Hepatology

METAVIR Fibrosis Score Calculator

Histologic stage of liver fibrosis (biopsy)

Primary source: Bedossa P, Poynard T. Hepatology 1996; 24(2): 289-293

Aleksandr A. Aulov, MD, internal medicine Last clinical review: April 28, 2026

Online calculation

Fibrosis stage (F)

About this score

METAVIR fibrosis staging is a histologic scale for assessing liver fibrosis, developed by the French METAVIR Cooperative Study Group (Bedossa P, et al., Hepatology 1996) for patients with chronic hepatitis C. It is applied by a pathologist to liver biopsy material.

The scale has 5 stages: F0 - no fibrosis; F1 - portal fibrosis without septa; F2 - portal fibrosis with rare septa; F3 - numerous septa without cirrhosis ("advanced fibrosis"); F4 - cirrhosis. F2 and above are considered "significant fibrosis" with clinical consequences. F3-F4 is "advanced fibrosis," at which treatment and monitoring decisions change.

A parallel activity (necroinflammation) scale exists: A0 - none, A1 - mild, A2 - moderate, A3 - severe. METAVIR is the standard scoring system in HCV research and most European clinical laboratories. Alternatives include Knodell and Ishak (more granular).

When to use

Liver biopsy in chronic HCV or HBV - standard pathology report.
Decision to start or change therapy for chronic hepatitis (though less critical in the DAA era).
HCC screening after reaching F3-F4 - mandatory ultrasound + AFP every 6 months regardless of SVR.
Stratification for enrollment in clinical trials.

Clinical example

Case

Liver biopsy in a 52-year-old woman with chronic HCV: architecture preserved, marked lymphocytic infiltrate in the portal tracts, septa forming between some portal tracts, but no false lobules.

Calculation

Numerous septa without cirrhosis = F3. Activity of the lymphocytic infiltrate is moderate = A2.

Interpretation and management

F3A2 - advanced fibrosis, moderate activity. Management: urgent start of DAA therapy (even if previously in remission, F3 is a priority), lifelong HCC screening (ultrasound + AFP every 6 months regardless of DAA success), Child-Pugh assessment if progression to cirrhosis is suspected. At 12 weeks after SVR, repeat noninvasive assessment (FibroScan, FIB-4).

Limitations and cautions

Biopsy is an invasive procedure with risk of bleeding and pain; noninvasive alternatives (FibroScan) are often sufficient.
Sampling error - the specimen represents 1/50,000 of liver volume and may not reflect the overall picture.
Inter-observer variability - two pathologists may assign different stages, particularly F2 vs F3.
Activity and fibrosis do not always correlate - high activity with low fibrosis and vice versa.

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Frequently asked questions

Is F2 serious?

F2 is "significant fibrosis" - the threshold above which most protocols recommend therapy (if the etiology is treatable). In HCV, the DAA era treats all stages regardless of F.

Can F4 be reversed?

Complete regression of cirrhosis is rare but achievable in some patients after removing the cause (SVR in HCV, abstinence in alcoholic liver disease). Partial regression with improved function is more commonly observed.

METAVIR vs Ishak - which is more precise?

Ishak (0-6) is more granular for research purposes. METAVIR (0-4) is simpler for routine practice and is the more widely used system in clinical settings.

Is biopsy needed in the DAA era?

Its use has sharply declined. Most decisions are now based on noninvasive markers. Biopsy remains reserved for conflicting data or unusual etiology.

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Aleksandr A. Aulov Physician, internal medicine, Sechenov School — independent medical education platform. Calculators are compiled from the original publications and current clinical guidelines. Interpretation thresholds follow the source study unless stated otherwise.

This calculator is intended for healthcare professionals. Do not use it for self-diagnosis or self-treatment. Management decisions are made by the treating clinician based on the full clinical picture of the individual patient.