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.

Successful diagnosis of a localized liver tumor via transjugular liver biopsy after ascites hampered a percutaneous approach

Liver biopsy is a crucial diagnostic procedure for liver-related conditions. However, it is challenging to use in cases with substantial ascites or coagulopathy. Transjugular liver biopsy has been introduced as an alternative method to overcome these limitations. Although transjugular liver biopsy is commonly used for diffuse liver diseases, its application to localized tumors has been limited. We report the case of a 66-year-old male initially diagnosed with unresectable pancreatic carcinoma, who later developed liver metastasis, peritoneal dissemination, and ascites. Treatment planning required tumor re-evaluation, but percutaneous liver biopsy was not viable because of the rapid accumulation of ascites and its presence on the liver surface. However, transjugular liver biopsy was a suitable alternative, given the proximity of the tumor to the right hepatic vein. The procedure, performed under fluoroscopic and ultrasound guidance, successfully obtained 4 specimens that were promptly diagnosed as liver metastases originating from pancreatic cancer. This case underscored the effectiveness of transjugular liver biopsy in situations where percutaneous biopsy is challenging because of conditions such as ascites. The combination of ultrasound guidance and rapid specimen assessment by pathology technicians can enhance diagnostic success rates. Transjugular liver biopsy is a valuable diagnostic tool in scenarios where percutaneous access poses significant difficulties.

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.

Update on endoscopic ultrasound-guided liver biopsy

Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a minimally-invasive alternative to the traditional (percutaneous or transjugular) liver biopsy techniques for the diagnosis of liver parenchymal diseases. Po-tentially, EUS-LB combines the advantages of percutaneous and transjugular liver biopsy in addressing focused sampling in addition to measuring portal pressure. Additionally, EUS-LB facilitates access to both the lobes of the liver which is not considered with the traditional percutaneous liver biopsy. Multiple studies have compared EUS-LB with conventional liver biopsy and reported comparable diagnostic yield, increased acquisition of complete portal tracts, and longer specimen length as compared to the traditional approaches. EUS-LB is associated with lesser post-procedural pain and shorter recovery time, while providing lower risk of complications when compared to traditional liver biopsy. Innovations in needle types, needle sizes and suction techniques have aimed at further optimizing the EUS-LB technique. This review article updates current literature with focus on the variations in the technique and equipment used for EUS-LB, and compares EUS-LB with traditional methods of liver biopsy.

[Analysis of 53 cases of transjugular liver biopsy]

Objective: To investigate the practicability and safety of transjugular liver biopsy (TJLB). Methods: Data of 53 cases with transjugular liver biopsy from June 2015 to June 2020 were collected. LABS-100 was used in all patients who underwent transjugular liver biopsy. Among them, 45 cases and eight were biopsied via hepatic vein and intrahepatic segment of the inferior vena cava. The surgical indications, related complications, and postoperative pathological diagnosis were analyzed and summarized. Results: TJLB was successful in all patients, with an average of 2.8 punctures per case. Satisfactory liver tissue and histopathological diagnosis was obtained in all patients. Two cases developed a cervical hematoma that was improved spontaneously, and one patient developed an intrahepatic hematoma that was improved after conservative treatment. Conclusion: TJLB is a practical and safe method for patients with contraindications to percutaneous liver biopsy.

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.

Heterogeneity of liver fibrosis in patients with congestive hepatopathy: A biopsy and explant comparison series

PURPOSE

Patients with end-stage heart failure and concomitant irreversible liver injury may be candidates for combined heart liver transplant (CHLT). Determining appropriate candidates for CHLT is essential given organ scarcity. Transjugular liver biopsy (TJLB) is used to evaluate the severity of parenchymal liver injury in transplant candidates. In patients with congestive hepatopathy (CH), the fibrosis pattern may be heterogenous.

METHODS

We reviewed all CHLT cases between 2007 and 2017, as well as lone-heart transplant cases with post-mortem autopsy. Pre-transplant TJLB was compared to explant to assess the performance of biopsy fibrosis staging.

RESULTS

12 patients were included. Median age at time of transplant was 58 and the cohort was predominantly male (75%). Seven (64%) TJLB were predominantly stage 4 fibrosis and 4 (36%) were stage 1. Advanced fibrosis was the dominant pattern in 7 (70%) explants and 5 (50%) explants had heterogenous fibrosis. In 50% of CH cases, there was discordance between the TJLB and explant. In the autopsy cases, the TJLB and autopsy findings differed.

CONCLUSIONS

In this series of matched TJLB and explanted livers, we found variable performance of TJLB in predicting the predominant fibrosis stage present in the liver.

Outcomes of transjugular liver biopsies for liver transplant recipients with bicaval and piggyback hepatic vein anastomoses

BACKGROUND

Liver transplant hepatic venous anastomoses are usually created using "bicaval" or "piggyback" techniques, which may result in unfavorable angulation between the inferior vena cava and hepatic veins, and makes hepatic vein catheterization and tissue sampling during transjugular liver biopsy (TLB) technically challenging.

PURPOSE

To compare the technical successes and complications of TLBs for recipients of liver transplants with bicaval and piggyback hepatic vein anastomoses.

MATERIAL AND METHODS

Information on type of hepatic vein surgical anastomosis was available for 190 adult patients in whom 306 consecutive TLBs were performed during 2009-2017: 158 with bicaval and 148 with piggyback anastomoses. The primary outcome of procedural success was defined as obtaining a tissue sample sufficient to make a pathologic diagnosis.

RESULTS

A technical success rate of 97% with adequate liver tissue for diagnosis was similar between the anastomotic groups (P = 0.50). TLB was unsuccessful in 3% of patients with piggyback anastomoses due to unfavorable hepatic venous anatomy whereas biopsy was successful in all patients with bicaval anastomoses (P = 0.02). Fluoroscopy times were not significantly different (12.1 vs. 13.9 min, P = 0.08). Rates of major complication were similar between the two groups (3% vs. 3%, P > 0.99).

CONCLUSION

TLB is safe and effective for liver transplant patients regardless of the type of hepatic vein anastomosis. While failure to catheterize or advance the stiffened biopsy cannula into the hepatic vein is more likely to occur in patients with piggyback anastomoses, this is a rare occurrence.

Utility and Safety of Transjugular Liver Biopsy in Children

Transjugular liver biopsy (TJLB) is widely used in adults when percutaneous liver biopsy (PLB) is contraindicated. The authors evaluated the safety, efficacy and utility of TJLB in pediatric patients with contraindications to PLB. Twenty-three children and adolescents (13 male) underwent 24 (one patient had two separate biopsies) consecutive biopsies (TJLB) under general anaesthesia (18) or intravenous sedation (6). PLB was contraindicated because of elevated prothrombin time (PT)/international normalized ratio (INR) (˃ 15.5/1.5) in 19 (79.2%) and thrombocytopenia (< 60,000/dL) in 15 (62.5%) procedures. Derangement in both INR and platelet count were found in 12 (50%) cases. Significant ascites was present in 10 (41.7%) procedures. Technical success rate with adequate biopsy sample was 95.8% (23/24) with no major complications. A new diagnosis was established in 9 (37.5%) cases. Another 14 (58.34%) biopsies confirmed the initial diagnoses. Four cases also revealed additional information guiding overall management and prognosis. Thus, TJLB is a safe and useful procedure in children.

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.

Transjugular Liver Biopsy in Patients with Liver Transplantation: Comparison of Quick-Core Biopsy and Forceps Biopsy

PURPOSE

To compare the safety and efficacy of transjugular liver biopsy (TJLB) using a Quick-Core biopsy needle or a forceps biopsy in patients with liver transplantation (LT) who were suspected of having rejection.

MATERIALS AND METHODS

From June 2015 to January 2017, 98 TJLBs (60 patients) with the Quick-Core biopsy needle and 95 TJLBs (58 patients) with a forceps biopsy system were attempted in patients with LT suspected of having rejection. Technical success, adequacy for diagnosis, number of biopsy instrument passes, the maximum and mean length of the obtained samples, and the complications were retrospectively analyzed.

RESULTS

TJLB was technically successful in all patients. Adequate specimens were obtained in 95.9% of the biopsy needle group and 91.6% in the forceps group (p = 0.246). The mean number of biopsies was 4.8 ± 1.8 in the biopsy needle group and 6.2 ± 1.7 in the forceps group. The mean size of the biopsy sample was 11.1 ± 3.0 mm in the biopsy needle group and 2.5 ± 1.2 mm in the forceps group. Only one minor complication (a subcapsular hematoma) occurred in the biopsy needle group. No major complication was observed in any patient.

CONCLUSION

TJLB using a Quick-Core biopsy needle or forceps can be safely and effectively performed in LT patients. The adequacy of sampling for diagnosis was equivalent between the groups.

LEVEL OF EVIDENCE

Level 4, case series.

Clinical application of transjugular liver biopsy

BACKGROUND

With the increasing incidence of liver diseases, liver biopsy plays an increasingly important role in the diagnosis and treatment of acute or chronic liver diseases. Although percutaneous liver biopsy has been widely used in clinical practice, transjugular liver biopsy (TJLB) is a safe and effective alternative for patients with contraindications to percutaneous liver biopsy, especially for patients with diffuse liver disease. Although TJLB has been widely carried out abroad, there are only a few related reports in domestic hospitals due to equipment reasons.

AIM

To discuss the safety and feasibility of using LABS 100 intrahepatic biopsy needle set produced by COOK company for TJLB in patients with contraindications to or high risk factors for percutaneous liver biopsy.

METHODS

The clinical data of ten patients who underwent TJLB at our hospital from November 2019 to March 2020 were analyzed retrospectively, including indications, success rate of operation, complications, and sampling results.

RESULTS

The success rate of operation was 100% and the complication rate was 10%, and all patients got enough liver tissue and pathological diagnosis.

CONCLUSION

TJLB is a safe and effective method for patients who are not suitable for percutaneous liver biopsy. Although TJLB has been widely carried out abroad, it is rarely carried out in China.

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.

Transjugular aspiration liver biopsy performed by hepatologists trained in HVPG measurements is safe and provides important diagnostic information

BACKGROUND

Transjugular liver biopsy (TJLB) represents an alternative to percutaneous liver biopsy especially in patients with impaired coagulation and ascites.

AIMS

To describe safety and diagnostic yield of aspiration TJLB performed by hepatologists experienced in hepatic venous pressure gradient (HVPG) measurements.

METHODS

445 TJLB of 399 patients between 01/2007-12/2016 were retrospectively assessed.

RESULTS

Histological diagnosis was obtained in 423 (95.1%) biopsies - including 11 (100%) patients with acute liver failure and 34 (97.1%) patients after liver transplantation. A median number of 5 portal tracts (interquartile range:2-9) was obtained. HVPG negatively correlated with sample length (Spearman ρ = -0.310; p < 0.001) and number of portal tracts (ρ = -0.212; p < 0.001). Among n = 151 patients with unknown etiology of liver disease, etiology was successfully identified on liver histology in 126 patients (83.4%). Complications occurred in 28 biopsies (6.3%) including 25 (5.6%) minor and 3 (0.7%) major complications. No deaths due to TJLB were observed. Neither the presence of ascites (6.6% complications) nor of coagulopathy (platelets<50G/L and/or prothrombin time<50%; 4.8% complications) increased the risk for complications.

CONCLUSIONS

TJLB performed by hepatologists experienced in HVPG measurements is safe - even in patients with ascites or coagulopathy. TJLB has good diagnostic value for histological evaluation of liver disease and acute liver failure.

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.

Transjugular liver biopsy after transjugular intrahepatic portosystemic shunt (TIPS) or direct intrahepatic portocaval shunt (DIPS): Is it feasible, effective, and safe?

PURPOSE

To evaluate our experience with transjugular liver biopsies (TJLB) in patients with previously placed transjugular intrahepatic portosystemic shunt (TIPS) or direct intrahepatic portocaval shunt (DIPS).

MATERIAL AND METHODS

A single-institution retrospective review was performed looking at all TJLBs in patients with previously placed TIPS or DIPS over the past seven years. There were six men and one woman (mean age 57.9±8.8 [SD] years; range: 47-71 years). Patient demographics, indications, procedural details, laboratory data, complications, and pathology were recorded. Patients with occluded TIPS were excluded from this study.

RESULTS

Seven TJLBs were performed, five in patients who had a TIPS and two who had a DIPS. Of the patients with TIPS, biopsies were performed from the same hepatic vein as TIPS in three procedures and from a different hepatic vein in two procedures. In DIPS patients, both biopsies were performed from the right hepatic vein. The reasons for the transjugular rather than the percutaneous approach to liver biopsy included ascites, coagulopathy, or need for concurrent TIPS/DIPS evaluation and/or revision. All procedures were technically successful with adequate samples obtained. There were no immediate or delayed complications.

CONCLUSION

Our results suggest that if needed a TJLB can safely and effectively be performed in patients with previously placed TIPS or DIPS.

Transjugular liver biopsy in severe alcoholic hepatitis

BACKGROUND

Alcoholic hepatitis and cirrhosis although part of spectrum of alcoholic liver disease can have overlapping features, and differentiating them using clinical, biochemical, and imaging features is not always possible. Standard therapy for each differs, and steroid therapy while beneficial in alcoholic hepatitis may be detrimental in cirrhosis due to high infectious complications. We analyzed our experience with liver biopsy in patients with severe alcoholic hepatitis.

METHODS

Male patients in the age group of 25-65 years who were clinically diagnosed with severe alcoholic hepatitis (DF > 32) were retrospectively analyzed and included in this study. All of them had undergone transjugular liver biopsy within the first 7 days of hospitalization.

RESULTS

Thirty patients were included. Most were in the 35-55 age group. Jaundice was present in all patients with fever and tender hepatomegaly also being common. On histopathological evaluation, 33.3% (n = 10) suspected clinically to have alcoholic hepatitis had underlying cirrhosis.

CONCLUSION

Cirrhosis is found in one third of patients with severe alcoholic hepatitis. This may alter our approach to management of this condition.

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 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.

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.

Transjugular liver biopsy

Liver biopsy is still the gold standard for evaluation of acute and chronic liver diseases, despite achievements regarding noninvasive diagnosis and staging in liver diseases. Transjugular liver biopsy (TJLB) has proved a good option when ascites and/or significant coagulopathy precludes a percutaneous approach. Because diagnostic hemodynamic procedures can be performed during the same session, it is useful in many clinical settings, regardless of the absence of percuteaneous contraindications. TJLB is a safe technique able to provide good-quality specimens with a low rate of complications. This article presents an overview of TJLB that discusses the technique, applicability, indications, contraindications, complications, and diagnostic accuracy.

Is liver biopsy necessary in the management of alcoholic hepatitis?

Acute alcoholic hepatitis (AAH) is characterised by deep jaundice in patients with a history of heavy alcohol use, which can progress to liver failure. A clinical diagnosis of AAH can be challenging to make in patients without a clear alcohol history or in the presence of risk factors for other causes of acute liver failure. Other causes of acute on chronic liver failure such as sepsis or variceal haemorrhage should be considered. Liver biopsy remains the only reliable method to make an accurate diagnosis. However, there is controversy surrounding the use of liver biopsy in patients with AAH because of the risks of performing a percutaneous biopsy and limitations in access to transjugular biopsy. We review the existing literature and find there are few studies directly comparing clinical and histological diagnosis of AAH. In the small number of studies that have been conducted the correlation between a clinical and histological diagnosis of AAH is poor. Due to this lack of agreement together with difficulties in accessing transjugular liver biopsy outside tertiary referral centres and research institutions, we cannot advocate universal biopsy for AAH but there remains a definite role for liver biopsy where there is clinical diagnostic doubt or dual pathology. It also adds value in a clinical trial context to ensure a homogeneous trial population and to further our understanding of the disease pathology. Further prospective studies are required to determine whether non-invasive markers can be used to accurately diagnose AAH.

Transjugular liver biopsy: indications, technique and results

Transjugular liver biopsy is a safe, effective and well-tolerated technique to obtain liver tissue specimens in patients with diffuse liver disease associated with severe coagulopathies or massive ascites. Transjugular liver biopsy is almost always feasible. The use of ultrasonographic guidance for percutaneous puncture of the right internal jugular vein is recommended to decrease the incidence of local cervical minor complications. Semiautomated biopsy devices are very effective in obtaining optimal tissue samples for a precise and definite histological diagnosis with a very low rate of complication. The relative limitations of transjugular liver biopsy are the cost, the radiation dose given to the patient, the increased procedure time by comparison with the more common percutaneous liver biopsy, and the need of a well-trained interventional radiologist.

Transjugular liver biopsy

Biopsy of the liver is considered the 'gold standard' and is often necessary for histopathological characterization of hepatic disease processes. The techniques to obtain liver specimen are percutaneous liver biopsy, transjugular liver biopsy and mini-laparoscopic liver biopsy. Percutaneous route is the preferred method for its simplicity, ease and safety. Transjugular biopsy of the liver has become an accepted alternative method of obtaining hepatic tissue in patients with an established contraindication to percutaneous liver biopsy viz. coagulopathy, ascites, extreme obesity, small shrunken liver etc. A total of 67 transjugular liver biopsies were performed between January 2004 and February 2012 in a tertiary care hospital. The procedure was performed on in patient basis after thorough pre procedure work up with jugular puncture under ultrasonography guidance and fluoroscopy guided liver biopsy using LABS 100 liver access and biopsy set. The commonest indication for liver biopsy was work up for indeterminate chronic liver disease and the most common contraindications for percutaneous biopsy that led to biopsy by transjugular route were coagulopathy and ascites. Technical success of the procedure was achieved in 96% cases and no major complications were encountered in this group. Transjugular liver biopsy is a valuable tool for clinical decision making in a specific sub set of patients in whom percutaneous biopsy is contraindicated. Transjugular approach with jugular access under real time USG guidance and liver biopsy using automated core biopsy needle is safe, well tolerated, effective and provides adequate tissue for histological assessment.

Transjugular liver biopsy: results of 97 patients

OBJECTIVE

To evaluate the feasibility and efficacy of transjugular liver biopsy in patients with contraindicated percutaneous biopsy.

MATERIALS AND METHODS

Between June 2005 and April 2010, 97 patients who were admitted for transjugular liver biopsy were enrolled in this retrospective study. All liver biopsies were obtained using an 18 gauge Quick-Core liver biopsy set through the right hepatic vein via the internal jugular vein. Clinical indication, histopathological diagnosis, and complications were noted.

RESULTS

Primary technical success was achieved in 93 (95.8%) patients. Hepatic veins could not be catheterized and opacified in two patients and in the remaining two patients the veins could be opacified and catheterized but we were not able to pass the biopsy needle into the hepatic vein because of the acute angle between the inferior vena cava and hepatic veins. At least two specimens were obtained from each patient. The most frequent histopathological diagnosis was cirrhosis. A subcutaneous hematoma around the puncture side was encountered in one patient.

CONCLUSION

Transjugular liver biopsy is a feasible and effective alternative in patients with contraindication for percutaneous biopsy.