MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACETICAL SCIENCES VU 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 THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisor: Prof PhD Trinh Tuan Dung PhD Duong Minh Thang Reviewer: 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: National Library of Vietnam Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences LIST OF PUBLISHED ARTICLE RELATING TO THESIS 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 , 13:247-251 Vu Thi Thu Trang, Trinh Tuan Dung, Nguyen Tien Thinh, Duong Minh Thang (2018), "Histopathological characteristics of fatty liver disease" Journal of 108 - Clinical Medecine and Pharmacy, 13:258263 Vu Thi Thu Trang, Trinh Tuan Dung, Nguyen Tien Thinh, Duong Minh Thang (2019), "Relationship between clinical, laboratory and fibrosis and value of non-invasive diagnostic methods for liver fibrosis in fatty liver disease" Journal of 108 Clinical Medecine and Pharmacy, 14:57-62 INTRODUCTION Fatty liver disease (FLD) is an abnormal accumulation of fat (mainly triglycerides) in liver cells due to many causes such as alcohol, metabolic disorders, nutritional disorders, poisoning, drugs, hepatitis virus The disease progresses silently from the steatosis stage to steatohepatitis and eventually to cirrhosis In fact, alcoholic fatty liver disease (AFLD) and nonalcoholic fatty liver disease (NAFLD) are common AFLD is all cases of alcohol abuse, while NAFLD includes metabolic and nutritional liver diseases that are often the result of insulin resistance and fat According to the World Health Organization statistics, the rate of fatty liver disease worldwide varies from 4% to 46% depending on the region and region Over the years, non-invasive diagnostic methods have been constantly researched and developed to replace liver biopsies However, the gold standard for diagnosing steatosis is still a liver biopsy and histopathological examination A liver biopsy not only helps diagnose fatty liver disease, but more importantly can accurately diagnose the level and stage of the disease, help predict and evaluate the effectiveness of treatment of fatty liver disease There are many researches on fatty liver disease in the world that show the serious consequences of the disease for individuals as well as the whole society In Vietnam, fatty liver disease is also on the rise and is currently a topical issue of the health sector and is of great concern to society However, so far there is no specific statistics on fatty liver status and there have not been many studies on fatty liver disease in Vietnam, especially studies with liver biopsy as gold standard in the diagnosis of fatty liver disease Therefore, we conduct this study for two main objectives: Analyze clinical features, some tests, ultrasound and histopathology in fatty liver disease Assessment the relationship between clinical, laboratory, ultrasound and histopathology and the value of some non- invasive 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 and methods (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 The thesis has 129 References (8 vietnamese references and 121 english references) and 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 relatively comprehensive results on fatty liver disease including clinical features, tests, ultrasound and histopathology of fatty liver disease and the difference between AFLD and NAFLD The thesis also assessed the relationship between clinical tests, ultrasound and the degree of histopathological damage in fatty liver disease In particular, the study has shown that the value of some noninvasive diagnostic methods in fatty liver disease such as APRI, FIB-4, Forns has good value for diagnosing liver fibrosis in fatty liver disease and The ANI index is a very good indicator for the differential diagnosis of alcoholic and nonalcoholic fatty liver These are valuable contributions both theoretically and practically in the diagnosis and treatment of steatosis CHAPTER I OVERVIEW 1.1 Epidemiology of fatty liver disease 1.1.1 AFLD Alcohol causes more than 200 different diseases and injuries on the body Alcohol is the first cause of liver disease in the West and the second cause in Asia after viral hepatitis 1.1.2 NAFLD According to the World Gastroenterology Organisation, the American association for the study of the liver diseases and the European association for the study of the liver, NAFLD is the most common cause of liver diseases worldwide The prevalence of NAFLD worldwide varies to 46%, while the prevalence of nonalcoholic 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 having more than 5% of steatosis hepatocytes diagnosed by histopathology or magnetic resonance imaging 1.2.2 Causes * Causes of chronic FLD: Alcoholism, obesity, diabetes, dyslipidemia, reversible surgery - jejunum, protein - energy deficiency, parenteral nutrition, rapid weight loss, genetic disorders of fatty acid oxidation in mitochondria, other liver diseases * Causes of acute FLD: Alcohol poisoning, FLD in pregnancy, Reye's syndrome, Jamaican vomiting, Wolman disease, toxins 1.2.3 Classification 1.2.3.1 Classification by histopathology: macrovesicular steatosis, microvesicular steatosis, mixture of large and small vacuoles steatosis 1.2.3.2 Classification by cause: alcoholic fatty liver, nonalcoholic fatty liver, secondary hepatic steatosis 1.2.4 Pathogenesis The accumulation of fat in the liver essentially results from four pathogenetic processes: - Increased uptake of free fatty acids (from food or body fat) via the portal vein - Increased synthesis of free fatty acids in the liver (from glucose or acetate) - Decreasedβ-oxidation of free fatty acids (above all in the mitochondria) - Decreased synthesis or secretion of lipoproteins (very low density lipoproteins, VLDL), the principal route for elimination of lipids from the liver 1.3 Clinical The clinical manifestations of FLD depend on the cause and stage of the disease The majority of steatosis cases have no clinical or non-specific symptoms 1.4 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 practice 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, most commonly used method for screening for FLD and is often the first choice to assess fatty liver Reports of sensitivity and specificity of ultrasound to detect all stages of hepatic steatosis are 60-94% and 66-95%, respectively However, ultrasound is only 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 in the diagnosis of steatosis, with moderate and severe steatosis (≥30% histologically), CT scan has a sensitivity of 84% and a specificity of 100% However, CT scans are less sensitive in cases of mild FLD below 30% and the specificity of diagnosing fatty liver is also affected by factors such as fibrosis, inflammation and edema, therefore CT scans are not distinguish between simple fatty liver and steatohepatitis 1.5.3 Magnetic resonance imaging - MRI MRI scans are a more accurate and relatively superior technique than ultrasound and CT scans to detect mild cases of fatty liver MRI can be used to quantify fat in liver parenchyma However, MRI scans are still difficult to distinguish from inflammation and fibrosis, however, due to the high cost of MRI has 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 also allows the diagnosis of hepatic steatosis but does not accurately assess the stages and types of lesions in FLD 1.6 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 pushing the nucleus to one side 1.6.1.2 Microvesicular steatosis Microvesicular steatosis is often associated in the metabolism of fat in the liver cells, causing the mitochondria to transform into many small drop-fat located in the cytoplasm of the hepatocytes surrounding the nucleus of the cell, not repelling the nucleus 1.6.2 Hepatocellular lesions 1.6.2.1 Hepatocyte balloning 1.6.2.2 Acidophil bodies (Apoptotic hepatocyte) 1.6.2.3 Necrosis of hepatocytes 1.6.3 Lobular and portal inflamation 1.6.4 Fibrosis 1.6.5 Other lesions in FLD 1.6.5.1 Mallory-Denk bodies 1.6.5.2 Nuclear vacuolation (Glycogenated nuclei) 1.6.5.3 Megamitochondria 1.6.6 Diagnose stage and degree of steatosis: by NAS score and FLIP algorithm There are stages: simple steatosis, steatohepatitis, cirrhosis CHAPTER SUBJECTS AND METHODS 2.1 Subjects 102 patients with FLD were diagnosed and treated at 108 Military Central Hospital from 12/2013 to 12/2016 2.1.1 Subject selection Patients ≥ 18 years of age, diagnosed by histopathology of fatty liver regardless of alcohol, non-alcohol, or other causes such 10 as hepatitis B, C, drugs Criteria for diagnosis of FLD: Diagnosis of FLD by histology when ≥ 5% of hepatocytes are steatosis (count the number of hepatocytes per domains at magnification 400 times, divided by the average number) 2.1.2 Exclusive criteria - Patients not agree to participate in the study - Pregnant and and nursing mothers - Patients with serious internal diseases such as kidney failure, severe heart failure, respiratory failure, severe infection, decompensated cirrhosis, liver cancer, liver abscess, biliary tract infection… - An unqualified liver biopsy: less than portals, less than 1.5 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: 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, abdominal distension, stool disorders, right upper abdominal pain, spider angioma, 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, total cholessterol, triglycerides, LDL-Cholesterol, HDL-Cholesterol 14 Table 3.3 Body mass index and waist circumference of FLD patients Index n % Waist Normal 49 48,0 circumference Increase 53 52,0 (cm) Normal 33 32,3 Overweight 36 35,3 BMI (kg/m2) Obesity 33 32,4 Average BMI 23,99 ± 2,04 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 Group AFLD NAFLD p Index (n = 34) (n = 43) Increase WC (8,8) 41 (95,3) BMI normal 21 (61,8) (2,3) Overweight 13 (38,2) 14 (32,6) < 0,05 Obesity 28 (65,1) Average BMI 22,52 ± 1,51 25,47 ± 1,52 Comment: NAFLD had average BMI and higher rate of overweight and obesity than AFLD, the difference was statistically significant Table 3.6 Clinical symptoms are seen in patients with FLD (n = 102) Symptoms n % Fatigue 42 41,2 Abdominal distension 29 28,4 Stool disorders 30 29,4 Right upper abdominal pain 27 26,5 Hepatomegaly 15 14,7 Spider angioma 13 12,7 Jaundice 2,9 15 Asymptomatic 35 34,3 Comment: 34.3% asymptomatic, fatigue 41.2%; abdominal distension 28.4%; stool disorders 29.4%; right upper abdominal pain 26.5% * Steatohepatitis and cirrhosis have more clinical symptoms than simple fatty liver * Clinical symptoms are more common in AFLD than in NAFLD group 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 increase MCV ( 41.1%) higher than NAFLD (85.7 ± 5.33 fl; 2.3%), p 0,05 Cirrhosis (11,8) Comment: AFLD had a higher incidence of portal fibrosis (94.1%) than NAFLD (62.8%), the difference was statistically significant, p