Pathology: ballooning degeneration

Ballooning degeneration is seen in this H&E stained liver biopsy- look closely for enlarged hepatocytes with a central nucleus, surrounded by fluffy white cytoplasm.  These are sick hepatocytes undergoing apoptosis, and the process of ballooning is irreversible. 

It is most commonly seen in NASH (and makes up part of the NAS grading system of severity) but can also be seen in alcoholic liver disease.  Sometimes ballooning can be confused with macrovesicular steatosis, though the later is associated with an eccentric (peripheral) nucleus.  The top left corner of this biopsy specimen shows an example of macrovesicular steatosis, though the nucleus cannot be seen. 

Vitamin E (400 IU/d) has been shown to decrease the degree of ballooning degeneration when used in NASH.

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