J Pathol Transl Med.  2020 May;54(3):228-236. 10.4132/jptm.2020.03.07.

A scoring system for the diagnosis of non-alcoholic steatohepatitis from liver biopsy

  • 1Gastrointestinal Pathology Study Group of the Korean Society of Pathologists, Korea
  • 2Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
  • 3Department of Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
  • 4Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 5Department of Pathology, Inje University Seoul Paik Hospital, Seoul, Korea
  • 6Department of Pathology, Yonsei University Wonju College of Medicine, Wonju, Korea
  • 7Department of Pathology, Inha University Hospital, Incheon, Korea
  • 8Department of Pathology, Jeonbuk National University Medical School, Jeonju, Korea
  • 9Department of Pathology, Dong-A University College of Medicine, Busan, Korea
  • 10Department of Pathology, Anatomic Pathology Reference Lab., Seegene Medical Foundation, Seoul, Korea
  • 11Department of Pathology, Daegu Catholic University School of Medicine, Daegu, Korea
  • 12Department of Pathology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
  • 13Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
  • 14Department of Pathology, Soon Chun Hyang University Seoul Hospital, Seoul, Korea


Liver biopsy is the essential method to diagnose non-alcoholic steatohepatitis (NASH), but histological features of NASH are too subjective to achieve reproducible diagnoses in early stages of disease. We aimed to identify the key histological features of NASH and devise a scoring model for diagnosis.
Thirteen pathologists blindly assessed 12 histological factors and final histological diagnoses (‘not-NASH,’ ‘borderline,’ and ‘NASH’) of 31 liver biopsies that were diagnosed as non-alcoholic fatty liver disease (NAFLD) or NASH before and after consensus. The main histological parameters to diagnose NASH were selected based on histological diagnoses and the diagnostic accuracy and agreement of 12 scoring models were compared for final diagnosis and the NAFLD Activity Score (NAS) system.
Inter-observer agreement of final diagnosis was fair (κ = 0.25) before consensus and slightly improved after consensus (κ = 0.33). Steatosis at more than 5% was the essential parameter for diagnosis. Major diagnostic factors for diagnosis were fibrosis except 1C grade and presence of ballooned cells. Minor diagnostic factors were lobular inflammation ( ≥ 2 foci/ × 200 field), microgranuloma, and glycogenated nuclei. All 12 models showed higher inter-observer agreement rates than NAS and post-consensus diagnosis (κ = 0.52–0.69 vs. 0.33). Considering the reproducibility of factors and practicability of the model, summation of the scores of major (× 2) and minor factors may be used for the practical diagnosis of NASH.
A scoring system for the diagnosis of NAFLD would be helpful as guidelines for pathologists and clinicians by improving the reproducibility of histological diagnosis of NAFLD.


Non-alcoholic fatty liver disease; Non-alcoholic steatohepatitis; Biopsy; Consensus
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