Skip to main content
SpringerLink
Log in

Visual Liver Score to Stratify Non-Alcoholic Steatohepatitis Risk and Determine Selective Intraoperative Liver Biopsy in Obesity

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Background

Non-alcoholic fatty liver disease (NAFLD) and its progressive form, non-alcoholic steatohepatitis (NASH), are endemic in obesity. We aimed to evaluate the diagnostic accuracy and reproducibility of a simple intraoperative visual liver score to stratify the risk of NASH and NAFLD in obesity and determine the need for liver biopsy.

Methods

This is a prospective cohort study of obese adults undergoing bariatric surgery. The surgical team used a visual liver score to evaluate liver colour, size and surface. This was compared to histology from an intraoperative liver biopsy.

Results

There were 152 participants, age 44.6 ± 12 years, BMI 45 ± 8.3 kg/m2. Prevalence of NAFLD was 70.4%, with 12.1% NASH and 26.4% borderline NASH. Single-visual components were less accurate than total composite score. Steatosis was most accurately identified (significant steatosis: AUROC 0.746, p < 0.05; severe steatosis: AUROC 0.855, p < 0.05). NASH was identified with moderate accuracy (AUROC 0.746, p = 0.001), with sensitivity 75% for a score ≥ 2. Stratification into low (≤ 1) and high-risk (≥ 4) scores accurately identified patients who should or should not have an intraoperative biopsy. Most patients with a normal-appearing liver did not have disease (94.4%). The structured visual assessment was quick and interobserver agreement was reasonable (κ = 0.53, p < 0.05).

Conclusions

A simple, structured tool based on liver appearance can be a useful and reliable tool for NAFLD risk stratification and identification of patients who would most and least benefit from a biopsy. A normal liver appearance reliably excludes significant liver disease, avoiding the need for liver biopsy in patients otherwise at high clinical risk of NASH.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

NASH:

Non-alcoholic steatohepatitis

BMI:

Body mass index

AUROC:

Area under the receiver operator characteristic curve

NAFLD:

Non-alcoholic fatty liver disease

IOLB:

Intraoperative liver biopsy

VLS:

Visual liver score

ALT:

Alanine aminotransferase

AST:

Aspartate aminotransferase

ULN:

Upper limit normal

GGT:

Gamma-glytamyl transferase

NAS:

NAFLD activity score

SD:

Standard deviation

IQR:

Interquartile range

PPV:

Positive predictive value

NPV:

Negative predictive value

References

  1. Angulo P. GI epidemiology: nonalcoholic fatty liver disease. Aliment Pharmacol Ther. 2007;25:883–9.

    Article  CAS  PubMed  Google Scholar 

  2. Ooi GJ, Burton PR, Doyle L, et al. Modified thresholds for fibrosis risk scores in nonalcoholic fatty liver disease are necessary in the obese. Obes Surg. 2017;27(1):115–25.

    Article  PubMed  Google Scholar 

  3. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology. Gastroenterology. 2012;142(7):1592–609.

    Article  PubMed  Google Scholar 

  4. Kleiner DE, Berk PD, Hsu JY, et al. Hepatic pathology among patients without known liver disease undergoing bariatric surgery: observations and a perspective from the longitudinal assessment of bariatric surgery (LABS) study. Semin Liv Dis. 2014;34(1):98–107.

    Article  Google Scholar 

  5. Teixeira AR, Bellodi-Privato M, Carvalheira JB, et al. The incapacity of the surgeon to identify NASH in bariatric surgery makes biopsy mandatory. Obes Surg. 2009;19(12):1678–84.

    Article  PubMed  Google Scholar 

  6. Shalhub S, Parsee A, Gallagher SF, et al. The importance of routine liver biopsy in diagnosing nonalcoholic steatohepatitis in bariatric patients. Obes Surg. 2004;14(1):54–9.

    Article  PubMed  Google Scholar 

  7. Mahawar KK, Parmar C, Graham Y, et al. Routine liver biopsy during bariatric surgery: an analysis of evidence base. Obes Surg. 2016;26(1):177–81.

    Article  PubMed  Google Scholar 

  8. Chiu CC, Lee WJ, Wang W, et al. Correlations of laparoscopy with histology and laboratory studies on liver diseases in bariatric patients. Obes Surg. 2008;18(2):204–11.

    Article  PubMed  Google Scholar 

  9. Dolce CJ, Russo M, Keller JE, et al. Does liver appearance predict histopathologic findings: prospective analysis of routine liver biopsies during bariatric surgery. Surg Obes Relat Dis. 2009;5(3):323–8.

    Article  PubMed  Google Scholar 

  10. Brunt EM, Kleiner DE, Wilson LA, et al. Nonalcoholic fatty liver disease (NAFLD) activity score and the histopathologic diagnosis in NAFLD: distinct clinicopathologic meanings. Hepatology. 2010;53(3):810–20.

    Article  Google Scholar 

  11. Kleiner DE, Brunt EM, Van Natta M, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology. 2005;41(6):1313–21.

    Article  PubMed  Google Scholar 

  12. Brunt EM, Kleiner DE, Behling C, et al. Misuse of scoring systems. Hepatology. 2011;54:369–70.

    Article  PubMed  Google Scholar 

  13. Dixon JB, Bhathal PS, O'brien PE. Nonalcoholic fatty liver disease: predictors of nonalcoholic steatohepatitis and liver fibrosis in the severely obese. Gastroenterology. 2001;121:91–100.

    Article  CAS  PubMed  Google Scholar 

  14. Jalan R, Harrison DJ, Dillon JF, et al. Laparoscopy and histology in the diagnosis of chronic liver disease. QLM. 1998;88(8):559–64.

    Google Scholar 

  15. Mcpherson S, Hardy T, Henderson E, et al. Evidence of NAFLD progression from steatosis to fibrosing-steatohepatitis using paired biopsies: implications for prognosis and clinical management. J Hepatol. 2014;62(5):1148–55.

    Article  PubMed  Google Scholar 

  16. Singh S, Allen AM, Wang Z, et al. Fibrosis progression in nonalcoholic fatty liver vs nonalcoholic steatohepatitis: a systematic review and meta-analysis of paired-biopsy studies. Clin Gastroenterol Hepatol. 2015;13(4):643–54.

    Article  PubMed  Google Scholar 

  17. Adams LA, Lymp JF, Sauver JS, et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology. 2005;129:113–21.

    Article  PubMed  Google Scholar 

  18. Ong JP, Pitts A, Younossi ZM. Increased overall mortality and liver-related mortality in non-alcoholic fatty liver disease. J Hepatol. 2008;49(4):608–12.

    Article  PubMed  Google Scholar 

  19. Labrecque D, Abbas Z, Anania F, Ferenci P, Khan AG, Goh K-L, et al. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. J Clin Gastroenterol. 2012;48(6):467-73.

  20. Prati D, Taioli E, Zanella A, et al. Updated definitions of healthy ranges for serum alanine aminotransferase levels. Ann Intern Med. 2002;137:1–10.

    Article  CAS  PubMed  Google Scholar 

  21. Liu K, Xiu W, Wong VW. Serum biomarkers for nonalcoholic fatty liver disease: are we there yet? [Editorial]. Hepatology. 2016;65(8):1087-95. doi:https://doi.org/10.1002/hep.28840

  22. Rockey DC, Caldwell SH, Goodman ZD, et al. Liver biopsy—AASLD position paper. Hepatology. 2009;49(3):1017–44.

    Article  PubMed  Google Scholar 

  23. Dyson JK, Anstee Q, Mcpherson S. Non-alcoholic fatty liver disease: a practical approach to treatment [review]. Frontline Gastroenterol. 2014;5(3):211-18.

  24. Ooi GJ, Burton PR, Doyle L, et al. Effects of bariatric surgery on liver function tests in patients with nonalcoholic fatty liver disease. Obes Surg. 2016;27(6):1533–42.

    Article  Google Scholar 

  25. Ooi GJ, Doyle L, Tie T, Wentworth JM, Laurie C, Earnest A, et al. Weight loss after laparoscopic adjustable gastric band and resolution of the metabolic syndrome and its components. Int J Obes. 2017;41(6):902-8.

  26. Bellentani S, et al. Epidemiology and natural history of non-alcoholic fatty liver disease (NAFLD). Ann Hepatol. 2009;8(Suppl 1):S4-8.

  27. Francque SMA, Verrijken A, Mertens I, et al. Noninvasive assessment of nonalcoholic fatty liver disease in obese or overweight patients. Clin Gastroenterol Hepatol. 2012;10(10):1162–8.

    Article  PubMed  Google Scholar 

  28. Lassailly G, Caiazzo R, Hollebecque A, et al. Validation of noninvasive biomarkers (FibroTest, SteatoTest, and NashTest) for prediction of liver injury in patients with morbid obesity. Eur J Gastroenterol Hepatol. 2011;23(6):499–506.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Centre for Obesity Research and Education, Central Clinical School, Monash University, Melbourne, Australia

    Geraldine J. Ooi, Paul R. Burton, Cheryl Laurie & Wendy A. Brown

  2. Department of General Surgery, The Alfred Hospital, Melbourne, Australia

    Geraldine J. Ooi, Paul R. Burton, Peter D. Nottle & Wendy A. Brown

  3. Centre for Obesity Research and Education, Monash University, Level 6, The Alfred Centre, 99 Commercial Road, Prahran, 3163, Australia

    Geraldine J. Ooi

  4. Department of Epidemiology, Monash University, Melbourne, Australia

    Arul Earnest

  5. Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia

    William W. Kemp & Stuart K. Roberts

  6. Department of Pathology, The Alfred Hospital, Melbourne, Australia

    Catriona A. McLean

Authors
  1. Geraldine J. Ooi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul R. Burton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Arul Earnest
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cheryl Laurie
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. William W. Kemp
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Peter D. Nottle
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Catriona A. McLean
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Stuart K. Roberts
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Wendy A. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All listed authors have contributed to and agree upon the content of the final manuscript. All authors contributed to study conception, design and data acquisition. GO, AE and CL performed data analyses. GO and WB drafted the initial version of the manuscript. All the authors critically revised and redrafted the manuscript, and all the authors approve the final version.

Corresponding author

Correspondence to Geraldine J. Ooi.

Ethics declarations

Conflict of Interest

GO, PB, CL and WB report being affiliated with the Centre for Obesity Research and Education. The centre has received funding for research purposes from Allergan and Apollo Endosurgery, the manufacturers of the LapBand™. The grant is not tied to any specific research project, and neither Allergan nor Apollo Endosurgery have control of the protocol, analysis and reporting of any studies. The centre also receives a grant from Applied Medical towards educational programs.

WB reports financial support for a bariatric surgery registry from the Commonwealth of Australia, Apollo Endosurgery, Covidien, Johnson and Johnson, Gore and Applied Medical; and a speaker’s honorarium from Merck Sharpe and Dohme. These are outside of the submitted work.

GO reports scholarships from the National Health and Medical Research Council and the Royal Australasian College of Surgeons.

AE, WK, CM, PN and SR have no other disclosures or conflicts of interest.

Electronic supplementary material

ESM 1

(DOCX 1416 kb).

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ooi, G.J., Burton, P.R., Earnest, A. et al. Visual Liver Score to Stratify Non-Alcoholic Steatohepatitis Risk and Determine Selective Intraoperative Liver Biopsy in Obesity. OBES SURG 28, 427–436 (2018). https://doi.org/10.1007/s11695-017-2859-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-017-2859-3

Keywords

Search

Navigation