To compare liver histology in HCV RNA positive patients with normal and elevated Alanine Aminotransferase Level (AST).This Cohort (prospective) study was conducted at Civil Hospital Karachi from Jan 2007 to July 2007. Forty patients with positive HCV RNA were included. Their liver function tests were followed for three months. Those having normal ALT on three occasions were taken as controls and those having elevated ALT were taken as cases. Liver biopsy was performed, Specimens were reviewed by single pathologist. Scheuer's scoring for grading of inflammation and staging of fibrosis of chronic hepatitis was used.Out of Forty patients having positive HCV RNA, 14 (35%) were male and 26 (65%) were female. Mean ALT in control group was 27.3 +/- 6.1 u/l, mean ALT in cases was 91.7 +/- 39.95 u/l. Mean age in controls was 34.2 +/- 10.75 years and in cases was 33.6 +/- 9.40 years. On histopathology, the mean grade of inflammation in controls was 1.40 +/- 0.681 while in cases was 1.20 +/- 0.834, which was not statistically significantly different in the two groups (p = 0.411). Similarly mean staging of fibrosis in controls was 1.20 +/- 0.768 and in cases was 1.35 +/- 1.348 which was also not statistically different in the two groups (p = 0.668). Stage 3 and 4 fibrosis was seen only in raised ALT group and not in the controls.Patients with persistently normal ALT and elevated ALT, although had similar grading of inflammation but the fibrosis score was more in elevated ALT group. None of the patients with normal ALT had normal histology, so decision for antiviral treatment should be individualized in this group also.