Association among Histopathology, Clinical Manifestation, and Ultrasonographic Grades in Pediatric Non-alcoholic Fatty Liver Disease

Sue Jung Jee; Yong Joo Kim; Soon Young Song; Seung Sam Paik

doi:10.4166/kjg.2011.57.3.158

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Jee, Kim, Song, and Paik: Association among Histopathology, Clinical Manifestation, and Ultrasonographic Grades in Pediatric Non-alcoholic Fatty Liver Disease

Original Article

Korean J Gastroenterol 2011;57(3):158-165.

Published online: 4 October 2011

DOI: https://doi.org/10.4166/kjg.2011.57.3.158

Association among Histopathology, Clinical Manifestation, and Ultrasonographic Grades in Pediatric Non-alcoholic Fatty Liver Disease

Sue Jung Jee, Yong Joo Kim, Soon Young Song¹, Seung Sam Paik²

¹Department of Pediatrics, Radiology, Hanyang University College of Medicine, Seoul, Korea

²Department of Pathology, Hanyang University College of Medicine, Seoul, Korea

Correspondence to: Yong Joo Kim, Department of Pediatrics, Hanyang University College of Medicine, 17, Haengdang-dong, Seongdong-gu, Seoul 133-792, Korea. Tel: +82-2-2290-8390, Fax: +82-2-2297-2380, E-mail: kyjoo@hanyang.ac.kr

Received 20 July 2010 Revised 6 October 2010 Accepted 13 December 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Nonalcoholic steatohepatitis (NASH) is the progressive form of non-alcoholic fatty liver disease (NAFLD), and its prevalence is increasing worldwide. Liver biopsy remains the best way to diagnose NASH and establish the presence of fibrosis, but has not been performed easily in children because of its invasiveness. We analyzed the ultrasonographic and histopathologic findings of pediatric NAFLD patients, and studied to find their association with clinical characteristics and laboratory findings.

Methods

The study involved 18 obese children ranging from 7 to 15 years of age, who were diagnosed with NASH by liver biopsy. We performed the abdomen ultrasonography before the liver biopsy. We reviewed their pathology slides and classified them by NASH CRN (Clinical Research Network) scoring system. We also reviewed the abdomen ultrasonographic findings of the patients and classified them into grade of 1, 2, and 3. We reviewed the medical records of the patients and investigated their clinical characteristics and laboratory findings.

Results

The ultrasonographic grades had significant association with NAFLD activity score, grade of steatosis amount, ballooning change, and portal inflammation. Serum triglyceride level was significantly higher in patients who showed high grade steatosis and high NAFLD activity score.

Conclusions

This study showed that serum triglycerides and ultrasonographic findings are highly correlated with pathologic findings in children with NAFLD.

Keywords: Children, Nonalcoholic steatohepatitis, Non-alcoholic fatty liver disease, Ultrasonographic finding, Liver histopathologic finding

References

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Table 1.

Grades of Hepatic Ultrasonographic Findings in Children with NAFLD¹⁴

Grade		Ultrasonographic findings
1	Mild	Slight diffuse increase in the fine echoes of the diaphragm and intrahepatic vessel borders
2	Moderate	Moderate diffuse increase in the fine echoes with slightly impaired visualization of the intrahepatic vessels and diaphragm
3	Severe	Marked increase in fine echoes with poor or no visualization of the intrahepatic vessel borders, diaphragm, and posterior portion of the right lobe of liver

NAFLD, nonalcoholic fatty liver disease.

Table 2.

Correlatoin between Histologic Grades and Ultrasonographic Grades

	Histologic grades	Ultrasonograghic grades		p-value
	Histologic grades	Children of grade 1 and grade 2 fatty liver (%)	Children of grade 3 fatty liver (%)	p-value
NAS ^a	Non-NASH (≤4)	4 (57.1)	1 (9.1)	0.026 ^b
	NASH(≥5)	3 (42.9)	10 (90.9)
Steatosis amount	Grade 0 (＜5%)	0 (0.0)	0 (0.0)
	Grade 1 (5–32%)	4 (57.1)	2 (18.2)	0.046 ^b
	Grade 2 (33–66%)	2 (28.6)	3 (27.3)
	Grade 3 (＞66%)	1 (14.3)	6 (54.5)
Lobular inflammation	Grade 0 (no foci)	0 (0.0)	0 (0.0)
	Grade 1 (＜2 foci/200x)	3 (42.9)	3 (27.3)	0.28
	Grade 2 (2–4 foci/200x)	4 (57.1)	6 (54.5)	0.28
	Grade 3 (＞4 foci/200x)	0 (0.0)	2 (18.2)
Portal inflammation	Grade 0 (none to minimal)	7 (100)	5 (45.5)	0.02 ^b
	Grade 1 (greater than minimal)	0 (0.0)	6 (54.5)
Ballooning degeneration	Grade 0 (none)	0 (0.0)	0 (0.0)
	Grade 1 (few)	4 (57.1)	1 (9.1)	0.03 ^b
	Grade 2 (many)	3 (42.9)	10 (90.9)
Fibrosis	Grade 0 (none)	0 (0.0)	0 (0.0)
	Grade 1 (zone 3 perisinusoidal)	1 (14.2)	2 (18.2)
	Grade 2 (perisinusoidaltal) and portal/periport	3 (42.9)	1 (9.1)	0.493
	Grade 3 (bridging fibrosis)	3 (42.9)	8 (72.7)
	Grade 4 (cirrhosis)	0 (0.0)	0 (0.0)

^a NAS (NAFLD activity score); sum of steatosis, lobular inflammation, and ballooning degeneration scores. NAS of 5 or more correlates well with a diagnosis of NASH.

^b p＜0.05.

Table 3.

Comparison of Biochemical Profiles according to the Degree of Steatosis

	Steatosis amount of hepatic cells on pathologic findings
	1	2	3	p-value
Number of patients	6	5	7
ALT (U/L)	191.17±220.00	144.80±93.28	188.00±108.57	0.857
AST (U/L)	90.67±91.92	74.60±36.88	199.85±52.32	0.490
ALP (U/L) TG (mg/dL)	274.17±80.99 117.67±51.71	225.60±110.22 119.00±30.20	282.00±63.27 219.47±52.68	0.498 0.002 ^a
Total cholesterol (mg/dL)	174.50±22.38	169.80±29.78	200.57±35.30	0.181
HDL (mg/dL)	39.67±8.89	41.40±6.87	40.86±14.28	0.964
LDL (mg/dL)	118.50±30.39	111.40±20.06	110.43±22.71	0.828
Total protein (g/dL)	7.78±0.31	7.78±0.40	7.61±0.30	0.600
Albumin (g/dL)	5.13±0.44	4.58±0.39	4.71±0.34	0.076
Total bilirubin (mg/dL)	0.50±0.20	0.52±0.21	0.31±0.14	0.127

All values are described as mean±SD.

^a p＜0.05.

Table 4.

Association between the Biochemical Profiles and the NAFLD Activity Scores

	Non-NASH ^a	NASH ^b	p-value
Number of patients	5	13
ALT (U/L)	149.60±184.05	187.61±133.56	0.632
AST (U/L)	71.60±73.08	107.53±60.89	0.303
ALP (U/L)	278.20±102.24	258.15±77.67	0.658
TG (mg/dL)	96.20±28.85	181.30±63.30	0.012 ^c
Total cholesterol (mg/dL)	163.20±22.88	191.07±31.74	0.094
HDL (mg/dL)	41.80±8.58	40.15±11.23	0.772
LDL (mg/dL)	112.20±31.72	113.84±21.46	0.900
Total protein (g/dL)	7.64±0.32	7.74±0.33	0.554
Albumin (g/dL)	5.02±0.49	4.73±0.40	0.234
Total bilirubin (mg/dL)	0.48±0.19	0.41±0.20	0.555

All values are described as mean±SD.

^a non-NASH: patients of the NAFLD activity scores of 0, 1, 2, 3, 4.

^b NASH: patients of the NAFLD activity scores of 5, 6, 7, 8.

^c p＜0.05.

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