INFO:Scoring and Grading Liver Biopsies Original HAI Modified HAI and the Metav

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Stage 2 isn't bad at all! My first biopsy said cirrhosis - that was in 1991 & I'm still kicking dragon butt - you've got a long way to go yetbefore you're in trouble. Your liver can & will regenerate if you clear the disease, even doing tx can give it time to get better. Here's a rather complicated but really complete explanation of Stages. Good for you with the weight loss, it's hard I know. SuZie & Sir SpYke the Fluffy (he says, everybody else thinks he's fat!) DETERMINING DISEASE PROGRESS WITH LIVER BIOPSY The most accurate way to check the severity of liver disease is with a biopsy. A liver biopsy is a test in which small pieces of liver tissue are removed so they can be examined under a microscope. The three main things that will be looked for are inflammation, fibrosis, and cirrhosis. The biopsy report may also reveal other histological and pathological findings such as the presence of lymphoid nodules, damage to small bile ducts, and/or the presence of

fat. Scoring and Grading Liver Biopsies 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 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(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. 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(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. 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(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(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(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 shows how the HAI inflammation scores relate to the grade of histological injury. In the HAI system, the various

inflammation scores are added together. These numbers are directly related to the descriptive grade of inflammation. 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 : InflammationPortal:Grade 0 no inflammationGrade 1 peri-portal inflammation no hepatocellular necrosisGrade 2 inflammation with mild interface hepatitisGrade 3 severe portal inflammation with moderate interface hepatitisGrade 4 marked inflammation with severe interface hepatitisLobular:Grade 0 no inflammationGrade 1 minimal, no necrosis (inflammatory cells within the lobule)Grade 2 moderate inflammatory cells with occasional liver cell necrosisGrade 3 marked inflammation with severe focal liver cell necrosisGrade 4

extensive inflammation with bridging necrosisFibrosis:Stage 1 none or mild peri-portal fibrosisStage 2 peri-portal fibrosis with/without extension and portal-portal bridgingStage 3 portal-central bridges but no nodular formationStage 4 probable or definite cirrhosisDefinitions: 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) Hepaticencephal 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 points3. 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 points5. 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 Cirrhosis7 to 9 points = Stage B Cirrhosis10 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

Next time I'm coming back as a cat