Poster Presentation

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Hepatitis C virus (HCV) chronic hepatitis
histopathological aspectsDr Siddhartha Dutta
GuptaNew Delhi
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Is liver biopsy a safe procedure ?
Focal lesions Reduced size Dysmorphic liver
Normal or minimally deranged coagulation profile
Ultrasound guided percutaneous needle biopsy
Normal coagulation profile
Percutaneous needle biopsy
Diffuse liver disease
Abnormal coagulation profile Platelet
abnormalities Fibrinolysis
Transjugular needle biopsy
Several large studies indicate a complication
risk of 0.015 Risk is related to the experience
and technique of the physician Overall mortality
0.1 to 0.01 Non fatal bleeding/ biliary leak
1 to 0.1 Safe procedure with negligible
complications
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Is a liver biopsy necessary in chronic hepatitis?
Establishment of diagnosis Diagnosis of
incidental lesions Assessment of histological
activity (Grading) Evaluation of the types of
necrosis Evaluation of structural changes
(Staging) Clues to etiology and possible
diagnosis Immunohistochemical assessment of viral
antigens Monitoring therapy
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Histological features of chronic hepatitis C
Feature AIIMS Czaja et al Shah et al Schmid et
al Scheuer et al Bach et al Polys 7.5 Lymph
foll 17.5 76.2 81.3 88.5 78.0 49.0 Granuloma 5.0 P
iecemeal 92.5 76.2 100.0 Bile duct 45.0 61.9 31.3
46.2 22.0 31.0 Bridging nec 15.0 61.9 50.0 Ball
ooning 10.0 47.6 30.8 Acid body 37.5 57.1 91.5 St
eatosis 55.0 52.4 62.5 51.5 53.7 72.0
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Grading and staging of chronic hepatitis C
Provides a semi-quantitative assessment of the
histological changes Grading Necrosis and
inflammation (histological activity) Staging
Fibrosis (end result of necrosis and
inflammation) Several systems are
available International Liver Group (Ishak et al
1995) Grading A. Interface hepatitis
(piecemeal necrosis) 0-4 B. Confluent
necrosis 0-6 C. Focal necrosis 0-4 D. Portal
inflammation 0-4 Histological Activity Grading
ABCD 0-18 Staging Fibrous expansion of
portal tract - Cirhosis 0-6 In paired biopsies a
change in the Grade of 2 or in the Stage of 1 is
considered to be a significant improvement or
deterioration
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Is it possible to avoid a biopsy while treating
Chronic Hepatitis C?
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Is it possible to avoid a biopsy while treating
Chronic hepatitis C?
Liver biopsies, serum ALT and hepatitis C virus
Total cases 65 Atleast one biopsy available 59
14.25 mths (6-30) Paired biopsies
available 40 Pre-Therapy Post Therapy Mean
Grade 5.62 (2-12) 3.8 (0-12) Mean Stage 1.5
(0-5) 1.3 (0-4) SVR (43) Grade 5.46 (3-12)
3.24 (0-5) SVR - (16) Grade 6.16 (3-12) 5.36
(2-12) HR (31) Grade 6.52 (3-12) 3.03 (0-6) HR
- (09) Grade 4.77 (3-8) 5.55 (3-12)
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Liver biopsies, serum ALT, and hepatitis C virus
Pre-Therapy Grading and HCV Genotype 1 (9)
5.77 (3-12) HR 4, HR- 3 Genotype 2
(4) 6.50 (4-12) HR 2, HR - 1 Genotype 3
(31) 5.10 (2-12) HR 17, HR - 3 Genotype 4 /
? (15) 6.40 (3-10) HR 13, HR - 2 Viral Load
lt2 (29) 5.5 Viral Load gt2 (30) 5.7
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Histological grade and stage in different HCV
genotypes
All Cases
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Relationship between serum ALT levels and
histological grade and stage in different HCV
genotypes
Grade Stage
Grade Stage
Grade Stage
Grade Stage
Grade Stage
All Cases
Type 4/?
Grade Stage
Grade
X Axis Grade /


Grade Stage Y Axis
ALT Levels
Grade Stage
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Pre-therapy histological grade and ALT levels in
relation to virological response
ALL CASES
ALT
GRADE
SUSTAINED RESPONSE
LACK OF RESPONSE
ALT
ALT
GRADE
GRADE
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Pre-therapy histological grade and ALT levels in
relation to histological response
NON-RESPONDERS
ALT (Pre Rx)
GRADE
RESPONDERS
ALT (Pre Rx)
GRADE
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Histological grade and ALT levels post-therapy
in relation to response
ALL CASES
ALL CASES
Sustained Virological ResponseABSENT
Sustained Virological ResponsePRESENT
ALT
ALT
Sustained Virological ResponseABSENT
Sustained Virological ResponseABSENT
ALT
ALT
Histological Response ABSENT
HistologicalResponse PRESENT
Sustained Virological ResponsePRESENT
Sustained Virological ResponsePRESENT
ALT
ALT
Histological Response ABSENT
HistologicalResponse PRESENT
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Histological response and ALT levels
ALT Levels Pre-Therapy Post-Therapy HR (31)
153.0 (42-380) 34.2 (13-182) HR - (09) 97.3
(48-155) 57.8 (13-107)
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Histological response in relation to
post-therapy ALT and sustained virological
clearance
No of Cases40
ALT levels
gt 52
lt 52
HR - TOT SVR 23 6 29
- 8 3 11 TOT 31 9 40
34
6
SVR
SVR
_
_


27
7
4
2
HR
HR
HR
HR
_
_
_




22
2
2
5
5
2
2
182, 146
74,105
92,107
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Summary
Liver biopsy is a safe procedure Liver biopsy is
indicated prior to starting therapy for Chronic
Hepatitis C Surrogate markers need to be
evaluated to assess response to therapy without
performing a liver biopsy post-therapy Combination
of ALT and molecular biology tests definitely
appears to be important