Transjugular liver biopsy is a safe and effective intervention to guide management for patients with a congenital bleeding disorder infected with hepatitis C

Evaluation of the Success Rate of Ultrasound-guided Transjugular Liver Biopsy (TJLB) and the Associated Complications

Introduction

Transjugular liver biopsy (TJLB) is a diagnostic radiological intervention, applied to patients with contraindications to percutaneous or laparoscopic liver biopsy. The aim of this study was to determine the safety, effectiveness, complications, and pathological impact of TJLB.

Methods

This cross-sectional study was conducted on 24 consecutive patients, undergoing TJLB at Imam Reza Hospital, affiliated to Mashhad University of Medical Sciences, from April 2010 to March 2011. The inclusion criteria were coagulopathy, thrombocytopenia, and ascites. TJLB was performed by a radiologist, and a guide wire was inserted in the right jugular vein. Right atrium and middle hepatic vein were catheterized, and then, Cook Quick-Core Biopsy Needle was used by ultrasound guidance. Data analysis was performed by SPSS version 16.

Results

The sample size included 24 subjects (54% males and 46% females). Success rate of TJLB was reported as 87.5% and the intervention duration was 23.89±9.34 min. No complications were reported in 37.5% of the patients; however, pain in the right upper quadrant (33.3%), leakage of contrast substance into the liver capsule (4.2%), and diffuse abdominal pain (4.2%). In 83% of biopsies, suitable samples were obtained for histopathological diagnosis, and 13% of patients were excluded from the study. According to the results, the mean central port track (CPT) was 6.75 ± 2.95.

Conclusion

TJLB is a relatively effective and safe procedure for patients with contraindications to percutaneous liver biopsy.

Transjugular liver biopsy

Liver biopsy is considered the gold standard for the evaluation of acute and chronic liver disorders. Transjugular liver biopsy (TJLB) was described by Dotter in 1964 and clinically performed for the first time by Hanafee in 1967. TJLB consists of obtaining liver tissue through a rigid cannula introduced into one of the hepatic veins, typically using jugular venous access. The quality of the TJLB specimens has improved so much that the samples obtained by this method are comparable with those obtained with the percutaneous technique. TJLB is indicated for patients with coagulopathy, ascites, peliosis hepatis, morbid obesity, liver transplant, or in patients undergoing a transjugular intrahepatic portosystemic shunt procedure. The technical success rate for a TJLB procedure ranges from 87 to 97%. Sample fragmentation has been reported in 14 to 25% of the TJLB samples. The complication rates are low and range between 1.3% and 6.5%. The purpose of this article is to provide a review of the fundamental aspects of the TJLB procedure, including technique, indications, contraindications, results, and complications.

Two cases of major hemorrhage secondary to transjugular liver biopsy

Transjugular liver biopsy is an essential procedure in the armamentarium of the interventional radiologist for patients who otherwise are unable to undergo percutaneous liver biopsy. Multiple conditions exist that necessitate the transjugular approach for biopsy, including acquired coagulopathy, congenital blood disorders, or requirement for measurements of hepatic venous and/or wedged hepatic vein pressures. The safety and efficacy of transjugular liver biopsy is well established, with many studies citing extremely low rates of complication with high rates of technical success. Nonetheless, transjugular liver biopsy is not without complications. The most often reported complication is asymptomatic capsular perforation; however occasionally, major hemorrhagic complications and even death have been reported. We describe two major hemorrhagic complications that manifested several days after the procedure and required emergent intervention.

Transjugular liver biopsy: comparison of sample adequacy with the use of two automated needle systems

PURPOSE

To compare the adequacy of transjugular liver biopsy (TJLB) specimens with use of the 18-gauge Quick-Core and Flexcore needles.

MATERIALS AND METHODS

The records of 233 patients who underwent a TJLB procedure from January 2005 to December 2006 were retrospectively reviewed. Tissue samples from a total of 194 procedures were available for review; 117 TJLB procedures were performed with a Quick-Core needle and 77 were performed with a Flexcore needle. A single pathologist reviewed all the liver biopsy specimens in a blinded fashion. The χ(2), Fisher exact, and Student t tests were used to analyze differences between groups.

RESULTS

The TJLB procedure was technically successful in 232 of 233 cases (99.6%). Histologic diagnosis was possible in 96% of cases. Sample fragmentation rates were 24.9% with the Quick-Core needle and 14.3% with the Flexcore needle (P = .1). The mean numbers of complete portal tracts (CPTs) per submitted tissue per procedure were 10.0 ± 4.6 for the Quick-Core needle and 12.2 ± 6.1 for the Flexcore needle (P = .003). The mean numbers of CPTs per liver sample were 2.63 ± 1.8 for the Quick-Core needle and 3.28 ± 3.3 for the Flexcore needle (P = .00004). Complications were more common in patients with multiple comorbidities such as renal failure and coagulopathy and those who had received a liver transplant.

CONCLUSIONS

This study demonstrates that the 18-gauge Flexcore TJLB system provided better liver biopsy specimens compared with the 18-gauge Quick-Core needle system.

Can serum TGF-beta 1 be used to evaluate the response to antiviral therapy of haemophilic patients with HCV-related chronic hepatitis?

Congenital coagulation disorders limit the use of liver biopsy, especially when repeated assessment is needed. TGF-beta 1 plays a pivotal role in inducing fibrosis and has been proposed as its surrogate marker. Aiming at validating the clinical utility of this cytokine, fifteen haemophilic patients suffering from HCV-related chronic hepatitis were treated with Peg-IFN alpha2beta plus Ribavirin. Serum TGFbeta 1, viral load and liver enzymes were analyzed at baseline and at six, twelve, and eighteen months. As expected, patients initially showed significantly higher TGF-beta 1 levels than age-matched controls (43.8 ng/mL, 28.7-46.4 vs. 26.9 ng/mL, 23.0-34.0, median and 95% CI; p=0.004). The end of therapy response rate was 67%. The main finding was a significant drop in TGF-beta 1 at six months compared to baseline values; this drop de facto predicted the levels reached in the following six months, which were fixed at lower concentrations (37.0 ng/mL, 21.9-43.8 and 27.0 ng/mL, 24.1-44.0 respectively; p<0.009), independently of treatment outcome (three patients were breakthrough, twelve were sustained virological responders (SVRs). During the treatment period none had clinical or biochemical signs of inflammation in other areas. Treatment was followed by a six-month follow-up, at the end of which TGF-beta 1 was increased compared to the previous values, reaching the initial levels in ten SVRs (45 ng/mL, 24.5-52.9). Interestingly, at a longer follow-up, two out of ten SVRs, who displayed the highest values of TGF-beta 1, relapsed. Serum TGF-beta 1 could be used to assess therapeutic outcome and short-term prognosis of HCV-related chronic hepatitis.

Percutaneous liver biopsy in hemophiliac children with chronic hepatitis C virus infection

OBJECTIVE

To develop a protocol for safe performance of percutaneous liver biopsies in children with deficiency of factor VIII (n = 12) or IX (n = 2) and chronic hepatitis C virus infection.

PATIENTS AND METHODS

Liver biopsies were performed after administration of factor VIII or IX, before and 24 weeks after cessation of antiviral therapy. To define the optimal means of providing replacement therapy, 10 children were enrolled in a randomized crossover design study of bolus versus continuous factor VIII for performance of the liver biopsy. For the crossover study, all of the patients were given a loading dose of 50 +/- 5 IU recombinant factor (rF)VIII/kg; a minimum of factor VIII activity of > or = 80% 30 to 60 minutes following factor VIII infusion was required for liver biopsy. For the bolus protocol, rFVIII 25 to 50 IU/kg was given 6, 14, 24, 36, 48, and 60 hours after completion of the loading dose. For the continuous protocol, rFVIII was given 3 to 4 IU/kg per hour for 48 hours, followed by a bolus of 25 IU/kg at 60 hours. In patients with factor IX deficiency, a loading dose of 100 IU/kg was followed by a bolus of 50 IU/kg at 3, 15, 27, and 48 hours after the loading dose.

RESULTS

Twenty liver biopsies were performed in children with factor VIII deficiency without major complications. One of the 3 biopsies in the patients with factor IX deficiency was complicated by a hemoperitoneum. Midazolam and fentanyl were used in the first 8 patients. However, postbiopsy pain, presumably secondary to hematoma in 2 patients and hemoperitoneum in 1, prompted us to use ultrasound to locate a suitable biopsy site and to change to propofol; this allowed us to better immobilize the liver, to minimize postbiopsy bleeding. The subsequent 15 biopsies were well tolerated without postbiopsy pain or other complication.

CONCLUSIONS

Percutaneous liver biopsy in children with factor VIII deficiency can be safely performed using either bolus or continuous infusion of recombinant factor VIII. A brief general anesthetic and ultrasound guidance are recommended.

Feasibility, safety and cost-effectiveness of transjugular liver biopsy following major surgery in patients with haemophilia

Prior to the introduction of virally inactivated clotting factor concentrates, the majority of patients with haemophilia became infected with the hepatitis C virus. Although transjugular liver biopsy can be safely performed in these patients, the procedure is associated with a significant financial burden mainly related to replacement therapy with clotting factor. The purpose of this study was to evaluate the feasibility and safety of transjugular liver biopsy in patients with haemophilia substituted with clotting factor concentrates for major surgical procedures. Over the last 5 years, transjugular liver biopsy was performed in nine patients with haemophilia within 1-10 days after orthopaedic (7), thoracic (1) or abdominal surgery (1). All patients had abnormal liver function tests and persistent hepatitis C viraemia. At the time of the biopsy, patients received recombinant factor VIII delivered by dose-adjusted continuous infusion through a central catheter inserted preoperatively in the left internal jugular (n = 8) or in an ante-cubital vein (n = 1). Before the biopsy, basal FVIII levels were raised to 80-100% by a bolus infusion and maintained above 80% for 24 h. The biopsy was informative in all cases. Only one patient developed an episode of supraventricular dysrhythmia. No bleeding or infectious complications were observed. When compared with elective liver biopsy performed outside the postsurgical period, the cost-savings per biopsy were 19 875 +/- 2660 euro. This study shows that intensive replacement therapy required by surgical procedures provides a safe and cost-effective opportunity for transjugular liver biopsy in patients with haemophilia and active hepatitis C.

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

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