Differential Diagnosis for Steatosis vs Steatohepatitis

To differentiate steatosis from steatohepatitis, it's crucial to understand the clinical, laboratory, and histological features of each condition. Here's a differential diagnosis categorized for clarity:

• Single Most Likely Diagnosis

  • Non-Alcoholic Fatty Liver Disease (NAFLD): This is the most common cause of both steatosis and steatohepatitis. The differentiation between simple steatosis (NAFLD) and non-alcoholic steatohepatitis (NASH) often requires liver biopsy, as clinical and laboratory findings can overlap. NASH is characterized by inflammation and fibrosis in addition to steatosis.

• Other Likely Diagnoses

  • Alcoholic Liver Disease (ALD): Both steatosis and steatohepatitis can be seen in ALD. The history of alcohol use is crucial for differentiation, though some patients with NAFLD may also consume alcohol.
  • Drug-Induced Liver Injury: Certain medications can cause both steatosis and steatohepatitis. A thorough medication history is essential for diagnosis.
  • Wilson's Disease: Though less common, Wilson's disease can present with steatosis and steatohepatitis, along with other characteristic features like neuropsychiatric symptoms and Kayser-Fleischer rings.

• Do Not Miss Diagnoses

  • Alpha-1 Antitrypsin Deficiency: This genetic disorder can lead to liver disease, including steatosis and steatohepatitis, and is critical to diagnose due to its implications for lung disease and family screening.
  • Hemochromatosis: While primarily known for causing iron overload, hemochromatosis can also lead to steatosis and steatohepatitis. Early diagnosis is crucial to prevent long-term complications like cirrhosis and hepatocellular carcinoma.

• Rare Diagnoses

  • Abetalipoproteinemia: A rare genetic disorder characterized by the inability to fully assemble and secrete lipoproteins, leading to steatosis.
  • Lipodystrophy: Characterized by abnormal fat distribution, lipodystrophy can lead to steatosis in the liver due to the lack of adipose tissue to store fat.
  • Glycogen Storage Diseases: Certain types can lead to steatosis due to the accumulation of glycogen and fat in hepatocytes.

Each of these diagnoses has distinct features that can help in differentiation, but liver biopsy often remains the gold standard for distinguishing between steatosis and steatohepatitis, especially in cases where the diagnosis is unclear after clinical and laboratory evaluation.