Liver and intrahepatic bile ducts - nontumor
Hepatitis (acute and chronic)
Chronic hepatitis - grading / staging

Topic Completed: 1 March 2015

Revised: 30 May 2019

Copyright: (c) 2002-2018,, Inc.

PubMed Search: Chronic hepatitis[TI] grading[TI] staging

Rifat Mannan, M.D.
Songyang Yuan, M.D., Ph.D.
Page views in 2018: 10,566
Page views in 2019 to date: 5,531
Cite this page: Mannan A.A.S.R. Chronic hepatitis - grading / staging. website. Accessed July 19th, 2019.
Definition / general
  • Grading and staging refers to a semiquantitative assessment of the necroinflammatory activity (grade) and degree of fibrosis (stage) in relation to chronic hepatitis
  • Terminology has evolved
  • In the past, chronic persistent hepatitis, chronic lobular hepatitis and chronic active hepatitis denoted the severity of chronic hepatitis
  • Hepatitis C epidemic and its waxing and waning course necessitated a relook and a change of terminology
  • Current recommendations are to indicate "chronic hepatitis," the severity of necroinflammatory activity (grade), the extent of fibrosis (stage) and etiology
Nomenclature systems for grading and staging
  • Knodell system
    • First chronic hepatitis scoring system to systematically categorize liver inflammation and fibrosis (Hepatology 1981;1:431)
    • Three categories of necroinflammatory activity (periportal injury with or without bridging necrosis, lobular injury and portal inflammation) and degree of fibrosis
    • These are assigned numeric values, which are added to obtain a hepatic activity index (HAI) that ranges from 0 to 22
    • Major criticism is the inclusion of fibrosis (stage) as a determinant of activity (grade)
  • Ishak modification of hepatitis activity index
    • Ishak et al. presented a modified system for grading and staging (J Hepatol 1995;22:696)
    • Major changes were eliminating the combined score and separating confluent necrosis, including bridging necrosis, into a fourth category of necroinflammatory activity
    • Also includes a stage of "developing cirrhosis," which is important to assess the progression of fibrosis
    • Description of all aspects of viral injury is helpful
    • However, because of its extensive details, it remains more useful for research purposes than routine liver biopsy reporting
  • METAVIR system
    • This grading system evaluates only 2 features (periportal necrosis and lobular necroinflammatory activity) (Hepatology 1994;20:15)
    • Portal inflammation is excluded because it is considered a prerequisite for the diagnosis of chronic hepatitis, even when there is no parenchymal activity
    • It is a relatively simple system, providing scores of mild, moderate or severe for activity and four stages of progression of fibrosis
  • Scheuer system
    • This also is a fairly simple system (J Hepatol 1991;13:372)
    • Only two categories are included (portal / periportal and lobular) for evaluation of activity
  • Batts-Ludwig system
    • Uses five categories (0 to 4) separately for both grade and stage (Am J Surg Pathol 1995;19:1409)
    • Grade is determined by evaluation of degree of interface activity, lobular inflammation and necrosis
    • Stage is scored from 0 (no fibrosis) to 4 (cirrhosis)
    • It provides a pictorial description of each grade and stage of the disease
  • Summary
    • These schemes are useful for evaluating the effects of a particular treatment regimen in clinical trials
    • For routine pathology reporting of liver biopsies, it does not matter which system is used; it is suggested that a simple scheme is sufficient
    • Pathologist should determine the needs of the clinician and which system is the most sensible one to use (Mod Pathol 2007;20:S3)
Suggested reporting
  • Each diagnosis in a liver biopsy for chronic hepatitis should include:
    1. Statement that it is chronic hepatitis
    2. Grade of necroinflammatory activity (name of the scoring system used)
    3. Stage of activity (name of the scoring system used)
    4. Known or suspected etiology
  • Examples:
    • Chronic hepatitis B, Metavir, grade 2/4 and stage 2/4 (fibrous septa)
    • Chronic hepatitis, Batts-Ludwig, grade 2/4 and stage 4/4 (cirrhosis), compatible with hepatitis C
Diagrams / tables

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Metavir classification for staging hepatitis C liver disease

Microscopic (histologic) images

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Grade 4, stage 3

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Stage 4

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