Development of a Scoring System to Differentiate Amiodarone-Induced Liver Injury From Alcoholic Steatohepatitis

Am J Clin Pathol. 2022 Mar 3;157(3):434-442. doi: 10.1093/ajcp/aqab142.


Objectives: Amiodarone-induced liver injury (AILI) is histopathologically similar to alcoholic steatohepatitis (ASH). We sought to elucidate their histologic differences and develop a scoring system to differentiate these two entities.

Methods: A cohort of 17 AILI and 17 ASH cases was included in the initial study. Cases from three different institutions were included for further validation.

Results: Macrovesicular steatosis was usually below 10% of the liver parenchyma in AILI. Hepatocyte ballooning degeneration was more common in ASH than in AILI. "Balloon-like" hepatocyte was more common in AILI than in ASH. Lobular neutrophilic inflammation, satellitosis, and cholestasis were more common in ASH. Mallory-Denk bodies and pericellular fibrosis in AILI were mainly located in zone 1 compared with a panacinar or zone 3 distribution in ASH. A scoring system was developed in which points were assigned to different histologic features; a total sum of less than 5 suggests AILI, more than 5 is ASH, and 5 is equivocal. This scoring system was then evaluated on a test cohort comprising 14 AILI cases, in which 13 cases were correctly assigned with a score less than 5. The sensitivity, specificity, and accuracy for diagnosing AILI in the test cohort were 92.9%, 91.7%, and 92.3%, respectively.

Conclusions: This scoring system can aid pathologists to differentiate AILI from ASH.

Keywords: Alcoholic steatohepatitis; Amiodarone; Drug-induced liver injury.

MeSH terms

  • Amiodarone* / adverse effects
  • Chemical and Drug Induced Liver Injury, Chronic* / pathology
  • Fatty Liver* / chemically induced
  • Fatty Liver* / diagnosis
  • Fatty Liver* / pathology
  • Fatty Liver, Alcoholic* / diagnosis
  • Fatty Liver, Alcoholic* / pathology
  • Humans
  • Liver / pathology


  • Amiodarone