A systematic review of the quality of liver biopsy specimens

MicroRNA signature at the time of clinical HCV recurrence associates with aggressive fibrosis progression post-liver transplantation

Diagnosis and prediction of the severity of hepatitis C virus recurrence (HCVrec) after liver transplantation (LT) remain a challenge. MicroRNAs have been recently recognized as potential disease biomarkers. Archival liver biopsy samples from 43 HCV+ LT recipients were collected at clinical HCVrec time and at 3 years post-LT. Patients were classified as progressors (P = F0/F1) or nonprogressors (NP = F3/F4) according to the severity of fibrosis on the 3-year biopsy. Training (n = 27) and validation (n = 16) sets were defined. RNA was isolated from all biopsies at clinical HCVrec time, labeled and hybridized to miRNA-arrays. Progressors versus nonprogressors were compared using the two-sample t-test. A p-value ≤0.01 was considered significant. The ingenuity pathway analysis tool was used for microRNA and miRNA:mRNA ontology data integration. Nine microRNAs were differentially expressed between groups. A supervised cluster analysis separated samples in two well-defined groups (progressors vs. nonprogressors). Pathway analysis associated those microRNAs with hepatitis, steatosis, fibrosis, cirrhosis and T cell-related immune response. Data integration identified 17 genes from a previous genomic study as 9-microRNAs signature targets. Seven microRNAs were successfully validated in the validation set using QPCR. We have identified a 9-microRNA signature able to identify early post-LT patients at high risk of severe HCVrec during long-term follow-up.

Sample size requirement for digital image analysis of collagen proportionate area in cirrhotic livers

AIMS

   The requirements for adequate cirrhotic liver biopsy size have not been established for quantitative fibrosis measurements (collagen proportionate area: CPA). We evaluated the CPA of virtual biopsies in cirrhosis to elucidate (i) the amount of tissue required to achieve reliable CPA measurements and (ii) the effect of aetiology on sample size requirements.

METHOD AND RESULTS

   A total of 120 cirrhotic tissue blocks (six aetiologies) were studied. A representative 100 mm(2) region was selected from each block and a reference CPA measured. Each image (n = 120) was divided into 100 × 1 mm(2) images; CPA was measured for each 1 mm(2) and virtual biopsies of different sizes were created from the 1 mm(2) components. For each virtual biopsy size the probability that the virtual biopsy CPA would be within 5% of the reference CPA was calculated. There were 441 000 virtual biopsies. Biopsy size versus probability plots indicated that, for 90% probability that the virtual biopsy CPA can be expected to be within 5% of the reference CPA, 22-28 mm(2) of analysable tissue is required depending on liver disease aetiology; and that a 75% probability level requires a biopsy with 12-15 mm(2) of analysable tissue.

CONCLUSION

   The sample size required for a given probability level depends on the aetiology of cirrhosis, and this should be taken into account when judging the reliability of cirrhotic liver biopsy CPA.

Treatment of chronic hepatitis delta virus with peg-interferon and factors that predict sustained viral response

AIM: To observe the efficacy of peg-interferon in the treatment of hepatitis delta virus (HDV) and to identify the factors that would be predictive of the sustained viral response (SVR).

METHODS: This prospective study was conducted in Medical Unit IV of the Liaquat University of Medical and Health Sciences Hospital Jamshoro from June 2008 to September 2011. This study cohort included all patients of either sex who presented during this time with hepatitis B surface antigen positivity, hepatitis B virus DNA > 20 000 IU/mL, serum glutamic pyruvic transaminase (SGPT) > 2(upper limit of normal), HDV-RNA positivity with fibrosis stage ≥ 2. Informed consent was obtained from each of these individuals. Patients were diagnosed with hepatitis D on the basis of detectable viral antibodies and the presence of HDV-RNA in their serum. A liver biopsy was performed in all cases and fibrosis staging was performed in accordance with the METAVIR scoring system. All eligible patients were administered peg-interferon at a weekly dosage of 1.5 μg/kg body weight for 48 wk. HDV-RNA was assayed at the end of this treatment period and again at 24 wk later. A biochemical response was determined by a normalization of SGPT at the end of the treatment or during follow up. The end of treatment response was defined by a HDV-RNA negative status. A sustained virological response was defined by undetectable serum HDV-RNA at six months after the end of treatment.

RESULTS: Among the 277 patients enrolled in our present study, 238 completed a course of peg-interferon therapy of which 180 (75.6%) were male and 58 (24.4%) female. Biochemical responses were achieved in 122/238 (51.3%) patients. End of treatment responses were achieved in 71/238 (29.8%) cases. A SVR was achieved in 70 of these patients (29.4%). A strong association was found between the SVR and the end of treatment responses (P = 0.001), biochemical responses (P = 0.001) and the degree of fibrosis (P = 0.002).

CONCLUSION: Peg-interferon therapy can induce remission in nearly one third of patients harboring HDV.

Tolerance of liver biopsy in a tertiary care center: comparison of the percutaneous and the transvenous route in 143 prospectively followed patients

BACKGROUND

Transjugular liver biopsy (TJLB) is usually performed when a percutaneous liver biopsy (PLB) is contraindicated. TJLB is an invasive procedure and the patient's tolerance may be variable.

AIM

To compare patient tolerance and quality of the biopsy sample between PLB and TJLB.

PATIENTS AND METHODS

A total of 143 patients underwent a liver biopsy; of these, 75 underwent TJLB and 68 underwent PLB. To evaluate patient tolerance, we used a visual analog scale that scored the intensity of the symptoms. The length of the biopsy sample and the total number of portal tracts per biopsy were also determined for assessment of biopsy quality.

RESULTS

The biopsy sample length was similar in both groups (18.88 ± 8.83 mm on PLB vs. 18.26 ± 10.30 mm on TJLB). No differences were found in the number of portal tracts between the two groups (10.43 ± 8.25 on TJLB vs. 12 ± 10.09 on PLB). Fewer complications were observed in the TJLB group compared with the PLB group (P=0.002).Further, higher degree of pain was reported by patients who underwent PLB compared with patients who underwent TJLB (3.18 ± 3.17 vs. 1.19 ± 2.07); as such, there was a greater need for analgesics on PLB.

CONCLUSION

TJLB and PLB techniques provide similar quality of tissue samples; however, TJLB is less painful and therefore better tolerated by patients.

Does the size of the needle influence the number of portal tracts obtained through percutaneous liver biopsy?

AIM

Liver biopsy (LB) is often essential for the diagnosis and staging of chronic viral hepatitis. The aim of our paper was to establish if the size of the biopsy needle influences the number of portal tracts obtained through LB.

MATERIAL AND METHODS

We conducted a retrospective study on 596 echoassisted percutaneous LBs performed in the Department of Gastroenterology and Hepatology Timisoara during a 4 years period. We included only those biopsy results that had mentioned both the type of needle and the number of portal tracts. All LBs were echoassisted and performed with Menghini modified needles 1.4 and 1.6 mm in diameter (technique with two passages into the liver). The liver fragments were analyzed by a senior pathologist and Knodell score was used to describe necroinflammatory activity as well as fibrosis. We compared the number of portal tracts obtained with 1.4 vs. 1.6 Menghini needles.

RESULTS

Type 1.4 mm Menghini needles were used for 80 LBs, while 1.6 mm type were used in 516 LBs. Liver fragments obtained with 1.6 mm Menghini needles had a significantly higher mean number of portal tracts as compared to those obtained with 1.4 needles (24.5 ± 10.6 vs. 20.8 ± 8.6, p = 0.003).

CONCLUSION

The 1.6 mm Menghini needles provide better liver biopsy specimens, with higher number of portal tracts, as compared to 1.4 mm Menghini needles.

Liver collagen proportionate area predicts decompensation in patients with recurrent hepatitis C virus cirrhosis after liver transplantation

BACKGROUND AND AIMS

Current histological scoring systems do not subclassify cirrhosis. Computer-assisted digital image analysis (DIA) of Sirius Red-stained sections measures fibrosis morphologically producing a fibrosis ratio (collagen proportionate area [CPA]). CPA could have prognostic value within a disease stage, such as cirrhosis. The aim of the present study was to evaluate CPA in patients with recurrent hepatitis C virus (HCV) allograft cirrhosis and assess its relationship with hepatic venous pressure gradient (HVPG).

METHODS

In 121 consecutively-transplanted HCV patients with HVPG, measured contemporaneously with transjugular liver biopsies, 65 had Ishak stage 5 or 6 disease (43 with HVPG measurement). Biopsies were stained with Sirius Red for DIA, and the collagen content was expressed as a CPA. In three cases, a tissue for Sirius Red staining was not obtained, and the patients were excluded.

RESULTS

Sixty-two patients were analyzed. The median HVPG was 8 mmHg (interquartile range [IQR]: 5-10). Portal hypertension (HVPG ≥ 6 < 10 mmHg) was present in 30 (69.8%), and HVPG ≥ 10 mmHg in 13 (30.2%). The median CPA was 16% (IQR 10.75-23.25). Median Child-Pugh score and HVPG were not significantly different between Ishak fibrosis stage 5 or 6, whereas CPA was statistically different: 13% in stage 5 (IQR 8.3-12.4) versus 23% in stage 6 (IQR 17-33.7, P < 0.001). In the multivariate analysis, CPA was the only variable significantly associated with clinically-significant portal hypertension (HVPG ≥ 10 mmHg, odds ratio: 1.085, confidence interval: 1.004-1.172, P = 0.040). A CPA of 14% was the best cut-off value for clinically-significant portal hypertension (CSPH) and liver decompensation, which occurred in 24 patients. Event-free survival was significantly shorter in patients with CSPH or with a CPA value ≥ 14%, or with a combination of both.

CONCLUSION

In Ishak stages 5 and 6, CPA correlated with HVPG, but had a wider range of values, suggesting a greater sensitivity for distinguishing "early" from "late" severe fibrosis/cirrhosis. CPA was a unique, independent predictor of HVPG ≥ 10 mmHg. CPA can be used to subclassify cirrhosis and for prognostic stratification.

Fibrosis distribution in explanted cirrhotic livers

AIMS

Little information is available regarding the distribution of fibrosis within cirrhotic livers. We measured collagen in cirrhotic explants to determine if fibrosis differs (i) between left (L) and right (R) lobes, and (ii) between different aetiologies.

METHODS AND RESULTS

Ten cases each of common aetiologies of cirrhosis were studied: alcoholic liver disease (ALD), primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), hepatitis C virus (HCV) and hepatitis B virus (HBV). A total of 120 tissue blocks (one block each from L and R lobes) were studied. Collagen was measured as collagen proportionate area (CPA), i.e. the proportion of the tissue sections stained by picro-Sirius red. L and R lobes contained similar amounts of fibrosis (r = 0.788; P < 0.0001) with good agreement between L and R lobes (Bland-Altman analysis, R lobe bias = 1.35%). Median CPA across all aetiologies (R plus L lobes) was 21.5%, (L = 8-40%, R = 10-47%). There was more fibrosis in ALD (30%, 15-47%) than PBC (23.5%, 16-34%) and PSC (22.5%, 8-33%), which in turn showed more than AIH (18.5%, 10-40%), HCV (17%, 13-31%) and HBV (16.5%, 8-30%).

CONCLUSIONS

At the time of transplantation cirrhotic livers have different ranges of collagen proportionate area, according to aetiology. R lobe fibrosis corresponds with L lobe fibrosis. The range of fibrosis within each aetiological group could be useful for prognostic subclassification.

High yield of same-session EUS-guided liver biopsy by 19-gauge FNA needle in patients undergoing EUS to exclude biliary obstruction

BACKGROUND

EUS-guided liver biopsy by Trucut yields variable specimen adequacy at high cost, limiting its utility. A modified EUS-guided technique with reliable adequacy could be a viable alternative to standard techniques in cost-effective clinical settings.

OBJECTIVE

To describe our experience with EUS-guided liver biopsy by 19-gauge FNA, non-Trucut, needle in a cost-effective setting: patients with abnormal liver test results of unclear etiology referred for EUS to exclude biliary obstruction in whom an unrevealing EUS would have prompted a next-step liver biopsy by the referring physician.

DESIGN

Prospective case series.

SETTING

Tertiary-care teaching hospital.

PATIENTS

Consecutive patients with abnormal liver tests referred for EUS.

INTERVENTIONS

EUS-guided liver biopsy by 19-gauge FNA needle (non-Trucut).

MAIN OUTCOME MEASUREMENTS

Diagnostic yield, specimen adequacy, and complications. An adequate specimen was defined as a length of 15 mm or longer and 6 or more complete portal tracts (CPTs).

RESULTS

Between July 2008 and July 2011, 22 of 31 consecutive patients meeting inclusion criteria underwent unrevealing EUS with same-session EUS-guided liver biopsy by 19-gauge FNA needle. A median of 2 FNA passes (range 1-3) yielded a median specimen length of 36.9 mm (range 2-184.6 mm) with a median of 9 CPTs (range 1-73 CPTs). EUS-guided liver biopsies yielded a histologic diagnosis and adequate specimens in 20 of 22 patients (91%). Expanded experience led to improved specimen adequacy. There were no complications.

LIMITATION

Small study size.

CONCLUSIONS

EUS-guided liver biopsy by using a 19-gauge FNA needle appears to be feasible and safe and provides excellent diagnostic yield and specimen adequacy.

Is ultrasound elastography of the liver ready to replace biopsy? A critical review of the current techniques

Accurate assessment of liver fibrosis in patients with chronic liver disease is necessary to determine prognosis, monitor disease progression and formulate treatment decisions. Currently, histological staging of liver biopsy is the most widely used reference standard for this purpose. Liver biopsy, however, has recognized risks, as well as sampling and observer error. These limitations have stimulated the search for new non-invasive approaches. Numerous methodologies, including serum markers, magnetic resonance elastography and ultrasound elastography, have evolved in the last decade to predict fibrosis in those with chronic liver disease. Ultrasound elastography methods assess liver fibrosis by determining liver stiffness and translate this into a quantifiable measurement for analysis. As these tests are non-invasive, without side-effect or discomfort, it is possible to conduct repeat examinations at much closer intervals than biopsy. The three most investigated ultrasound elastography methods are transient elastography, realtime elastography and acoustic radiation force impulse. Although significant strides have been made in the development of the technology, an unequivocal advocacy of elastography as a surrogate for biopsy is still not established. The aim of this review is to evaluate the advantages, limitations and clinical relevance of the three ultrasound-based modalities. Also, the review shall assess the current and possible future clinical application the modalities may serve both separate and in conjunction with liver biopsy.

Biomarkers of liver fibrosis: what lies beneath the receiver operating characteristic curve?

Noninvasive biomarkers of liver fibrosis represent an intense area of research with the goals of improving patient care, disease stratification, and aiding the development of future antifibrotic therapies. Despite the rapid progress in recent years, there remain questions about how diagnostic studies are designed, statistical methods to account for spectrum bias, clinically relevant thresholds of fibrosis that should be delineated, how diagnostics can be improved, and strengthening the reference test to judge emerging biomarkers. This review discusses the current methods to address these issues and where further progress is needed.

Usefulness of a novel serum proteome-derived index FI-PRO (fibrosis-protein) in the prediction of fibrosis in chronic hepatitis C

BACKGROUND

Liver biopsy is an imperfect standard for the assessment of chronic hepatitis C liver fibrosis. In this study, the diagnostic role of proteome-derived protein markers and the usefulness of a protein-based index were assessed.

METHODS

Characteristics, clinical biochemistry, and protein markers of patients with chronic hepatitis C from a study (n=62) and validation group (n=73) were statistically assessed according to fibrosis severity. Multivariate models were built using linear discriminant analysis for the prediction of minor fibrosis (F0-F1), moderate fibrosis (F2-F3), and cirrhosis (F4). The best model was validated and diagnostic performance was compared with the aspartate aminotransferase-to-platelet ratio index based on their receiver operator characteristic curves.

RESULTS

Statistical analysis resulted in significant outcomes for both clinical and protein markers. The best multivariate model was based on four protein markers: α-2-macroglobulin (A2M), haptoglobin, hemopexin, and galectin-3-binding protein. A2M and hemopexin were the primary predictors according to this model. A novel index A2M/hemopexin [fibrosis-protein (FI-PRO) index] showed a diagnostic performance rate of 0.80-0.92 for the detection of significant fibrosis (F2-F4) and advanced fibrosis (F3-F4) in the validation group, which was better compared with aspartate aminotransferase-to-platelet ratio index. FI-PRO had an overall positive predictive value of 86% for significant fibrosis and a negative predictive value of at least 90% for advanced fibrosis.

CONCLUSION

Proteome-derived protein markers were successfully implemented in clinical diagnosis of hepatitis C fibrosis, which resulted in the FI-PRO index. The efficiency and usability of FI-PRO should be validated in large-scale, prospective studies.

Elastography for the diagnosis of severity of fibrosis in chronic liver disease: a meta-analysis of diagnostic accuracy

BACKGROUND & AIMS

Transient elastography is a non-invasive method, for the assessment of hepatic fibrosis, developed as an alternative to liver biopsy. We studied the performance of elastography for diagnosis of fibrosis using meta-analysis.

METHODS

MEDLINE, EMBASE, SCI, Cochrane Library, conference abstracts books, and article references were searched. We included studies using biopsy as a reference standard, with the data necessary to calculate the true and false positive, true and false negative diagnostic results of elastography for a fibrosis stage, and with a 3-month maximum interval between tests. The quality of the studies was rated with the QUADAS tool.

RESULTS

We identified 40 eligible studies. Summary sensitivity and specificity was 0.79 (95% CI 0.74-0.82) and 0.78 (95% CI 0.72-0.83) for F2 stage and 0.83 (95% CI 0.79-0.86) and 0.89 (95% CI 0.87-0.91) for cirrhosis. After an elastography result at/over the threshold value for F2 or cirrhosis ("positive" result), the corresponding post-test probability for their presence (if pre-test probability was 50%) was 78%, and 88% respectively, while, if values were below these thresholds ("negative" result), the post-test probability was 21% and 16%, respectively. No optimal stiffness cut-offs for individual fibrosis stages were validated in independent cohorts and cut-offs had a wide range and overlap within and between stages.

CONCLUSIONS

Elastography theoretically has good sensitivity and specificity for cirrhosis (and less for lesser degrees of fibrosis); however, it should be cautiously applied to everyday clinical practice because there is no validation of the stiffness cut-offs for the various stages. Such validation is required before elastography is considered sufficiently accurate for non-invasive staging of fibrosis.

Evaluation of diagnostic coelioscopy including liver and kidney biopsy in freshwater turtles (Trachemys scripta)

The objective of this study was to establish a safe and effective endoscopic technique for the examination of coelomic viscera and for the collection of liver and kidney biopsy specimens from turtles by use of a 2.7-mm rigid endoscopy system that is commonly available in zoologic veterinary practice. Twenty-two adult freshwater turtles (Trachemys scripta) were anesthetized for both left and right coelioscopic examinations. Ease of entry and organ visualization were scored, and liver and kidney biopsy specimens were collected from each turtle by use of 1.7-mm endoscopic biopsy forceps. Biopsy samples were evaluated histologically for quality and crush artifact. Five days after surgery, all turtles were euthanatized and underwent full necropsy examination. For all 22 turtles, left and right mean entry and visualization scores were satisfactory to excellent for all measured parameters except spleen because the spleen was impossible to locate from the left side. No iatrogenic trauma was evident, and biopsy specimens were consistent with tissues collected at necropsy. Liver biopsies suffered from greater crush artifact, compared with kidney biopsies. By use of a 2.7-mm rigid endoscopy system, coelioscopy, liver and kidney biopsy procedures can be performed safely, swiftly, and with ease in turtles. Biopsy specimens obtained by this technique are suitable for histologic examination. Endoscopy is recommended for the examination and biopsy of coelomic viscera in chelonians.

Should we routinely measure portal pressure in patients with cirrhosis, using hepatic venous pressure gradient (HVPG) as a guide for prophylaxis and therapy of bleeding and rebleeding? No

Portal hypertension (PH) is a severe complication of liver cirrhosis. Measurement of the degree of portal hypertension is usually performed by measuring the hepatic venous pressure gradient (HVPG) which is the difference between the free hepatic venous pressure (FHVP) and the wedged hepatic venous pressure (WHPG). The HVPG accurately reflects the degree of PH in the majority of liver diseases. PH is defined by an increase of HVPG values above the normal upper limit of 5 mm Hg, while clinically significant PH is defined by an HVPG to ≥10 mm Hg. Although measurement of HVPG potentially has several applications, in clinical practice its major use has been related to the assessment of hemodynamic response to pharmacological therapy, in order to evaluate the efficacy of treatment and to predict the risk of rebleeding from esophageal varices. When properly performed, HVPG is a reliable, safe and good predictive tool in the management of portal hypertension. However, the need for appropriate equipment, sufficient and reliable operators and costs, have discouraged its use outside Liver Units specifically devoted to the clinical management of portal hypertension. This has diminished its applicability. Combining its use with transjugular liver biopsy and using the prognostic value of HVPG may help encourage its use.

Noninvasive tests for evaluation of fibrosis in HCV recurrence after liver transplantation: a systematic review

Noninvasive tests (NIT) for evaluation of hepatic fibrosis have not been evaluated extensively in liver transplantation. We systematically reviewed the literature regarding NIT after liver transplantation. We identified 14 studies evaluating NIT based on serum markers and/or liver imaging techniques: 10 studies assessed NIT in recipients with recurrent HCV infection for fibrosis and four studies evaluated predictors of progression of fibrosis in recurrent HCV. Transient Elastography (TE) had good discrimination for significant fibrosis (median AUROC: 0.88). Among the serum NIT, APRI had good performance (median AUROC: 0.75). TE performed better than serum (direct and indirect) NIT for significant fibrosis with median AUROC 0.88 (vs. 0.66, P < 0.001), median sensitivity 0.86 (vs. 0.56, P = 0.002), median NPV 0.90 (vs. 0.74, P = 0.05) and median PPV 0.80 (vs. 0.63, P = 0.02). TE compared to indirect serum NIT, had better performance, but was not superior to APRI score. Finally, direct, compared to indirect NIT, were not significantly different except for specificity: median: 0.83 vs. 0.69, respectively, P = 0.04. In conclusion, NIT could become an important tool in clinical management of liver transplant recipients, but whether they can improve clinical practice needs further evidence. Their optimal combination with liver biopsy and assessment of collagen content requires investigation.

Perspectives on fibrosis progression in hepatitis C: an à la carte approach to risk factors and staging of fibrosis

The morbidity and mortality of chronic hepatitis C is related to progressive fibrosis and the development of cirrhosis. The development of fibrosis in patients with HCV is highly influenced by immune status, host response to the virus and associated factors, such as, age, sex, alcohol intake, diabetes, obesity and coinfection with other viruses. The rate of fibrosis progression differs depending on several factors, including the stage of fibrosis and the time since infection. Routine assessment of fibrosis through biopsy every 3-5 years has poor patient acceptance and reliability, and might result in missed opportunities to improve or modify treatment priorities. Enhanced understanding of the pathophysiology of liver fibrosis in HCV infection has led to the development of a number of non-invasive assessment modalities. The ideal test would discriminate fibrosis in the categories none/early (stages 0/1), intermediate (stage 2) and advanced fibrosis/cirrhosis (stages 3/4) and be readily available, inexpensive and accurate. Biomarker tests utilize individual or combined serum markers to determine the degree of fibrosis. Other strategies combine biomarkers with clinical variables, such as patient age or utilize liver imaging or functional assessments. Incorporation of appropriately validated non-invasive assessments of liver fibrosis will likely improve the clinical care of patients with HCV infection.

Antiviral therapy reduces portal pressure in patients with cirrhosis due to HBeAg-negative chronic hepatitis B and significant portal hypertension

BACKGROUND/AIMS

Lamivudine improves liver histology in patients with chronic hepatitis B (CHB), but its effects on portal pressure remain unknown. We evaluated the effect of lamivudine monotherapy on hepatic venous pressure gradient (HVPG) in CHB-related cirrhosis with significant portal hypertension.

METHODS

We studied 19 patients with cirrhosis due to HBeAg-negative CHB and HVPG >or=10 mm Hg treated with oral lamivudine (100mg daily). Liver biochemistry, Child-Pugh and MELD score were determined every 3 months, alpha-fetoprotein and HBV DNA every 6 months and HVPG at baseline and at 12 months after lamivudine initiation. Diuretics, beta-blockers, antibiotics and/or endoscopic therapy were used for routine indications.

RESULTS

At 12 months, a significant reduction was observed in ALT (p=0.001), HBV DNA (p=0.002), Child-Pugh (p=0.012) and MELD score (p=0.006). Four patients developed virological breakthrough during treatment. At 12 months, HVPG decreased in all but one patient [baseline: 14.4+/-3.9 and 12 months: 12.4+/-3.3 mm Hg (p=0.007)]. HVPG decreased >20% or below the 12 mm Hg threshold in 10 of 13 patients with baseline HVPG >or=12 mm Hg. HVPG increased in a patient with hepatic flare after virological breakthrough.

CONCLUSION

In conclusion, in patients with cirrhosis due to HBeAg-negative CHB, lamivudine monotherapy reduces HVPG, especially when virological suppression and biochemical remission is achieved.

Azathioprine in liver transplantation: a reevaluation of its use and a comparison with mycophenolate mofetil

Calcineurin inhibitors (CNIs) combined with steroids with or without azathioprine (AZA), have been a standard immunosuppression regimen after liver transplantation (LT). Since 2000 many centers have substituted AZA by mycophenolate mofetil (MMF). However, in LT the superiority of MMF over AZA is not clearly demonstrated. Therefore, we questioned the benefit of MMF versus AZA in LT with regard to rejection, renal dysfunction and hepatitis C virus (HCV) recurrence and survival. Using a literature search, relevant randomized controlled trials (RCT) and cohort studies were identified: two RCTs compared MMF to AZA only for acute rejection. Treated rejection was less with MMF in only one RCT (38.5% vs. 47.7%; p = 0.025), with no difference in patient and graft survival. No RCTs compared MMF and AZA in patients with CNI-related chronic renal dysfunction. Among two studies evaluating MMF, with substitution of AZA, one was stopped due to severe rejection. Recurrent HCV was less severe in 5/9 studies with AZA compared with 2/17 using MMF, six of which documented worse recurrence. Published data in LT show little, if any, clinical benefit of MMF versus AZA. RCTs should reevaluate AZA in LT. Evaluation of HCV replication and recurrence will be particularly important as AZA may have advantages over MMF.

Computer-assisted image analysis of liver collagen: relationship to Ishak scoring and hepatic venous pressure gradient

Histopathological scoring of disease stage uses descriptive categories without measuring the amount of fibrosis. Collagen, the major component of fibrous tissue, can be quantified by computer-assisted digital image analysis (DIA) using histological sections. We determined relationships between DIA, Ishak stage, and hepatic venous pressure gradient (HVPG) reflecting severity of fibrosis. One hundred fifteen patients with hepatitis C virus (HCV) who had undergone transplantation had 250 consecutive transjugular liver biopsies combined with HVPG (median length, 22 mm; median total portal tracts, 12), evaluated using the Ishak system and stained with Sirus red for DIA. Liver collagen was expressed as collagen proportionate area (CPA). Median CPA was 6% (0.2-45), correlating with Ishak stage (stage 6 range, 13%-45%), and with HVPG (r = 0.62; P < 0.001). Median CPA was 4.1% when HVPG was less than 6 mm Hg and 13.8% when HVPG was 6 mm Hg or more (P < 0.0001) and 6% when HVPG was less than 10 mm Hg and 17.3% when HVPG was 10 mm Hg or higher (P < 0.0001). Only CPA, not Ishak stage/grade, was independently associated by logistic regression, with HVPG of 6 mm Hg or more [odds ratio, 1.206; 95% confidence interval (CI), 1.094-1.331; P < 0.001], or HVPG of 10 mm Hg or more (odds ratio, 1.105; 95% CI, 1.026-1.191; P = 0.009). CPA increased by 50% (3.6%) compared with 20% in HVPG (1 mm Hg) in 38 patients with repeated biopsies.

CONCLUSION

CPA assessed by DIA correlated with Ishak stage scores and HVPG measured contemporaneously. CPA was a better histological correlate with HVPG than Ishak stage, had a greater numerical change when HVPG was low, and resulted in further quantitation of fibrosis in cirrhosis.

Effects of liver biopsy sample length and number of readings on sampling variability in nonalcoholic Fatty liver disease

BACKGROUND & AIMS

Liver biopsy is required to diagnose nonalcoholic steatohepatitis (NASH) in patients with suspected non-alcoholic fatty liver disease (NAFLD); recent studies suggested significant sampling variability. Using percutaneous liver biopsy samples from patients with suspected NAFLD, we examined the relationship between histological yield and length of biopsies, number of cores and number of independent readings.

METHODS

Three cores of liver tissue were collected, by percutaneous liver biopsy, from each of 50 patients suspected to have NAFLD. The diagnostic yield (percent with definite NASH) and other histological findings from 2 independent, blinded examinations of 2 cores and from all 3 cores combined were assessed.

RESULTS

Steatosis, lobular inflammation and fibrosis scores were significantly higher when 3 samples were analyzed, compared with 2. However, between groups, there were no significant differences in hepatocyte ballooning, proportion with an NAFLD activity score > or =4 or proportion with definite NASH (57% vs 61%, P = .3). The length of the biopsy sample correlated with percentage of patients found to have definite NASH (29%, 46%, 56%, and 65% in biopsies measuring <10 mm, 10-14 mm, 15-24 mm, and > or =25 mm, respectively; P < .0001). When biopsy specimens were read twice by the same pathologist, the composite of the 2 independent readings yielded a significantly higher yield for several histological features, compared with the first reading.

CONCLUSIONS

There is a significant relationship between histological yield and sample length and number of independent readings of liver biopsy samples. More studies are needed to optimize the strategy for liver biopsy, to more effectively assess histology in patients with suspected NAFLD.

Initial experience with EUS-guided Tru-cut biopsy of benign liver disease

BACKGROUND

Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tissue acquisition is traditionally obtained by a surgical, transvascular, or percutaneous route.

OBJECTIVE

To describe our initial experience with EUS-guided Tru-cut biopsy (EUS-TCB) of benign liver disease.

DESIGN

A prospective case series.

SETTING

A tertiary-referral hospital in Indianapolis, Indiana.

PATIENTS

Consecutive subjects undergoing EUS with suspected hepatic parenchymal disease.

INTERVENTIONS

EUS-TCB of the liver.

MAIN OUTCOME MEASUREMENTS

Liver biopsy specimen yield, diagnosis, and procedural complications. Specimens were routinely stained with hematoxylin and eosin and with special stains for reticulin, iron, and trichome. Each case was reviewed by a single experienced pathologist for the number of portal spaces, total specimen length, and final diagnosis. An adequate specimen was defined as 6 or more complete portal tracts.

RESULTS

Between February 2007 and March 2008, 21 consecutive patients (mean age 45 years; 13 women) were evaluated. The most common indications for liver biopsy were suspected nonalcoholic steatohepatitis (n = 9), intrahepatic cholestasis (n = 4), and suspected cirrhosis (n = 3). Transgastric biopsy (median 3 passes, range 1-4) into the left lobe (n = 18) or both the left and caudate lobe (n = 3) yielded a median total specimen length of 9 mm (range 1-23 mm). The median total number of portal tracts in the specimen was 2 complete (range 0-10) plus 3 partial (range 0-8) tracts. Six or more complete portal tracts were present in 6 of 21 (29%). A histologic diagnosis was obtained in 19 of 21 (90%). There were no complications.

LIMITATIONS

The small sample size and low-risk population.

CONCLUSIONS

In our initial experience, transgastric EUS-TCB of suspected benign liver disease by using a 19-gauge needle appears safe and feasible. Samples obtained are usually smaller than those traditionally considered adequate for histologic assessment. Further refinement of this technique appears indicated.

Adequacy of endoscopic ultrasound core needle biopsy specimen of nonmalignant hepatic parenchymal disease

BACKGROUND & AIMS

The adequacy and diagnostic yield of hepatic parenchymal disease Trucut biopsy have not been determined. Therefore, our aim was to determine the adequacy of endoscopic ultrasound (EUS)-guided Trucut liver biopsy for histopathologic evaluation to include the number of complete portal tracts contained per millimeter of acquired tissue.

METHODS

A single institution retrospective review was made of 9 prospectively identified patients who underwent a transgastric left liver lobe EUS-guided Trucut biopsy during a 36-month period.

RESULTS

Adequate diagnostic material, to include complete portal tract number evaluation (median, 7) and connective tissue staining, was acquired to establish a histopathologic diagnosis in all 9 cases. Sixty-three complete portal tracts were established, resulting in 0.4 portal tracts per millimeter of tissue acquired. Findings established by EUS Trucut left liver lobe biopsy included mild steatosis (n = 4), cryptogenic cirrhosis (n = 2), chronic ductopenic biliary tract disease (n = 1), portal fibrosis with ductular proliferation (n = 1), and alcoholic cirrhosis with hemosiderosis (n = 1).

CONCLUSIONS

EUS-guided Trucut left liver lobe biopsy yields suitable aggregate tissue for diagnostic purposes to establish the presence of chronic liver disease.

Review article: the therapeutic and prognostic benefit of portal pressure reduction in cirrhosis

BACKGROUND

Hepatic venous pressure gradient (HVPG) measurement is not a routinely used technique, despite its therapeutic and prognostic value.

AIM

To review the role of HVPG from published literature.

METHODS

Systematic literature review.

RESULTS

In acute variceal bleeding, HVPG is prognostic identifying 'difficult to treat' group, which now has defined clinical correlations. In secondary prevention of portal hypertensive bleeding, a reduction to < or = 12 mmHg confers near complete protection against rebleeding. The target of > or = 20% HVPG reduction from baseline needs prospective assessment to test a change of therapy, if no reduction occurs. The acute HVPG response to beta-blockade needs further assessment. In primary prevention, the cost-effectiveness of HVPG measurement is not favourable given the efficacy of medical therapy. In chronic liver disease, wedge hepatic venous pressure (WHVP) is prognostic for survival. Pharmacological reduction in portal pressure decreases complications and improves survival, possibly independent of a concomitant improvement in liver function. This latter requires urgent confirmation as it is clinically very relevant. HVPG monitoring can be used to assess anti-viral therapy particularly in cirrhosis, ergonomically combined with transjugular biopsy.

CONCLUSIONS

The prognostic and therapeutic value of HVPG is established beyond portal hypertensive bleeding for which there are some clinical surrogates. HVPG measurement should now be part of everyday clinical practice.

Preventative hepatology: minimising symptoms and optimising care

Most care of liver disease is in the ambulatory setting, and therefore the clinical needs of patients represent those of any other chronic illness. Emphasis must be given to preventative strategies such that liver lifetime (including pre-emptive strategies related to potential allograft survival) is maximised through timely intervention and avoidance of side effects. This review addresses the pertinent practical clinical concerns faced by clinicians as they manage adult patients with chronic liver disease, with an emphasis on preventing and managing symptoms and complications directly and indirectly related to the underlying disease.

Proteomics in liver fibrosis is more than meets the eye

Liver fibrosis is a serious health issue for many liver patients and is currently diagnosed using liver biopsy. The erroneous nature of this technique urges the search for better, noninvasive alternatives. In this regard, proteomics has been described as a useful biomarker discovery tool and has become increasingly applied in the study of liver fibrosis. Experimental and clinical studies have already provided deeper insights in the molecular pathways of liver fibrosis and even confirmed previous findings. Recent advances in proteomic strategies and tools enable multiple fractionation, multiple protein identifications and parallel analyses of multiple samples. Despite its increasing popularity, proteomics still faces certain pitfalls concerning preanalytical variability, protein coverage and statistic reliability. Proteomics is still evolving, but will undoubtedly contribute to a better understanding of the basics of the pathology and certainly offer opportunities in liver fibrosis diagnostics and therapeutics.

Pathology of chronic hepatitis C in children: liver biopsy findings in the Peds-C Trial

There is relatively little information in the literature on the histopathology of chronic hepatitis C in children. The Peds-C Trial, designed to test the efficacy and safety of peginterferon alfa-2a and ribavirin in children, provided an opportunity to examine liver biopsies from 121 treatment-naïve children, ages 2 to 16 (mean, 9.8 years) infected with the hepatitis C virus (HCV) and with no other identifiable cause for liver disease, signs of hepatic decompensation, or another significant nonhepatic disease. Liver biopsies were scored for inflammation, fibrosis, steatosis, and other histological features. Inflammation in the biopsy was minimal in 42%, mild in 17%, moderate in 38%, and severe in only 3%. Five had bridging fibrosis, and 2 had cirrhosis. Steatosis was absent in 56%, minimal in 34%, and mild in 10%. Inflammation scores correlated with fibrosis scores, serum alanine aminotransferase levels, and duration of infection, but not with age, body mass index z score, or HCV genotype. Fibrosis scores correlated with inflammation but not with age, HCV genotype, body mass index z score, or steatosis parameters. Steatosis correlated with serum alanine aminotransferase levels and body mass index z scores; overweight children had more fibrosis than the non-overweight. In conclusion, in this cohort of HCV-infected children, inflammation, fibrosis, and steatosis were milder than reported for treatment-naïve adults with chronic hepatitis C, but there were several with bridging fibrosis or cirrhosis. The positive correlation of inflammation with duration of infection and fibrosis and of obesity with fibrosis suggest that children with chronic hepatitis C will be at risk for progressive liver disease as they age and possibly acquire other comorbid risk factors.

Percutaneous liver biopsy in clinical practice

Percutaneous liver biopsy (PLB) is the standard procedure for obtaining hepatic tissue for histopathological examination, and remains an essential tool in the diagnosis and management of parenchymal liver diseases. The use of liver biopsy (LB) is increasing with the advent of liver transplantation and the progress being made in antiviral therapeutic agents. While blind percutaneous needle biopsy is the traditional technique, the use of ultrasound (US) guidance has increased considerably. Literatures were reviewed to assess the existing clinical practice of PLB with an emphasis on the technique, the operator, types of biopsy needles, quality of LB specimens and the risk of complications. The best available evidence indicates that the use of ultrasound-guided biopsy (UGB) is superior to blind needle biopsy (BNB). The odds ratios of the controlled studies showed that BNB carried a higher risk for major complications, postbiopsy pain and biopsy failure. Therefore, percutaneous LB under US control is superior to BNB and it is recommended that UGB be considered the standard of care for this important and widely used invasive procedure in the field of clinical hepatology.

Quantitative assessment of hepatic fibrosis in an animal model with magnetic resonance elastography

Chronic liver disease is a world-wide problem that causes progressive hepatic fibrosis as a hallmark of progressive injury. At present, the gold standard for diagnosing hepatic fibrosis is liver biopsy, which is an invasive method with many limitations, including questionable accuracy and risks of complications. MR elastography (MRE), a phase-contrast MRI technique for quantitatively assessing the mechanical properties of soft tissues, is a potential noninvasive diagnostic method to assess hepatic fibrosis. In this work, MRE was evaluated as a quantitative method to assess the in vivo mechanical properties of the liver tissues in a knockout animal model of liver fibrosis. This work demonstrates that the shear stiffness of liver tissue increases systematically with the extent of hepatic fibrosis, as measured by histology. A linear correlation between liver stiffness and fibrosis extent was well-defined in this animal model. An additional finding of the study was that fat infiltration, commonly present in chronic liver disease, does not significantly correlate with liver stiffness at each fibrosis stage and thus does not appear to interfere with the ability of MRE to assess fibrosis extent. In conclusion, MRE has the potential not only for assessing liver stiffness, but also for monitoring potential therapies for hepatic fibrosis.

Ultrasound-based transient elastography for the detection of hepatic fibrosis: systematic review and meta-analysis

BACKGROUND & AIMS

Ultrasound-based transient elastography is a promising noninvasive alternative to liver biopsy for detecting hepatic fibrosis. However, its overall test performance in various settings remains unknown. The aims of this study were to perform a systematic review and meta-analysis of diagnostic accuracy studies comparing ultrasound-based transient elastography with liver biopsy for hepatic fibrosis.

METHODS

Electronic and manual bibliographic searches to identify potential studies were performed. Selection of studies was based on reported accuracy of ultrasound-based transient elastography compared with liver biopsy. Data extraction was performed independently by 2 reviewers. Meta-analysis combined the sensitivities, specificities, and likelihood ratios of individual studies. Extent and reasons for heterogeneity were assessed.

RESULTS

Nine studies in full publication were identified. For patients with stage IV fibrosis (cirrhosis), the pooled estimates for sensitivity were 87% (95% confidence interval [CI], 84%-90%), specificity 91% (95% CI, 89%-92%), positive likelihood ratio 11.7 (95% CI, 7.9-17.1), and negative likelihood ratio 0.14 (95% CI, 0.10-0.20). Among 7 investigations reporting patients with stages II-IV fibrosis, the pooled estimates for sensitivity were 70% (95% CI, 67%-73%), specificity 84% (95% CI, 80%-88%), positive likelihood ratio 4.2 (95% CI, 2.4-7.2), and negative likelihood ratio 0.31 (95% CI, 0.23-0.43). Diagnostic threshold (or cut-off value) bias was identified as an important cause of heterogeneity for pooled results in both patient groups.

CONCLUSIONS

Ultrasound-based transient elastography appears to be a clinically useful test for detecting cirrhosis.

Hepatic venous pressure gradient to assess fibrosis and its progression after liver transplantation for HCV cirrhosis

Progression of fibrosis following recurrent hepatitis C virus (HCV) infection is frequent after liver transplantation (LT). Histology remains the gold standard to assess fibrosis, but the value of hepatic venous pressure gradient (HVPG) is being explored. We evaluated patients with recurrent HCV infection after LT to assess whether HVPG correlates with liver histology, particularly fibrosis. A total of 90 consecutive patients underwent 170 HVPG measurements concomitant with transjugular liver biopsy (TJB), with 31.5 (range, 6-156) months of follow up. Median biopsy length was 22 mm and total portal tract count was 12 (complete 6, partial 6). Median HVPG was 4 mmHg: 38% of patients > or =6 mmHg (portal hypertension, PHT), 13% > or =10 mmHg. HVPG correlated with Ishak stage (r = 0.73, P < 0.001) for mild (0-3) and severe fibrosis (4-6), and grade score (r = 0.47, P < 0.001), but neither correlated with interval from LT nor biopsy length. HVPG was > or =10 mmHg in 15 patients: 12 had stage 5 or 6, and 3 severe portal expansion. HVPG was repeated in 49, between 7 and 60 months with weak correlation to fibrosis score (r = 0.30, P = 0.045). A total of 12 patients with HVPG > or =6 mmHg had fibrosis score < or =3, while 8 patients had normal HVPG but fibrosis stage > or =4. These discrepancies were mostly associated with specific histological features such as perisinusoidal fibrosis rather than errors in measuring HVPG. In 29 with HVPG <6 mmHg at 1 yr, none decompensated compared to 4 of 13 (31%) with PHT. In conclusion, HVPG correlates with fibrosis and its progression, due to recurrent HCV infection, assessed in TJB.

Ultrasound-guided liver biopsy in real life: comparison of same-day prebiopsy versus real-time ultrasound approach

BACKGROUND AND AIM

Currently, an increasing number of liver biopsies are performed by radiologists under real-time ultrasound control. A routine ultrasound assessment of a puncture site before performing percutaneous biopsy is reported to increase diagnostic yield and decrease complication rates. It is not clear if real-time ultrasound is superior to marking the puncture site before biopsy as regards reducing biopsy size and avoiding fragmentation and complications. The aim of this study was to compare ultrasound assessment of the puncture site before performing percutaneous liver biopsy with real-time ultrasound liver biopsy for suspected diffuse liver disease.

METHODS

Consecutive percutaneous liver biopsies (n = 631) for diffuse liver disease were evaluated. Group A consisted of patients who had real-time guided-ultrasound biopsy performed by radiologists (241 patients; M/F, 35/106; median age 48 year [range, 17-76]; needle 18 G). Group B patients were assessed by radiologists using ultrasound of the puncture site on the same day that biopsies were performed by experienced gastroenterologists/hepatologists on the ward using the marked site (390 patients; M/F, 276/114; median age 43 year [range, 15-75]; needle 16 G).

RESULTS

There were no differences in severity of liver disease, establishing a diagnosis (OR, 1.92 [95% CI, 0.84-4.34]; P = 0.12), length of liver biopsy specimens, number of fragments or complications. Two independent variables were significantly associated with a histological diagnosis: longer biopsy length (P < 0001) and fragment number of two or less (P < 0.001).

CONCLUSION

Real-time ultrasound did not improve diagnostic yield or result in fewer complications. Marking the puncture site seems adequate and has the practical advantage that it takes up less of the radiologists' time.

Noninvasive diagnosis of hepatic fibrosis in chronic hepatitis C

Assessment of hepatic fibrosis is important for determining prognosis, guiding management decisions, and monitoring disease. Histological evaluation of liver biopsy specimens is currently considered the reference test for staging hepatic fibrosis. Since liver biopsy carries a small but significant risk, noninvasive tests to assess hepatic fibrosis are desirable. This editorial gives an overview on noninvasive methods currently available to determine hepatic fibrosis and their diagnostic accuracy for predicting significant fibrosis and cirrhosis in chronic hepatitis C. Based on available data, the performance of simple tests derived from routine laboratory parameters appears to be similar to that of more complex and expensive fibrosis panels. Transient elastography seems more accurate than blood tests for diagnosing cirrhosis.

Transjugular liver biopsy--indications, adequacy, quality of specimens, and complications--a systematic review

Transjugular liver biopsy (TJLB) is considered an inferior biopsy, used when percutaneous liver biopsy (PLB) is contraindicated. According to recent literature, specimens with 6 complete portal tracts (CPTs) are needed for histological diagnosis of chronic liver disease but 11 CPTs to reliably stage and grade. Mean CPT number in PLB series is 7.5; more passes increase complications. Sixty-four series reporting 7649 TJLBs were evaluated for quality of specimen and safety. Major indications were coagulation disorders and/or ascites. Success rate was 96.8%. Fragmentation rate was 34.3%, not correlating with length or diagnostic adequacy. With a mean of 2.7 passes, mean CPT number was 6.8. Histological diagnosis was achieved in 96.1% of TJLBs, correlating with length (p=0.007) and CPT number (p=0.04). Tru-Cut specimens had a mean CPT number of 7.5 and, compared to Menghini specimens, were longer (p<0.008), less fragmented (p<0.001) and more diagnostic (p<0.001). Thinner needles (>16-G) provided significantly longer and less fragmented specimens. Minor and major complication rates were 6.5% and 0.56%, respectively, and increased in children, but not with additional passes. In adults, mortality was 0.09% (haemorrhage 0.06%; ventricular arrhythmia 0.03%). TJLB is safe, providing specimens qualitatively comparable to PLB, and may improve further using > or = 18-G Tru-Cut needle and >3 passes.

Evaluation of an endoscopic liver biopsy technique in green iguanas

OBJECTIVE

To establish a safe and effective endoscopic technique for collection of liver biopsy specimens from lizards by use of a 2.7-mm rigid endoscope system that is commonly available in zoologic veterinary practice.

DESIGN

Prospective study.

ANIMALS

11 subadult male green iguanas (Iguana iguana).

PROCEDURES

Each lizard was anesthetized, and right-sided coelioscopic examination of the right liver lobe and gallbladder was performed. Three liver biopsy specimens were collected from each lizard by use of a 2.7-mm rigid endoscope and 1.7-mm (5-F) biopsy forceps. Biopsy samples were evaluated histologically for quality and crush artifact. Ten days following surgery, all iguanas were euthanatized and underwent full necropsy examination.

RESULTS

For all 11 iguanas, the right liver lobe and gallbladder were successfully examined endoscopically, and 3 biopsy specimens of the liver were collected without complications. Mean +/- SD durations of anesthesia and surgery were 24 +/- 7 minutes and 6.8 +/- 1.0 minutes, respectively. At necropsy, there was no evidence of trauma or disease associated with the skin or muscle entry sites, liver, or any visceral structures in any iguana. All 33 biopsy specimens were considered acceptable for histologic interpretation; in most samples, the extent of crush artifact was considered minimal.

CONCLUSIONS AND CLINICAL RELEVANCE

By use of a 2.7-mm rigid endoscope, liver biopsy procedures can be performed safely, swiftly, and easily in green iguanas. Biopsy specimens obtained by this technique are suitable for histologic examination. For evaluation of the liver and biopsy specimen collection in lizards, endoscopy is recommended.

Transjugular liver biopsy in patients with diffuse liver disease: comparison of three cores with one or two cores for accurate histological interpretation

BACKGROUND

Transjugular liver biopsy (TJLB) can be performed to obtain more than two cores safely. This advantage has not been evaluated in terms of diagnostic accuracy or grading/staging evaluation.

AIM

To evaluate whether three separate cores of TJLB provide more histological information compared with two or one cores.

METHODS

Twenty-three patients, who had three separate passes, with each core >/=7mm in length using a 19G Tru-cut needle, were evaluated. Each TJLB was blindly coded; the pathologist randomly assessed: (a) each core separately covering the other two, (b) two cores simultaneously covering the third and (c) the three cores together for diagnostic yield, inflammation and fibrosis.

RESULTS

The mean TJLB length was 32+/-5.5mm. In 12 one-core (52%) and 18 2-core (78%) assessments, diagnosis (mainly cirrhosis) was made correctly in each core. The within-patient standard deviations for one-core vs two-core assessment were similar for grading (0.42 and 0.47, respectively), but higher for staging (0.39 and 0.15, respectively). Staging was underestimated in assessing one-core and less for two cores compared to three cores.

CONCLUSION

Three non-fragmented cores (each core >/=7mm in length) of TJLB can be considered a minimum requirement for histological assessment, giving better reproducibility in diagnosis as well as for inflammation and fibrosis.