Transjugular liver biopsy

Miliary tuberculosis diagnosed by diffuse hepatic uptake on PET/CT and transjugular liver biopsy

The patient was an 81-year-old man. In his 20s, he had been treated with pharmacotherapy for pulmonary tuberculosis for 1 year. He presented to the Department of Respiratory Medicine with a chief complaint of dyspnea. The possibility of respiratory disease appeared to be low, but hepatic impairment was detected. The patient was thus referred to our department. Though the cause of hepatic impairment was unknown, the soluble interleukin-2 receptor level was elevated, suggesting malignant lymphoma. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) revealed diffuse, homogenous, intense FDG uptake in the entire liver, and transjugular liver biopsy confirmed the diagnosis. Histopathological examination revealed an epithelioid granuloma, and auramine staining was positive for bacilli suggestive of tuberculosis. CT revealed diffuse micronodular shadows in the lung, yielding a diagnosis of miliary tuberculosis. Therefore, the patient was prescribed antituberculosis medication by the Department of Respiratory Medicine. His subsequent clinical course was good. The miliary (hepatic) tuberculosis was typical based on the diffuse, homogenous, intense FDG uptake throughout the liver observed on PET-CT.

Endoscopic ultrasound-guided tissue acquisition for the diagnosis of focal liver lesion

In patients with liver tumors, the histopathology examination can assist in diagnosis, staging, prognosis, and therapeutic management strategy. Endoscopic ultrasound (EUS)-guided tissue acquisition using fine needle aspiration (FNA) or more newly fine needle biopsy (FNB) is a well-developed technique in order to evaluate and differentiate the liver masses. The goal of the EUS-FNA or EUS-FNB is to provide an accurate sample for a histopathology examination. Therefore, malignant tumors such as hepatocarcinoma, cholangiocarcinoma and liver metastasis or benign tumors such as liver adenoma, focal hyperplastic nodular tumors and cystic lesions can be accurately diagnosed using EUS-guided tissue acquisition. EUS-FNB using 19 or 22 Ga needle provide longer samples and a higher diagnostic accuracy in patients with liver masses when compared with EUS-FNA. Few data are available on the diagnostic accuracy of EUS-FNB when compared with percutaneously, ultrasound, computer tomography or transjugulary-guided liver biopsies. This review will discuss the EUS-guided tissue acquisition options in patients with liver tumors and its efficacy and safety in providing accurate samples. The results of the last studies comparing EUS-guided liver biopsy with other conventional techniques are presented. The EUS-guided tissue acquisition using FNB can be a suitable technique in suspected liver lesions in order to provide an accurate histopathology diagnosis, especially for those who require endoscopy.

Endohepatology: The endoscopic armamentarium in the hand of the hepatologist

ABSTRACT

Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.

Comparison of the Safety of Transjugular and Percutaneous Liver Biopsies

PURPOSE

To compare adverse events (AEs) between the transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) approaches.

MATERIALS AND METHODS

A total of 1,300 patients who underwent liver biopsy between July 1, 2014 and January 31, 2018, were examined, and bivariate and multivariate analyses were used to determine predictors of the biopsy method used and AEs. To reduce bias in the comparison of the AE rates between patients who had TJLB or PLB, propensity score matching was used to control for baseline disease severity.

RESULTS

PLB and TJLB were performed in 601 and 699 patients, respectively. The mean Charlson Comorbidity Index score was 3 (±2), and antiplatelet or anticoagulation therapy at the time of biopsy was used in <10% of patients. Patients with suspected cirrhosis or portal hypertension (odds ratio [OR], 9.9), an international normalized ratio of >1.5 (OR, 5.9), or a platelet count of <100 × 103/mL (OR, 3.9) were more likely to undergo TJLB. After propensity matching, which identified a population of patients with a mean international normalized ratio of <1.5 and platelet count of >150 × 103/mL, the only difference in the AE rate was for pain, which was present in 8% and 10% of patients after TJLB and PLB, respectively (P < .001). Bleeding requiring transfusion occurred in 2 patients who underwent TJLB and 1 patient who underwent PLB. There was 1 case of death occurring after TJLB.

CONCLUSIONS

Severe/life-threatening AEs occurring after liver biopsy were uncommon, and the 2 liver biopsy approaches appeared to have similar safety profiles for low-risk patients. After matching for underlying disease severity, pain was the AE that was more likely to occur in patients who underwent PLB.

Transjugular liver biopsy: enlarge the indications for liver biopsy with reliable diagnostic quality

BACKGROUND

Complications and diagnostic efficiency for liver biopsy are main concerns for clinicians. This study aimed to assess the safety and efficacy of transjugular liver biopsy (TJLB) compared with percutaneous liver biopsy (PLB) when patients had equal level of liver function and number of passes, using propensity score matching (PSM).

METHODS

The clinical and pathological data of patients who received TJLB or PLB between January 2012 and October 2022 were collected. Matching factors included age, gender, cirrhosis, portal hypertension, liver function, creatinine, number of passes, hemodialysis, history of anti-coagulation and anti-platelet, and comorbidities. Coagulation indexes were not considered as matching factors due to different indications of the two techniques.

RESULTS

2711 PLBs and 30 TJLBs were evaluated. By PSM, 75 patients (50 PLBs, 25 TJLBs) were matched. The complication rates for TJLB and PLB were 4.0% (1/25) and 10.0% (5/50) (P > 0.05). Two PLBs had hepatic hemorrhage, one of which required only close monitoring (Grade 1) and the other needed hemostasis and rehydration therapy (Grade 2). The other 3 cases presented with mild abdominal pain (Grade 1). And only one TJLB presented with mild pain. The median number of complete portal tracts were 6.0 and 10.0 for TJLBs and PLBs (P < 0.05). Moreover, the median length of sample for TJLBs and PLBs were 10.0 and 16.5 mm (P < 0.05). The diagnostic efficiency of hepatopathy of unknown etiology of TJLB versus PLB groups before and after matching were 96.4% vs. 94.1% and 95.7% vs. 93.2%, respectively (P > 0.05).

CONCLUSION

TJLB is an effective invasive diagnostic procedure that expands indications for liver biopsy with reliable diagnostic quality.

Quantitative analysis of tissue area of endoscopic ultrasound-guided liver biopsy specimens using 19-gauge fine-needle biopsy needle in patients with diffuse liver disease: A single-center retrospective study

BACKGROUND/PURPOSE

Endoscopic ultrasound-guided liver biopsy (EUS-LB) is a novel liver biopsy technique. We aimed to evaluate the efficacy and safety of EUS-LB in comparison with percutaneous liver biopsy (PLB).

METHODS

This retrospective study evaluated the safety and efficacy of EUS-LB using a 19-gauge fine needle biopsy (FNB) needle compared with PLB using a spring-loaded 16-gauge needle in patients with diffuse liver disease at our hospital from April 2017 to December 2020. The primary outcomes included the total hepatic tissue surface area and the total number of portal tracts. Secondary outcomes included the success and adverse event rates.

RESULTS

Twenty patients each underwent EUS-LB and PLB. There was no statistical difference in the sum of liver tissue surface area (22 mm² vs 22.6 mm² , P = .910) and the total number of portal tracts (29 vs 25, P = .916). The success rate was 95% (19/20) for EUS-LB and 100% (20/20) for PLB (P = 1). There were two adverse events in the PLB group but none in the EUS-LB group (P = .487).

CONCLUSIONS

Endoscopic ultrasound-guided liver biopsy using FNB has an optimal tissue yield and success rate and is safe compared to PLB. Thus, EUS-LB may be a new alternative to PLB.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

Prevention of bleeding after percutaneous biopsy with a small intestinal submucosa hemostatic plug

Percutaneous biopsies (PBs) are the gold standard diagnostic procedures indicated for renal and hepatic disorders. Nevertheless, they can cause hemorrhages and are contraindicated for coagulopathic patients. In this study we designed, fabricated, and evaluated a small intestinal submucosa (SIS) plug to reduce, and potentially cease, bleeding to decrease death risk after percutaneous hepatic and renal biopsies in healthy and coagulopathic in vivo models. First, the plug's blocking capacity was determined with an increase in its diameter of 24 ± 11% after immersion in human blood, and the capacity to induce clotting on its surface. The plug's in vivo performance was evaluated in a healthy porcine model, which showed minimal inflammatory reaction without side effects confirmed by histological results after 30 days. The plug's response in the coagulopathic model was assessed using heparinized swine for 2 days, which revealed localized microhemorrhages and mild inflammatory response without any lesions to the surrounding tissue. No major adverse events nor macroscopic hemorrhages were detected in the animal models. Furthermore, we assessed the plug's efficacy to reduce and stop bleeding using a transplant-discarded human liver model (n = 14). In this case, the mass of blood lost was 43.8 ± 21.8% lower in plugged transplant-discarded human liver biopsies compared to control biopsies without a plug. The bleeding was stopped within three minutes in 92% of plugged cases, but only in 8% of non-plugged cases. We demonstrated the feasibility of making a hemostatic SIS plug, which does not induce major inflammatory reaction and can effectively reduce and stop bleeding after PBs in non-coagulopathic and coagulopathic in vivo models, and in a transplant-discarded human liver model. STATEMENT OF SIGNIFICANCE: Percutaneous biopsy (PB) is a gold standard diagnostic procedure, but it can provoke life-threatening complications and is contraindicated for patients with coagulopathic disorders. This study demonstrates that small intestinal submucosa (SIS) can be manufactured into a biocompatible thrombogenic plug, insertable through a commercial Tru-Cut needle sheath. This device takes advantage of the collagen-rich composition of SIS to stop and reduce bleeding more effectively than the traditional PB, indicating that it could be routinely employed in a traditional biopsy to increase safety, or as a cost and time-reducing alternative to transjugular biopsy for coagulopathic patients.

Clinical Usefulness of Transjugular Liver Biopsy in Patients With Hematological Diseases With Liver Dysfunction

Introduction

Transjugular liver biopsy (TJLB) is indicated for patients in whom percutaneous liver biopsy is contraindicated, such as those with hematological diseases complicated by liver dysfunction. However, the clinical utility of TJLB in this group of patients has not been thoroughly investigated. The objective of this study is to evaluate the clinical efficacy of TJLB in patients with hematological diseases complicated by liver dysfunction.

Methods

We analyzed the data of patients who developed liver disorders during treatment for hematological diseases at our hospital and required tissue diagnosis via TJLB. The clinical features of patients were analyzed.

Results

Twenty-seven patients (mean age, 60.07 years; 12 men, 15 women) requiring tissue diagnoses via TJLB after developing liver disorders while undergoing treatment for hematological diseases were enrolled. One patient with autoimmune hemolytic anemia was diagnosed with drug-induced liver injury; two patients with amyloidosis had nonalcoholic steatohepatitis; one patient with acute promyelocytic leukemia had a drug-induced liver injury; one patient with chronic myelomonocytic leukemia had liver infiltration caused by an underlying disease; three patients with idiopathic thrombocytopenic purpura had autoimmune hepatitis; four patients with malignant lymphoma had liver infiltration by the underlying disease, and one patient with multiple myeloma had liver disorder caused by disseminated intravascular coagulation. Moreover, one patient had hepatitis B reactivation, another had hepatitis E, and six patients had a drug-induced liver injury. The treatment regimen was altered in cases of liver infiltration caused by the underlying disease, and the drug was changed for patients with drug-induced liver injury.

Conclusion

The etiology of liver disorders in patients with hematological diseases varies widely. Therefore, histological diagnosis using TJLB is useful to determine an appropriate therapeutic strategy for underlying hematological diseases.

Transjugular Liver Biopsy

Transjugular liver biopsy (TJLB) was first performed in 1970 and has since become a standard procedure in interventional radiology practices. TJLB can be used when a percutaneous liver biopsy is contraindicated, such as patients with ascites, coagulopathy, congenital clotting disorders or for patients undergoing concurrent evaluation for portal hypertension. While TJLB specimens tend to be smaller with less complete portal triads numerous studies have shown the samples to be adequate for diagnosis and staging. This article will review what the interventional radiologist needs to know about TJLB including indications/work-up, technical details, tips and tricks, and complications.

Transjugular liver biopsy and hepatic venous pressure gradient measurement in patients with and without liver cirrhosis

BACKGROUND

Transjugular liver biopsy (TJLB) and hepatic venous pressure gradient (HVPG) measurement are diagnostic procedures for patients with acute and chronic liver diseases. Technical execution of TJLB and HVPG may be challenging in patients with advanced liver disease.

OBJECTIVE

We studied consecutive TJLB and HVPG procedures and investigated technical success, complications, quality of biopsies, indications and treatment changes in patients with and without liver cirrhosis.

METHODS

In the study period from 2010 to 2018, 575 consecutive TJLB and HVPG procedures were analyzed. Demographic characteristics, procedure-related and follow-up data were extracted from medical records.

RESULTS

In total, 259 (45%) patients were diagnosed with liver cirrhosis whereas 316 (55%) patients had no evidence of advanced chronic liver disease. Technical success of TJLB was significantly higher in patients without liver cirrhosis (287; 92%) compared to patients with liver cirrhosis [184; 76.7% (P = 0.001)]. Technical success of HVPG measurement was not different between both groups (P = 0.553). Liver biopsy specimens were significantly shorter in patients with liver cirrhosis (P = 0.001). Medical therapy was adjusted in 163 (28.4%) patients. In patients with liver cirrhosis, results of TJLB led less frequently to therapy initiation or adjustment compared to patients without liver cirrhosis (P = 0.001). In multivariate analysis, liver cirrhosis (Exp(B) 1.866; P = 0.012), alanine aminotransferase (Exp(B) 0.248; P < 0.001) and INR (Exp(B) 0.583; P = 0.027) were independently associated with treatment change.

CONCLUSION

Technical success and therapeutic decisions of TJLB are directly linked to presence or absence of liver cirrhosis.

Liver Biopsy in Pregnancy: Two Case Reports and Review of the Literature

The etiology of most cases of liver diseases in pregnancy can be diagnosed with a thorough history, physical examination, laboratory values, serology, and noninvasive imaging. However, atypical clinical and laboratory presentations of liver diseases/chemistries require a liver biopsy to render an accurate diagnosis in cases where the biopsy results affect the timing of delivery or impact choice of medical therapy. According to the American College of Gastroenterology, liver biopsy can be effectively and safely conducted in pregnant women. Conventional routes of performing a liver biopsy include the percutaneous, transjugular route, and surgical methods. Endoscopic ultrasound-guided liver biopsy is a recent technique that has not yet gained widespread adoption but can potentially serve as an alternative route for obtaining the liver sample. Adverse events associated with liver biopsy include abdominal pain and hemorrhage. Maternal and fetal outcomes are limited to increased risk of preterm birth and small for gestational age neonate. However, very few studies have formally evaluated the safety of liver biopsy in pregnant women. In this review, we present two successful cases of liver biopsy performed during pregnancy and summarize the most recent evidence regarding the safety and outcomes of the procedure in pregnancy to assist clinicians in their decision to perform a liver biopsy during pregnancy or postpone it until after delivery.

The utility and complications of plasma administration in cirrhotic patients undergoing minimally invasive procedures

Patients with cirrhosis have coagulopathy often necessitating correction with blood products, such as plasma products (fresh frozen plasma and plasma frozen within 24 h) prior to certain invasive procedures. However, plasma administration has the potential for substantial negative adverse effects such as volume overload, transfusion-related lung injury and allergic/anaphylactic reactions. In addition, its effectiveness in preventing bleeding is similarly unclear. The purpose of this study was to determine the safety and efficacy of plasma administration in cirrhotic patients undergoing minimally invasive procedures, specifically vascular access placement, transjugular liver biopsies, renal biopsies and thoracenteses. In this retrospective cohort study, we identified patients receiving plasma products in preparation for an invasive procedure, with the primary outcomes of volume overload and bleeding. Of the 145 transfusion events that met the criteria from 2015 to 2018, the median INR decreased from 2.7 to 2.2 pre and post plasma administration and 13.8% of recipients had complications of volume overload. The cost of acquisition of plasma administered below clinically impactful doses accumulates to an estimated 19 000 dollars over this time period, not including nursing preparation or production costs. Plasma products minimally, if at all, improved laboratory values of coagulation and in some patients led to adverse effects.

Endo-hepatology: An emerging field

Gastroenterologists have long been spearheading the care of patients with various forms of liver disease. The diagnosis and management of liver disease has traditionally been a combination of clinical, laboratory, and imaging findings coupled with percutaneous and intravascular procedures with endoscopy largely limited to screening for and therapy of esophageal and gastric varices. As the applications of diagnostic and therapeutic endoscopic ultrasound (EUS) have evolved, it has found a particular niche within hepatology now coined endo-hepatology. Here we discuss several EUS-guided procedures such as liver biopsy, shear wave elastography, direct portal pressure measurement, paracentesis, as well as EUS-guided therapies for variceal hemorrhage.

Intravascular Ultrasound-Guided Transvenous Biopsy of Abdominal and Pelvic Targets Difficult to Access by Percutaneous Needle Biopsy: Technique and Initial Clinical Experience

PURPOSE

To report initial clinical experience with intravascular ultrasound (US)-guided transvenous biopsy (TVB) for perivascular target lesions in the abdomen and pelvis using side-viewing phased-array intracardiac echocardiography catheters.

MATERIALS AND METHODS

In this single-institution, retrospective study, 48 patients underwent 50 intravascular US-guided TVB procedures for targets close to the inferior vena cava or iliac veins deemed difficult to access by conventional percutaneous needle biopsy (PNB). In all procedures, side-viewing phased-array intracardiac echocardiography intravascular US catheters and transjugular liver biopsy sets were inserted through separate jugular or femoral vein access sheaths, and 18-gauge core needle biopsy specimens were obtained under real-time intravascular US guidance. Diagnostic yield, diagnostic accuracy, and complications were analyzed.

RESULTS

Intravascular US-guided TVB was diagnostic of malignancy in 40 of 50 procedures for a diagnostic yield of 80%. There were 5 procedures in which biopsy was correctly negative for malignancy, with a per-procedure diagnostic accuracy of 90% (45/50). Among the 5 false negatives, 2 patients underwent repeat intravascular US-guided TVB, which was diagnostic of malignancy for a per-patient diagnostic accuracy of 94% (45/48). There were 1 (2%) mild, 2 (4%) moderate, and 1 (2%) severe adverse events, with 1 moderate severity adverse event (venous thrombosis) directly attributable to the intravascular US-guided TVB technique.

CONCLUSIONS

Intravascular US-guided TVB performed on difficult-to-approach perivascular targets in the abdomen and pelvis resulted in a high diagnostic accuracy, similar to accepted thresholds for PNB. Complication rates may be slightly higher but should be weighed relative to the risks of difficult PNB, surgical biopsy, or clinical management without biopsy.

Accuracy and Safety of 1,055 Transjugular Liver Biopsies in Postliver Transplant Patients

INTRODUCTION

The purpose of this study was to investigate the rates of complications and diagnostic yield of transjugular liver biopsy (TJLB) in deceased donor liver transplant (DDLT) recipients.

METHODS

From January 2009 to December 2019, 1,055 TJLBs were performed in 603 adult DDLT recipients with a mean age of 54 (±12 years). Data were retrospectively reviewed to determine the diagnostic efficacy and incidence of major and minor complications in the 3-day and 1-month period after TJLB. In addition, data were stratified according to platelet count and international normalized ratio to determine the safety of TJLB in patients with varying degrees of coagulopathy.

RESULTS

TJLB yielded diagnostic rate of 98.1% (1,035/1,055), with an overall complication rate of 8.3% (88/1,055). Major complications accounted for 0.85% (9/1,055), and minor complications occurred in 7.48% (79/1,055). When patients were stratified by platelet count (0-50, 51-100, 101-200, 201-300, and >300 × 103 platelets/μL), no significant difference was noted in complication rates (9.5%, 8.6%, 7.6%, 8.5%, and 10.7%, respectively). When grouped by international normalized ratio (0-1, 1.1-2.0, 2.1-3.0, and >3.0), there was no statistical difference in complication rates (8.3%, 8.5%, 7.7%, and 0%, respectively).

DISCUSSION

TJLB is a safe, adequate, and effective method to investigate hepatic disorders in DDLT recipients with severe coagulopathy.

Transjugular Liver Biopsy with Hemodynamic Evaluation: Correlation between Hepatic Venous Pressure Gradient and Histologic Diagnosis of Cirrhosis

Objectives:

Measurement of hepatic vein pressures is the accepted gold standard for the evaluation of portal hypertension. This study was conducted to evaluate the correlation between hepatic vein pressure measurements and histologic findings from transjugular liver biopsies. The hypothesis was that higher hepatic venous pressure gradients would correlate with a histologic diagnosis of cirrhosis.

Material and Methods:

We identified all patients who underwent transjugular liver biopsies at our institution between January 2015 and December 2019. Of these, 178 patients who had undergone hemodynamic evaluations during the biopsy procedure were included in the study. Demographic information and laboratory data were extracted from the patients’ electronic medical records. The hepatic vein pressure gradient (HVPG) was determined by subtracting the free hepatic venous pressure from the wedged hepatic venous pressure (WHVP), and the portosystemic gradient (PSG) was determined by subtracting the right atrial pressure from the WHVP. HVPG and PSG were compared by linear regression analysis and by calculating their receiver operating characteristics (ROC).

Results:

HVPG and PSG measurements were significantly associated with cirrhosis, with area under the ROC curve of 0.79 and 0.78, respectively. At the optimal cutoff of 9 mmHg, sensitivity and specificity for HVPG were 71% and 83% for HVPG and 67 % and 81% for PSG, respectively. No statistical difference was observed between the two measurements.

Conclusion:

A transhepatic venous pressure gradient above a cutoff of 9 mmHg is predictive of histologic cirrhosis, regardless of whether it is expressed as HVPG or PSG, with acceptable to excellent performance characteristics.

Feasibility and Safety of Transjugular Liver Biopsy for Japanese Patients with Chronic Liver Diseases

Background and study aim: Transjugular liver biopsy (TJLB) can be used in patients who are ineligible for percutaneous liver biopsy (PLB) with acute and chronic hepatic disease. This study aimed to evaluate the usefulness and safety of TJLB in patients who were not indicated for PLB. Methods: Between July 2014 and February 2019, a total of 134 patients underwent liver biopsies at our institution. Among these, PLB was performed in 110 patients and TJLB in 24 patients. A retrospective comparison of clinical results in these patients was then performed. The primary endpoints of this study were the utility and safety of TJLB in patients who were not indicated for PLB. Results: The procedural success rate was 100% in both groups. The clinical response rate and the effective tissue sampling rate were 100% in the TJLB group and 97% in the PLB group (p = 0.55). There was no difference in the number of portal fields examined retrospectively between the two groups. No serious adverse events were observed in either group. Conclusions: It is suggested that TJLB is useful because it can be safely performed in patients with poor general condition who are not indicated for PLB.

Safety and adequacy of endoscopic ultrasound-guided random liver biopsy in comparison with transjugular and percutaneous approaches

Background and study aims  Endoscopic ultrasound-guided liver biopsy (EUS-LB) is an accepted technique for tissue acquisition. Traditionally, random LB has been performed with percutaneous (PC-LB) and transjugular (TJ-LB) approaches. The purpose of this study was to compare the safety profile and efficacy of EUS-LB, PC-LB, and TJ-LB. Patients and methods  A retrospective analysis was performed at a tertiary academic medical center. Inclusion criteria for analysis were all adult patients who underwent EUS-LB since inception and TJ-LB/PC-LB over a 3-year span (June 2016 to June 2019). The primary outcome assessed was any adverse events. Secondary outcomes included technical success resulting in tissue acquisition and diagnostic adequacy of the sample for histologic analysis. Results  A total of 513 patients were included for analysis. There were 135 EUS-LB, 287 PC-LB, and 91 TJ-LB. The most common indication for LB was abnormal liver function tests. For the primary outcome, the rate of adverse events was low with five reported (< 1 %). There were two in the EUS-LB group, two in the PC-LB group, and one in TJ-LB group, and this difference was not statistically significant ( P  = 0.585). The technical success rate was 100 % in each group. The rate of diagnostic adequacy was 100 % in TJ-LB group and 99 % in both EUS-LB and PC-LB groups. This difference was not statistically significant ( P  = 1.000). The most common histologic finding was non-specific changes (33.7 %) followed by non-alcoholic steatohepatitis (15.60 %). Conclusion  In comparison with PC-LB and TJ-LB, EUS-LB has comparable safety profile, technical success rate, and diagnostic adequacy. EUS-LB should be considered as an option for random liver biopsy.

Safety of percutaneous versus transjugular liver biopsy: A propensity score matched analysis

PURPOSE

This study sought to identify the complication, mortality, and readmission rates of patients undergoing either percutaneous (PCLB) or transjugular liver biopsy (TJLB) when propensity matched for demographics and hepatic comorbidities.

METHODS

A retrospective review of New York's Statewide Planning and Research Cooperative System ICD9 coded database from the years 2009-2013 was conducted. Patients over the age of 18 undergoing either PCLB or TJLB were included. Patients with hepatic neoplasm or metastasis were excluded. 2:1 PCLB:TJLB propensity match for age, race, payment, coagulopathy, thrombocytopenia/purpura, hypercoagulability, ascites, acute liver failure, chronic hepatitis, cirrhosis, and bone marrow disease was conducted. Univariate analysis compared demographics, complications, readmissions, and mortality.

RESULTS

1467 patients met inclusion criteria (PCLB = 978, TJLB = 489). Propensity match was successful in that there were no significant differences in demographics or hepatic comorbidities. TJLB had significantly lower rates of hematoma (0.20 % vs 1.20 %, p = 0.049) and higher rates of cardiac complications (0.40 % vs 0.00 %, p = 0.045). Other complication, readmission, and mortality rates did not differ significantly. Logistic regression found no significant predictors of readmission within 7 days or any complication within 5 days.

CONCLUSION

This retrospective, multi-center database review of adult patients undergoing PCLB or TJLB propensity matched for demographics and hepatic comorbidities found that TJLB patients had a significantly higher rate of cardiac complications while PCLB patients had a significantly higher rate of hematoma. These findings support prior literature suggesting a trend towards safety of TJLB compared to PCLB in patients with hemostatic disorders and/or advanced liver disease.

Transjugular Liver Biopsy: Safe Even in Patients With Severe Coagulopathies and Multiple Biopsies

To investigate the safety profile and diagnostic efficacy of transjugular liver biopsy (TJLB), with a focus on patients with severe coagulopathies and with multiple biopsies.

Endoscopic ultrasound guided liver biopsy: Recent evidence

Liver biopsy (LB) is an essential tool in diagnosing, evaluating and managing various diseases of the liver. As such, histopathological results are critical as they establish or aid in diagnosis, provide information on prognosis, and guide the appropriate selection of medical therapy for patients. Indications for LB include evaluation of persistent elevation of liver chemistries of unclear etiology, diagnosis of chronic liver diseases such as Wilson's disease, autoimmune hepatitis, small duct primary sclerosing cholangitis, work up of fever of unknown origin, amyloidosis and more. Traditionally, methods of acquiring liver tissue have included percutaneous LB (PCLB), transjugular LB (TJLB) or biopsy taken surgically via laparotomy or laparoscopy. However, traditional methods of LB may be inferior to newer methods. Additionally, PCLB and TJLB carry higher risks of adverse events and complications. More recently, endoscopic ultrasound guided LB (EUS-LB) has evolved as an alternative method of tissue sampling that has proven to be safe and effective, with limited adverse events. Compared to PC and TJ routes, EUS-LB may also have a greater diagnostic yield of tissue, be superior for a targeted approach of focal lesions, provide higher quality images and allow for greater patient comfort. These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue. Herein, we provide a review of the recent evidence of EUS-LB for liver disease.

Endoscopic ultrasound guided liver biopsy for parenchymal liver disease

Liver biopsy plays an essential role in the diagnosis, evaluation and management of a vast proportion of liver diseases. Conventionally, percutaneous and trans-jugular approaches have been used to obtain liver biopsies. Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a safe and effective alternate in the past two decades. EUS-LB carries a role in evaluation of both benign and malignant diseases of the liver. It can offer higher resolution imaging of the liver and can detect smaller lesions than computed tomography scan of the abdomen or ultrasound scans with the option for doppler assistance to reduce complications. Current evidence demonstrates the superiority of EUS-LB for a targeted approach of focal lesion and there is also evidence of less sampling variability in heterogeneous parenchymal pathologies. These advantages combined with an improved safety profile had led to the rapid progress in the development of new techniques, equipment and procedures for EUS-LB. We provide a comprehensive review of EUS-LB for parenchymal liver disease.

Medical liver biopsy: background, indications, procedure and histopathology

Histological analysis of liver tissue continues to play an important role in modern hepatological practice. This review explores the indications for medical liver biopsy in addition to the procedure itself, potential complications, preparation of tissue and routine staining. A broad selection of histological images is included to illustrate the appearance of liver tissue both in health and in several important diseases.

The utility of ultrasound guidance in transjugular liver biopsy: our experience

PURPOSE

To demonstrate the utility of ultrasound (US) guidance in improving the safety and efficacy of transjugular liver biopsy (TJLB) by analyzing all the TJLBs performed by us in the last 4 years.

MATERIALS AND METHODS

Forty-seven patients who underwent TJLB in the last 4 years in our two centers were retrospectively analyzed. US guidance was used for all but for one patient during the two crucial steps of the procedure-for internal jugular vein (IJV) access and during the parenchymal biopsy. Biopsies were obtained under real-time sonographic guidance from the right lobe after confirming an adequate room for needle throw without breaching the liver capsule or any major hilar structures. Post-procedure complications, tissue yield, and histopathological adequacy of samples were analyzed.

RESULTS

Overall technical success rate was 100%. No major complications were found where ultrasound-assisted TJLB (uTJLB) was performed. One patient who underwent non-US guided TJLB had an event of a capsular breach and intra-peritoneal hemorrhage requiring coil embolization. Samples were of adequate dimension. Histopathological positivity was 100%. The overall complication rate for uTJLB was 4.7% which was due to minor complications in two patients.

CONCLUSIONS

Addition of US unit to the angiographic suite is effortless and Interventional Radiologists being already skilled in US can easily implement this simple yet valuable modification to conventional TJLB procedures. Our experience on uTJLB further emphasizes the role of US guidance in improving the procedural success rate, safety profile, and efficacy in the histopathological outcome of TJLB in all patients irrespective of age and disease burden.

Autoimmune Hepatitis with Concomitant Idiopathic Thrombocytopenic Purpura Diagnosed by Transjugular Liver Biopsy

Patients with autoimmune hepatitis (AIH) may sometimes have concomitant idiopathic thrombocytopenic purpura (ITP). Severe thrombocytopenia in ITP interferes with percutaneous liver biopsy for pathological diagnosis of AIH. Here, we report a case of AIH with ITP in a 63-year-old woman. The patient presented to our hospital with liver dysfunction and thrombocytopenia. For histological examination, transjugular liver biopsy (TJLB) was performed, leading to a diagnosis of AIH. Corticosteroids treatment led to an improvement in her liver enzyme levels and platelet count. In conclusion, patients with AIH may sometimes have concomitant ITP. TJLB was effective for making the diagnosis of AIH with severe thrombocytopenia due to ITP.

Plugged percutaneous biopsy of the liver in living-donor liver transplantation recipients suspected to have graft rejection

Background Percutaneous biopsy is a widely-accepted technique for acquiring histologic samples of the liver. When there is concern for bleeding, plugged percutaneous biopsy (PPB) may be performed, which involves embolization of the biopsy tract. Purpose To evaluate the efficacy and safety of PPB of the liver in patients suspected to have graft rejection after living-donor liver transplantation (LDLT). Material and Methods During January 2007 and December 2013, 51 patients who underwent PPB of the liver under the suspicion of post-LDLT graft rejection were retrospectively analyzed. A total of 73 biopsies were performed. Biopsy was performed with a 17-gauge core needle and 18-gauge cutting needle. The needle tract was embolized using gelatin sponge (n = 44) or N-butyl cyanoacrylate (NBCA) (n = 29). The specimens were reviewed to determine their adequacy for histologic diagnosis. We reviewed all medical records after PPB. Results Specimens were successfully acquired in all procedures (100%). They were adequate for diagnosis in 70 cases (95.9%) and inadequate in three (1.3%). Average of 9.8 complete portal tracts was counted per specimen. One minor complication (1.4%) occurred where the patient had transient fever after the procedure. Conclusion PPB is easy and safe to perform in LDLT recipients and provides high diagnostic yield.

Asian-Pacific Association for the Study of the Liver (APASL) consensus guidelines on invasive and non-invasive assessment of hepatic fibrosis: a 2016 update

Hepatic fibrosis is a common pathway leading to liver cirrhosis, which is the end result of any injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Despite the fact that liver biopsy (LB) has been considered the "gold standard" of assessment of hepatic fibrosis, LB is not favored by patients or physicians owing to its invasiveness, limitations, sampling errors, etc. Therefore, many alternative approaches to assess liver fibrosis are gaining more popularity and have assumed great importance, and many data on such approaches are being generated. The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The first consensus guidelines of the APASL recommendations on hepatic fibrosis were published in 2009. Due to advances in the field, we present herein the APASL 2016 updated version on invasive and non-invasive assessment of hepatic fibrosis. The process for the development of these consensus guidelines involved review of all available published literature by a core group of experts who subsequently proposed consensus statements followed by discussion of the contentious issues and unanimous approval of the consensus statements. The Oxford System of the evidence-based approach was adopted for developing the consensus statements using the level of evidence from one (highest) to five (lowest) and grade of recommendation from A (strongest) to D (weakest). The topics covered in the guidelines include invasive methods (LB and hepatic venous pressure gradient measurements), blood tests, conventional radiological methods, elastography techniques and cost-effectiveness of hepatic fibrosis assessment methods, in addition to fibrosis assessment in special and rare situations.

Epidemiology and natural history of non-alcoholic fatty liver disease

Non-alcoholic steatohepatitis (NASH) is part of the spectrum of non-alcoholic fatty liver disease (NAFLD) that leads to progressive liver disease and presents a growing challenge to public health. Because of the increased prevalence of metabolic syndrome and obesity, NAFLD and NASH have expanded to a substantial extent. In NASH patients, advanced fibrosis is the major predictor of morbidity and liver-related mortality, and an accurate diagnosis of NASH is mandatory. Although there is currently no validated test of serum biomarkers available to diagnose NASH, and histologic evaluation with a liver biopsy remains the gold standard, screening for fibrosis is recommended in patients with suspicion of NASH. Clinical prediction models and serum biomarkers for advanced fibrosis have relatively good negative predictive value and can be useful for screening. Also, transient elastography is increasingly available to estimate fibrosis in NASH. Therefore, due to the lack of a reliable and accepted non-invasive diagnostic modality, screening for NASH in the general population is not currently recommended. Better understanding of the natural history of NASH is needed to evaluate the utility and cost-effectiveness of screening.

Evaluation of Percutaneous Liver Biopsy Complications in Patients with Chronic Viral Hepatitis

OBJECTIVE

Liver biopsy is still the gold standard for the determination of liver fibrosis and necroinflammatory activity. It is an invasive method and may lead to severe complications. The aim of this study was to determine the evaluation of percutaneous liver biopsy complications in patients with chronic viral hepatitis.

MATERIALS AND METHODS

1165 patients, who were followed with the diagnosis of chronic viral hepatitis and who were applied percutaneous liver biopsy between January 2000 and February 2013 at the out-patient clinic of Infectious Diseases and Clinical Microbiology, were included in the study.

RESULTS

Of 1165 patients who underwent liver biopsy, 196 (86 male, 110 female) were diagnosed with chronic hepatitis C, 969 (559 male, 410 female) were diagnosed with chronic hepatitis B. The mean age was 43.3 and 55.4% were male. 11% of the patients were diagnosed with chronic renal failure and underwent haemodialysis. Minor complication rate was about 20% (severe pain required usage of analgesic drugs in 19.8%, abdominal pain in 22.6%) whereas major complication rate was 1.15% (pneumothorax in 0.17%, heamobilia in 0.08%, hematoma in 0.9%). We did not observe severe complications such as fever, abscess, anaphylaxis, bacteraemia, organ perforations, sepsis or death.

CONCLUSION

Despite being an invasive procedure, percutaneous liver biopsy can be considered a safe method because of the low rates of severe complications observed in our patients.

Assessing inflammatory liver injury in an acute CCl4 model using dynamic 3D metabolic imaging of hyperpolarized [1-(13)C]pyruvate

To facilitate diagnosis and staging of liver disease, sensitive and non-invasive methods for the measurement of liver metabolism are needed. This study used hyperpolarized (13)C-pyruvate to assess metabolic parameters in a CCl4 model of liver damage in rats. Dynamic 3D (13)C chemical shift imaging data from a volume covering kidney and liver were acquired from 8 control and 10 CCl4-treated rats. At 12 time points at 5 s temporal resolution, we quantified the signal intensities and established time courses for pyruvate, alanine, and lactate. These measurements were compared with standard liver histology and an alanine transaminase (ALT) enzyme assay using liver tissue from the same animals. All CCl4-treated but none of the control animals showed histological liver damage and elevated ALT enzyme levels. In agreement with these results, metabolic imaging revealed an increased alanine/pyruvate ratio in liver of CCl4-treated rats, which is indicative of elevated ALT activity. Similarly, lactate/pyruvate ratios were higher in CCl4-treated compared with control animals, demonstrating the presence of inflammation. No significant differences in metabolite ratios were observed in kidney or vasculature. Thus this work shows that metabolic imaging using (13)C-pyruvate can be a successful tool to non-invasively assess liver damage in vivo.

One hundred thirteen consecutive transgastric liver biopsies for hepatic parenchymal diseases: a single-institution study

The transgastric approach is a novel method for obtaining liver biopsies in patients undergoing upper gastrointestinal endosonography. Avoidance of vascular puncture and ability to acquire tissue in patients with obesity or ascites offers a practice niche for this technique. Although several series have reported on specimen adequacy, biopsy core length, and number of portal tracts, none has addressed the diagnostic challenges presented by the fragmented nature of these specimens. We systematically evaluated 113 transgastric liver biopsies obtained for diagnosis of parenchymal liver disease by 3 needle types and compared them with 100 percutaneous and 100 transjugular liver biopsies, respectively. Parameters recorded were number of tissue cores, sizes of longest and shortest cores, numbers of complete and incomplete portal tracts, morphologic characteristics, and adequacy of specimen for diagnosis and staging. In contrast to percutaneous and transjugular liver biopsies, transgastric biopsies often contained >10 tissue fragments and smaller tissue cores. In addition, 2 of the 3 types of transgastric needles obtained less numbers of complete portal tracts. Transjugular biopsies were also smaller and contained less number of complete portal tracts than percutaneous specimens but, unlike transgastric biopsies, only rarely contained >10 tissue fragments. Specimen adequacy for diagnosis and staging was 80%, 100%, and 98% for transgastric, percutaneous, and transjugular biopsies, respectively. Difference in specimen adequacy is related to tissue fragmentation of transgastric liver biopsies rather than biopsy core length or numbers of complete portal tracts. Tissue fragmentation is particularly challenging for staging chronic liver disease.

Endoscopic ultrasound-guided liver biopsy

Liver biopsy remains the cornerstone in the diagnosis and management of liver disorders. Results of liver biopsy can often drive therapeutic decision-making. Unfortunately, studies have shown conventional biopsy techniques to carry significant sampling variability that can potentially impact patient care. Endoscopic ultrasound (EUS) is gaining traction as an alternative method of biopsy. For parenchymal disease, it can decrease sampling variability. It offers a more targeted approach for focal lesions. Its diagnostic yield and limited adverse event profile make it a promising approach for liver biopsy.

Major complications due to transjugular liver biopsy: Incidence, management and outcome

PURPOSE

The purpose of this study was to retrospectively evaluate the incidence of intraperitoneal bleeding and other major complications of transjugular liver biopsy (TJLB) and analyze their outcome and management.

MATERIALS AND METHODS

The clinical files of 341 consecutive patients who had TJLB were retrospectively analyzed. There were 237 men and 104 women (mean age: 51.38±12.8 years; range: 17-89 years). All patients had TJLB because standard percutaneous transhepatic biopsy was contraindicated. Patients' files were reviewed to search for major and minor procedure-related complications during or immediately after TJLB.

RESULTS

TJLBs were technically successful in 331/341 patients (97.07%; 95%CI: 94.67-98.58%). Major complications consisted exclusively of intraperitoneal bleeding due to liver capsule perforation and were observed in 2/341 patients (0.59%; 95%CI: 0.07-2.10%). They were treated using transcatheter arterial or venous embolization with a favorable outcome. The most frequent minor complications were abdominal pain (35/341; 10.26%; 95%CI: 7.25-13.99%) and supraventricular arrhythmia (15/341; 4.40%; 95%CI: 2.48-7.15%). No cases of inadvertent injury of the carotid artery were observed.

CONCLUSION

Major complications during TJLB are extremely rare and can be managed using arterial or venous embolization with a favorable outcome. Our results reinforce the general assumption that TJLB is a safe and well-tolerated technique.

Transvenous hepatic biopsy in stable Fontan patients undergoing cardiac catheterization

Liver pathology complicates Fontan palliation. Previous reports established that both hepatic sinusoidal and portal fibrosis occur in patients after Fontan procedures. Past studies predominantly included symptomatic patient cohorts. Thus, the authors of this study aimed to characterize hepatic pathology via transvenous hepatic biopsies in 21 asymptomatic patients at the time of elective cardiac catheterization. Seven of these patients (33 %) were accompanied by an interventional procedure. Hepatic biopsies showed evidence of either sinusoidal or portal fibrosis or both in all but one patient. The findings showed a statistically significant (p = 0.005) moderately strong positive correlation between fibrosis scores and time since Fontan surgery. Additionally, no significant correlation was found between fibrosis scores and inferior vena cava pressure, pulmonary vascular resistance, platelet counts, or serum laboratory testing of hepatic function.

Long-term influence of chemotherapy on steatosis-associated advanced hepatic fibrosis

To determine whether chemotherapy treatment at least 6 months prior to the detection of hepatic steatosis is associated with advanced hepatic fibrosis. Demographics, comorbid conditions, and laboratory data for cancer patients with hepatic steatosis were reviewed. The primary end point of this study was a low probability of fibrosis as calculated by the AST-to-platelet ratio index (APRI)-a surrogate for the absence of histologic bridging fibrosis and/or cirrhosis. Of 279 patients, 117 (41.9 %) were treated with chemotherapy and 197 (66.3 %) had a low probability of fibrosis by APRI. A smaller proportion of patients treated with chemotherapy had a low probability of hepatic fibrosis compared with untreated patients (64.1 vs. 75.3 %, p = 0.04). On multivariable analysis, chemotherapy treatment was a negative predictive factor for a low probability of fibrosis (OR 0.366 [95 % CI 0.184-0.708], p < 0.01). Among chemotherapy-treated patients, 75 (64.1 %) had a low probability of fibrosis. There were no differences in chemotherapy duration (mean 7.8 vs. 7.5 cycles) and interval from last dose to steatosis diagnosis (24.3 vs. 21.4 months) between patients with and without a low probability of fibrosis. A smaller proportion of patients treated with irinotecan or 5-fluorouracil had a low probability of fibrosis (37.3 vs. 66.7 %, p = 0.04). On multivariable analysis, irinotecan or 5-fluorouracil treatment was a negative predictive factor for low probability of fibrosis (OR 0.277 [95 % CI 0.091-0.779], p = 0.02). Prior chemotherapy treatment, especially with 5-fluorouracil or irinotecan, is a negative predictor for the absence of advanced hepatic fibrosis among patients with steatosis.