European Journal of Cardiovascular Medicine

The liver is one of the most functionally diverse and metabolically active organs in the human body. It plays a central role in numerous physiological processes, including metabolism, detoxification, storage, synthesis of vital proteins, and immune surveillance. Given this complexity, the liver is susceptible to a broad spectrum of pathological conditions. These conditions may range from mild reversible changes such as fatty infiltration to severe irreversible damage like cirrhosis or hepatocellular carcinoma. [1,2]

While many hepatic disorders present with clinical symptoms, a significant number remain asymptomatic during life. These "silent liver diseases" are often masked by other more apparent systemic conditions or go undiagnosed due to a lack of overt symptoms. As a result, their detection frequently occurs only during postmortem examination, where a detailed and systematic analysis of the organ reveals underlying pathology.

Silent liver diseases, including steatosis, steatohepatitis, and early-stage cirrhosis, contribute significantly to the global burden of liver-related morbidity and mortality. Due to their asymptomatic nature, these conditions often remain undiagnosed until advanced stages or are detected incidentally during imaging, surgery, or postmortem examination. Non-alcoholic fatty liver disease (NAFLD), in particular, is now considered the most common liver disorder worldwide, with an estimated global prevalence of 25–30%. In India, studies suggest that the prevalence of NAFLD ranges from 9% to 32%, influenced by factors such as urbanization, dietary habits, metabolic syndrome, and sedentary lifestyles. The high occurrence of incidental liver lesions in young adults, as seen in this study, highlights an underrecognized public health issue and calls for enhanced awareness, early screening, and preventive strategies to reduce long-term complications and healthcare costs. [3,4,5]

The liver is particularly vulnerable to metabolic, toxic, infectious, and hemodynamic insults. These may be primary, originating within the liver itself, or secondary, due to systemic diseases such as congestive cardiac failure, chronic alcoholism, metabolic syndromes, or extrahepatic infections like tuberculosis or sepsis. In forensic and medicolegal autopsy cases, incidental findings in the liver can often uncover previously unrecognized health conditions and offer explanations for unexpected death.

One of the most common pathological findings in both liver biopsies and postmortem specimens is fatty change (steatosis). This may be associated with metabolic disorders, alcohol abuse, or drug toxicity.

The accumulation of lipids within hepatocytes can present in macrovesicular or microvesicular patterns, often without overt liver dysfunction during life. In some cases, it may progress to steatohepatitis, an inflammatory condition that may further advance to fibrosis or cirrhosis.

Other abnormal histopathological findings commonly encountered in autopsy livers include chronic venous congestion (typically due to right-sided heart failure), glycogen storage diseases, hepatitis, cirrhosis, amyloidosis, hydatid cysts, abscesses, granulomatous diseases such as tuberculosis or syphilis, hemochromatosis, and primary or metastatic malignancies. Each of these lesions reflects an underlying systemic or intrinsic hepatic disease process, and their identification is critical in understanding the pathology leading to or contributing to death.

Histopathological evaluation serves as a cornerstone in the diagnosis of liver diseases, particularly in forensic pathology and autopsy settings. The standard approach begins with the examination of tissue sections stained with hematoxylin and eosin (H&E) to assess cellular architecture, inflammation, necrosis, fibrosis, and other morphological changes. Depending on the findings, special stains—such as Masson’s trichrome for fibrosis, PAS (Periodic Acid-Schiff) for glycogen, reticulin for hepatic architecture, and Prussian blue for iron deposits—may be employed for further characterization. (5,6)

Overall, the postmortem histopathological examination of liver specimens not only enhances our understanding of silent hepatic pathologies but also provides valuable epidemiological data, helps in quality assurance in clinical diagnostics, and supports public health interventions aimed at preventing liver-related morbidity and mortality.

AIMS AND OBJECTIVES

• To study various incidental pathological lesions of the liver in postmortem cases.
• To correlate liver diseases with age, sex, and histopathological findings.

Study Design:
Retrospective observational study

Study Period:
January 2022 to February 2025

Study Location:
Department of Pathology

Sample Size:
50 postmortem liver specimens

Data Source:
Postmortem liver specimens submitted to the Department of Pathology, with clinical and demographic details obtained from departmental registers.

Specimen Processing:
All specimens were fixed in 10% buffered formalin, processed using standard paraffin embedding techniques, and stained with H&E.

METHODOLOGY

Inclusion Criteria:
Postmortem cases from deaths due to suspicious circumstances, assaults, accidents, burns, drowning, or poisoning. Liver specimens were taken either as isolated organs or as part of multiple viscera.

Exclusion Criteria:
Specimens showing moderate to marked autolytic changes due to delayed transport were excluded.

Out of the 50 liver specimens studied:

• 37 (74%) showed pathological lesions.
• 13 (26%) showed normal histology.

Age and Gender Distribution:

• Most cases were in the third decade (21–30 years).
• Males (70%) were more commonly affected than females (30%), with a male-to-female ratio of 2.4:1.

Table 1: Histopathological Findings (n=50):

Table 2 : Age and sex wise distribution of  the cases

Table 3 : Sex wise distribution of all the cases

STEATOSIS

Figure 3 : (A) Swollen soft liver with yellowish brown colour(Fatty change) (B) Macrovesicular Change (Fatty change)(H & E 400x ) (C) Macrovesicular n Microvesicular Change (H & E 400x )

Figure 4 : (A) Cut surface shows appearance due to sinusoidal dilatation and congestion (nutmeg liver) (B) Marked sinusoidal dilatation and congestion (H & E ,400x)

Figure 5 : (A)External surface- various sized small nodules (Cirrhotic nodules) (B) variable hepatic nodule separated by thick fibrous septae (cirrhotic nodules) (H & E ,100x )  (C) Fibrous septa appears blue ,Masson’s Trichrome stain (H & E ,400x )

Figure 6:  Chronic hepatitis - marked portal chronic inflammation(lymphocytes) along with interface activity that extend around portal tract(H & E 400x ).

Histopathological examination continues to serve as the gold standard for the diagnosis and classification of liver diseases, offering definitive insights into the type, stage, and extent of hepatic injury. This is particularly important in cases of silent liver diseases, which may progress without clinical symptoms and are only revealed during postmortem examinations. The present study underlines the significance of incidental liver findings, many of which could have long-term clinical implications if detected during life.

In this study, 74% of postmortem liver specimens exhibited pathological changes, with steatosis (28%) emerging as the most frequently observed lesion. This observation is consistent with global epidemiological trends, as non-alcoholic fatty liver disease (NAFLD) has become one of the leading causes of chronic liver disease. When compared to previous studies, our prevalence rate of steatosis is higher than that reported by Behera et al. (1) at 21% and Simon KA et al. (3) at 11.1%, indicating potential regional or demographic variations. This may reflect changing lifestyles, dietary patterns, and a rising burden of metabolic syndrome, particularly among younger populations in developing countries.

The present study also demonstrates a male predominance (70%), aligning with similar findings from Singal et al. (4) who reported 82.8%, and Behera et al. (1) with 82%. This gender disparity may be due to higher exposure to risk factors such as alcohol consumption, occupational toxins, or undiagnosed metabolic conditions among males, especially in rural and semi-urban regions. Furthermore, males may be more frequently involved in forensic autopsy cases, including those related to road traffic accidents, assaults, or unnatural deaths, contributing to the observed male predominance.

Steatohepatitis (16%) and chronic venous congestion (14%) were the next most common findings. Steatohepatitis represents a progressive form of NAFLD, which, if left unchecked, can lead to cirrhosis or hepatocellular carcinoma. These findings are clinically significant, as many of these cases were found in younger individuals, particularly in the 21–30 year age group, echoing concerns from studies like Umesh BR et al. (6) and Devi PM et al. (13), who emphasized the rising burden of liver pathology in young, asymptomatic adults. Chronic venous congestion, often associated with right-sided heart failure, also reinforces the need for integrated systemic evaluation in such patients.

Interestingly, cirrhosis and hepatitis were seen in 8% of cases each. While cirrhosis typically results from long-standing liver injury, the presence of early-stage cirrhotic nodules in asymptomatic individuals indicates missed opportunities for diagnosis and intervention. The interface hepatitis observed microscopically in chronic hepatitis cases could suggest viral or autoimmune etiology, though further ancillary testing (e.g., serological markers) is necessary for confirmation—highlighting a limitation of retrospective postmortem-only studies.

The findings from this study align with the work of Sotoudehmanesh et al. (9), who analyzed autopsy reports from Tehran and found that a substantial number of hepatic lesions went undetected during life. Likewise, the classic text by Saphir (10) and the comprehensive references in Robbins & Cotran (7) emphasize that autopsy continues to reveal hidden burdens of disease, especially in systems like the liver, which has significant functional reserve and may remain clinically silent until terminal stages.

Taken together, these results suggest a need for greater clinical vigilance, particularly in screening young adults for metabolic and hepatic abnormalities. Public health initiatives focusing on early detection of fatty liver disease through imaging and liver function tests, especially in high-risk groups, could reduce long-term complications. Additionally, the routine histopathological analysis of autopsy tissues remains invaluable for epidemiological surveillance and healthcare planning.

Table: Comparative Histopathological Findings in Postmortem Liver Studies

Several other studies further support the high prevalence and diversity of hepatic lesions observed in postmortem specimens. In a study by Bal et al. (14), histopathological examination of autopsy livers revealed steatosis and cirrhosis as predominant findings, aligning with the results of our present study. Devi SV et al. (15), in a retrospective study, emphasized the diagnostic value of autopsy in identifying clinically undetected liver diseases, particularly fatty changes and congestion, in otherwise healthy-appearing individuals. Chawla et al. (16) observed a notable frequency of steatosis in their autopsy series and highlighted the increasing trend of fatty liver changes among younger adults, likely reflecting evolving dietary and lifestyle habits. Similarly, Khetan et al. (17) focused on medico-legal autopsies and demonstrated that a significant proportion of liver abnormalities, including early-stage cirrhosis and steatohepatitis, were not suspected during life. A large-scale autopsy review by Mahadevan et al. (18) of over 1000 cases underscored the silent yet widespread nature of liver pathologies such as fibrosis, chronic hepatitis, and fatty liver changes, many of which were found in individuals with no documented liver disease. These findings collectively reinforce the importance of routine histopathological assessment in postmortem studies and support the epidemiological relevance of our observations.

The present study highlights the high prevalence of incidental pathological liver lesions in postmortem specimens, with steatosis emerging as the most common silent liver disease, followed by steatohepatitis, chronic venous congestion, hepatitis, and cirrhosis. These lesions were predominantly observed in young adult males, emphasizing the silent progression of liver diseases in the apparently healthy population.

The results underscore the critical role of histopathological examination in uncovering subclinical hepatic pathology that often goes undiagnosed during life. The male predominance and early age distribution further indicate the need for heightened clinical vigilance, public awareness, and early screening programs, especially targeting younger individuals at risk of metabolic syndrome or with a history of alcohol use and sedentary lifestyle.

Given the wide spectrum of findings and their potential to contribute to morbidity and mortality, routine liver evaluation in postmortem examinations should be emphasized. Moreover, data derived from such autopsy-based studies hold significant epidemiological value and can aid in public health planning, early intervention strategies, and ultimately reducing the burden of chronic liver disease in the general population.

1. Behera A, Sahu A, Nayak SK, Agrawal KC. Liver autopsy study - incidental pathological findings. Pathology Update: Trop J Path Micro. 2017;3(4):390–5.
2. Puri A, Garg P, Tayal I, Singh N. Analysis of various hepatic pathologies in autopsy cases: a retrospective study. J Adv Med Dent Sci Res. 2017;5(4):103.
3. Simon KA, Dantkale S, Shinde S. Comparative study of pathological lesions of liver in autopsy cases. Int J Res Med Sci. 2020;8:412–6.
4. Singal P, Kaur M, Deepika. Incidental Findings in Autopsy Examination of Liver: A Study of 70 cases. Ann Int Med Den Res. 2017;3(3):30–2.
5. Singh D, Tiwari RC, Kumar A, et al. A comprehensive review of pathological examination in forensic medicine: past, present, and future. Cureus. 2022;14:e22740.
6. Umesh BR, Gayathri BN, Harendra Kumar ML. Spectrum of liver pathology at autopsy. Int J Res Rev. 2015;2(3):79–86.
7. Robbins and Cotran. Pathologic Basis of Disease, Vol.2, South Asia Ed. New Delhi: Elsevier India; 2014:837–841.
8. Desmet V, Rosai J. Rosai and Ackerman’s Surgical Pathology, Vol.1. St. Louis, USA: Elsevier Mosby; 2004:925–940.
9. Sotoudehmanesh R, Sotoudeh M, Ali-Asgari A, Abedi-Ardakani B, Tavangar SM, Khakinejad A, Sadeghi Z, Malekzadeh R. Silent liver diseases in autopsies from forensic medicine of Tehran. Arch Iran Med. 2006;9(4):324–8.
10. Saphir O. Autopsy Diagnosis and Techniques. 4th ed. New York: Paul B. Hoeber Inc; 1958:354–65.
11. Isak K, Markin R. Liver. In: Anderson’s Pathology; 1990; Vol.2:1787.
12. Bal MS, Singh SP, Bodal VK, et al. Pathological findings in liver autopsy. J Indian Acad Forensic Med. 2004;26(2):55–57.
13. Devi PhM, Myrthong BG, Meera Th, Nabachandra H. Pathological findings of liver in autopsy cases: a study at Imphal. J d. 2013;35:206.

14. Bal MS,Indian Acad Forensic Me Bodal VK, Oberoi SS, Gill KS, Bhatia A. Histopathological findings in liver autopsy. J Indian Acad Forensic Med. 2004;26(2):55–57.
15. Devi SV, Kanchan T, Shetty M, Menezes RG, Nagesh KR. Histopathological findings in autopsy liver – a one-year retrospective study. Egypt J Forensic Sci. 2011;1(1):14–17.
16. Chawla U, Sharma P, Kudesia M, Agarwal S. Histopathological findings in liver autopsy with special reference to steatosis. Sch J App Med Sci. 2015;3(1F):382–386.
17. Khetan D, Khetan R, Gupta A. Autopsy-based study of unsuspected liver diseases in medico-legal deaths. J Forensic Med Toxicol. 2012;29(1):21–26.
18. Mahadevan A, Kasturi K, Yasha TC, Shankar SK. Pathology of liver in autopsies: a retrospective study of 1000 cases. Indian J Pathol Microbiol. 2005;48(2):167–171.