Fatty change is a common morphologic feature seen in a wide variety of liver diseases, the most common of which in North America are alcohol-related liver diseases and non-alcoholic steatosis and steatohepatitis. Most patients are clinically asymptomatic in early-stage disease with the diagnosis made incidentally on routine workup or on noting a fatty liver on ultrasound. The majority of the patients are obese with about half clinically diabetic, and about two-thirds have other features of the metabolic syndrome including hypertension and dyslipidemia. The clinical presentations of patients in the cirrhotic stage include jaundice, ascites, impotence or amenorrhea, vascular spiders and palmar erythema, and visible collateral veins on the abdominal wall due to portal hypertension. The fibrous septa are remarkable in that there is often prominent increase in portal venous and lymphatic radicals due to portal hypertension.