1- This document discusses the use of histological stains and scoring systems for assessing chronic liver disease on liver biopsy specimens. 2- It provides descriptions of the Ishak and METAVIR scoring systems which are commonly used to grade necroinflammatory activity and stage fibrosis in chronic hepatitis C. 3- Guidelines are given for optimal liver biopsy technique and interpretation of stains to diagnose specific liver diseases.

1. Pr.Dr .Magdy Ismael
Ahmed

2. Routine H&E, special stains are greatly helpful
STAIN SHOWS GOOD FOR
M. trichrome Type I collagen Fibrosis.
Reticulin Type III collagen.
Necrosis
(collapse).
Van Giesson stain Collagen type I Fibrosis
Sirusred Type I&III collagen Permanent stain
PAS with diastase
Complex
carbohydrate
(Non-glycogen)
B.M , α1- anti-
trypsin globules.
Prussian blue
(Perl`s stain)
Iron Blue pigment
Orcein stain
Victoria blue stain
Copper
,elatsin
Chronic
cholestasis.

6. Perls` stain`

7. Orcein stain
HBV

8. I. Diagnosis, grading &
staging of
II-Investigation of
cholestatic liver
disease:
Indications/ III
-Chronic Hepatitis (C &
B)
-Fatty liver disease
(steatosis/
steatohepatitis)
-Auto-immune
hepatitis
-Haemochromatosis &
Wilson’s disease
-Other metabolic
liver diseases
-Large duct biliary
obstruction
-Primary biliary
cirrhosis
-Primary sclerosing
cholangitis
-Drug reaction
-Biliary atresia &
ductopenia
-Diagnosis of a liver mass
-Evaluation of fever of
unknown origin
-Evaluation of post-
transplant status

9.  Ultilization of appropriate needle (type ,size..)
 Careful choice of sampled area:-
-Away from the capsule(>0.5 cm,to avoid
septum and focal nodularity)
-Right lobe better than left lobe (larger in
size ,covered by little capsule)
 Appropriate sample (length=1.5cm,wideth1-2 mm
6-8 portal triads )
 Appropriate preparation and reading.

10.  Semiquantitative analysis (Ishake &METAVIR)
 Morphometric analysis (not clinically useful)
 Non-invasive techniques {serological assess –
ment (fibro test ,acti test) ,radiological /US
measurements (fibroscan)}
 Liver biopsy (gold standard)

11. The two most widely applied scoring systems
in assessment of Chronic hepatitis C are:
Ishak et al., 1995 (Modified Knodell and his
colleagues)
METAVIR System(A group of French
investigators, 1994 )still most commonly
used system

12. Grading:- describe the intensity of necro-
inflamm atory activity in chronic hepatitis .its
range (0-18).
Staging :-It measures fibrosis and architectual
alteration . Its range (0-6)
Grading and staging must be regarded as
approxim -ation ,considering the size and sample
quality.

13. Parameters of grading :
1- Portal inflammation: Score (1- 4).
2- Interface hepatitis: Score (1- 4).
3- Spotty (Focal) lytic necrosis:
Score (1- 4).
4- Confluent necrosis: Score (1- 6).
-----------------
18

14. 0 Absent
1 Mild, some or
all portal tracts
2 Moderate, some
or all portal tracts
3 Moderate/ marked,
all portal tracts
4 Marked, all portal
tracts

15.  Types of necrosis :-
 Focal (spotty) lytic necrosis and Apoptosis with liver cell
drop out :- Death and removal of individual hepatocytes within intact
parenchyma performed by T-lymphocyte and the residual of cells removed
by blood flow or phagocytosis.
 Confluent necrosis (simple & zonal) :-death and removal of
adjacent group of hepatocyts .It is commonly peri-venular.(zone 3)
 Bridging necrosis:- Confluent necrosis connecting two structures
(either C-C or P-C or P-P)
 Panacinar (multiacinar):-confluent necrosis involve the three zones
and destroy the entire acinus.
 Interphase hepatitis(Piece meal necrosis ):- Death of hepatocyts
at interphase of parenchyma and C.T of portal area ( Interphas hepatitis is
preferred than piece meal necrosis due to inflammation > necrosis and
due to apoptosis other than necrosis)

16.  0 Absent
 1 Mild (focal, few
portal tracts)
 2 Mild/ moderate (focal
, most portal tracts)
 3 Moderate (involving
<50% of all tract’
circumferences)
 4 Severe (involving
>50% of all tracts’
circumferences)

18. Interface hepatitisInterface hepatitis
<50% >50%/ Moderate

19.  0 Absent
 1 One focus or less per
10X objective
 2 2-4 foci
 3 5-10 foci
 4 More than 10 foci

20.  0-Absent
 1 Focal (away from zone 3)
 2 Zone 3 necrosis, in some areas
 3 Zone 3 necrosis in most areas
 4 Zone 3 + occasional p-c.
 5 Zone 3+ multiple p-c.
 6 Panacinar or multiacinar necrosis

21.  4 Portal inflammation
 4 Interface hepatitis
 4 Spotty necrosis
 6 Confluent necrosis
 18 Maximum Total

22. (S)

26. Change Score
-No fibrosis 0
- Some portal (Expanded) ± short fibrous septa 1
-Most portal areas(Expanded) ± short fibrous septa 2
-Most portal areas (Expanded) + occasional (P-P)
bridging
3
-Portal areas (expanded) + Marked (P-P) & (P-C) Bridging 4
-Marked bridging (P-P and/or P-C) + occasional nodules
( incomplete cirrhosis or merging into cirrhosis)
5
Probable or definite cirrhosis 6

27. 0 1 2 3 4 5 6

28. F3

29. F4

30. F5

31. F6

32. Separately assess the degree of Activity
(A) and Fibrosis (F)
Stages of fibrosis (F0-F4), similar to
Scheuer.
F0: No fibrosis.
F1: Portal tract fibrosis without septa
F2: Portal tract fibrosis with rare septa
F3: Numerous septa without cirrhosis.
F4: Cirrhosis.

33. F1
F2
F4
F3

43. Ishak, 1995. activity grade : A
( 0-18)
METAVIR. Activity grade: A
( 0-3 )
 Score (1-6 )
 Score (7-12)
 Score (13-18)
 A1
 A2
 A3

44. Grade of activity (A0-A3)
A0: No histologic necro-
inflammatory injury
A1: Minimal activity
A2: Moderate
A3: Marked (Severe) activity

45.  The degree of activity is assessed by
integration of both piecemeal necrosis
and lobular necrosis as described in a
simple algorithm.
 Portal lymphoid infiltrate and
bridging necrosis are not considered .

47. Interface hepatitis, with detected apoptotic
body

49. PMN=0
LN= o
LN= 1
LN= 2
LN=0,1
LN=2
LN=0,1
LN=2
LN=0,1,2
PMN=1
PMN=2
PMN=3
A=0
A=1
A=2
A=1
A=2
A=2
A=3
PMN=piece meal nerosis.0=none,1=mild,2=mderate ,3=severe
LN=Lobular necrosis.). 0=none or mild ,1=moderate ,2=severe
A=Histological activity .0=None ,1=Mild,2=moderate,3=Severe

50. MILD ACTIVITY (A1)
+
Periportal necrosis = 1 Lobular necrosis =1

51. METAVIR - Algorithm
NL = 0 A = 0
NP = 0 NL = 1 A = 1
NL = 2 A = 2
NP = 1 NL = 0,1 A = 1
NL = 2 A = 2
NL = 0,1 A = 2
NP = 2 NL = 2
NP = 3 NL = 0,1,2 A = 3

52. SEVERE ACTIVITY (A3)
+
Periportal necrosis = 2 Lobular necrosis = 2
P. Bedossa

53. METAVIR - Algorithm
NL = 0 A = 0
NP = 0 NL = 1 A = 1
NL = 2 A = 2
NP = 1 NL = 0,1 A = 1
NL = 2 A = 2
NL = 0,1 A = 2
NP = 2 NL = 2
NP = 3 NL = 0,1,2 A = 3

54. 1-auto-immune hepatitis:-
-Clinical findings
1-Common in females (M:F -1:9(
2-Elevated liver enzymes at disease activity.
3-Presence of polyclonal hyper- gammaglobulinemia and
auto-immune Abs (ASMA,ANA,ALVKM.ect(
4-Absence of viral markers
-Histological findings:-
1-Extensive interface hepatitis rich in plasma cells
2-Rosetting of hepatocyts
3-Lobular inflammation may or may not be present
4-Intact bile ducts (D.D PBC)
5-The inflammation may lead to portal fibrosis , bridging &
cirrhosis

56. BD

57. a-Absence of viral markers
b-Presence of PAS +ve DR globules or Hx&E stained
globules in periportal areas, in cases of α 1-anti-
trypsin deficiency.(genetic disorder ,discovered
in infants and children. In which the synthesized
protein fail to migrate from (ER) to Golgi zone
and thus accumulates inside ER as hyaline
globules (arrows).
c-Or Presence of Mallory hayline bodies ,fatty
change ,micronodular cirrhosis and cu in
periportal heptocytes in cases of Wilson,s diasese

59. PAS +ve DR

60. Mallory bodies

62. 3-Drug induced hepatitis
(Aldomet,inhibix,macrodantin,diclofenac)
a-Absence of viral markers or
b-Drug induced auto-antibodies or CU.
c-History of taking the drug.

63. D.D diseases mimic Ch.V.hepatitis .
1- PBC :-
a-Markdely elevated Alk.phosphatase & GGT.
b->90 % of cases, with high titres of circulating anti-
mitochondrial antibodies (AMA)
c- Granulomatous destruction of small and medium sized
intrahepatic bile ducts
d-Ductular proliferation
e-Peripheral cholestasis
f-The inflammation may lead to scarring & cirrhosis

65.  A chronic cholestatic liver disease
(raised alkaline phosphatase)
 In which there is progressive fibro-
oblitrative destruction of segments of the
extrahepatic and large intrahepatic bile
ducts
 On endoscopy gives a specific beaded
appearance (strictures & dilatations)
 There is ulcerative colitis in 70% of
patients

68. Cholestasis

69. 2-Lymphoma &leukemia (dense
lymphoplasmacytic infiltrates):-
a-No-true interface hepatitis
b-No true apoptosis only hepatocyte
atrophy
c-No fibrosis.
d-No acidophil bodies.
e-Monomorphism ,marked atypia

71. 1.Count the number of portal tracts(6-8)

72. 2. Note portal tract expansion & septa formation
(best done with reticulin stain)

73. 3. Examine the portal tracts

74. 4. Assess
Interface hepatitis

75. 5. Spotty necrosis
6. Confluent necrosis

76. 7. Any steatosis, what type & how much

77. 8. Any iron, and how much

78. 9. Any copper-associated protein?

79.  1-The statement that it is chronic hepatitis
and mention the known or suspected cause of
the hepatitis
 2-The grade of activity (including the name of
scoring system itself)
 3-The stage of activity (including the name of
scoring system itself)