European Journal of Cardiovascular Medicine

In developed countries, hepatitis C virus (HCV) infection is the commonest cause of chronic liver disease with prevalence as high as 60–90% in affected patients [1], while HBV infection is more important than HCV as a cause of chronic hepatitis in developing countries such as India [2]. Although serological and virological parameters are useful to confirm the clinical diagnosis of chronic hepatitis, the liver biopsy remains the gold standard for evaluating hepatitis in terms of assessing histological activity and stage of disease. It is also important in excluding other coexistent disease processes. A number of systems have evolved to score liver biopsies [3]. The use of such scoring systems on paired liver biopsies, obtained from patients before and after therapy, is particularly useful in the objective documentation of reduction in inflammation or fibrosis brought about by antiviral therapy or interferon [4]. The Ishak system is comprehensive and shows good inter-observer agreement [5]. The METAVIR scoring system has been implemented in Western countries, and has been particularly useful in scoring of biopsies from patients with HCV infection [6]. Each of these scoring systems individually generates reliable scores, with relatively little intra- and interobserver variations within each system, when carried out by hepatopathologists [7]. There is no study comparing these two scoring systems.

The present study was undertaken to compare the grade and stage obtained using the Ishak system with that obtained using the METAVIR system, and to determine the degree of correlation between these two scoring systems using biopsies obtained from patients with chronic hepatitis B or C. A secondary aim of the study was to determine whether there was any correlation between necroinflammatory score (HAI grade) and serum transaminase levels, and to compare the prevalence of specific histological findings in HBV and HCV biopsies.

1. Study Area: The study was conducted in the Department of Pathology and Hepatology at Gouri Devi medical college Durgapur, a tertiary care teaching hospital in Durgapur, India.

1. Study Population:

Patients clinically and serologically diagnosed with chronic hepatitis B or C, who underwent liver biopsy for histopathological evaluation.

1. Study Period: The study was conducted over a period of 18 months,
2. Sample Size: 100

A total of 100 liver biopsy samples from confirmed cases of chronic hepatitis B and C were included in the study.

1. Inclusion Criteria:

• Patients aged 18 years and above.
• Serologically confirmed cases of chronic hepatitis B (HBsAg positive for >6 months) or hepatitis C (HCV RNA positive).
• Availability of adequate liver biopsy tissue.
• Informed written consent for participation and biopsy.

1. Exclusion Criteria:

• Patients with co-infection of HBV and HCV.
• Biopsies inadequate for histological evaluation.
• Patients with other causes of liver disease (e.g., alcoholic hepatitis, autoimmune hepatitis, Wilson’s disease, NAFLD).
• Patients on immunosuppressive or hepatotoxic drugs.

1. Study Design:

This was a hospital-based, descriptive, cross-sectional study.

1. Materials:

Formalin-fixed, paraffin-embedded liver biopsy tissues.

Hematoxylin and Eosin (H&E), Masson’s Trichrome, and Reticulin stains.

Serological test kits for HBsAg and HCV RNA.

Light microscope for histological assessment.

1. Methods:

Liver biopsies were obtained using percutaneous needle biopsy under ultrasound guidance. Tissues were fixed in 10% formalin, processed, and stained using standard histopathological protocols. Histological grading of necroinflammatory activity and staging of fibrosis were performed using METAVIR and Ishak scoring systems. Data were recorded and analyzed to compare histological patterns in HBV and HCV cases.

1. Study Tools:

Structured data collection form.

Histopathological scoring sheets.

Statistical software (e.g., SPSS) for data analysis.

Statistical Analysis:

Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Necroinflammatory Score (Ishak vs. METAVIR) – HBV and HCV (n = 100)

Table 2: Fibrosis Score (Ishak vs. METAVIR) – HBV and HCV (n = 100)

Table 3: Necroinflammatory Score – HBV only (n = 100)

Table 4: Necroinflammatory Score – HCV only (n = 100)

Table 5: Necroinflammatory Score vs Serum Transaminases (n = 100)

Of the 100 patients, 65 (65%) had chronic HBV infection and 35 (35%) had chronic HCV infection. Eighty of the patients were male and 20 were female. The mean age of HCV patients was 43.9 years compared to 32.5 years for HBV patients. All 65 patients with HBV tested positive for HBsAg, and 53 were HBeAg positive. HBV DNA was measured in 22 patients, of whom 20 tested positive. Among HCV patients, 34 were HCV antibody positive, while in one renal transplant patient the diagnosis was made based on HCV RNA positivity without antibody testing. All 31 HCV patients tested for HCV RNA were found to be positive. Serum transaminase levels (SGOT and SGPT) were normal in 34 patients (34%), elevated twofold in 28 (28%), threefold in 15 (15%), and more than threefold in 23 (23%).

The types of biopsy included percutaneous in 75 patients (75%), transjugular in 23 (23%), and wedge in two (2%). The average number of biopsy fragments was two, with biopsy lengths ranging from 1–1.5 cm and portal tracts ranging from six to ten, confirming adequacy of all samples for evaluation. Using the Ishak scoring system, most biopsies (91 patients, 91%) showed only minimal or mild chronic hepatitis, while moderate chronic hepatitis was observed in seven (7%) and severe chronic hepatitis in two (2%). Interface hepatitis was present in 45 (69.2%) of HBV and 26 (74.3%) of HCV biopsies (P = NS). Focal confluent necrosis was seen in seven (10.8%) HBV and five (14.3%) HCV biopsies (P = NS). Bridging necrosis was limited to HBV cases, noted in five (7.7%) biopsies (P = NS). Lobular inflammation (predominantly mild) was identified in 61 (93.8%) HBV and 30 (85.7%) HCV biopsies (P = NS). Portal inflammation was seen in 64 (98.5%) HBV and 34 (97.1%) HCV biopsies (P = NS).

Chronic viral hepatitis is a significant problem worldwide. Presently available therapies lead to sustained resolution of inflammation in only a minority of treated patients, and newer therapies are constantly being introduced. Such therapies need to be evaluated particularly to determine whether they halt inflammation and result in regression of fibrosis. Histological scoring systems to evaluate inflammation and fibrosis offer objective measures of improvement in either of these parameters [6], and have been used to evaluate therapy of hepatitis B or hepatitis C with a variety of antiviral agents [7]. Histological scoring of activity and fibrosis are also used in studies designed to understand the influence of concomitant injurious factors on the progression of liver disease in patients with HCV or HBV [9], as well as in studies to understand the natural history of infection with HCV [10].

Subsequently, a number of other systems have evolved including those proposed by Scheuer, the Ishak system, and the French METAVIR system [6]. All the newer systems, in contrast to the Knodell scoring system, have a common factor in that the assessment of necroinflammatory changes or ‘activity’ is separated from the assessment of fibrosis or stage of the disease. The two recently used scoring systems are the Ishak system and the METAVIR system. This study compares, for the first time, these two scoring systems, and shows that scoring of fibrosis by either system is very closely concordant, while the assessment of necroinflammatory change shows a moderate degree of concordance between the two systems.

The reason for the minor discordance between the two systems with respect to necroinflammatory change is likely due to the fact that the two systems do not include the same parameters for assessment in this category. The Ishak system includes the assessment of interface hepatitis (piecemeal necrosis), confluent necrosis, focal lobular necrosis or apoptosis or inflammation, and portal inflammation in arriving at a necroinflammatory score. On the other hand, the METAVIR system assesses only piecemeal necrosis and lobular necrosis in computing an activity score. The lack of assessment of portal inflammation in the METAVIR score may be one factor responsible for the divergence noted between the two scores. Another factor could be the lack of weightage for bridging necrosis in the METAVIR system. However, when HBV (5/65 showing bridging necrosis) and HCV (0/35 showing bridging necrosis) biopsies were separately analyzed, the degree of agreement between Ishak and METAVIR scores were similar for both groups. By contrast, the concordance between the two systems with regard to assessment of fibrosis was near perfect (weighted kappa 0.998). The degree of concordance between the two scoring systems remained the same regardless of whether the biopsy was from a HBV or an HCV patient.

The use of the kappa score as a statistical method has been thought to be controversial by some [11]. The score is dependent on the number of categories which are being studied and does not actually quantify the degree of disagreement, i.e. in interobserver studies whether a disagreement is small or large, or due to random or systematic variation. Interpretation of the scores obtained is generally as follows: scores of 0–0.19 indicate only slight agreement, 0.20–0.39 fair agreement, 0.40–0.59 moderate agreement, 0.60–0.79 substantial agreement, and a score of >0.80 indicates almost perfect agreement. The weighted kappa score, which takes into consideration the size or degree of disagreement between the two systems, is a more suitable method for comparing ordered categories. Its interpretation is similar to the kappa score. Hence although not a perfect score, the weighted kappa was used in comparing the different categories in both the systems used.

Comparative use of the two scoring systems also led to other subjective observations that cannot be quantitatively expressed. The Ishak system numerical score has a wide range. Converting the numerical activity score to four categories (minimal, mild, moderate or severe) was necessary in order to facilitate comparison with the METAVIR activity score. In our experience, scoring in each individual category could be equated to the METAVIR system as follows. Lobular necrosis scores of 1 and 2 in the Ishak system were equivalent to a score of 1 in the METAVIR system, while scores of 3 and 4 (with or without bridging necrosis) equated to a METAVIR score of 2 in the equivalent category. An interface hepatitis score of 1 in the Ishak system was equivalent to a score of 1 in the METAVIR system, scores 2 and 3 to 2, and score 4 to 3, respectively, in the METAVIR system. In the staging score of the Ishak system, a score of 1 corresponded to F1 of the METAVIR system, scores 2 and 3 to F2, scores 4 and 5 to F3, and score 6 to F4 of the METAVIR system.

While we did find a good concordance between the necroinflammatory and fibrosis scores of the Ishak and METAVIR scoring systems, in our experience of routinely scoring all liver biopsies with chronic hepatitis in our institution, we found the Ishak system to be more reproducible, user-friendly and comprehensive. It provides a quantitative value that is well understood by clinicians. The Ishak system fibrosis score is more detailed than other existing systems and is considered to be of particular value in cases where there are occasional nodules but not yet well-defined cirrhosis (i.e. score 5) [12]. However, there is no sufficient reason to endorse one system over the other, and the choice of scoring system would perhaps be dictated by the preference of the clinician and the pathologist.

A recently published study compared the Knodell scoring system with the Ishak and Scheuer systems in the evaluation of hepatitis C patients treated with interferon [13]. Complete responders showed significant improvement in both grade and stage using the Ishak or Scheuer systems, but improvement only in grade using the Knodell system. This study additionally observed that the Scheuer fibrosis score was predictive of non-response to interferon in chronic hepatitis C. The intention of the present study was to compare the Ishak system with the METAVIR since they are the two recently used scoring systems in the grading and staging of chronic viral hepatitis, and hence cannot comment about differences from the Knodell system.

There was very little correlation between histological assessment of necroinflammatory activity and the presence of elevated transaminases. This is not surprising, and others have reported that the HAI score did not correlate with serum ALT levels, but that the individual scores for piecemeal necrosis, as well as for portal inflammation, correlated weakly with elevations in serum ALT [14].

The study also demonstrated that either scoring system could be applied regardless of the etiology of the chronic viral hepatitis, with very similar concordances found when biopsies from HBV and HCV patients were analyzed separately. This provides a clearer rationale for the use of either scoring system in hepatitis B and C virus infection. There was no difference noted between HBV and HCV biopsies with regard to the frequency of observation of interface hepatitis, lobular necrosis, focal confluent necrosis or portal inflammation. However, micronodular cirrhosis was significantly more common in HCV biopsies compared to HBV biopsies, in concordance with earlier observations that micronodular cirrhosis is fairly common in biopsies from HCV infected patients [15]. Additional observations indicated that the presence of ground glass hepatocytes/Shikata cells was noted only in HBV biopsies, where it was seen in 37 (56.9%), while lymphoid aggregates, steatosis, bile duct damage, and bile ductular proliferation were all significantly more common in HCV than in HBV biopsies.

This histopathological study of chronic hepatitis B and C underscores the critical role of liver biopsy in assessing disease severity and guiding management. Scoring systems such as METAVIR, Ishak, and Knodell provide reliable frameworks for grading inflammation and staging fibrosis, with good inter- and intra-observer agreement when interpreted by hepatopathologists. In developed countries, HCV remains the leading cause of chronic liver disease, while HBV predominates in developing nations like India. Accurate histological evaluation is essential for documenting treatment response and disease progression, emphasizing the need for standardized scoring and expert interpretation in the clinical management of chronic viral hepatitis.

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