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40). In microvesicular fatty liver, small droplets collect in the endoplasmic reticulum and in secondary lysosomes that do not fuse. Hepatocytes exhibit a foamy cytoplasm and a central nucleus. With hepatotoxins primarily affecting protein synthesis or with protein malnutrition, the lipid tends to collect in zone 1 (periportal). Microvesicular fat tends to collect in zone 3 (central). Symptoms, Signs, and Diagnosis Macrovesicular fatty liver most often is discovered on physical examination as nontender, smooth, diffuse hepatomegaly in an alcoholic, obese, or diabetic patient. It can present with right upper quadrant pain, tenderness, and jaundice, or it may be the only physical abnormality found after a sudden, unexpected, and presumably metabolic death. There is a poor association between fatty liver and abnormal findings on the commonly used biochemical tests for liver disease.
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