Biopsy Grading and Staging	Grading describes the degree of inflammation and necrosis. Staging describes the degree of fibrosis (scarring). If your doctor tells you a number to describe your biopsy results, it is important to ask which scoring system is used in assessing the results of the biopsy.

The Knodell Histological Activity Index (HAI)	Simple and popular, but because of the way biopsy specimens are evaluated, different laboratories can produce different results from the same sample.

The Ishak Modified HAI	A modification of the Knodell HAI system, more sensitive and accurate in assessing fibrosis. Fibrosis staging is scored from 0 to 6, which permits physicians to better assess the effect of therapy on fibrosis.

The METAVIR System	A simple system that has been carefully evaluated and found to be accurate across large groups of hepatitis patients.

The Scheuer System	A very simple method for describing biopsy results, initially developed to rate chronic viral hepatitis but now applied to nonviral hepatitis as well.

The Batts and Ludwig System	Another fairly simple system used for rating portal inflammation, lobular inflammation and fibrosis.

When you receive the results of your liver biopsy, you will hear the terms inflammatory grade and fibrotic stage. Health care providers use these terms to indicate the amount of injury to the liver.
There are three different methods used for scoring liver biopsies. This can cause confusion for both patients and health care providers. Be aware that the scoring systems are also subject to interpretation by the pathologist who examines your biopsy.

The three scoring and grading systems for liver biopsies are the Original HAI (Histology Activity Index), the Modified HAI, and the Metavir. There are important things to know about how biopsies are scored in order to understand what your score means.

A score for a given biopsy characteristic in one system does not mean the same thing in the other systems.
The scores for all of the characteristics of the tissue sample are added together for a final score, except as specified in the notes under the table for that system (see below Tables 1-5).
A final score from one biopsy may have the same score as that of a follow-up biopsy, but the scores for individual characteristics may have changed. This means your situation could actually be better or worse depending on the individual characteristic scores.

Until there is a single biopsy scoring system, there are things you need to know and track regarding your liver biopsy results.

What system did the pathologist use to grade each of your biopsies?
If you have had more than one biopsy, you need to look at changes in both the individual characteristics and the overall score.

Make sure your health care provider completely explains the results of your biopsy to you. Ask for an explanation of the individual scores as well as the overall score. You should be given a description of the inflammatory grade and fibrotic stage. Ask to speak with the pathologist who evaluated your biopsy if your health care provider is unable to provide this information.

Biopsies are invasive and therefore, you are not likely to have one done often. For this reason, it is very important that you understand the results of your liver biopsy so you can use this information to help you make decisions about your health care.

The following tables comparing the three systems used to score liver biopsies are courtesy of David Kleiner, MD of the National Cancer Institute.

http://www.hepcchallenge.org/manual/progression_final.htm

Table 1. Comparison of Scoring Systems: Periportal Necroinflammatory Changes
Score	Original HAI[a]⁽³⁾	Modified HAI⁽⁴⁾	Metavir[b]⁽⁵⁾
0	None	Absent	Absent
1	Mild piecemeal necrosis	Mild (focal, few portal areas)	Diffuse alteration of the periportal tract in some portal tracts or focal
2		Mild/Moderate (focal, most portal areas)	Diffuse alteration of the periportal tract in some portal tracts or focal
3	Moderate piecemeal necrosis (involves less than 50% of the circumference of most portal tracts	Moderate (continuous around <50% of tracts or septae)	Diffuse alteration of the periportal plate in all portal tracts
4	Marked piecemeal necrosis (involves more than 50% of the circumference of most portal tracts	Severe (continuous around >50% of tracts or septae)
[a] The Periportal component of the Knodell HAI has been split into a Periportal piecemeal necrosis and a bridging/confluent necrosis component for better comparison to the other scoring systems. In order to recreate the original scale, the bridging/confluent necrosis component should be added to the Periportal piecemeal necrosis component.
[b] The Periportal component of the METAVIR score is used with the focal necrosis score to determine overall inflammatory activity.

Table 2. Comparison of Scoring Systems: Bridging and Confluent Necrosis
Score	Original HAI[a]⁽³⁾	Modified HAI⁽⁴⁾	Metavir[b]⁽⁵⁾
0	Absent	Absent	Absent
1		Focal confluent necrosis	Present
2	Bridging necrosis (more than two such bridges)	Zone 3 necrosis in some areas
3		Zone 3 necrosis in most areas
4		Zone 3 necrosis + occasional portal-central bridging necrosis
5		Zone 3 necrosis + multiple portal-central bridging necrosis
6	Multilobular necrosis	Panacinar or multiacinar necrosis
[a] The Periportal component of the Knodell HAI has been split into a Periportal piecemeal necrosis and a bridging/confluent necrosis component for better comparison to the other scoring systems. In order to recreate the original scale, the bridging/confluent necrosis component should be added to the Periportal piecemeal necrosis component.
[b] The METAVIR score for bridging necrosis is not used in the overall activity determination by this system and is provided only for comparison with other scales.

Table 3. Comparison of Scoring Systems: Focal (Spotty) Lobular Necrosis and Hepatocellular Apoptosis
Score	Original HAI[a]⁽³⁾	Modified HAI⁽⁴⁾	Metavir[b]⁽⁵⁾
0	None	Absent	Less than one necroinflammatory focus per lobule
1	Mild (acidophilic bodies, ballooning degeneration, and/or scattered foci of hepatocellular necrosis in less than 1/3 of lobules/nodules	One focus or less per 10x field	At least one necroinflammatory focus per lobule
2		Two to 4 foci per 10x field	Several necroinflammatory foci per lobule or confluent/bridging necrosis
3	Moderate (involvement of 1/3 to 2/3 of lobules/nodules)	Five to 10 foci per 10x field
4	Marked (involvement of more than 2/3 of lobules/nodules)	More than 10 foci per 10x field

Table 4. Comparison of Scoring Systems: Portal Inflammation
Score	Original HAI[a]⁽³⁾	Modified HAI⁽⁴⁾	Metavir[b]⁽⁵⁾
0	No portal inflammation	None	Absent
1	Mild (sprinkling of inflammatory cells in less than 1/3 of portal tracts)	Mild, some or all portal areas	Presence of mononuclear aggregates in some portal tracts
2		Moderate, some or all portal areas	Mononuclear aggregates in all portal tracts
3	Moderate (increased inflammation in 1/3 - 2/3 of portal tracts)	Moderate/marked, all portal areas	Large and dense mononuclear aggregates in all portal tracts
4	Marked (dense packing of inflammatory cells in more than 2/3 of portal tracts)	Marked, all portal areas
*[a]* The METAVIR score for bridging necrosis is not used in the overall activity determination by this system and is provided only for comparison with other scales.

Table 5. Comparison of Scoring Systems: Fibrosis
Score	Original HAI[a]⁽³⁾	Modified HAI⁽⁴⁾	Metavir[b]⁽⁵⁾
0	No fibrosis	No fibrosis	No fibrosis
1	Fibrosis portal expansion	Fibrosis expansion of some portal areas, with or without short fibrous septa	Stellate enlargement of portal tracts without septae formation
2		Fibrosis expansion of most portal areas, with or without short fibrous septa	Enlargement of portal tracts with rare septae formation
3	Bridging fibrosis (portal-portal or portal-central linkage)	Fibrosis expansion of most portal areas, with occasional portal to portal bridging	Numerous septae without fibrosis
4	Cirrhosis	Fibrosis expansion of portal areas, with marked bridging (portal to portal as well as portal to central)	Cirrhosis
5		Marked bridging with occasional nodules (incomplete cirrhosis)
6		Cirrhosis, probable or definite
*[a]* The METAVIR score for bridging necrosis is not used in the overall activity determination by this system and is provided only for comparison with other scales.

Table 6. Relationship of Aggregate Inflammation Scores to grade of Activity
Sum of inflammation scores in HAI or modified HAI systems	Description of activity
0	None
1-4	Minimal
5-8	Mild
9-12	Moderate
13-18	Marked

Grade and Stage :

Inflammation
Portal:
Grade 0 no inflammation
Grade 1 peri-portal inflammation no hepatocellular necrosis
Grade 2 inflammation with mild interface hepatitis
Grade 3 severe portal inflammation with moderate interface hepatitis
Grade 4 marked inflammation with severe interface hepatitis
Lobular:
Grade 0 no inflammation
Grade 1 minimal, no necrosis (inflammatory cells within the lobule)
Grade 2 moderate inflammatory cells with occasional liver cell necrosis
Grade 3 marked inflammation with severe focal liver cell necrosis
Grade 4 extensive inflammation with bridging necrosis

Fibrosis:
Stage 1 none or mild peri-portal fibrosis
Stage 2 peri-portal fibrosis with/without extension and portal-portal bridging
Stage 3 portal-central bridges but no nodular formation
Stage 4 probable or definite cirrhosis

Definitions:

Necrosis One of the two mechanisms by which cell death occurs (the other being the physiological process of apoptosis. Necrosis is caused by the progressive degradative action of enzymes and is generally associated with severe cellular trauma. It is characterized by mitochondrial swelling, nuclear flocculation, and uncontrolled cell lysis. Decay or death of one or more cells, resulting from irreversible damage. Death of living tissue; death of a portion of tissue differentially affected by local injury (as loss of blood supply,burning, corrosion, or the local lesion of a disease)

Portal Communicating part or area of an organism, such as Portal Vein. The point at which something enters the body. Of or relating to the Porta Hepatis

Fibrosis Scar formation resulting from the repair of tissue damage. If it occurs extensively in the liver, it is called cirrhosis, Formation of fibrous tissue; fibroid or fibrous degeneration. Condition marked by increase of interstitial fibrous tissue, fibrous degeneration

Bridging Fibrosis When scarring from portal cell to portal cell occurs. Fibrous tissue extends from the portal cells. In early bridging the finger like protrusions of scar tissue do not extend completely from one portal cell to the next.

Grading system for cirrhosis: the Child-Pugh score


Score	Bilirubin (mg/dl)	Albumin (gm/dl)	PT (Sec)	Hepatic encephal	Ascites (grade)
1	< 2	> 3.5	1 - 4	None	None
2	2 - 3	2.8 - 3.5	4 - 6	1 - 2	Mild
3	> 3	< 2.8	> 6	3 - 4	Severe

Child class: A= 5 - 6, B= 7 - 9, C= > 9

Staging Cirrhosis

Hepatitis has 4 stages. Stage 4 Hepatitis = Cirrhosis.

Then,

There's 3 stages to Cirrhosis:
Stage A ("compensated"; not too sick)
Stage B (beginning to decompensate; complications beginning to appear)
Stage C ("decompensated"; end stage)

Doctors use something called a CTP Score, to see what Stage of cirrhosis that a person is in.

The CTP Score is based on FIVE QUESTIONS.
You receive a point value (score) for each of the answers.

Here's how it works:

1. Total Serum Bilirubin
.....if Bilirubin is <2 mg/dl: score 1 point
.....if Bilirubin is 2-3 mg/dl: score 2 points
.....if Bilirubin is >3 mg/dl: score 3 points

2. Serum Albumin
.....if Albumin is >3.5 g/dl: score 1 point
.....if Albumin is 2.8 to 3.5 g/dl: score 2 points
.....if Albumin is <2.8 g/dl: score 3 points

3. INR
.....if INR is <1.70: score 1 point
.....if INR is 1.71 to 2.20: score 2 points
.....if INR is >2.20: score 3 points

4. Ascites
.....No Ascites: score 1 point
.....Ascites controlled medically: score 2 points
.....Ascites poorly controlled: score 3 points

5. Encephalopathy
.....No Encephalopathy: score 1 point
.....Encephalopathy controlled medically: score 2 points
.....Encephalopathy poorly controlled: score 3 points

Total your score.

Sum total score gives grades of:
5 to 6 points = Stage A Cirrhosis
7 to 9 points = Stage B Cirrhosis
10 to 15 points = Stage C Cirrhosis

A person has to be at least Stage B or Stage C, in order to get referred for an "Evaluation" for a chance at the liver transplant waiting list. (Stage A Cirrhosis is not sick enough to think about a referral for an evaluation).

iCTP scores and MELD scores are two completely different things.

MELD scores are use for allocation of donor livers

PS- There's more examples of these scorecards at 112.1 (you can scroll through about a dozen of them there)

Thank you Imkindly, please visit her wonderful support forum :

ihttp://forums.delphiforums.com/liverfailure