1. | Histological Evaluation |
| 1.1 Are there more than four portal tracts? | ( ) Yes | ( ) No |
| 1.2 Is specimen otherwise considered adequate? | ( ) Yes | ( ) No |
2. | Portal Tract (check one under each category) |
| 2.1 Overall inflammation intensity | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe |
| 2.2 Bile duct inflammation/damage | ( ) Yes | ( ) No |
| 2.3 Granuloma(s) | ( ) Yes | ( ) No |
| 2.4 Bile duct loss | ( ) Yes | ( ) No |
| 2.5 Bile duct/cholangiolar proliferation (any tract) | ( ) Yes | ( ) No |
| 2.6 Bile duct atrophy/pyknosis (majority of tracts) | ( ) Yes | ( ) No |
| 2.7 Florid duct lesion | ( ) Yes | ( ) No |
| 2.8 Fibro-obliterative duct lesion | ( ) Yes | ( ) No |
3. | Inflammatory or necrotizing arteritis | ( ) Yes | ( ) No |
4. | Obliterative arteriopathy | ( ) Yes | ( ) No |
5. | Subendothelial inflammation |
| 5.1 Severity | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe |
| 5.2 Location | ( ) N/A | ( ) Portal | ( ) Central | ( ) Both |
6. | Fibrosis (check one under each category) |
| 6.1 Portal | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe (bridging) |
| 6.2 Central | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe (bridging) |
| 6.3 Architectural distortion | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe |
7. | Lobular disarray/ballooning | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe |
8. | Necrosis (check one under each category) |
| 8.1 Piecemeal or bridging | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe |
| 8.2 Infarct (ischemia) | ( ) Yes | ( ) No |
| 8.3 Other necrosis | ( ) Yes | ( ) No |
| 8.4 Central lobular | ( ) Yes | ( ) No |
9. | Cholestasis | ( ) Yes | ( ) No |
10. | Fat | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe |
| 10.1 Type | ( ) Micro | ( ) Macro | ( ) Mixed | ( ) N/A |
11. | Lobular inflammation (check one under each category) |
| 11.1 Severity | ( ) None | ( ) Mild | ( ) Mod | ( ) Severe |
| 11.2 Location | ( ) N/A | ( ) Perivenular | ( ) Panlobular | ( ) Random/Focal |
| 11.3 Granulomatous | ( ) Yes | ( ) No |
12. | Rejection Activity Index | Range | Score |
| 12.1 Portal inflammation | (0-3) | ( ) |
| 12.2 Bile duct inflammation/damage | (0-3) | ( ) |
| 12.3 Venous endothelial inflammation | (0-3) | ( ) |
| 12.4 Total | (RAI = __/9) |