Non-alcoholic fatty liver disease: The diagnosis and management

Table 1 Causes of nonalcoholic fatty liver disease[69]

Acquired metabolic disorders

Diabetes mellitus

Dyslipidemia

Kwashiorkor and marasmus

Obesity

Starvation

Cytotoxic and cytostatic drugs

L-asparaginase

Azacitidine

Azaserine

Bleomycin

Methotrexate

Puromycin

Tetracycline

Other drugs and toxins

Amiodarone

4,4'-diethylaminoethoxyhexestrol

Dichlorethylene

Ethionine

Ethyl bromide

Estrogens

Glucocorticoids

Highly active antiretroviral therapy

Hydrazine

Hypoglycin

Orotate

Perhexilene maleate

Safrole

Tamoxifen

Metals

Antimony

Barium salts

Chromates

Phosphorus

Rare earths of low atomic number

Thallium compounds

Uranium compounds

Inborn errors of metabolism

Abetalipoproteinemia

Familial hepatosteatosis

Galactosemia

Glycogen storage disease

Hereditary fructose intolerance

Homocystinuria

Systemic carnitine deficiency

Tyrosinemia

Weber-Christian syndrome

Wilson disease

Surgical procedures

Biliopancreatic diversion

Extensive small bowel resection

Gastric bypass

Jejunoileal bypass

Miscellaneous conditions

Industrial exposure to petrochemicals

Inflammatory bowel disease

Partial lipodystrophy

Jejunal diverticulosis with bacterial overgrowth

Severe anemia

Total parenteral nutrition

Table 2 Brunt schema for grading nonalcoholic steatohepatitis[99]

Severe (grade 3)	Moderate (grade 2)	Mild (grade 1)
Typically > 66% (panacinar); commonly mixed steatosis	Any degree and usually mixed macrovesicular and microvesicular	Predominantly macrovesicular; involves < 33%-66% of the lobules	Steatosis
Predominantly zone 3; marked	Obvious and present in zone 3	Occasionally observed; zone 3 hepatocytes	Ballooning
Scattered acute and chronic inflammation; polymorphs may appear concentrated in zone 3 areas of ballooning and perisinusoidal fibrosis	Polymorphs may be noted associated with ballooned hepatocytes, pericellular fibrosis; mild chronic inflammation may be seen	Scattered and mild acute (polymorphs) inflammation and occasional chronic inflammation (mononuclear cells)	Lobular inflammation
Mild or moderate	Mild to moderate	None or mild	Portal inflammation

Table 3 Non-alcoholic fatty liver disease activity score[9]

Score	Steatosis
0	< 5%
1	5%-33%
2	> 33%-66%
3	> 66%
Lobular inflammation (counted in 20 × fields)
1	< 2 foci
2	2-4 foci
3	> 4 foci
Ballooning
1	Few
2	Many