The liver is the largest organ in the human body. It performs numerous and vital functions including metabolism of nutrients, detoxification of xenobiotics, synthesis of plasma proteins, storage of vitamins and minerals, and immunological surveillance. Its complex vasculature and metabolic roles make it highly susceptible to a spectrum of pathological insults including metabolic derangements, toxins, infectious agents and circulatory disturbances.^1,2 Many hepatic pathologies, however, remain clinically silent until advanced stages, especially in medico-legal autopsy settings, making systematic post-mortem evaluation crucial for understanding the full burden of liver disease in the community.

Autopsy studies provide unique insights into undiagnosed or sub-clinical hepatic diseases, which may otherwise remain unreported in clinical practice and contribute to unexpected morbidity or mortality.³ In the Indian context, the shifting epidemiologic milieu characterised by rising prevalence of alcohol consumption, non-alcoholic fatty liver disease (NAFLD), obesity, diabetes and metabolic syndrome, as well as lifestyle transitions and urbanisation have resulted in a rising liver disease burden.^4,5

In medico-legal autopsies, histopathological examination of the liver not only assists in determining cause and manner of death, but also uncovers hidden liver pathology that has public health relevance. Prior Indian autopsy studies have demonstrated high proportions of hepatic lesions such as steatosis, congestion, hepatitis and cirrhosis in unsuspected cases.^6,7 Therefore, this retrospective study aims to analyse the histopathological spectrum of liver lesions identified in medico-legal autopsies over two years in a tertiary care centre, and to assess their distribution by age, sex, manner of death and underlying risk factors such as alcohol history. Most Indian autopsy studies evaluating liver histopathology were conducted more than a decade ago and predate the recent epidemiological rise in metabolic syndrome, obesity and non-alcoholic fatty liver disease (NAFLD). Our study provides contemporary post-2020 data from a tertiary care centre and additionally evaluates the association of hepatic lesions with demographic and medico-legal parameters. Such data are limited in current Indian literature.

This retrospective observational analytical study was conducted in the Department of Pathology of a tertiary care centre during January 2024 and December 2025. The aim of the Study was to evaluate the histopathological spectrum of liver lesions in medico-legal autopsy cases and to analyse their distribution with respect to age, sex, manner of death, and alcohol consumption. Inclusion Criteria • All medico-legal autopsy cases performed during the period having adequate liver tissue for histopathological examination. • Cases with available demographic and autopsy records. • Both male and female cases of all age groups. Exclusion Criteria • Severely autolysed or decomposed liver specimens unsuitable for histopathological evaluation. • Inadequate tissue samples. • Cases with incomplete autopsy records. Specimen Collection and Processing • Liver tissue was obtained as part of routine viscera sampling during medico-legal autopsy. • Gross examination included assessment of weight, colour, consistency, and external appearance. • Representative sections were fixed in 10% neutral buffered formalin. • Routine paraffin processing was performed. • Sections of 3-5 μm thickness were prepared. Histopathological Examination • Sections were stained with Haematoxylin and Eosin (H&E). • Microscopic examination was performed to identify pathological lesions. • Cirrhosis and fibrosis were diagnosed using established histomorphological criteria on H&E sections. • Special stains such as Reticulin and Masson’s Trichrome were not performed because of the retrospective study design and reliance on routinely processed autopsy specimens. Data Collection The following variables were collected from autopsy records: • Age • Sex • Manner of death • History of alcohol consumption (where available) • Histopathological findings of liver tissue Statistical Analysis • Data were entered and analysed using SPSS version 26.0. • Categorical variables were expressed as frequencies and percentages. • Associations between categorical variables were assessed using Chi-square test. • A p-value <0.05 was considered statistically significant.

During the study period, 652 medico-legal autopsies were examined. Normal liver histology was observed in 212 cases (32.5%), while 25 cases (3.8%) were autolysed and excluded from further histopathological evaluation. Pathological hepatic lesions were identified in 415 cases (63.7%), which constituted the study cohort.

The histopathological spectrum of liver lesions is presented in Table 1 and Figure 1. Steatosis was the most common lesion, observed in 168 cases (40.5%), followed by hepatic congestion in 117 cases (28.2%) and hepatitis in 75 cases (18.1%). Cirrhosis was identified in 42 cases (10.1%). Granulomatous hepatitis and miscellaneous lesions were observed in 5 cases each (1.2%), while Hepatic neoplasms were noted in 3 cases (0.7%) of which primary malignancy was seen only as one case of hepatocellular carcinoma and remaining two cases of metastatic deposit from prostate carcinoma. Miscellaneous lesions included liver abscess (n = 3) and simple cysts (n = 2). Percentages were calculated with respect to total pathological cases (n = 415). (Table 1).

The age-wise distribution of cases with liver pathology is summarised in Table 2. The highest number of cases was seen in the 41–50 years age group (110 cases; 26.5%), followed by 31–40 years (92 cases; 22.2%) and 51–60 years (83 cases; 20.0%). Cases in the 0–20 years and 21–30 years age groups accounted for 55 (13.3%) and 47 (11.3%) cases respectively. The lowest frequency was observed in individuals aged 71–80 years (6 cases; 1.4%) (Table 2).  No statistically significant association was observed between age group and sex distribution (χ² = 0.78, df = 6, p = 0.99).

Among cases with pathological liver findings, males predominated (236 cases) compared to females (179 cases).

The manner of death among cases with hepatic lesions is detailed in Table 3. Road traffic accidents were the most common cause of death (122 cases; 29.4%), followed by sudden natural deaths (119 cases; 28.7%). Other causes included poisoning (58 cases; 14.0%), drowning (41 cases; 9.9%), hanging (20 cases; 4.8%), electrocution (15 cases; 3.6%), and burns (15 cases; 3.6%). The manner of death could not be ascertained in 25 cases (6%).

A documented history of alcohol consumption was available in 46 % of cases with major hepatic lesions. Associations between alcohol history and major hepatic lesions were analysed using Chi-square test. A p-value <0.05 was considered statistically significant. (Table 4)

Figure 1: Clustered bar diagram showing sex-wise distribution of histopathological liver lesions.

Figure 2: Cirrhosis of Liver: Gross photograph showing nodular surface and distorted hepatic architecture.

Figure 3: Hepatic steatosis: Photomicrograph showing macro and microvesicular fat accumulation in hepatocytes. [H&E:40X]

Figure 4: Passive venous congestion of Liver: Photomicrograph showing dilated, congested central veins and sinusoids. [H&E:40X]

Figure 5: Cirrhosis of Liver: Photomicrograph showing regenerative nodules separated by fibrous septa. [H&E:40X]

Figure 6: Hepatocellular carcinoma: Photomicrograph showing malignant hepatocytes arranged in trabecular patterns. [H&E:40X]

Figure 7: Metastatic Prostatic adenocarcinoma: Photomicrograph showing malignant glandular formations infiltrating the hepatic parenchyma. [H&E:40X]

Table 1: Sex-wise distribution of histopathological liver lesions

Table 2: Distribution of pathological cases according to age and sex

^*Chi-square test was applied to assess association between age group and sex (χ² = 0.78, df =6, p = 0.99).  Mean ± SD = 39.8 ± 16.0 years

Table 3: Distribution of pathological cases according to the manner of death

Table 4: Association between alcohol consumption and major hepatic lesions

^*A statistically significant association was observed between alcohol consumption and hepatic steatosis (p <0.001) as well as cirrhosis (p =0.001). No significant association was observed with hepatitis or passive venous congestion.

Our autopsy-based histopathological study provides valuable insight into the spectrum of hepatic lesions in medico-legal autopsies. Out of 652 autopsies examined during the study period, pathological liver lesions were identified in 415 cases (63.7%), while 32.5% showed normal liver histology and 3.8% were autolysed and excluded from further evaluation. The high proportion of pathological findings highlights the silent nature of many liver diseases that remain undiagnosed during life and are detected incidentally at autopsy.

Simon et al (2020) reported hepatic pathology in 25% of autopsy cases, while Selvi et al observed pathological changes in approximately 32–40% of cases.8,9 The higher prevalence observed in our study may reflect regional differences in lifestyle patterns, increasing alcohol consumption, metabolic disorders, and the rising burden of non-alcoholic fatty liver disease (NAFLD) in India.

Age Distribution

The highest frequency of hepatic lesions was observed in the 41–50 years age group, consistent with findings by Bal et al and Singal et al.10,12 In contrast, Simon et al reported higher incidence in younger individuals.8 The predominance in middle age likely reflects cumulative exposure to alcohol, metabolic disorders and environmental risk factors.

Sex Distribution

Our study demonstrated male predominance which is consistent with most autopsy studies. Simon et al reported a male-to-female ratio of 1.5:1, while Bhagat et al. documented a ratio of approximately 3:2.8,13 Male predominance may be explained by greater exposure to risk factors such as alcohol consumption, occupational hazards, and lifestyle-related diseases.

Steatosis (Fatty Liver)

Steatosis was the most common histopathological lesion (40.5%), accounting for 168 cases (Figure 3). This finding is consistent with the growing global prevalence of fatty liver disease. Hepatic steatosis is often considered one of the earliest morphological indicators of liver injury and may occur due to alcohol consumption, obesity, diabetes mellitus, metabolic syndrome, malnutrition, or drug toxicity.

Comparable findings have been reported in several autopsy studies. Bal et al observed steatosis in 39% of cases, Selvi et al reported 39.5%, while Singal et al documented 34% fatty liver in their series.9,10,12 Internationally, autopsy studies from Europe and the United States have reported steatosis in 20–40% of adults, particularly in populations with high prevalence of obesity and metabolic syndrome.

Our study documented history of alcohol consumption in 46% of cases, which strongly correlates with fatty liver and cirrhosis (Table 4). In recent years, non-alcoholic fatty liver disease (NAFLD) has emerged as a major contributor to steatosis worldwide. Epidemiological studies suggest that NAFLD prevalence in India ranges between 9% and 32%, particularly in urban populations with sedentary lifestyles and metabolic disorders. The presence of fatty liver in a substantial proportion of autopsy cases in our study reflects this evolving epidemiological trend.

Passive venous Congestion

The second most common finding in our study was Passive venous congestion (28.2%), accounting for 117 cases (Figure 4). Passive venous congestion of the liver is frequently encountered in autopsy examinations and is usually associated with terminal circulatory disturbances, cardiac failure, or traumatic death.

Previous studies have reported variable incidence of Passive venous congestion. Bal et al documented congestion in 9% of cases, while Selvi et al observed 15.6%.9,10 The relatively higher frequency of congestion in the present study may be explained by the predominance of road traffic accidents (29.4%) and sudden natural deaths (28.7%), which together accounted for more than half of the cases. Acute circulatory failure and hypoxia in such cases often lead to hepatic venous congestion.

Furthermore, congestion may also represent a terminal event in many deaths rather than a primary pathological process. Therefore, its presence should be interpreted in the context of the manner and mechanism of death.

Hepatitis

Inflammatory liver disease was observed in 18.1% of cases accounting for 75 cases which included both acute and chronic hepatitis. This incidence is higher than that reported by Simon et al. who documented hepatitis in 3.5% of cases while findings are comparable with other studies like Singal et al, Selvi et al, Umesh Babu et al and Madhubala Devi et al documented inflammatory hepatic changes in 9%,13.9%,20.9% and 22% of cases respectively. 9,11,12,14.

Hepatitis detected in autopsy studies may represent viral hepatitis, drug-induced liver injury, alcohol-related inflammation, or autoimmune processes. In many instances, the absence of clinical history makes etiological categorisation difficult. However, histological features such as portal inflammatory infiltrates, hepatocellular necrosis, and lobular inflammation can provide valuable clues.

India continues to have a significant burden of viral hepatitis, particularly hepatitis B and hepatitis C infections. According to national epidemiological estimates, hepatitis B prevalence ranges between 2% and 7%, while hepatitis C prevalence is approximately 1%. These infections contribute substantially to chronic liver disease and may explain the inflammatory changes observed in autopsy specimens.

Cirrhosis

Cirrhosis was identified in 42 cases (10.1%) in our study. Cirrhosis represents the end stage of chronic hepatic injury characterised by fibrosis and regenerative nodules leading to architectural distortion of the liver (Figure 2 and Figure 5).

The frequency of cirrhosis observed in our study is comparable to several previous autopsy studies. Bal et al reported cirrhosis in 14% of cases while Madhubala Devi et al documented cirrhosis in 25% of cases.10,14 However, Umesh Babu et al reported a lower incidence of 1.9% and Selvi et al observed 2.8% of cases.9,11

The incidence in our study lies within this wide reported range. Alcohol consumption remains the most important etiological factor in cirrhosis in many developing countries. The 46% prevalence of alcohol consumption among the cases in our study suggests that alcohol-related liver disease likely contributed significantly to cirrhosis development (Table 4). International studies have similarly identified alcohol as a major risk factor for cirrhosis, although metabolic syndrome and viral hepatitis are increasingly important causes globally.

Granulomatous Hepatitis

Granulomatous hepatitis was observed in 1.2% of cases in the present study. This finding is consistent with Devi et al having 2% incidence.15

In India, tuberculosis remains an important cause of hepatic granulomas. In our study, granulomatous lesions were associated with disseminated tuberculosis in the affected individuals. The liver is a common site for granuloma formation due to its rich vascular supply and reticuloendothelial activity.

Hepatic neoplasms 

Hepatic neoplasms were relatively uncommon accounting to 0.7% of cases. Only one case represented primary hepatocellular carcinoma (Figure 6), while two cases were metastatic deposits from prostate carcinoma (Figure 7). Similar findings have been reported by Simon et al having Hepatic neoplasms in 1% of cases while Bal et al reported higher incidence of 3% cases.8,10

The relatively low frequency of hepatic neoplasms in medico-legal autopsies may be due to the fact that many patients with advanced malignancy die in hospital settings and undergo clinical autopsy rather than medico-legal autopsy.

Manner of Death

In our study, road traffic accidents (29.4%) were the most common manner of death among cases with hepatic pathology, followed closely by sudden natural deaths (28.7%) (Table 3). Similar patterns have been observed in medico-legal autopsy studies where accidental deaths constitute a large proportion of cases.

Interestingly, many individuals who died due to trauma or accidental causes were found to have underlying liver pathology, highlighting the importance of autopsy examination in detecting silent disease.

Public Health Implications

The findings our study highlight the significant burden of undiagnosed liver disease in the population. The high prevalence of steatosis and cirrhosis suggests an increasing impact of alcohol consumption and metabolic disorders. These findings underscore the need for targeted public health interventions addressing the conditions.

Limitations of the Study

This study was limited by its retrospective design and dependence on available autopsy records. Detailed clinical, biochemical, virological and radiological data were unavailable for comprehensive clinicopathological correlation. Special histochemical stains were not performed uniformly, and severely autolysed specimens were excluded, which may have introduced selection bias. Nevertheless, the study provides valuable contemporary data on the spectrum of unsuspected hepatic lesions in medico-legal autopsies.

Our study demonstrated a high prevalence of unsuspected hepatic pathology in medico-legal autopsies, with hepatic steatosis being the predominant lesion. The findings reflect the growing burden of alcohol-related and metabolic liver disease in the community and emphasise the continuing epidemiological value of autopsy-based histopathological evaluation.

.    Crawford JM, Liu C. Liver and biliary tract. In: Kumar V, Abbas AK, Aster JC, editors. Robbins and Cotran Pathologic Basis of Disease. 10th ed. Philadelphia: Elsevier; 2021. p. 821–895.

2. Schiff ER, Maddrey WC, Sorrell MF. Schiff’s Diseases of the Liver. 12th ed. Chichester (UK): Wiley-Blackwell; 2017. p. 1–25.
3. Choudhury S, Laishram RS, Potom S. Histopathological patterns of liver diseases in medical autopsies. J Evid Based Med Healthc. 2017;4(31):1820-1823.
4. Singh D, Tiwari RC, Kumar A, et al. The role of pathological examination of the liver in a medicolegal autopsy. J Forensic Leg Med. 2023;89:102403.
5. Yami H, Cicy PJ, Anu R, Nobin H, Renju R, Sankar S. Steatosis and other pathological changes in liver: an autopsy study. Int J Pharm Clin Res. 2024;16(3):181-186.
6. Porwal V, Jain D, Khandelwal S, Garg S, Rathi A. Spectrum of liver pathology in autopsy cases: A study at Ajmer. Ann Pathol Lab Med. 2018;5(5):A393-398.
7. Kaushal N, Mehra A, Devgan S. Histopathological spectrum of findings in liver in autopsy cases: a case study in tertiary centre. Indian J Forensic Med Toxicol. 2023;17(4):102-107.
8. Simon KA, Dantkale S, Shinde S. Comparative study of pathological lesions of liver in autopsy cases. Int J Res Med Sci. 2020;8:412-416.
9. Selvi RT, Selvam V, Subramaniam PM. Silent liver disease in and around of Salem population: an autopsy study. J Clin Diagnos Res. 2012;6(2):207-10.
10. Bal MS, Singh SP, Bodal VK, Oberoi SS, Surinder K. Pathological findings in liver autopsy. J Indian Acad Forensic Med. 2004;26(2):971-3.
11. Umesh Babu HR, Gayathri BN, Harendra Kumar ML. Spectrum of liver pathology at autopsy. Int J Res Rev. 2015;2(3):79-83.
12. Singal P, Kaur M, Deepika. Incidental findings in Autopsy Examination of Liver: A Study of 70 cases. Ann Int Med Dent Res. 2017;3:30-32.
13. Bhagat R, Singh S, Kumar V. Histopathological spectrum of liver diseases in autopsy cases. J Med Sci Clin Res. 2019;7:123-129.
14. Madhubala Devi P. Histopathological study of liver lesions in autopsy cases. Indian J Pathol. 2013;35:215-220.
15. Devi PM, Myrthong BG, Meera TH. Pathological findings of liver in autopsy cases; A study at Imphal. J Indian Acad Forensic Med. 2013;35(3):0971-3.