Comparative Evaluation of Haematoxylin-Eosin and Masson's Trichrome Staining, with Non-Invasive Indices (FIB-4 and APRI), for Staging Liver Fibrosis: A Blinded Dual-Reader Biopsy Study in Iraq

Introduction: Accurate staging of liver fibrosis informs prognosis and management in chronic liver disease. Whether stain choice affects staging reproducibility, and how simple serum indices complement histology, remain incompletely studied in Iraqi patients. Methods: In this cross-sectional study, 80 liver biopsies (METAVIR F0, F1–F2, F3, F4; n = 20 each; HBV, HCV, NAFLD, and other aetiologies) were stained with haematoxylin-eosin (H&E) and Masson's trichrome and independently re-staged by two blinded pathologists. FIB-4 and APRI were calculated; diagnostic performance was assessed using receiver operating characteristic analysis and Spearman correlations. Results: Inter-reader agreement was higher for Masson's trichrome (weighted κ = 0.979) than for H&E (κ = 0.939). Agreement with the original diagnostic stage was 93.8–96.2% versus 76.2–87.5%, respectively. FIB-4 and APRI showed acceptable discrimination of advanced fibrosis (≥F3 area under the curve 0.873 and 0.886, respectively), and both indices correlated strongly with histological stage (ρ ≈ 0.71) and morphometric collagen area (ρ ≈ 0.69). Conclusion: Masson's trichrome improved the reproducibility of fibrosis staging compared with H&E, and FIB-4 and APRI performed acceptably as non-invasive adjuncts that complement, rather than replace, histological assessment. These findings require validation in larger, multicentre studies.