4 Brunt necroinflammatory grade 3 (WC)]]~~
	\|Necroinflammatory grades Brunt 3, NAH 8. Fibrosis stage 4. Steatosis is pan-acinar (UL). Acinar inflammatory aggregates More than 4 inflammatory aggregates are seen in a 20X field (UR black arrowheads). Many cells show ballooning degeneration, with tufts/flocks of material cytoplasm (LL yellow arrowheads) Trichrome limns regenerative nodules (LR magenta arrowheads). Original oculars UL 4X, UR 20X, LL 40X (higher pixel photograph), LR 10X
	\|}		\|}