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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Liver biopsy is considered the gold standard for assessing the grade of liver injury, the stage of liver fibrosis, and in guiding therapy. Recent guidelines advise obtaining a liver biopsy only in patients in which a biopsy would alter the course of treatment. Characteristic findings of hepatitis C on biopsy include interface hepatitis, cytoplasmic dissociation, steatosis, prominence of Kuppfer cells, and lymphoid follicle formation.

Liver Biopsy

Liver biopsy is considered the gold standard for assessing the grade of liver injury (inflammation graded 1 to 4) and stage of liver fibrosis (0 to 4 with the METAVIR score, and 0 to 6 with the Ishak score) prior to the initiation of therapy. The other main objectives include guidance of medical therapy, and identifying advanced fibrosis that necessitates monitoring for esophageal varices and hepatocellular carcinoma.[1] With more recent guidelines, although still recommended, liver biopsy is reserved to those patients in which a biopsy would alter the course of treatment.[2] This recommendation takes into consideration that despite being a preferred approach, liver biopsy is invasive and has a significant risk for severe complications. Liver biopsies are also subject to sampling errors.[3] Generally, a liver biopsy is not indicated in patients with HCV genotypes 2 and 3 as approximately 80% of these patients achieve a sustained virological response. There is ongoing debate about the use of liver biopsy in patients with genotype 1 and the less common genotypes 4,5, and 6.[1]


Chronic hepatitis C is characterized by interface hepatitis also known as piecemeal necrosis. This lymphocytic infiltrate is intially periportal. If patients remain untreated, continuous erosion of the hepatic parenchyma will lead to expanded portal areas with eventual fibrosis. Other characteristic findings include:[4]

  • Cytoplasmic dissociation (swelling of hepatocytes with cytoplasmic rarefaction)
  • Hepatocyte apoptosis
  • Steatosis
  • Sinusoidal inflammatory infiltrates
  • Prominence of Kupffer cells
  • Lymphoid follicle formation
  • Bile duct epithelial changes


  1. 1.0 1.1 Ghany MG, Strader DB, Thomas DL, Seeff LB, American Association for the Study of Liver Diseases (2009). "Diagnosis, management, and treatment of hepatitis C: an update". Hepatology. 49 (4): 1335–74. doi:10.1002/hep.22759. PMID 19330875.
  2. Dienstag JL (2002). "The role of liver biopsy in chronic hepatitis C." Hepatology. 36 (5 Suppl 1): S152–60. doi:10.1053/jhep.2002.36381. PMID 12407589.
  3. Yee HS, Chang MF, Pocha C, Lim J, Ross D, Morgan TR; et al. (2012). "Update on the management and treatment of hepatitis C virus infection: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Office". Am J Gastroenterol. 107 (5): 669–89, quiz 690. doi:10.1038/ajg.2012.48. PMID 22525303.
  4. Ishak KG (2000). "Pathologic features of chronic hepatitis. A review and update". Am J Clin Pathol. 113 (1): 40–55. doi:10.1309/42D6-W7PL-FX0A-LBXF. PMID 10631857.

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