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Fatty liver disease describes the accumulation of excess fat in liver cells. Fatty liver may cause no damage but in some cases the excess fat leads to inflammation in the liver, known as steatohepatitis. In adults, fatty liver has traditionally been most frequently associated with alcohol ingestion. Therefore, the term nonalcoholic is used to differentiate the disorders described in this section from alcohol-induced fatty liver. Non-alcoholic fatty liver disease (NAFLD) is an umbrella term describing a range of abnormalities from simple steatosis to cellular injury, fibrosis, and even cirrhosis resulting from fat accumulation. Non-alcoholic steatohepatitis (NASH) is a subtype of NAFLD that includes steatosis, ballooning degeneration, and inflammation. A large variety of acquired conditions can result in fatty liver disease (see Table 426-1) but by far the most common cause in the pediatric population is overweight and obesity. In the United States, about two-thirds of adults are overweight or obese, and 31.9% of children are overweight or obese (see also Chapter 32).1As the prevalence of obesity has increased, so has the prevalence of comorbid diseases, such as nonalcoholic fatty liver disease (NAFLD). NASH was first reported by Ludwig and colleagues2 in 1980, when they described a combination of histologic findings similar to alcoholic steatohepatitis in adults not consuming significant amounts of alcohol. In 1983, Moran, and colleagues3 described NASH in obese children. Although steatosis alone has not been shown to progress to cirrhosis, NASH can progress to cirrhosis, and NASH-related cirrhosis has been reported in children as young as 10 years of age.4 Currently, NAFLD is considered to be the most common reason for unexplained abnormal liver tests in the pediatric population and the most common chronic liver disease in the Western world.5

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Table 426-1. Causes of Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH)



Because nonalcoholic fatty liver disease (NAFLD) is truly a histologic diagnosis and most people with the disease are clinically asymptomatic, autopsy studies are best designed to assess the prevalence of NAFLD and nonalcoholic steatohepatitis (NASH). In 1990, Wanless and Lentz6 reported that 70% of obese adults have steatosis compared to 35% of lean adults, and 18.5% ...

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