Liver biopsy assessment in chronic viral hepatitis: a personal, practical approach

Abstract

The terminology for assessment of chronic viral hepatitis in liver biopsy specimens has become confusing with the proliferation of grading and staging schemes that have paralleled the rise of the hepatitis C epidemic and the importance of mixed viral infections. This review represents a personal approach to the interpretation of these biopsy specimens, aiming at clarifying and simplifying the important points for the general pathologist confronted by these diagnostic dilemmas. The most commonly used schemes-Ishak modification of the Knodell 'hepatic activity index', Scheuer, Metavir, Batts-Ludwig classifications-are presented with evaluation of their pros and cons. Which scheme is selected is less important than the consistent use of a single scheme and the clear naming of that scheme in pathology reports. The importance and clinical implications of identifying severe necroinflammatory activity in the form of 'confluent necrosis' is discussed. Pathologists must also be clear about assessing concomitant diseases, in particular, alcoholic or non-alcoholic fatty liver disease, and be aware that grading/staging schemes for chronic hepatitis do not apply to mixed disease conditions. Other important features to be evaluated in all chronic hepatitis biopsy specimens include iron (which may represent hereditary hemochromatosis or secondary uptake) and neoplasia-associated changes, namely large cell change and small cell change; these findings and their clinical import are updated and reviewed. Sample approaches to composing useful diagnostic reports are also presented. Modern Pathology (2007) 20, S3-S14. doi:10.1038/modpathol.3800693Keywords: grading; staging; chronic hepatitis; viral hepatitis; liver biopsy Once upon a time, the assessment of liver biopsy specimens from patients with chronic viral hepatitis was very simple. There were three categories created for us by the Gnomes (not fairytale, mythical, woodland folk, but 'an International Working Group' of liver pathologists): chronic persistent, active, and lobular hepatitis (CPH, CAH, and CLH, respectively).1 In addition, one would describe the scarring and the progression toward cirrhosis. These categories were sufficient because there were only three likely diseases to be dealt with: autoimmune hepatitis, hepatitis B, and non-A-non-B hepatitis. For the first two, these categories of histopathology were reasonably prognostic. Also, only autoimmune hepatitis had a treatment, which was immune suppression. As for non-A, non-B hepatitis, welly there wasn't much to be said for that beyond describing the histologic changes, knowing that CPH, CAH, and CLH were not predictive in those cases.Then things changed. Hepatitis C was discovered and the true extent of the epidemic was made clear. Antiviral treatments were developed that required assessments in clinical trials and detailed comparison between pre-and post-treatment biopsies. Continuing intravenous drug use in urban centers made mixed viral infections more common. Most liver biopsies were not performed for autoimmu...

Histopathologic diagnosis of chronic viral hepatitis

“…Lymphoid aggregates or fully formed follicles, although typical for hepatitis C, can also be seen in all forms of viral hepatitis. Inflammation may encroach on the bile ducts, particularly in hepatitis C, leading to damage or even destruction [5,8,9].…”

“…Referring to the way in which the limiting plate was eroded, morphologic appearance is also termed as "piecemeal necrosis" ( Figure 1). The term interface hepatitis is now often preferred, because there is evidence to suggest that apoptosis rather than necrosis may be involved in the periportal areas [1,5,9,10]. …”

The Relationship between Treatment Response and Histological Scoring Systems Applied in Chronic Hepatitis B

“…METAVIR scoring system is presented in the literature as the scoring system experienced by interobserver compatibility rather than persons'own experiences between scoring systems 1,20,21 . Most widely used in Europe, this is an algorithmic approach system rather than simple scoring system as Modified Knodell system.…”

“…Most widely used in Europe, this is an algorithmic approach system rather than simple scoring system as Modified Knodell system. There are important articles with different comments on all scoring systems in the literature [21][22][23][24][25][26][27][28] .…”

Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations

“…Cirrhosis is the final stage of CLD [3] . Liver biopsy is still an important diagnostic tool in CLD [4] .…”