Pediatric nonalcoholic fatty liver disease: overview with emphasis on histology

Nonalcoholic fatty liver disease (NAFLD) is a disease in which excessive fat accumulates in the liver of a patient without a history of alcohol abuse. This disease includes simple steatosis and nonalcoholic steatohepatitis (NASH). NAFLD/NASH is recognized as a hepatic manifestation of metabolic syndrome. In recent years, pediatric NAFLD has increased in line with the increased prevalence of pediatric obesity. The estimated prevalence of pediatric NAFLD is 2.6%-9.6%, and it is associated with sex, age, and ethnicity. With regard to the pathogenesis of NAFLD, the "two-hit" hypothesis is widely accepted and oxidative stress is thought to play an important role in the second hit. Although clinical symptoms, laboratory data, and imaging findings are important, liver biopsy is regarded as the gold standard for the diagnosis of NAFLD/NASH. In addition, liver biopsy is essential for assessing the degree of necro-inflammatory change and fibrosis in NASH. Two different types of steatohepatitis (type 1 and type 2 NASH) have been reported, with type 2 NASH being present in as many as 51% of pediatric NAFLD patients. However, we and others have observed that type 1 and 2 patterns commonly overlap. Although pharmacotherapy has been studied in clinical trials, lifestyle modification by diet and exercise remains the mainstay of treatment for NAFLD/NASH.