DIAGNOSIS OF FIBROSIS.
The complete evaluation of a patient with diffuse liver diseases requires clinical evaluation, laboratory tests, and pathological examination. The liver biopsy is regarded as the historical gold standard for diagnosis and assessment of prognosis in CLD.[28,29] At least three scoring methods are commonly used to stage liver fibrosis: the Knodell, Ishak, and METAVIR scores.[30,31] The Knodell and METAVIR score fibrosis from stage 04, with stage 4 as cirrhosis, whereas Ishak scores fibrosis from 06 where 5 is incomplete or early cirrhosis and 6 indicates established cirrhosis.[32] These methods are semi-quantitative and the invasiveness of liver biopsies with its associated life-threatening risks and morbidity make it a poor choice when considering assessment of liver fibrosis progression or regression. Furthermore, there is the issue of sampling error, defined as variable levels of fibrosis throughout the liver, with biopsy only examining a small (1/50,000) portion of the liver.[33,34] Liver biopsy has been shown to have significant inter and intraobserver variability among pathologists, with an average 20% error rate in the staging of fibrosis.[35] The minimum suitable length of liver tissue needed for assessing liver fibrosis reliably is 25 mm and the presence of an experienced hepatopatholgist is important.[34