Twenty-year audit of percutaneous liver biopsy in a major Australian teaching hospital

Non-Invasive Diagnostic of NAFLD in Type 2 Diabetes Mellitus and Risk Stratification: Strengths and Limitations

The progressive potential of liver damage in type 2 diabetes mellitus (T2DM) towards advanced fibrosis, end-stage liver disease, and hepatocarcinoma has led to increased concern for quantifying liver injury and individual risk assessment. The combination of blood-based markers and imaging techniques is recommended for the initial evaluation in NAFLD and for regular monitoring to evaluate disease progression. Continued development of ultrasonographic and magnetic resonance imaging methods for accurate quantification of liver steatosis and fibrosis, as well as promising tools for the detection of high-risk NASH, have been noted. In this review, we aim to summarize available evidence regarding the usefulness of non-invasive methods for the assessment of NAFLD in T2DM. We focus on the power and limitations of various methods for diagnosis, risk stratification, and patient monitoring that support their implementation in clinical setting or in research field.

Non-invasive assessment of steatohepatitis indicates increased risk of coronary artery disease

INTRODUCTION

Fatty liver diseases (FLD), especially defined as metabolic dysfunction-associated FLD (MAFLD), is of growing importance for patients and health-care providers. Extrahepatic comorbidities, predominantly coronary artery disease (CAD), contribute to excess morbidity and mortality in FLD. Although the association of FLD and CAD is well known, underlying pathophysiological links are not fully understood. Non-invasive means of liver diagnostic enable a fast and thorough characterization of FLD. We therefore assessed the severity of FLD in a cohort of patients at risk of CAD.

METHODS

Patients scheduled for coronary angiography were characterized by anthropometry, serum-based indices of liver fibrosis (NFS, FIB4), abdominal ultrasound and vibration controlled transient elastography (VCTE) including controlled attenuation parameter (CAP) and the Fibroscan-AST (FAST) score. Patients were stratified according to indication of therapeutic coronary intervention.

RESULTS

120 patients were recruited, MAFLD was found in 41%, while advanced fibrosis or cirrhosis were present in only 5%. Coronary vascular intervention was indicated in 42% (n = 50). Severity of steatosis assessed by CAP and risk of fibrosis defined by elevated liver stiffness (VCTE>8 kPa) and fibrosis indices were associated with the need for coronary intervention. FAST score, a marker of fibrotic steatohepatitis, was elevated in the intervention group (0.22 vs. 0.12, p<0.001). Multivariate regression analysis revealed FAST score as strongest predictor of CAD (OR 2.3 95%, CI 1.40-2.96).

DISCUSSION

MAFLD is a frequent comorbidity in patients at CAD risk, but advanced liver disease has a low prevalence in patients undergoing elective coronary angiography. Therefore, a routine VCTE-based screening for FLD cannot be recommended in cardiac patients. The association of indicators of steatohepatitis with advanced CAD points to inflammatory processes as a conjoint mechanism of both diseases.

Major complications after ultrasound-guided liver biopsy: An annual audit of a Chinese tertiary-care teaching hospital

BACKGROUND

As ultrasound-guided percutaneous liver biopsy (PLB) has become a standard and important method in the management of liver disease in our country, a periodical audit of the major complications is needed.

AIM

To determine the annual incidence of major complications following ultrasound-guided PLB and to identify variables that are significantly associated with an increased risk of major complications.

METHODS

A total of 1857 consecutive cases of PLB were included in our hospital from January 2021 to December 2021. The major complication rate and all-cause 30-d mortality rate were determined. Multivariate analyses were performed by logistic regression to investigate the risk factors associated with major complications and all-cause 30-d mortality following ultrasound-guided PLB.

RESULTS

In this audit of 1857 liver biopsies, 10 cases (0.53%) of major complications occurred following ultrasound-guided PLB. The overall all-cause mortality rate at 30 d after PLB was 0.27% (5 cases). Two cases (0.11%) were attributed to major hemorrhage within 7 d after liver biopsy. Fibrinogen less than 2 g/L [odds ratio (OR): 17.226; 95% confidence interval (CI): 2.647-112.102; P = 0.003], post-biopsy hemoglobin level (OR: 0.963; 95%CI: 0.942-0.985; P = 0.001), obstructive jaundice (OR: 6.698; 95%CI: 1.133-39.596; P = 0.036), application of anticoagulants/antiplatelet medications (OR: 24.078; 95%CI: 1.678-345.495; P = 0.019) and age (OR: 1.096; 95%CI: 1.012-1.187; P = 0.025) were statistically associated with the incidence of major complications after PLB.

CONCLUSION

In conclusion, the results of this annual audit confirmed that ultrasound-guided PLB can be performed safely, with a major complication rate within the accepted range. Strict patient selection and peri-biopsy laboratory assessment are more important than procedural factors for optimizing the safety outcomes of this procedure.

Fibroscan® and Shear Wave correlated well in hepatic fibrosis evaluation of patients with chronic liver diseases "in real life situation"

BACKGROUND

A new noninvasive medical device based on ultrasound elastography such as the Shear Wave Elastography (SWE) was designed in order to measure the liver hardness. The purpose of this work was to evaluate the correlation of the results of the liver elasticity measurements obtained by Fibroscan® (FS) and SWE for patients with chronic liver diseases.

METHODS

Between January and October 2017, the patients who were followed during this period of time underwent noninvasive assessments of liver fibrosis by SWE in the intercostal spaces during abdominal ultrasound procedures and/or FS. The correlation between FS and SWE was estimated and tested at a 0.05 significance level.

RESULTS

Four hundred and seventy-six patients were included in this study. The main etiologies of chronic liver disease were non alcoholic fatty disease (NAFLD), chronic viral hepatitis B (HBV) and chronic viral hepatitis C (HCV). All patients underwent a SWE and 167 among them underwent a FS procedure. The patients who were followed revealed a median FS measurement of 5.80 kpa (Q25 = 4.90 kPa; Q75 = 8 kPa) and a median SWE measurement of 7.00 kPa (Q25 = 6.10 kPa; Q75 = 8.10 kPa). We could observe a significant correlation between the FS and SWE measurements (0.49; P = .001) in the total cohort. The average absolute difference between the measurements of these 2 methods was of 2.54 kPa (sd = 3.39). There was no significant correlation for patients with NAFLD no matter whether they presented with signs of suspected non alcoholic steatohepatitis (NASH) or not (R = 0.20; P = .108). All patients intending to perform the examination were able to undergo the SWE, allowing 33.3% of the patients who failed the FS to have a noninvasive evaluation of their fibrosis.

CONCLUSION

The SWE technique proved to be as efficient as the FS one for the evaluation of the liver fibrosis in real life situation.

Combinational elastography for assessment of liver fibrosis in patients with liver injury

OBJECTIVE

We investigated the utility of combinational elastography with point shear wave elastography (pSWE) and real-time tissue elastography (RTE) for evaluating liver fibrosis in patients with liver injury.

METHODS

In this prospective single-institution study, patients scheduled for a liver biopsy to determine the presence of liver disease were enrolled. Liver fibrosis in each patient was evaluated using both shear wave velocity (Vs) shown by pSWE and the liver fibrosis index (LFI) shown by RTE, while a liver biopsy sample was obtained from the same area that was subjected to an elastography examination. Results of the latter were compared with those obtained in a histological examination.

RESULTS

Multivariate analysis showed that Vs and LFI were significantly correlated with the liver fibrosis stage in all of the enrolled patients. Sub-analysis findings compared patients with and without non-alcoholic fatty liver disease (NAFLD) and demonstrated that Vs was significantly correlated with the liver fibrosis stage in both groups, whereas LFI was correlated with that only in the non-NAFLD patients. However, a multivariate analysis demonstrated a significant correlation between steatosis grade and LFI in the NAFLD patients.

CONCLUSIONS

RTE is less useful than pSWE for assessing liver fibrosis in patients with NAFLD.

Retrospective analysis of safety of ultrasound-guided percutaneous liver biopsy in the 21st century

BACKGROUND

Ultrasound-guided percutaneous liver biopsy is a standard procedure, but it might be burdened with serious adverse events, mainly hemorrhagic. Literature lacks recent studies taking into account new ultrasound machines, more sensitive to tiny vessels and the evolution of the bioptic technique, including ultrasound guidance in all instances. Hence, the primary aim of this study was to evaluate complication rates of ultrasound-guided percutaneous liver biopsy in a recent population. Secondary aims were to evaluate if the experience of operator is a determinant of risk of complication and to identify other potential risk factors.

METHODS

We evaluated 800 procedures carried out in one hospital in the period 2010-2018.

RESULTS

Complication rate resulted in 4%, with the occurrence of moderate hemorrhagic complications in 0.75%. No cases of severe events or death were registered. A higher risk of bleeding was found to be associated with less experienced operators, while the need to perform multiple needle insertions increased the probability of adverse events.

CONCLUSION

The present findings confirmed ultrasound-guided percutaneous liver biopsy to be a substantially safe procedure with a low risk of overall adverse events and bleeding in particular, especially when performed by expert operators.

Evaluation of Risk Factors for Bleeding After Ultrasound-Guided Liver Biopsy

Purpose

This study was performed to analyze the risk factors for hemorrhagic complications after ultrasound-guided liver biopsies.

Patients and Methods

In this retrospective study, we reviewed 1193 ultrasound-guided percutaneous liver biopsies performed in our hospital from January 2018 to December 2020. Relevant patient characteristics, indications for biopsy, laboratory findings, biopsy technique, hemorrhagic complications, and pathologic outcomes were collected.

Results

We analyzed 834 procedures performed on 807 patients with complete data. The bleeding group comprised 45 patients with post-procedure bleeding, and non-bleeding group comprising the remaining 789 patients. Univariate analysis showed that age (p < 0.001), number of needle passes (p = 0.009), platelet count (p = 0.002), prothrombin time (p < 0.001), and international normalized ratio (p < 0.001) were associated with post-procedure bleeding. Multivariable regression analysis showed that age under 18 years (p < 0.001), low platelet count (p = 0.001), and increased needle passes (p = 0.025) were independent risk factors for bleeding complications.

Conclusion

Sex and focal liver lesions did not affect the risk of post-procedure bleeding. The international normalized ratio and prothrombin time were associated with an increased incidence of bleeding; however, they had no predictive value. Age, number of needle passes, and platelet count were identified as reliable predictors of bleeding.

Value and risk of percutaneous liver biopsy in patients with cirrhosis and clinical suspicion of autoimmune hepatitis

OBJECTIVE

The decision regarding whether to perform a liver biopsy in patients with cirrhosis and clinically suspected autoimmune hepatitis (AIH) remains a challenge. This study aimed to assess the utility and complications of percutaneous liver biopsy in cirrhosis for differentiating AIH from other liver conditions.

METHODS

A clinicopathological database of patients undergoing percutaneous liver biopsies for suspected AIH (unexplained hepatitis with elevated γ-globulin and autoantibody seropositivity) was reviewed to identify patients presenting with cirrhosis. Biopsy slides were reviewed by an experienced hepatopathologist who was blinded to clinical data.

RESULTS

In 207 patients who underwent liver biopsy for suspected AIH, 59 patients (mean age: 59.0±12.0 years, 83.1% female) had clinically diagnosis of cirrhosis. Mean Child-Turcotte-Pugh score was 6.6±1.6, and 44% of patients had a Child-Turcotte-Pugh score≥7. According to the revised International AIH Group (IAIHG) criteria, histology assessment combined with clinical information facilitated a diagnosis of AIH or overlap syndrome of AIH and primary biliary cholangitis (PBC) in 81.4% of cases. Liver biopsy identified other aetiologies, including PBC (n=2), non-alcoholic steatohepatitis (n=6) and cryptogenic cirrhosis (n=3). A reliable diagnosis of AIH could be made using histological category of the simplified criteria in 69.2% and 81.8% of cases using IAIHG scores before biopsy of <10 and 10-15, respectively. Three patients with cirrhosis (5.1%) experienced bleeding following biopsy, but none of 148 patients with non-cirrhosis had bleeding complication (p=0.022).

CONCLUSION

Liver biopsy provides important diagnostic information for the management of patients with cirrhosis and suspected AIH, but the procedure is associated with significant risk.

Audit of medical (non-targeted) liver biopsy specimen quality, pathology reporting and effect on patient management

AIMS

To evaluate our medical liver pathology practice and its influence on patient management, using audit templates published by the UK Royal College of Pathologists (RCPath).

METHODS

We audited medical liver biopsies reported in our centre in 2019 using RCPath proformas. Data were collected from pathology reports and corresponding electronic patient record.

RESULTS

60 cases were selected for audit from 135 eligible biopsies reported in 2019. 58/60 cases were core biopsies and 2/60 were laparoscopic wedge biopsies. 53/57 (93%) core biopsies with available data met RCPath adequacy criteria (length >15 mm and/or ≥6 portal tracts). Most reports (57/60; 95%) were judged to have helped patient management. 25/60 (42%) biopsy reports helped to clarify the clinical diagnosis and 48/60 (80%) led to altered management.

CONCLUSIONS

We demonstrate the utility of the RCPath audit templates, highlighting the clinical value of medical liver biopsies in the diagnostic work-up and management of patients with liver disease.

What proportion of people have a follow-up biopsy in randomized trials of treatments for non-alcoholic steatohepatitis?: A systematic review and meta-analysis

Background and aim

Trials of treatments for non-alcoholic steatohepatitis require endpoint assessment with liver biopsies. Previous large-scale trials have calculated their sample size expecting high retention but on average did not achieve this. We aimed to quantify the proportion of participants with a valid follow-up biopsy.

Methods

We conducted a systematic review of MEDLINE and Embase until May 2020 and included randomized clinical trials of any intervention in non-alcoholic steatohepatitis with at least 1-year follow-up. We were guided by Cochrane methods to run a meta-analysis with generalized linear mixed models with random effects.

Results

Forty-one trials (n = 6,695) were included. The proportion of participants with a valid follow-up biopsy was 82% (95%CI: 78%-86%, I² = 92%). There was no evidence of a difference by location, trial length, or by allocated treatment group. Reasons for missing follow-up biopsies were, in ranked order, related to participants (95 per 1,000 participants (95%CI: 69–129, I² = 92%), medical factors, protocol, trial conduct, and other/unclear. Biopsy-related serious adverse events occurred in 16 per 1,000 participants (95% CI: 8–33, I² = 54%). No biopsy-related deaths were reported.

Conclusions

The proportion of participants with a valid follow-up biopsy in therapeutic trials in non-alcoholic steatohepatitis is on average 82%, with around 1 in 10 participants declining a follow-up biopsy. These findings can inform adequately-powered trials.

Liver Fibrosis in Non-alcoholic Fatty Liver Disease: From Liver Biopsy to Non-invasive Biomarkers in Diagnosis and Treatment

An increasing percentage of people have or are at risk to develop non-alcoholic fatty liver disease (NAFLD) worldwide. NAFLD comprises different stadia going from isolated steatosis to non-alcoholic steatohepatitis (NASH). NASH is a chronic state of liver inflammation that leads to the transformation of hepatic stellate cells to myofibroblasts. These cells produce extra-cellular matrix that results in liver fibrosis. In a normal situation, fibrogenesis is a wound healing process that preserves tissue integrity. However, sustained and progressive fibrosis can become pathogenic. This process takes many years and is often asymptomatic. Therefore, patients usually present themselves with end-stage liver disease e.g., liver cirrhosis, decompensated liver disease or even hepatocellular carcinoma. Fibrosis has also been identified as the most important predictor of prognosis in patients with NAFLD. Currently, only a minority of patients with liver fibrosis are identified to be at risk and hence referred for treatment. This is not only because the disease is largely asymptomatic, but also due to the fact that currently liver biopsy is still the golden standard for accurate detection of liver fibrosis. However, performing a liver biopsy harbors some risks and requires resources and expertise, hence is not applicable in every clinical setting and is unsuitable for screening. Consequently, different non-invasive diagnostic tools, mainly based on analysis of blood or other specimens or based on imaging have been developed or are in development. In this review, we will first give an overview of the pathogenic mechanisms of the evolution from isolated steatosis to fibrosis. This serves as the basis for the subsequent discussion of the current and future diagnostic biomarkers and anti-fibrotic drugs.

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.

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.

What recovery position should patients adopt after percutaneous liver biopsy?

INTRODUCTION

Percutaneous liver biopsy (PLB) is an invasive procedure used for the assessment of liver diseases. The patient's recovery position after the PLB differs among hospitals and departments. This study aims to evaluate adverse events and patient acceptability according to the recovery position adopted after the PLB.

PATIENTS AND METHODS

From September 2014 to March 2017, patients submitted to PLB were randomly assigned to a recovery position arm: right-side position (RRP), dorsal position (DRP), or combined position. A validated numerical rating scale was used to evaluate the level of pain and the overall acceptability of the PLB experience.

RESULTS

Ninety (27 patients in RRP, 33 in DRP and 30 in combined position arm) patients were included in the study. There were no differences between the three groups regarding demographic and clinical parameters, except for the number of previous biopsies - higher in the combined group (P=0.03). No major adverse events occurred. Minor complications described were pain (36.7% of patients), vasovagal reaction (2.2%) and nauseas/vomit (3.3%). Pain level and pain duration did not differ significantly between groups. Pain occurred more often in women (P=0.04) and younger patients (P=0.02). The number of passages, operator and previous biopsy did not influence the occurrence of pain. The RRP group considered the procedure less acceptable than the DRP group (P=0.001) or the combined group (P=0.002). There were no differences between the last two arms.

CONCLUSION

Although RRP is the most frequently used position, it appears to be less acceptable without any protective role in terms of adverse events.

Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review

PURPOSE

Percutaneous tissue biopsy is a mainstay of diagnostic and interventional radiology, providing a minimally invasive method for diagnosing malignant and benign disease. The purpose of this review was to collect and summarize the best available evidence regarding the risk factors associated with bleeding complications in image-guided liver biopsy.

METHODS

A literature review was performed, searching Medline, EMBASE, CINAHL, the Cochrane Library, the National Institute for Health and Care Excellence (NICE) and Canadian Agency for Drugs and Technology in Health (CADTH) databases for any studies evaluating bleeding complications in image-guided liver biopsy. A total of 68 articles, published between January 1994 and April 2015, were reviewed in full, with 34 ultimately eligible for inclusion in the review.

RESULTS

Bleeding of any kind occurred in up to 10.9% of image-guided liver biopsies, with major bleeding episodes ranging from 0.1% to 4.6% and minor bleeding events occurring in up to 10.9% of biopsies. The overall rate of bleeding was, however, found to be less than 2%. Several risk factors (patient, operator, and procedure-related) were identified as potentially indicative of an increased risk of post-biopsy bleeding. Patient-related risk factors included patient age (>50 years or <2 years), inpatient status (8/12 vs. 4/12, P < 0.001), comorbidities and/or concurrent diagnoses and coagulation status (rate of bleeding was 3.3% for international normalized ratio [INR] 1.2-1.5 vs. 7.1% for INR >1.5, P < 0.001). There was no consensus on impact of operator experience (>200 biopsies/year vs. <50/year) on post-biopsy bleeding rate. Procedure-related risk factors included needle size (cutting biopsy vs. fine needle aspiration, P < 0.001) and the presence of a patent track on post-biopsy ultrasound (P < 0.001). Lastly there was no difference found between targeted vs. nontargeted biopsies and number of needle passes.

CONCLUSION

Reported rate of post-biopsy bleeding ranges between 0% and 10.9%, although the vast majority of studies reported bleeding rates under 2%. Several patient, operator, and procedure-related risk factors are associated with a higher risk of bleeding following liver biopsy.

Diagnostic Accuracy of Aspartate Aminotransferase to Platelet Ratio Index and Fibrosis 4 Scores in Predicting Advanced Liver Fibrosis in Patients with End-stage Renal Disease and Chronic Viral Hepatitis: Experience from Pakistan

Objectives

The aim was to assess the diagnostic accuracy of APRI and FIB-4 in assessing the stage of liver fibrosis in end stage renal disease (ESRD) patients with chronic viral hepatitis and to compare the two tests with standard tru-cut liver biopsy.

Material and Methods

The study was conducted at Sindh Institute of Urology and Transplantation Karachi (SIUT) from May 2010 to May 2014. All ESRD patients, being considered as candidates for renal transplantation and in whom liver biopsy was performed were included. Fibrosis stage was assessed on liver biopsy using Ishak scoring system. The serum transaminases and platelet counts were used to calculate APRI and FIB-4 scores.

Results

Out of 109 patients, hepatitis C and B virus infections were present in 104 (95.4%) and 3(2.8%), respectively, while 2 (1.8%) patients had both infections. The mean Ishak fibrosis score was 1.95 ± 2. Advanced fibrosis was noted in 37 (34%) patients. Univariate analysis showed that advanced liver fibrosis was associated with lower platelets counts (P=0.001) and higher aspartate aminotransferase (AST) (P=0.001), alanine aminotransferase (ALT) (P=0.022), APRI score (P=0.001) and FIB-4 score (P=0.001). On logistic regression analysis, only APRI score (P < 0.001) was found to be the independent variable associated with advanced liver fibrosis. APRI score cutoff ≥1 indicating advanced fibrosis showed sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 91.9%, 90.3%, 82.9%, 95.6%, respectively with area under the curve (AUC) of 0.97. Similarly, a FIB-4 score cutoff ≥1.1 had sensitivity, specificity, PPV and NPV of 70.27%, 66.67%, 52% and 81.36%, respectively with AUC of 0.74.

Conclusion

APRI is more accurate noninvasive test for assessing advanced liver fibrosis in ESRD patients as compared to FIB-4. It can be used to obviate the need for liver biopsy in this high risk population.

Coagulopathy in Children With Liver Disease

It was thought that a high international normalized ratio predicted bleeding in patients with chronic liver disease (CLD) and patients were "autoanticoagulated." Contrary to this belief, while patients with CLD experienced bleeding, they also developed thromboses. In the last decade, the prevailing literature challenged the idea that an elevated international normalized ratio increased bleeding risk. The global assays of coagulation such as thromboelastography (TEG)/rotational thromboelastometry and thrombin generation assays provide additional insight into coagulation processes. It has become apparent that a parallel reduction of procoagulant and anticoagulant factors leave patients in a new "balanced" state, albeit a fragile one, where the balance can be easily disrupted. The inherent differences in coagulation between children and adults such as differences in levels of procoagulant and anticoagulant factors, underlying liver disease, and the paucity of studies in children make extrapolation of these findings to the pediatric population problematic. Ultimately, this is an area that requires further investigation to avoid inappropriate use of blood products and medication.

Multiple biopsy passes and the risk of complications of percutaneous liver biopsy

BACKGROUND AND AIM

To minimize the sample variability of liver biopsy, the tissue length should be at least 25 mm. Consequently, more than one biopsy pass is needed with cutting biopsy needles. We aimed to investigate the risk factors of biopsy-related complication, including the number of biopsy passes.

METHODS

All consecutive liver biopsies performed between 2005 and 2014 were included. Biopsies were ultrasound assisted and performed with cutting biopsy needles. A complication was an event where the patient visited a healthcare provider because of biopsy-related complaints. Complications followed by hospitalization 2 or more days or intervention were considered severe.

RESULTS

In total, 1806 liver biopsies were analyzed. Overall, 102 (5.6%) complications were observed, of which 31 (1.7%) were severe. One (0.06%) patient died. Common complications were pain (n=75/102; 74%) and bleeding (n=34/102; 33%). Two biopsy passes were not associated with an increased risk of complications compared with one biopsy pass [odds ratio (OR): 1.59; 95% confidence interval (CI): 0.83-3.04; P=0.16], whereas three or more biopsy passes increased this risk compared with one (OR: 2.97; 95% CI: 1.38-6.42; P=0.005) or two biopsy passes (OR: 1.87; 95% CI: 1.10-3.19; P=0.021). The risk of severe complications was not influenced by the number of biopsy passes (P>0.24). Hepatic malignancy (OR: 3.21; 95% CI: 1.18-8.73; P=0.022) and international normalized ratio 1.4 or more (OR: 7.03; 95% CI: 2.74-18.08; P<0.001) were risk factors of severe complications.

CONCLUSION

Severe complication rate and mortality were low. Performing multiple biopsy passes was not associated with severe complications, whereas hepatic malignancy or elevated international normalized ratio were associated with an increased risk.

Post biopsy Liver Hemorrhage Successfully Controlled by Ultrasound-guided Percutaneous Microwave Ablation

Percutaneous microwave coagulation therapy has been one of the major new developments in tumor ablation. Microwave ablation has also been used intraoperatively to achieve hemostasis at surgical margins in laparotomy. However, the use of microwave ablation for coagulation and hemostasis through percutaneous approach has not been described in the literature. Here, we report a case of hepatic amyloidosis with massive post biopsy liver hemorrhage, which could not be by transarterial embolization, and subsequently controlled by ultrasound-guided percutaneous microwave ablation. To the best of our knowledge, this is the first reported case of this technology application in human.

Transjugular Liver Biopsy in a Multiple Myeloma Patient with Hepatomegaly, Portal Hypertension and "Miliary" Liver Lesions: A Case Report

The present report describes a 50-year-old female recently diagnosed with multiple myeloma who presented with hepatosplenomegaly, miliary-type hyper enhancing liver tumors, and esophageal varices. We performed a transjugular liver biopsy when liver biopsy was requested to evaluate the miliary-type liver lesions. This was done to lower the risk of bleeding given the patient's anemia and probable portal hypertension. This approach was successful in safely providing diagnostic samples for surgical pathology and flow cytometry to assess the nature of focal miliary liver lesions. It also proved portal hypertension.

Ultrasound elastography: liver

Ultrasound elastography, also termed sonoelastography, is being used increasingly in clinical practice to aid the diagnosis and management of diffuse liver disease. Elastography has been shown to be capable of differentiating advanced and early-stage liver fibrosis, and consequently a major application in clinical liver care includes progression to cirrhosis risk stratification through (1) assessment of liver fibrosis stage in HCV and HBV patients, (2) distinguishing non-alcoholic steatohepatitis from simple steatosis in non-alcoholic fatty liver disease patients, and (3) prognostic evaluation of liver disease is autoimmune liver disease. In addition, elastographic characterization of focal liver lesions and evaluation of clinically significant portal hypertension have the potential to be clinically useful and are areas of active clinical research.

Liver biopsy in children: position paper of the ESPGHAN Hepatology Committee

Liver biopsy (LB) is still the criterion standard procedure for obtaining liver tissue for histopathological examination and a valuable tool in the diagnosis, prognosis, and management of many parenchymal liver diseases. The aim of this position paper is to summarise the present practice of paediatric LB and make recommendations about its performance. Although histological evaluation of the liver is important in assessing prognosis and exploring treatment, noninvasive techniques (ie, imaging, laboratory markers) may replace use of liver histology. The indications for LB are changing as present knowledge of aetiologies, pathomechanism, and therapeutic options in paediatric liver disease is evolving. Adult and paediatric literature was reviewed to assess the existing clinical practice of LB with focus on the technique, indications, risk of complications, and contraindications in paediatrics. This position paper presents types of LB, indications, complications, contraindications, and an essential checklist for paediatric LB.

Liver transplantation for hepatocellular carcinoma: Role of inflammatory and immunological state on recurrence and prognosis

Criteria for liver transplantation (LT) for hepatocellular carcinoma (HCC) and post-LT indicators of prognosis are historically based on the measurement of the tumor mass. Recently, high throughput technologies have increased the prediction of recurrence, but these tools are not yet routinely available. The interaction between HCC and the immune system has revealed an imbalance of lymphocyte phenotypes in the peritumoral tissue, and the increase of regulatory T cells with respect to cytotoxic lymphocytes has been linked to a higher rate of post-LT HCC recurrence. Moreover, some inflammatory markers have shown good reliability in predicting cancer reappearance after surgery, as a result of either a systemic inflammatory response or a decreased capacity of the organism to control the tumor growth. Among these markers, the neutrophil-to-lymphocyte ratio appears to be the most promising and easily available serum parameter able to predict HCC recurrence after LT and following other types of treatment, although the exact mechanisms determining its elevation have not been clarified. Post-LT immunosuppression may impact on cancer control, and the exposure to high levels of calcineurin inhibitors or other immunusuppressants has recently emerged as a negative prognostic factor for HCC recurrence and patient survival. Despite the absence of prospective randomized trials, inhibitors of the mammalian target of rapamycin have been shown to be associated with lower rates of tumor recurrence compared to other immunosuppressors, suggesting their use especially in patients with HCC exceeding the conventional indication criteria for LT.

Effect of operator experience and frequency of procedure performance on complication rate after ultrasound-guided percutaneous liver biopsies

OBJECTIVE

The aim of the present study was to assess whether the complication rate after ultrasound-guided percutaneous liver biopsies in children is affected by how frequently the procedure is performed by the operator.

METHODS

Medical charts and ultrasound descriptions of 311 ultrasound-guided percutaneous liver biopsy procedures performed by 18 radiologists at a single center from 2000 to 2011 were reviewed. Postbiopsy ultrasound the following day was performed after 97% of the procedures.

RESULTS

There were no differences in the procedure-associated rate of major bleeding incidents (2.2% vs 0.8%, P = 0.38), minor bleeding incidents (15.2% vs 10.2%, P = 0.31), or abdominal pain (13.0% vs 10.6%, P = 0.61) among operators who performed ≤10 procedures and those who performed >10 procedures during the study period. A higher rate of minor bleeding incidents were recorded after liver biopsy when operators had performed <10 biopsies compared with operators who had performed >20 pediatric liver biopsies during the study period (odds ratio 3.4 [1.3-9.1], P = 0.02). No association between the number of biopsies performed by the operator during the 2 years preceding the date of the biopsy and complications was found.

CONCLUSIONS

Major complications are infrequent after pediatric liver biopsies and no relation between operator experience and major complications was found. We found a significant, but minor, effect of operator procedure frequency on the rate of minor bleeding incidents after ultrasound-guided pediatric liver biopsies.

Fine needle aspirating and cutting is superior to Tru-cut core needle in liver biopsy

BACKGROUND

Liver biopsy is the "gold standard" for evaluating liver disorders, but controversies over the potential risk of complications and patient discomfort still exist. Using a 21G fine needle, we developed a new biopsy procedure, fine needle aspirating and cutting (FNAC). Our procedure obtains enough tissue for pathological examination and meanwhile, reduces the risk of biopsy complications. The present study was to determine the safety and efficiency of 21G FNAC compared with 18G Tru-cut core needle (TCN) in liver tumor biopsies.

METHODS

Ninety-four patients with unresectable malignant tumors were included in this study. Patients were divided into 2 groups: 18G TCN and 21G FNAC. The total positive rate (TPR) and safety of both groups were compared.

RESULTS

TPR was not different between the two groups. Liver puncture track subcapsular hemorrhage and arteriovenous shunt were reported with 18G TCN but not with 21G FNAC. The incidence of pain caused by biopsy was higher for the 18G TCN group compared to the 21G FNAC group (P<0.05). About 82.6% of the patients in the 18G TCN group had a sample length >0.5 cm, but 52.1% in the 21G FNAC group (P<0.05). More than 50% of patients in both groups had sufficient tissue for immunohistochemical examination.

CONCLUSIONS

TPR is not different between the 21G FNAC and 18G TCN biopsy procedures, but the safety of 21G FNAC is superior to that of 18G TCN. Tissues obtained by either of these two procedures are sufficient for a pathological diagnosis.

How often do our liver core biopsies reach current definitions of adequacy?

Needle core biopsy is a key tool in diagnosis and assessment of many medical liver diseases, but there is evidence that the combination of small size of the specimen obtained and the patchy nature of many of these diseases can result in misdiagnosis or incorrect staging. The Royal College of Pathologists has therefore published guidelines for assessment of adequacy. To assess whether these guidelines were being observed, we reviewed cases reported in our department over a 15-year period. Results showed that only 19.8% of cores would be considered adequate, 56.4% were suboptimal and 23.8% were inadequate. We discuss the issues around recommendations on the minimum size of liver biopsies, potential factors limiting biopsy size and whether further refinement of the guidelines for adequacy is required.

Percutaneous ultrasonographically guided liver punctures: an analysis of 1961 patients over a period of ten years

Background

Ultrasonographically guided punctures of the liver represent a decisive tool in the diagnosis of many diseases of the liver. Objective of the study was to determine the extent to which the complication rate for ultrasonographically guided punctures of the liver is affected by less comprehensively studied risk factors.

Methods

A total of 2,229 liver biopsies were performed in 1,961 patients (55.5% males; 44.5% females). We recorded actual complications and assessed the following risk factors: needle gauge, puncture technique, examiner experience, coagulation status, puncture target (focal lesion versus parenchyma), lesion size, patient sex and age.

Results

he rate of complications stood at 1.2% (n = 27), of which 0.5% (n = 12) were major and 0.7% (n = 15) minor complications. A significant increase in complications involving bleeding was observed with larger-gauge needles compared with smaller-gauge needles and for cutting biopsy punctures compared with aspiration biopsies (Menghini technique). In the bivariate analysis complications were 2.7 times more frequent in procedures performed by experienced examiners compared with those with comparatively less experience. Lower values for Quick’s test and higher partial thromboplastin times were associated with a higher rate of bleeding. Neither the puncture target, lesion size or patient sex exerted any measurable influence on the puncture risk. Advanced patient age was associated with a higher rate of complications involving bleeding.

Conclusions

Our study helps to establish the importance of potential and less comprehensively studied risk factors and may contribute to further reduction in complications rates in routine clinical practice.

Ursodeoxycholic acid therapy in cystic fibrosis liver disease--a retrospective long-term follow-up case-control study

BACKGROUND

The prevention and treatment of liver disease associated with cystic fibrosis remain a significant unresolved problem.

AIM

To assess the long-term effects of continuous ursodeoxycholic acid (UDCA) therapy in cystic fibrosis patients with constantly elevated serum liver enzymes.

METHODS

The primary endpoint was the incidence of overt liver disease. Between 1989 and 2005, UDCA treatment was started in 98 subjects from a cohort of 382 cystic fibrosis patients. These subjects were compared with a historic control group of 352 subjects who attended our centre between 1975 and 1989 before UDCA became standard treatment. For the long-term comparison of liver function and lung function tests, a group of 98 matched contemporary cystic fibrosis patients were compared with the 98 subjects treated with UDCA.

RESULTS

Overt liver disease developed in only one of the 382 patients who was treated with UDCA for increased serum liver enzymes compared with nine patients in the historic control group (P < 0.05). Serum liver enzyme levels declined in most patients receiving UDCA treatment during the 17-year follow-up (87/98, P < 0.05). No difference was seen in lung function between subjects with cystic fibrosis-related liver disease and the matched controls.

CONCLUSIONS

Regular and systematic screening for liver involvement enables early introduction of UDCA therapy in affected cystic fibrosis patients, reduces the development of severe liver disease and leads to a significant and persistent improvement in serum liver tests, without impairing long-term pulmonary outcome.

Use of multiphoton microscopy to diagnose liver cancer and lung metastasis in an orthotopic rat model

Liver or lung biopsy for suspicious lesions has several disadvantages such as bleeding, bile leak or pneumothorax, needle track seeding, and time-consuming histopathological procedure. The ability to directly observe cellular and subcellular details and then perform "optical biopsy" is a major goal in the development of new interventional techniques. Multiphoton microscopy (MPM) enables real-time noninvasive visualization of tissue architecture and cell morphology in live tissue. We performed a study to evaluate whether MPMcan make real-time optical diagnosis for liver cancer and lung metastasis using an orthotopic rat model with Morris hepatoma. We found that real-time high-resolution MPMimaging could clearly show tissue architecture and cell morphology. In the normal liver tissue, MPMimaging clearly revealed the blood-filled sinusoids and cords of hepatocytes. In the cancerous tissue, MPMimaging clearly illustrated that cancer cells displayed marked cellular and nuclear pleomorphism. MPMimages were comparable to golden standard hematoxylin-eosin staining images. Moreover, MPMimaging had deep penetration with the capability of optical sectioning. In short, MPMcan make real-time optical diagnosis for liver cancer and lung metastasis. This study provides the groundwork for further using multiphoton endoscopy to perform real-time noninvasive "optical biopsy" for liver cancer and lung metastasis in the near future.

A prospective evaluation of the role of transient elastography for the detection of hepatic fibrosis in type 2 diabetes without overt liver disease

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a major risk factor for the development of non-alcoholic fatty liver disease (NAFLD) and subsequently hepatic fibrosis. Transient elastography (TE) is a rapid, reproducible non-invasive test that may be appropriate as a screening tool for the presence of hepatic fibrosis.

AIM

Assess the utility of TE as a screening tool for the presence of hepatic fibrosis in a T2DM population with no known liver disease.

METHODS

T2DM patients without known liver disease were included. Patients were assessed with TE in addition to biochemical parameters.

RESULTS

A successful TE evaluation could be obtained in 74 of 81 (91%) included subjects. Of these, 26 (35%) had a liver stiffness measurement (LSM) ≥ 7.65 kPa. Sixteen of these subjects had confirmatory liver biopsies with significant (≥ F2 fibrosis) present in 12 (75%) and cirrhosis diagnosed in 2 subjects. 15/16 (94%) had histological steatohepatitis. Compared with those with a lower LSM, subjects with an LSM ≥ 7.65 kPa had higher ALT levels (38.0 ± 21.7 vs 26.1 ± 11.1 U/L, p = 0.021) and increased prevalence of hepatic steatosis by ultrasound (85% vs 63%, p = 0.005).

CONCLUSION

Significant hepatic fibrosis in the T2DM population is frequently under-recognized. TE may be a feasible tool for the screening of T2DM patients for the presence of hepatic fibrosis.

Quantitative liver function tests improve the prediction of clinical outcomes in chronic hepatitis C: results from the Hepatitis C Antiviral Long-term Treatment Against Cirrhosis Trial

Risk for future clinical outcomes is proportional to the severity of liver disease in patients with chronic hepatitis C virus (HCV). We measured disease severity by quantitative liver function tests (QLFTs) to determine cutoffs for QLFTs that identified patients who were at low and high risk for a clinical outcome. Two hundred and twenty-seven participants in the Hepatitis C Antiviral Long-term Treatment Against Cirrhosis (HALT-C) Trial underwent baseline QLFTs and were followed for a median of 5.5 years for clinical outcomes. QLFTs were repeated in 196 patients at month 24 and in 165 patients at month 48. Caffeine elimination rate (k(elim)), antipyrine (AP) clearance (Cl), MEGX concentration, methionine breath test (MBT), galactose elimination capacity (GEC), dual cholate (CA) clearances and shunt, perfused hepatic mass (PHM), and liver and spleen volumes (by single-photon emission computed tomography) were measured. Baseline QLFTs were significantly worse (P = 0.0017 to P < 0.0001) and spleen volumes were larger (P < 0.0001) in the 54 patients who subsequently experienced clinical outcomes. QLFT cutoffs that characterized patients as "low" and "high risk" for clinical outcome yielded hazard ratios ranging from 2.21 (95% confidence interval [CI]: 1.29-3.78) for GEC to 6.52 (95% CI: 3.63-11.71) for CA clearance after oral administration (Cl(oral)). QLFTs independently predicted outcome in models with Ishak fibrosis score, platelet count, and standard laboratory tests. In serial studies, patients with high-risk results for CA Cl(oral) or PHM had a nearly 15-fold increase in risk for clinical outcome. Less than 5% of patients with "low risk" QLFTs experienced a clinical outcome.

CONCLUSION

QLFTs independently predict risk for future clinical outcomes. By improving risk assessment, QLFTs could enhance the noninvasive monitoring, counseling, and management of patients with chronic HCV.

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.

Safety and effectiveness of blind percutaneous liver biopsy: analysis of 1412 procedures

BACKGROUND

Percutaneous liver biopsy is one of the most important and widely used methods for diagnosing chronic liver diseases; however, controversies related to the potential risk of complications and patient discomfort still exist.

OBJECTIVES

The objective of this study was to evaluate the safety and success rate of blind percutaneous liver biopsy.

PATIENTS AND METHODS

We conducted a retrospective analysis of 1412 blind percutaneous thick-needle liver biopsies performed during 1977-2000 at a single center on 1110 patients, using archived medical data of the center.

RESULTS

The overall success rate of obtaining a liver sample with this method was 95.3%. Of all the samples assessed, 91.7% were determined to be fully representative for an evaluation by the pathologist. Complications occurred in 259 procedures (18.3%). While no fatalities associated with liver biopsy were noted, 9 serious complications (0.64%) directly related to biopsies were reported. Pain was the most common complication (15.3%). Significantly more complications (pain and vasovagal reactions) were reported in females (22.1%) than in males (16.1%) (P = 0.005). The rate of complications was significantly correlated with the stage of fibrosis (P = 0.027), i.e. the higher the fibrosis stage, the higher the complication rate. Previous surgical procedures involving the abdominal cavity or thorax influenced the effectiveness of liver biopsy (P = 0.017). Less operator experience was significantly associated with a higher rate of procedure failure (P = 0.002). Statistical significance of the relationship between individual operator efficiency and complication rate (P = 0.000) and that between individual operator efficiency and biopsy failure rate (P = 0.002) was observed.

CONCLUSIONS

Blind percutaneous liver biopsy is a safe and effective invasive procedure, despite the fact that noninvasive fibrosis assessment methods are currently widely available and used instead of histological evaluation. Complications risk and failure rate are low if indications and contraindications are considered carefully and the biopsy is performed by a skilled and experienced operator. Certain groups of patients may benefit from an image-guided procedure to improve its effectiveness.

Transient elastography for predicting esophageal/gastric varices in children with biliary atresia

Background

Transient elastography (TE) is an innovative, noninvasive technique to assess liver fibrosis by measuring liver stiffness in patients with chronic liver diseases. The purpose of this study has been to explore the accuracy of TE and clinical parameters in predicting the presence of esophageal/gastric varices in children with biliary atresia (BA) following portoenterostomy.

Methods

Patients with BA status post portoenterostomy and normal children were recruited. Splenomegaly and presence of EV/GV were determined by physical examination and endoscopy, respectively. Aspartate transaminase to platelet ratio index (APRI) was used as a serum fibrosis marker. TE was performed by using FibroScan. Data was expressed as mean ± SD.

Results

Seventy-three BA patients (male:female = 32:41; age 9.11 ± 5.64 years) and 50 normal controls (male:female = 19:31; age 11.00 ± 3.31 years) were enrolled. The liver stiffness score of BA patients was significantly higher than that of normal controls (27.37 ± 22.48 and 4.69 ± 1.03 kPa; p < 0.001). Patients with EV/GV had significantly higher liver stiffness score and APRI than those without EV/GV. As for EV/GV diagnosis, the areas under the receiver operating characteristic curve were 0.89 (95% CI 0.80 to 0.98) for TE and 0.87 (95% CI 0.78 to 0.96) for APRI, respectively. The sensitivity (and specificity) of TE (using a cut-off value of 12.7 kPa) and APRI (using a cut-off value of 1.92) in predicting EV/GV were 84% (77%) and 84% (83%), respectively, whereas the sensitivity (and specificity) of splenomegaly in predicting EV/GV were 92% (85%).

Conclusions

Transient elastography is a useful tool for predicting the presence of EV/GV. In addition, basic physical examination, routine biochemical and hematological tests, are still worthwhile and correlate well with the presence of EV/GV in patients with BA post portoenterostomy.

Increased liver elasticity in patients with biliary obstruction

BACKGROUND

Transient elastography (with the FibroScan® apparatus) is a recently developed method for evaluating the severity of liver fibrosis by measuring liver elasticity. Liver elasticity may differ from the normal level in patients with obstructive jaundice because the retained bile may expand the liver. Because little is known about liver elasticity in patients with obstructive jaundice, we evaluated this feature in these patients.

METHODS

Between April 2007 and April 2008, 178 patients with biliary or pancreatic disease underwent transient elastography at the University of Tokyo Hospital. We excluded 77 patients because of concomitant cirrhotic liver disease, liver tumors, or a history of abdominal surgery. The remaining 101 patients were included in the study and were divided into obstructive jaundice (OJ; n = 43) and nonobstructive jaundice (NJ; n = 58) groups.

RESULTS

The basic patient characteristics did not differ significantly between the two groups, except for the causative diseases. The mean liver elasticity was significantly higher in the OJ group than in the NJ group (12.0 vs. 6.2 kPa, p < 0.01). In 24 patients from the OJ group, transient elastography was performed before and after biliary drainage; there was a marked reduction in the elasticity after the procedure in these patients (p < 0.01).

CONCLUSIONS

Liver elasticity increases in patients with biliary obstruction. This increase is reduced after biliary drainage, implying that the increased FibroScan® values before drainage are not due to liver fibrosis, but to temporarily increased elasticity.

Reduced mortality rates following elective percutaneous liver biopsies

BACKGROUND & AIMS

Estimates of complication rates following elective percutaneous liver biopsy vary and might not accurately reflect current practice. We studied mortality and complication rates, by indication, in patients after they underwent liver biopsies.

METHODS

We performed a study using hospital episode statistics collected by the National Health Service in England from 1998 to 2005 of elective percutaneous liver biopsies; data were linked with those from the Office for National Statistics to determine mortality rates. Using data from 61,187 people who underwent liver biopsies, all-cause mortality at 7 and 30 days after biopsy, 7-day mortality directly related to liver biopsy, and episodes of bleeding up to 7 days after biopsy were determined.

RESULTS

Overall all-cause mortality by 7 days after biopsy was 2 per 1000 biopsies (95% confidence interval, 1.8-2.5); this rate varied markedly by indication for biopsy, with rates as high as 12 per 1000 for patients investigated for cancer. Death within 7 days directly related to liver biopsy occurred, at most, every 1 in 10,000 biopsies in patients investigated for liver disease or abnormal liver function test results. Overall, 6 episodes of major bleeding occurred per 1000 biopsies.

CONCLUSIONS

All-cause mortality risk following elective percutaneous liver biopsy is approximately 0.2%, with a higher risk of major bleeding. Deaths directly related to liver biopsy occur approximately 1 in every 10,000 biopsies. This risk is substantially lower than that of previous reports, indicating that the safety of this procedure has improved.

Complication rate of percutaneous liver biopsies among persons with advanced chronic liver disease in the HALT-C trial

BACKGROUND & AIMS

Although percutaneous liver biopsy is a standard diagnostic procedure, it has drawbacks, including risk of serious complications. It is not known whether persons with advanced chronic liver disease have a greater risk of complications from liver biopsy than patients with more mild, chronic liver disease. The safety and complications of liver biopsy were examined in patients with hepatitis C-related bridging fibrosis or cirrhosis who were enrolled in the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis trial.

METHODS

Standard case report forms from 2740 liver biopsies performed at 10 study sites between 2000 and 2006 were reviewed for serious adverse events, together with information from questionnaires completed by investigators about details of biopsy techniques used at each hospital.

RESULTS

There were 29 serious adverse events (1.1%); the most common was bleeding (16 cases; 0.6%). There were no biopsy-related deaths. The bleeding rate was higher among patients with platelet counts of 60,000/mm(3) or less and among those with an international normalized ratio of 1.3 or greater, although none of the patients with an international normalized ratio greater than 1.5 bled. Excluding subjects with a platelet count of 60,000/mm(3) or less would have reduced the bleeding rate by 25% (4 of 16), eliminating only 2.8% (77 of 2740) of biopsies. Operator experience, the type of needle used, or the performance of the biopsy under ultrasound guidance did not influence the frequencies of adverse events.

CONCLUSIONS

Approximately 0.5% of persons with hepatitis C and advanced fibrosis experienced potentially serious bleeding after liver biopsy; risk increased significantly in patients with platelet counts of 60,000/mm(3) or less.

Liver transient elastography (Fibroscan): a place in the management algorithms of chronic viral hepatitis

Treatment guidelines are continuously evolving in chronic viral hepatitis, taking into consideration our greater understanding of natural history and therapeutic efficacy and safety. Key in the decision making process is an assessment of liver injury. Traditionally, liver biopsy has provided this information; however, this is an invasive procedure and not completely reliable. Liver transient elastography (Fibroscan) is exciting new technology that allows estimation of hepatic fibrosis through measurement of liver stiffness. It is acceptably accurate, safe, cheap, quick and widely applicable, and can reduce the need for liver biopsy in chronic hepatitis. In chronic hepatitis C, it can identify those most likely to benefit from treatment, as well as those with cirrhosis who require more specific care. In chronic hepatitis B, it could screen groups previously excluded from treatment (normal alanine aminotransferase and low DNA) to identify the subgroup that would benefit from therapy. It cannot replace biopsy in all settings, but it will narrow the group who do require biopsy, and provide information on liver damage in patients for whom biopsy would probably not have been considered.

The predictors of the presence of varices in patients with primary sclerosing cholangitis

The predictors for developing varices in patients with primary sclerosing cholangitis (PSC) have not been well studied prospectively. We sought to define the predictors for the presence of varices at baseline and for newly developing varices in patients with PSC. We used prospectively collected data from a multicenter randomized trial of high dose ursodeoxycholic acid for PSC. All 150 patients enrolled were reviewed for predictors of varices and we excluded 26 patients who had esophageal varices at baseline so that predictors of newly developing varices could be determined. Clinical examination, blood tests, and upper endoscopy were done before randomization, at 2 years and after 5 years. Liver biopsy was performed at entry and at 5 years. The median age (interquartile range) of patients was 45.9 years (35.8, 54.9). In a multivariable logistic regression, a higher Mayo risk score (> or =0.87) or a higher aspartate/alanine aminotransferase (AST/ALT) ratio (> or =1.12) were significantly associated with the presence of varices at initial endoscopy (odds ratio = 1.9 and 3.9). By the end of the study, 25 patients had new varices (20.2%). In a Cox model, after adjustment for baseline variables lower platelet count and higher total bilirubin at 2 years were significantly associated with the presence of new varices. The platelet count of 205 (x 10(9)/L) and the total bilirubin level of 1.7 mg/dL were the best cutoff values for the detection of new varices.

CONCLUSION

A higher Mayo risk score and higher AST/ALT ratio were significantly associated with the presence of varices at initial endoscopy. Lower platelet count and higher total bilirubin at 2 years were significantly associated with an increased risk of developing new varices in patients with PSC.

Incidence of bleeding after 15,181 percutaneous biopsies and the role of aspirin

OBJECTIVE

The objective of our study was to report the incidence of bleeding after imaging-guided percutaneous core biopsy at a single center using a standardized technique.

MATERIALS AND METHODS

We performed a retrospective review of percutaneous core biopsies performed at our institution from January 2002 through February 2008. Data were collected at the time of biopsy, and clinical information was obtained 24 hours and 3 months after the biopsy. The specific information that was collected included the results of coagulation studies, aspirin use, the organ biopsied, the size of the biopsy needle, and the number of needle passes. Bleeding complications were defined using the Common Terminology Criteria for Adverse Events (CTCAE, version 3.0) established by the National Cancer Institute.

RESULTS

Among the 15,181 percutaneous core biopsies performed during the study period, 70 hemorrhages (0.5%) that were CTCAE grade 3 or greater were identified within 3 months of biopsy. The incidence of bleeding in patients taking aspirin within 10 days before biopsy was 0.6% (18/3,195), which was not statistically different compared with the incidence of bleeding in those not taking aspirin (52/11,986, 0.4%; p = 0.34). The incidence of bleeding after liver biopsy was 0.5%; kidney biopsy, 0.7%; lung biopsy, 0.2%; pancreas biopsy, 1.0%; and other biopsy, 0.2%. There were significant associations between major bleeding and serum platelet count and international normalized ratio (p < 0.001), although the association between major bleeding and the size of the biopsy needle was not significant (p = 0.97).

CONCLUSION

The overall incidence of major bleeding after imaging-guided percutaneous core needle biopsy is low. Recent aspirin therapy does not appear to significantly increase the risk of such bleeding complications.

Liver biopsies for chronic hepatitis C: should nonultrasound-guided biopsies be abandoned?

BACKGROUND/OBJECTIVE

Liver biopsy has been the gold standard for grading and staging chronic hepatitis C virus (HCV)- mediated liver injury. Traditionally, this has been performed by trained practitioners using a nonimage-guided percutaneous technique at the bedside. Recent literature suggests an expanding role for radiologists in obtaining biopsies using an ultrasound (US)-guided technique. The present study was undertaken study to determine if the two techniques produced liver biopsy specimens of similar quality and hypothesized that at our institution, non-US-guided percutaneous liver biopsies for HCV would be of higher quality than US-guided specimens.

METHODS

Liver biopsies from 100 patients with chronic HCV infection (50 consecutive US-guided and 50 consecutive non-US-guided), were retrospectively identified using a hospital histopathology database. All original biopsy slides were coded and prospectively reanalyzed by a single hepatopathologist who was blinded to the technique used in obtaining the biopsy. Additionally, all liver biopsies for chronic HCV infection completed at the centre from 1998 to 2007 were identified and the technique used was recorded. Biopsy quality was determined primarily by the number of complete portal tracts (CPTs) identifiable in the slides. The total length of specimen and the degree of fragmentation were secondary outcome measures.

RESULTS

There was a slight difference observed between the US-guided and non-US-guided groups in mean age (46.3 years versus 42.5 years, respectively; P=0.018) but no differences in sex, presence of cirrhosis, bilirubin, creatinine, international normalized ratio, and grade or stage of disease. Biopsies obtained using the US-guided technique produced higher quality specimens than the non-US-guided technique based on our primary outcome of number of CPTs in the biopsy (11.8 versus 7.4; P<0.001). US-guided specimens also were longer (24.4 mm versus 19.7 mm; P=0.001), had less fragmentation (P=0.016), and a higher overall histopathological quality assessment (P=0.026) than the non-US-guided biopsies. However, there was no significant difference between the two groups in the ability to grade and stage the disease (96% US-guided versus 90% in non-US-guided (P=0.20). Over a 10-year period, 763 biopsies for chronic HCV infection were identified with an obvious trend toward the increased use of US-guided technique observed at 2% in 1998 to 85% in 2007.

CONCLUSIONS

US-guided liver biopsies for chronic HCV are the most common method of obtaining specimens at the Kingston General Hospital, Kingston, Ontario, and are of higher quality than non-US-guided specimens. However, there is no significant difference in the two techniques in the ability to grade and stage chronic HCV.

Non-invasive evaluation of liver fibrosis by transient elastography and biochemical markers in elderly inpatients

AIM

The objective of this study was to evaluate liver fibrosis using non-invasive methods in elderly patients.

METHODS

In a prospective two-day study, all consecutive patients of geriatric units were examined using transient elastography (FibroScan) and biochemical markers (Hepascore, Aspartate Transaminase (AST) to platelet ratio index [APRI], Forns score, FibroTest). Three groups of patients were included: elderly patients without liver disease (group A, 85.2+/-7.3 years); healthy younger control subjects without liver fibrosis (group B, 46.4+/-15.2 years); and elderly patients with confirmed liver disease (group C, 82.4+/-2.3 years).

RESULTS

FibroScan) results in the elderly patients correlated well with fibrosis surrogates, but were more difficult to obtain than in the younger subjects. Mean liver stiffness was 6.1 kPa (group A) versus 4.9 kPa (group B) and versus 10.2 kPa (group C) (P<0.0001). FibroTest results were 0.5 in group A versus 0.2 in group B, and versus 0.6 in group C (P<0.0001). In group A, statistical analysis showed that diabetes was associated with advanced liver fibrosis (FibroScan) > or = 9.5 kPa). A body mass index greater than 26kg/m2, age greater than 85 years, comorbidity score and polymedication were not associated with fibrosis.

CONCLUSION

Although liver stiffness may be more difficult to assess in the elderly, FibroScan may nevertheless serve as a new, non-invasive method for detecting liver fibrosis in this population.

13C-methacetin-breath test compared to also noninvasive biochemical blood tests in predicting hepatic fibrosis and cirrhosis in chronic hepatitis C

BACKGROUND

The (13)C-methacetin-breath test and also several noninvasive blood tests comprising routine laboratory parameters have been proposed to predict fibrosis and cirrhosis in chronic hepatitis C. The aim of the study was to compare the diagnostic accuracy between these tests referring to hepatic histology as gold standard.

METHODS

96 patients with chronic hepatitis C virus infection underwent percutaneous liver biopsy and the (13)C-methacetin-breath test. The Fibroindex, the aspartate aminotransferase to platelet ratio index , and the aspartate aminotransferase to alanine aminotransferase ratio were used as parameters for the staging of fibrosis. The main endpoint was the area under the characteristic curves for the diagnosis of advanced fibrosis (F3-F4) and cirrhosis (F4) according to the Batts Ludwig criteria.

RESULTS

ROC analysis revealed a cut-off <14.6 per thousand best with 92.6% sensitivity and 84.1% specificity for the (13)C-methacetin-breath test, for the Fibroindex >1.82 70.4% sensitivity and 91.3% specificity, for the aspartate aminotransferase to platelet ratio >1.0 a 66.7% sensitivity and 75.4% specificity, and for the aspartate aminotransferase to alanine aminotransferase ratio >1.0 63.0% sensitivity and 59.4% specificity in predicting liver cirrhosis. The areas under the curve for the breath test, the Fibroindex, aspartate aminotransferase to platelet ratio and the aspartate aminotransferase to alanine aminotransferase ratio were 0.958, 0.845, 0.799, and 0.688, respectively, when predicting cirrhosis. For identifying patients with advanced fibrosis, the areas under the curve were 0.827, 0.804, 0.779, and 0.561, respectively. Discordances between Fibroindex (21%), aspartate aminotransferase to platelet ratio (29%) or aspartate aminotransferase to alanine aminotransferase ratio (37.6%) and liver biopsy were significantly more frequent than between (13)C-breath test (11.6%) and liver biopsy (P<0.05).

CONCLUSION

The (13)C-methacetin-breath test is more reliable in predicting advanced fibrosis and cirrhosis than simple biochemical parameters (aspartate aminotransferase to platelet ratio; aspartate aminotransferase to alanine aminotransferase ratio).

How to measure the diagnostic accuracy of noninvasive liver fibrosis indices: the area under the ROC curve revisited

BACKGROUND

The area under the ROC curve (AUC) is widely used to measure the diagnostic accuracy of noninvasive fibrosis indices. However, use of the AUC assumes a binary gold standard, whereas fibrosis staging is based on an ordinal scale and also depends on the distribution of fibrosis stages in the study sample. We explored other fibrosis staging accuracy measures designed for ordinal gold standards, the C-statistic and the Obuchowski measure.

METHODS

We performed a simulation study to assess the bias in estimating the accuracy measures when the distribution of fibrosis stages in the study sample do not fit the reference distribution in the population to which the indices are applied. We also estimated the type I error of the tests comparing these measures in 2 samples with different distributions of fibrosis stages. We illustrated the practical use of these measures by reanalyzing real data.

RESULTS

Compared with the AUC or the C-statistic, the Obuchowski measure showed limited bias when the distribution of fibrosis stages in the study sample differed from the reference distribution. The type I error was strongly inflated with the AUC or the C-statistic but was preserved in the Obuchowski measure. When we compared noninvasive indices on real data, AUC analysis led to discordant results depending on how the fibrosis stages were grouped together. One single conclusion was drawn from the analysis based on the Obuchowski measure.

CONCLUSIONS

We recommend using the Obuchowski measure for assessing the diagnostic accuracy of noninvasive indices of fibrosis.