liver biopsy presents a very useful tool in the diagnosis and management of various liver diseases . most histological laboratories use perls stain as a routine special stain to evaluate the amount of iron present in liver biopsies . in oman , the examination of liver biopsies is also a routine histopathological test counting for about 102 biopsies a year . hematoxylin and eosin ( h and e ) stain , which is the most widely used histological stain , gives an excellent general morphological picture of the nucleus , and cytoplasmic details . iron can be seen in h and e stain as a gold - brown granules in macrophages . however , most histopathologists prefer perls or prussian blue stain to evaluate the presence of iron in liver biopsies as considered to be the gold standard . in perls stain , the forming precipitate is insoluble in acid and , therefore , acid solutions are used as counterstains . the aim of this study was to evaluate the efficiency of h and e stain in demonstrating iron in liver biopsies as well as to determine the possibility of replacing perls stain by h and e stain . this study was ethically approved by the medical research committee and ethics committee ( # 519 ) . slides of perls and h and e stains of liver biopsies were taken from the archival files of the department of pathology from 2006 to 2011 . totally , 238 pairs of slides ( perls and h and e ) were found and 38 pairs were excluded because they had insufficient materials and so 200 pairs were obtained . briefly , in all pairs , liver biopsies were first fixed in 10% neutral buffered formalin for 24 h and histoprocessed . the blocks were then cut into sections of 3 m thickness using a rotary microtome . the sections were stained with harris h and e and perls stains . for each batch of perls stains , the positive result of iron was defined by detecting blue deposits as an intracellular pigment . while in h and e stain , the iron deposits were defined by detecting golden - brown pigments as intracellular granules . formalin pigment was excluded from the assessment as it stains deep brown to black color . the degree of staining of iron in perls and h and e stains was graded by the following criteria ; absent , trace , sparse , moderate , and abundant . of the 200 cases , 97 were negative using both perls and h and e stains while 84 were positive by both stains . the remainder had discordant results : seventeen were positive by h and e but negative with perls ( false positives ) . h and e stain missed iron in 2 cases , which were positive on perls [ table 1 ] . of these 17 cases , 8 were graded as trace , 8 as sparse , and one was graded as moderate [ table 2 ] . h and e stain revealed 97.67% sensitivity , 85.08% specificity , 90.5% accuracy , positive predictive valve 83.16% , and 97.98% , negative predictive value [ table 3 ] . 18 out of 33 ( 54% ) cases were graded as a trace in both perls stain and h and e stain [ figures 1 and 2 ] . furthermore , 21 cases ( 100% ) showed an abundant iron with both stains [ figures 3 and 4 ] . comparison of h and e and perls staining methods on the liver biopsy sections comparison of the grade of iron between h and e and perls staining methods accuracy of h and e staining method in the diagnosis of 200 liver biopsies perls stain showing iron pigment in liver biopsy ( trace grade ) ( 40 ) h and e stain showing liver pigment in liver biopsy ( trace grade ) ( 40 ) perls stain showing iron pigment in liver biopsy ( abundant grade ) ( 40 ) h and e stain showing iron pigment in liver biopsy ( abundant grade ) ( 40 ) the findings of this study showed that h and e stain has 97.7% sensitivity and 85.08% specificity in demonstrating iron pigment in the examined liver biopsies . these data are in line with our recent study showing that h and e stain was sensitive in 86% in demonstrating iron pigment in bone marrow trephine biopsies . another study showed a sensitivity of 70% for the detection of iron pigment in bone marrow trephine biopsies using h and e stain . it is noteworthy that the studies on liver biopsy to evaluate iron pigment on perls and h and e stained slides are very scanty . hematoxylin and eosin staining demonstrates a good morphological details of nucleus , and cytoplasm . on the other hand , in addition , perls stain requires to be prepared fresh , consumes time , and the reagents are costly . if one slide can combine all the histopathological details including the demonstration of iron , it will subsequently save histologist and pathologist time . only 2% showed the absence of iron using h and e stain while perls stain showed positive reaction for iron pigment . there are many reasons for the absence of iron in the liver biopsies using h and e stain ; difficulties to visualize small pigments , inability to show all content of iron , and probably the color of h and e stain overrides the iron brown color . in fact , this finding is in line with other similar studies which showed higher percentage in which perls staining of the bone marrow trephine biopsies was positive , but no iron was seen on the h and e stained sections . despite the perls stain representing an extra step to be performed , it is preferred due to its simplicity and specificity in detecting blue iron pigment in a red background and excluding mimics . fixation is an important factor in the evaluation of iron content in the liver biopsies . in this study , thus , the formation of formalin pigment was unlikely to occur . if it occurs , it is easy to identify formalin pigment as mentioned previously . the 17 cases which showed only brown pigments in perls stain and were thought to contain iron in h and e stain would demonstrate as other pigments like lipofuscin or bile pigments which also have a golden brown color but are not iron . these pigments can lead to mis - diagnosis as iron pigment in h and e stain and can be distinguished from iron by their location . we demonstrate that the h and e stain is a sensitive method to detect iron pigment in liver biopsies , particularly when present in large quantities . a negative h and e stain might obviate the need for extra perls staining , thus saving costs and shortening report turn - around times .
background : perls stain is routinely used to demonstrate iron in liver biopsies . 
 we tested the hypothesis that it may be unnecessary in cases , where no iron or another similar pigment was seen on the routine hematoxylin and eosin ( h and e ) stained section.aim:the aim of this study was to evaluate the efficiency of h and e stain in demonstrating iron in liver biopsies as well as to determine the possibility of replacing perls stain with h and e stain.materials and methods : two hundred pairs of slides of liver biopsies were taken from the archival files of the department of pathology from 2006 to 2011 . 
 perls and h and e slides were independently reviewed for the presence of iron.results:hundred and one cases showed the presence of iron using h and e stain . 
 84 of 86 cases showed positive iron using both perls and h and e stains . 
 seventeen cases were positive using h and e stain but negative with perls. only two cases did not show the presence of iron using h and e stain . 
 ninety - seven cases were negative using both perls and h and e stains . 
 h and e stain showed a sensitivity , specificity , accuracy , positive predictive valve , and negative predictive value of 97.67% , 85.08% , 90.5% , 83.16% , and 97.98% , respectively.conclusion:we demonstrate that the h and e stain is a sensitive method to detect iron pigment in liver biopsies , particularly when present in large quantities . 
 a negative h and e stain might obviate the need for extra perls staining , thus saving costs and shortening report turn - around times .