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

Editorial Board Member: Raul S. Gonzalez, M.D.
Editor-in-Chief: Debra Zynger, M.D.
Leo Lin, M.D., Ph.D.
Kimberley J. Evason, M.D., Ph.D.

Topic Completed: 27 August 2019

Revised: 7 November 2019

Copyright: (c) 2002-2019, PathologyOutlines.com, Inc.

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

Leo Lin, M.D., Ph.D.
Kimberley J. Evason, M.D., Ph.D.
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Cite this page: Lin L, Evason KJ. Chronic hepatitis - grading / staging. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/liverchronichepgrading.html. Accessed November 18th, 2019.
Definition / general
  • Chronic hepatitis: liver fibrosis occurring as a result of hepatocyte-based injury and inflammation, most commonly due to viral or autoimmune hepatitis
    • Separate scoring systems should be used for steatohepatitis and biliary disorders
  • Grade: amount of necroinflammatory activity; indicates rate of disease progression
  • Stage: amount of fibrosis; indicates how far disease has progressed
Essential features
  • Batts-Ludwig system is the most widely used scale for assessing grade (amount of necroinflammatory activity) and stage (degree of fibrosis) in chronic hepatitis
Terminology
ICD coding
    ICD10:
  • B18.0 - chronic viral hepatitis B with delta-agent
  • B18.1 - chronic viral hepatitis B without delta-agent
  • B18.2 - chronic viral hepatitis C
  • B18.8 - other chronic viral hepatitis
  • B18.9 - chronic viral hepatitis, unspecified
  • K73.0 - chronic persistent hepatitis, not elsewhere classified
  • K73.1 - chronic lobular hepatitis, not elsewhere classified
  • K73.2 - chronic active hepatitis, not elsewhere classified
  • K73.8 - other chronic hepatitis, not elsewhere classified
  • K73.9 - chronic hepatitis, unspecified
Diagrams / tables

Images hosted on other servers:
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METAVIR staging

Microscopic (histologic) description
  • Batts-Ludwig system is the most common grading and staging system (Am J Surg Pathol 1995;19:1409)
  • Scale 0-4 for grade and stage
  • Grade: amount of portal / periportal and lobular activity (count whichever is greater)
    • Portal / Periportal activity
      • 0-none or confined to portal tracts
      • 1-minimal, patchy interface hepatitis
      • 2-mild interface hepatitis involving some or all portal tracts
      • 3-moderate interface hepatitis involving all portal tracts
      • 4-severe interface hepatitis / bridging necrosis
    • Lobular activity
      • 0-none
      • 1-minimal: rare spotty necrosis (can find 1-2 dead hepatocytes in biopsy)
      • 2-mild: scattered necrotic hepatocytes
      • 3-moderate: confluent necrosis (clusters of dead hepatocytes)
      • 4-severe: bridging necrosis
  • Stage: amount of fibrosis
    • 0-none
    • 1-portal fibrosis: fibrous portal expansion
    • 2-periportal fibrosis: periportal septae
    • 3-bridging fibrosis: portal-portal fibrous septae, distorted architecture
    • 4-probable or definite cirrhosis: nodule formation
Microscopic (histologic) images

Contributed by Kimberley J. Evason, M.D., Ph.D.
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Mild periportal activity

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Lobular activity

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Mild lobular activity

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Stage 1, Batts-Ludwig methodology

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Stage 2, Batts-Ludwig methodology

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Stage 3, Batts-Ludwig methodology

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Stage 4, Batts-Ludwig methodology

Positive stains
  • Trichrome highlights fibrosis and is used to determine stage
  • Sirius red also highlights fibrosis
Sample pathology report
  • Liver, biopsy:
    • Chronic hepatitis with mild activity (grade 2, scale 0-4, Batts-Ludwig methodology) and bridging fibrosis (stage 3, scale 0-4, Batts-Ludwig methodology), consistent with clinical history of chronic hepatitis C
Board review question #1

    Which of the following is true about this finding?

  1. Indicative of fibrosis and used to determine grade in a patient with chronic hepatitis C
  2. Indicative of fibrosis and used to determine stage in a patient with chronic hepatitis C
  3. Indicative of lobular necroinflammatory activity and used to determine grade in a patient with chronic hepatitis C
  4. Indicative of lobular necroinflammatory activity and used to determine stage in a patient with chronic hepatitis C
Board review answer #1
C. Indicative of lobular necroinflammatory activity and used to determine grade in a patient with chronic hepatitis C

Comment Here

Reference: Chronic hepatitis - grading / staging
Board review question #2
    A 55 year old man with chronic hepatitis C undergoes liver biopsy for grading and staging. Sections show portal based inflammation, with mild interface activity. Within the lobules, there are foci of confluent necrosis (clusters of dead hepatocytes) but not bridging necrosis. Trichrome stain shows periportal fibrous expansion without definite septae formation or bridging. What would be the most appropriate grade and stage according to the Batts-Ludwig methodology (scale 0-4)?

  1. Grade 1, stage 2
  2. Grade 1, stage 3
  3. Grade 2, stage 1
  4. Grade 2, stage 3
  5. Grade 3, stage 1
  6. Grade 3, stage 2
Board review answer #2
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