 Abstract | | |
This is a review on the updated terminology of chronic hepatitis, a topic that has gained much popularity in the current literature of gastroenterology. The aim of this review is to familiarize readers with its use and to discourage the old terminology. The new terminology of chronic hepatitis takes into consideration etiology, severity (grade) and degree of chronicity measured by fibrosis (stage). The use of the new terminology would standardize our diagnosis with the aim of standardizing therapeutic modalities for the purpose of reproducibility of results.
How to cite this article:
Satti MB. Chronic hepatitis - an update on terminology. Saudi J Gastroenterol 1996;2:120-3 |
Chronic hepatitis is defined as a necroinflammatory disease of the liver continuing for at least six months. However, in certain conditions, this time limit may prove unsatisfactory. For instance, autoimmune hepatitis and HCV may be diagnosed before such a time limit, as both may be asymptomatic for a long time [1] . For this reason a recent report of a working group considered "autoimmune hepatitis" a priori chronic and suggested to drop the qualifier "chronic" and use "autoimmune hepatitis" for all such cases [2] . On pathological terms chronic hepatitis, often signed out either as chronic active or chronic persistent, was introduced nearly three decades ago, merely to categorize the grade "activity" of liver disease for the purpose of prognosis and possible use of immunosuppressive therapy [3] .
Unfortunately, this terminology, though intended to indicate the grade of a specific disease, was commonly misinterpreted by clinicians and pathologists alike. It was turned over the years into morphologic diagnoses or even diagnostic entities, regardless of the underlying etiology or pathogenesis. This led to great concern from experts in the field who called for a change in terminology [4],[5],[6],[7],[8],[9],[10] to keep pace with the exponential expansion of knowledge of the causative agents of chronic hepatitis, in particular the hepatitis viruses, autoimmunity and drugs. Progression to end-stage liver disease and survival was also found to depend on the etiology [11] . For example what is morphologically called "Chronic Persistent Hepatitis" (CPH), due to HBV was found to be prognostically different from an apparent CPH due to HCV. Furthermore, drug-related chronic hepatitis does regress with discontinuation of therapy of some causative drugs.
The existing terminology gives no consideration for etiology. All what clinicians and pathologists look for is presence of piece-meal necrosis to diagnose "Chronic Active Hepatitis" (CAH). This has proved insufficient for therapeutic interventions, especially when considering the discordant progress in therapy of viral hepatitis and autoimmune hepatitis. It has been shown that chronic hepatitis may relate to the interaction of multiple infections [12] or infections with other factors [13],[14],[15],[16] where this adversely affects prognosis. All these factors together further strengthened the need for a classification that is based on etiology but at the same time incorporate the histological parameters for prognostication i.e. activity and degree of fibrosis.
| The updated terminology | |  |
The new proposal on terminology has been published by an international working party [17],[18] . The emphasis here shifts from purely histologic to a combination of histologic, clinical and serologic factors. The diagnosis of a case of chronic hepatitis should thus take care of all three aspects combined.
i. Etiology
ii. Grade (activity) of the disease
iii. Stage (extent of fibrosis)
i. Etiologic classification of chronic hepatitis
The classification recognized the categories shown in [Table - 1].
ii. Grade of chronic hepatitis
The grade is a measure of severity of the necroinflammatory process. The Knodell Histological Activity Index (HAI) [19] has been criticized as it combines the necroinflammatory processes and fibrosis; the latter is taken as a measure of the stage of the disease. Schemes that evaluate the degree of inflammation and the extent of necrosis have been published [6],[9],[17],[20],[21] [Table - 2]. An updated version of the Knodell HAI has recently been published [22] .
iii. Stage of chronic hepatitis
Stage refers to the degree and extent of fibrosis. This has been described in a number of recent articles [6],[7],[17],[19],[23] . Assessment requires collagen stains (Masson's Trichrome), to minimize observer variation [24] . The stage is descriptive on the extent of fibrosis with a numerical equivalence [Table - 3].
| Role of the pathologist | | |
The pathologist should provide the following information for the clinician [20] :
- Confirm the diagnosis of chronic hepatitis.
- Indicate the degree of activity (grade).
- Report on the presence or absence and extent of fibrosis (stage).
- Provide an etiological diagnosis based on routine, histochemical and immunohistochemical stains and where necessary in situ hybridization or in situ PCR.
- Describe other lesions that may be present: e.g. alcoholic liver disease, hemosiderosis, granulomas and steatohepatitis.
- Indicate the presence of probable preneoplastic lesions such as liver cell dysplasia in cirrhosis.
- Evaluation of effect of therapy by comparing pretreatment and posttreatment biopsies.
| Role of the clinician | | |
The role of the pathologist is not complete without close collaboration of the clinician. The latter should provide the following information to the pathologist:
- Summary of patient's clinical data (history of drug use, alcohol, family history).
- Profile of liver functions.
- Serological tests for: HBV, HDV, HCV, auto antibodies work up: ANA, AMA. ASA.
- Relevant imaging studies.
| Diagnosis | | |
Chronic hepatitis may not be an easy diagnosis to make on histology alone. This is particularly true when clinical and serological data are not available to the pathologist. Portal inflammation alone may not be sufficient to diagnose chronic hepatitis and therefore terms such as "nonspecific reactive hepatitis" may be used. This is of relatively common occurrence in asymptomatic HCV positive patients. Chronic hepatitis would be suspected only in the presence of lymphocytic piece-meal necrosis or lobular inflammation.
Finally in a comprehensive worked up case the diagnosis should include the etiology, grade and stage, e.g.:
- Chronic hepatitis C, with moderate activity and periportal fibrosis (stage 2).
- Chronic hepatitis B with marked activity and bridging fibrosis (stage 3).
- Chronic hepatitis, autoimmune with moderate activity and cirrhosis (stage 4).
| Conclusion | | |
This review highlights the new terminology of chronic hepatitis. The old terminology of CAH, CPH and CLH, is to be dropped as recommended by the International Working Party [18] . However, in the interim period it is advisable to use the old terminology in parenthesis. The new terminology emphasizes the close collaboration of hepatologists and pathologists so as to streamline reporting and standardize therapeutic modalities.
| References | | |
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Correspondence Address:
Mohamed B Satti
Department of Pathology, & Consultant Pathologist, King Fahd Hospital P.O. Box 40029, Al- Khobar 31952
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 19864819 
[Table - 1], [Table - 2], [Table - 3] |
