Unifying Concepts

Histologic Scoring Systems for Chronic Liver Disease

Grading and staging refers to a semiquantitative assessment of the necroinflammatory activity (grade) and degree of fibrosis (stage) in relation to chronic hepatitis.

Ishak modification for hepatic activity index (HAI) for scoring of necroinflammatory activity in chronic hepatitis

(A) Periportal or periseptal interface hepatitis (piecemeal necrosis)
Absent 0
Mild (focal, few portal areas) 1
Mild/moderate (focal, most portal areas) 2
Moderate (continuous around <50% of tracts or septa) 3
Severe (continuous around >50% of tracts or septa) 4
(B) Confluent necrosis
Absent 0
Focal confluent necrosis 1
Zone 3 necrosis in some areas 2
Zone 3 necrosis in most areas 3
Zone 3 necrosis+occasional portal-central (P-C) bridging 4
Zone 3 necrosis+multiple P-C bridging 5
Panacinar or multiacinar necrosis 6
(C) Focal (spotty) lytic necrosis, apoptosis and focal inflammation
Absent 0
One focus or less per times 10 objective 1
Two to four foci per times 10 objective 2
Five to ten foci per times 10 objective 3
More than ten foci per times 10 objective 4
(D) Portal inflammation
Absent 0
Mild, some or all portal areas 1
Moderate, some or all portal areas 2
Moderate/marked, all portal areas 3
Marked, all portal areas 4

Scheuer classification for grading and staging of chronic hepatitis

Grade Portal/periportal activity
None 0
Portal inflammation 1
Mild piecemeal necrosis 2
Moderate piecemeal necrosis 3
Severe piecemeal necrosis 4
Lobular activity
None 0
Inflammation but no necrosis 1
Focal necrosis or acidophil bodies 2
Severe focal cell damage 3
Damage includes bridging necrosis 4
Stage Fibrosis
None 0
Enlarged, fibrotic portal tracts 1
Periportal or portal-portal septa, but intact architecture 2
Fibrosis with architectural distortion, but no obvious cirrhosis 3
Probable or definite cirrhosis 4

Metavir classification for staging of hepatitis C liver disease

No scarring 0
Minimal scarring 1
Scarring has occurred and extends outside the areas in the liver that contains blood vessels 2
Bridging fibrosis is spreading and connecting to other areas that contain fibrosis 3
Cirrhosis or advanced scarring of the liver 4



  1. Christensen C, Bruden D, Livingston S, Deubner H, Homan C, Smith K, Oh E, Gretch D, Williams J, McMahon B. Diagnostic accuracy of a fibrosis serum panel (FIBROSpect II) compared with Knodell and Ishak liver biopsy scores in chronic hepatitis C patients. J Viral Hepat. 2006 Oct;13(10):652-8. [Medline]
  2. Theise ND. Liver biopsy assessment in chronic viral hepatitis: a personal, practical approach. Mod Pathol. 2007 Feb;20 Suppl 1:S3-14. [Medline]
  3. Hudacko R, Theise N. Liver biopsies in chronic viral hepatitis: beyond grading and staging. Arch Pathol Lab Med. 2011 Oct;135(10):1320-8. [Medline]
  4. Ishak K1, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, Denk H, Desmet V, Korb G, MacSween RN, et al. Histological grading and staging of chronic hepatitis. J Hepatol. 1995 Jun;22(6):696-9. [Medline]


Created Jun 23, 2015.

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