VU THI THU TRANGRESEARCH ON CLINICAL FEATURES, SOME TESTS, ULTRASOUND AND HISTOPATHOLOGY OF FATTY LIVER DISEASE Speciality: Gastroenterology Code: 62.72.01.43 ABSTRACT OF MEDICAL PHD THE
Trang 1VU THI THU TRANG
RESEARCH ON CLINICAL FEATURES, SOME TESTS,
ULTRASOUND AND HISTOPATHOLOGY
OF FATTY LIVER DISEASE
Speciality: Gastroenterology Code: 62.72.01.43
ABSTRACT OF MEDICAL PHD THESIS
HA NOI - 2019
Trang 21 Prof PhD Trinh Tuan Dung
2 PhD Duong Minh Thang
Reviewer:
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2
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This thesis will be presented at Institute Council at:
108 Institute of Clinical Medical and Pharmaceutical Sciences
Day Month Year
The thesis can be found at:
1. National Library of Vietnam
2. Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences
Trang 31 Vu Thi Thu Trang, Trinh Tuan Dung, Nguyen Tien Thinh, Duong Minh Thang (2018), "Clinical and laboratory characteristics of fatty
liver disease" Journal of 108 - Clinical Medecine and Pharmacy ,
methods for liver fibrosis in fatty liver disease" Journal of 108 Clinical Medecine and Pharmacy, 14:57-62.
Trang 4Fatty liver disease (FLD) is an abnormal accumulation offat (mainly triglycerides) in liver cells due to many causes such asalcohol, metabolic disorders, nutritional disorders, poisoning,drugs, hepatitis virus The disease progresses silently from thesteatosis stage to steatohepatitis and eventually to cirrhosis Infact, alcoholic fatty liver disease (AFLD) and nonalcoholic fattyliver disease (NAFLD) are common AFLD is all cases of alcoholabuse, while NAFLD includes metabolic and nutritional liverdiseases that are often the result of insulin resistance and fatAccording to the World Health Organization statistics, therate of fatty liver disease worldwide varies from 4% to 46%depending on the region and region Over the years, non-invasivediagnostic methods have been constantly researched anddeveloped to replace liver biopsies However, the gold standardfor diagnosing steatosis is still a liver biopsy andhistopathological examination A liver biopsy not only helpsdiagnose fatty liver disease, but more importantly can accuratelydiagnose the level and stage of the disease, help predict andevaluate the effectiveness of treatment of fatty liver disease.There are many researches on fatty liver disease in theworld that show the serious consequences of the disease forindividuals as well as the whole society In Vietnam, fatty liverdisease is also on the rise and is currently a topical issue of thehealth sector and is of great concern to society However, so farthere is no specific statistics on fatty liver status and there havenot been many studies on fatty liver disease in Vietnam,especially studies with liver biopsy as gold standard in thediagnosis of fatty liver disease Therefore, we conduct this studyfor two main objectives:
1 Analyze clinical features, some tests, ultrasound and histopathology in fatty liver disease.
2 Assessment the relationship between clinical, laboratory, ultrasound and histopathology and the value of some non-
Trang 5invasive diagnostic methods in fatty liver disease.
Thesis layout
The thesis has 136 pages, including: Introduction (2 pages),Chapter 1: Overview (34 pages), Chapter 2: Subjects andmethods (22 pages), Chapter 3: Results (40 pages), Chapter 4:Discussion (35 pages), Conclusion (2 pages), Recommendations(1 page) The thesis has 51 tables, 16 Charts, 19 Pictures Thethesis has 129 References (8 vietnamese references and 121english references) and 2 appendices
The new main contributions of the thesis
This is the first study to evaluate the detailed histopathology
of fatty liver disease in Vietnam The study has given relativelycomprehensive results on fatty liver disease including clinicalfeatures, tests, ultrasound and histopathology of fatty liver diseaseand the difference between AFLD and NAFLD The thesis alsoassessed the relationship between clinical tests, ultrasound andthe degree of histopathological damage in fatty liver disease Inparticular, the study has shown that the value of some non-invasive diagnostic methods in fatty liver disease such as APRI,FIB-4, Forns has good value for diagnosing liver fibrosis in fattyliver disease and The ANI index is a very good indicator for thedifferential diagnosis of alcoholic and nonalcoholic fatty liver.These are valuable contributions both theoretically andpractically in the diagnosis and treatment of steatosis
Trang 6CHAPTER I OVERVIEW 1.1 Epidemiology of fatty liver disease
1.1.1 AFLD
Alcohol causes more than 200 different diseases andinjuries on the body Alcohol is the first cause of liver disease inthe West and the second cause in Asia after viral hepatitis
1.1.2 NAFLD
According to the World Gastroenterology Organisation, theAmerican association for the study of the liver diseases and theEuropean association for the study of the liver, NAFLD is themost common cause of liver diseases worldwide The prevalence
of NAFLD worldwide varies 4 to 46%, while the prevalence ofnonalcoholic steatohepatitis is lower limit of 3-5%
1.2 Definition, causes, classification, pathogenesis of fatty liver disease
1.2.1 Definition
Fatty liver is characterized by excessive accumulation of fat(mainly triglycerides) in liver cells FLD is defined as havingmore than 5% of steatosis hepatocytes diagnosed byhistopathology or magnetic resonance imaging
1.2.2 Causes
* Causes of chronic FLD: Alcoholism, obesity, diabetes,dyslipidemia, reversible surgery - jejunum, protein - energydeficiency, parenteral nutrition, rapid weight loss, geneticdisorders of fatty acid oxidation in mitochondria, other liverdiseases
* Causes of acute FLD: Alcohol poisoning, FLD inpregnancy, Reye's syndrome, Jamaican vomiting, Wolmandisease, toxins
1.2.3 Classification
1.2.3.1 Classification by histopathology: macrovesicularsteatosis, microvesicular steatosis, mixture of large and small
Trang 71.4 Biological markers for diagnosing FLD
1.4.1 Biological markers of hepatic steatosis
1.4.1.1 FLI (Fatty liver index)
1.4.1.2 HSI (hepatic steatosis index)
1.4.1.3 LAP (lipid accumulation product)
1.4.2 Biological markers identifying steatohepatitis and cirrhosis
1.4.2.1 Liver enzymes AST, ALT,GGT
1.4.2.2 The APRI index
1.4.2.3 The Forns index
1.4.2.4 The FIB-4 index
1.4.3 The ANI index distinguishes between AFLD and NAFLD
The ANI index is simple, convenient, and can be used in clinical
Trang 8practice to distinguish between AFLD and NAFLD.
ANI = -58,5 + 0,637 (MCV) + 3,91 (AST/ALT) - 0,406 (BMI) + 6,35(male)
1.5 Image diagnostic methods
1.5.1 Ultrasound
Ultrasound is a simple, convenient, inexpensive, mostcommonly used method for screening for FLD and is often thefirst choice to assess fatty liver Reports of sensitivity andspecificity of ultrasound to detect all stages of hepatic steatosisare 60-94% and 66-95%, respectively However, ultrasound isonly good for moderate to severe FLD (> 30% of fat cells are fat)
1.5.2 Computed tomography - CT
Computed tomography is highly sensitive and specific inthe diagnosis of steatosis, with moderate and severe steatosis(≥30% histologically), CT scan has a sensitivity of 84% and aspecificity of 100% However, CT scans are less sensitive incases of mild FLD below 30% and the specificity of diagnosingfatty liver is also affected by factors such as fibrosis,inflammation and edema, therefore CT scans are not distinguishbetween simple fatty liver and steatohepatitis
1.5.3 Magnetic resonance imaging - MRI
MRI scans are a more accurate and relatively superiortechnique than ultrasound and CT scans to detect mild cases offatty liver MRI can be used to quantify fat in liver parenchyma.However, MRI scans are still difficult to distinguish frominflammation and fibrosis, however, due to the high cost of MRIhas not been widely used clinically to diagnose fatty liver
1.5.4 Techniques liver elastography
The general value of methods of measuring liver elasticity
in FLD is to allow the assessment of liver fibrosis Fibroscan alsoallows the diagnosis of hepatic steatosis but does not accuratelyassess the stages and types of lesions in FLD
Trang 91.6 Histology of FLD
1.6.1 Steatosis: There are two types of steatosis, macrovesicular steatosis and microvesicular steatosis.
1.6.1.1 Macrovesicular steatosis
Marcovesicular steatosis is caused by the deposition of fat
in the cytoplasm of liver cells that form large fat particles pushingthe nucleus to one side
1.6.1.2 Microvesicular steatosis
Microvesicular steatosis is often associated in themetabolism of fat in the liver cells, causing the mitochondria totransform into many small drop-fat located in the cytoplasm ofthe hepatocytes surrounding the nucleus of the cell, not repellingthe nucleus
1.6.6 Diagnose stage and degree of steatosis: by NAS score
and FLIP algorithm There are 3 stages: simple steatosis,steatohepatitis, cirrhosis
CHAPTER 2 SUBJECTS AND METHODS
Trang 10as hepatitis B, C, drugs
Criteria for diagnosis of FLD:
Diagnosis of FLD by histology when ≥ 5% of hepatocytesare steatosis (count the number of hepatocytes per 5 domains atmagnification 400 times, divided by the average number)
2.1.2 Exclusive criteria
- Patients do not agree to participate in the study
- Pregnant and and nursing mothers
- Patients with serious internal diseases such as kidneyfailure, severe heart failure, respiratory failure, severe infection,decompensated cirrhosis, liver cancer, liver abscess, biliary tractinfection…
- An unqualified liver biopsy: less than 4 portals, less than1.5 cm in length
2.2 Methods
2.2.1 Research design: Cross-sectional descriptive study
2.2.2 Cỡ mẫu: Convenience sample, n=102.
2.2.3 Research criteria
2.2.3.1 Cause: 3 groups: alcoholic fatty liver, non-alcoholic fatty
liver, fatty liver from many causes / unidentified cause
2.2.3.2 Clinical criterias
* Age, gender, BMI, waist circumference
* History: Alcohol abuse, diabetes, hypertension, dyslipidemia,metabolic syndrome, hepatitis B, C
* Functional and physical symptoms: Fatigue, abdominaldistension, stool disorders, right upper abdominal pain, spiderangioma, jaundice, hepatomegaly, asymptomatic
2.2.3.3 Hematology and blood biochemistry
- Hematology: RBC count, WBC count, platelet count, Hb, MCV,Prothrombin ratio
- Biochemistry: Urea, creatinine, total bilirubin, total protein,albumin, fasting blood glucose, AST, ALT, GGT, totalcholessterol, triglycerides, LDL-Cholesterol, HDL-Cholesterol
Trang 112.2.3.4 Liver ultrasound criteria
* Grade of steatosis: 3 grades (I, II, III)
* Ultrasound lesions: Hepatomegaly, diffuse steatosis,pseudotumor (hypoechoic foci, hyperechoic foci, echo mixturefoci)
2.2.3.5 Histology criteria
* The stages of FLD: 3 stages (simple fatty liver, steatohepatitis,cirrhosis)
* Steatosis:
- Grade of steatosis: 3 grades (1, 2, 3)
- Classification of steatosis: macrovesicular steatosis,microvesicular steatosis, and mixed steatosis (includemacrovesicular steatosis and microvesicular steatosis )
- Location of steatosis: zone 3, zone 1, diffuse
* Inflammation
- Lobular inflammation: 3 grades (mild, moderate, severe)
- Portal inflammation: 3 grades (mild, moderate, severe)
- Cells of inflammation: lympho and mixed cells
- Grade of steatohepatitis: NAS score
* The damage to liver cells: hepatocyte ballooning,hepatocellular necrosis, acidophil bodies Mallory–Denk bodies,nuclear vacuolation, megamitochondria
* Other lesions: Large lipogranuloma, microgranulomas, ductularreaction, hepatocellular dysplasia
* Fibrosis: Evaluation by 3 staining methods (H.E staining,Trichrome Masson staining, Vimentin staining)
- Locations of liver fibrosis
- Stade of liver fibrosis: Evaluation by 2 score (Metavir andNAS)
2.2.3.6 Non-invasive diagnosis of cause, steatosis and fibrosis
- ANI: Differential diagnosis of ALD and NAFLD
- Test of steatosis: HSI, FLI, LAP
- Test of fibrosis: APRI, FIB-4, Forns
2.2.4 Equipment
Trang 12Modern testing machines, imaging and histopathologydiagnostic facilities are routinely used in the 108 hospital, biopsyguns (fast-gun), biopsy needles (fast-cut).
2.2.5 Steps of research process
of coordinated lesions will take two pieces of liver tissue: onepiece of normal liver tissue and one piece at the location ofsuspected lesions
* Contraindications: According to the regulations of the Ministry
of Health
2.2.4.5 Histopathological test: performed at the Department of
Pathological Anatomy - the 108 Military Central Hospital
* Fixing and handling: liver biopsy pieces are fixed in the biopsyroom with 10% neutral buffer formol and transferred to theDepartment of Pathological Anatomy within 24 hours
* Template staining: By 3 different techniques: Eosin (HE) staining, Trichrome Masson staining andimmunohistochemistry staining with Vimentin antibody(Vimentin staining)
Hematoxylin-2.2.6 Statistical analysis: By medical statistical methods, using
SPSS 21.0 software
Trang 132.3 Research ethics: In accordance with the regulations of the
108 Military Central Hospital and the 108 Institute of ClinicalMedical and Pharmaceutical Ssiences
CHAPTER III RESULTS 3.1 Clinical characteristics of FLD
* Cause: NAFLD 42,2%; AFL 33,3%, fatty liver from many
causes / unidentified cause 24,5%
* Stage: steatohepatitis 83,3%, simple fatty liver 11,8%, cirrhosis
4,6%
* Age, gender: The average age of patients with FLD is 49.77 ±
11.89 The ratio of male to female is 2:1
Trang 14Table 3.3 Body mass index and waist circumference of FLD
Comment: waist circumference was 52%, overweight was 35.3%,
obesity was 32.4%, average BMI was 23.99 ± 2.04
Table 3.4 Body indicators of AFLD and NAFLD patients
Comment: NAFLD had average BMI and higher rate of
overweight and obesity than AFLD, the difference wasstatistically significant
Table 3.6 Clinical symptoms are seen in patients with FLD (n =
Trang 15Asymptomatic 35 34,3
Comment: 34.3% asymptomatic, fatigue 41.2%; abdominal
distension 28.4%; stool disorders 29.4%; right upper abdominalpain 26.5%
* Steatohepatitis and cirrhosis have more clinical symptoms thansimple fatty liver
* Clinical symptoms are more common in AFLD than in NAFLDgroup
3.2 Laboratory characteristics of patients with FLD
* Routine hematological tests are almost normal
* AFLD had an average MCV (95.94 ± 10.5fl) and an increaseMCV ( 41.1%) higher than NAFLD (85.7 ± 5.33 fl; 2.3%), p
<0.001
Table 3.11 Serum hepatic enzyme tests in patients with FLD
Comment: Liver enzymes fluctuate in a large range Increase of
GGT is 56.9%, increase of AST is 34.5%, increase of ALT is
39.2%
* The group of simple steatosis had almost no increase in liverenzymes, the group of steatohepatitis and cirrhosis had 38.9%increase in serum AST; 44.4% increased serum ALT; 62.2%increased serum GGT
* AFLD had higher rate of increase and activity of AST and GGT
than NAFLD group, the difference was statistically significantwith p <0.05
* 24.7% of patients with FLD had hyperglycemia, 16.8% hadfasting blood sugar disorders 67.6% of patients had