Assessment of liver damage

Blood Tests

One way of assessing if liver cells are dying is by testing the level of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in the blood. This is not particularly reliable as in most cases of chronic hepatitis C infection the liver function tests tend to fluctuate. Over the space of just a few days the results can vary from normal to noticeably raised. Raised ALT levels are present in around two-thirds of those infected while the remaining third show no evidence of elevated levels at all. These traditional liver function tests are not very effective indicators of liver damage in chronic hepatitis C. Currently the most reliable way to assess the extent of liver damage is by liver biopsy, however a fibroscan or other non-invasive techniques will be sufficient in most cases.

There are also blood tests that are used in the UK as markers of liver damage, such as Fibrotest, Fibrosure, and Actitest. Another way some doctors determine the presence of cirrhosis is by looking over time at the AST/ALT ratio. It seems that if the AST is consistently higher than ALT or equal to it, this is highly suggestive of cirrhosis.


At present the most accurate way to check the extent of liver damage is by biopsy. However, it is very unlikely to be used as there are other less invasive methods available. A liver biopsy is a test in which small pieces of liver tissue are removed and examined under a microscope. This is done via a long needle inserted usually between the 8th and 9th ribs under the right arm. The tissue will be assessed to see the extent of inflammation and fibrosis (as well as revealing other abnormalities such as damage to bile ducts and the presence of fat).

The degree of inflammation is described in terms of inflammatory grade. Fibrosis is described by fibrotic grade. There are several different scoring and grading systems for liver biopsies and the same numbers are not comparable with another system, all of which can seem confusing. The systems used in the UK are the Ishak HAI, the Metavir and the Knodell systems and the Child-Pugh grading system for cirrhosis. The biopsy will indicate which stage of inflammation and fibrosis (scarring) are present in the liver. Inflammatory grade will range from none to extensive inflammation. Fibrotic grade will range from minimal scarring, scarring that has developed outside of the portal tracts (see below), to fibrosis that has spread or is bridging towards neighbouring portal tracts to cirrhosis.

In hepatitis C active fibrosis begins around the portal areas in the liver. The portal areas are tiny tracts of connective tissue within the liver that contain branches of the portal vein (the main blood supply of the liver linking through the small intestine, stomach, pancreas and spleen).

As the fibrosis worsens, it may extend from one portal zone to the others which adjoin it. This is called bridging fibrosis. Bridging fibrosis is the stage before cirrhosis and ranges from early to marked bridging fibrosis. Cirrhosis is characterized by serious scarring that alters the liver’s structure and its ability to function.

The most extensive study of the rate of progression of fibrosis split people into three groups – ‘rapid fibrosers’, ‘intermediate fibrosers’ and ‘slow fibrosers’. The largest group in the study, just over a third, were intermediate fibrosers who would be expected to develop cirrhosis around thirty years after initial infection with HCV. Just over a third of patients were expected to develop cirrhosis in less than 20 years (rapid fibrosers), while just under a third would progress to cirrhosis in more than 50 years, if ever (slow fibrosers).


Fibroscan is a non-invasive test using a sound wave to measure the elasticity of the liver and is being used more and more in the UK. As damage to the liver increases, so it becomes stiffer. The stiffer or less elastic the liver, the faster the sound wave travels. The Fibroscan has been shown to be accurate in measuring little or no damage and in measuring cirrhosis. It has been less accurate at distinguishing intermediate degrees of fibrosis.

The machine is calibrated from 0 to 75, with around 4 representing no liver damage, 4-12 increasing amounts of fibrosis, 12-15 the beginnings of cirrhosis.

Its advantage over a biopsy is that it is quick and completely painless. This is because the probe is simply placed against the skin and nothing is inserted into the body. It is also capable of distinguishing differing degrees of cirrhosis as 80% of its entire range measures cirrhosis. For example, a score of 30 indicates existing or imminent decompensation.