Role of Liver Biopsy in Chronic Hepatitis B

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From Medscape Gastroenterology

Ask the Experts about Liver Disease

Role of Liver Biopsy in Chronic Hepatitis B

Posted 01/07/2008

F. Balistreri, MD

Question

What is the role of grade of inflammation found on liver biopsy in starting

antiviral therapy in hepatitis B virus (HBV) infection with or without

considering the stage of disease?

Response from F. Balistreri, MD

Dorothy M. M. Kersten Professor of Pediatrics, University of Cincinnati College

of Medicine, Cincinnati, Ohio; Medical Director, Liver Transplantation Program,

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

The major value of a liver biopsy in a patient with chronic hepatitis B

infection is to rule out other causes of liver disease, assess the degree of

liver damage, and provide information regarding disease progression. The issue

is not always clearcut -- liver histology can improve significantly in patients

who have spontaneous hepatitis B e antigen (HBeAg) seroconversion or sustained

response to antiviral therapy. Likewise, liver histology can worsen rapidly in

patients who have recurrent exacerbations or reactivation of hepatitis B.

In practice, the issue of whether to initiate treatment in a patient with

chronic hepatitis B does not depend on histologic findings, such as the grade of

inflammation. The liver biopsy is of limited value in predicting response to

interferon therapy and the data are limited regarding the value in predicting

response to any of the oral antiviral agents. The best candidates for treatment

are those individuals with positive predictors of response -- these patients can

be identified on the basis of serum HBV DNA levels, hepatic biochemical tests,

and serologic studies. The best indicators of sustained virologic response are

low pre-treatment serum HBV DNA titers and elevated alanine aminotransferase

(ALT) levels. The decision as to whether to obtain a liver biopsy should take

into consideration age, the upper limits of normal (ULN) for serum ALT level,

HBeAg status, HBV DNA levels, and other clinical features suggestive of chronic

liver disease. The American Association for the Study of Liver Diseases (AASLD)

guidelines suggest that " patients who remain HBeAg positive with HBV DNA levels>

20,000 IU/mL after a 3-6 month period of elevated ALT levels between 1-2x ULN,

or who remain HBeAg positive with HBV DNA levels> 20,000 IU/mL and are>40 years

old, should be considered for liver biopsy, and treatment should be considered

if biopsy shows moderate/severe inflammation or significant fibrosis. " [1]

Therefore, liver biopsy is most useful in persons who do not meet clearcut

guidelines for treatment.

One could argue that a biopsy could indicate cirrhosis and that the presence of

cirrhosis increases the risk for hepatocellular carcinoma (HCC). However,

periodic screening for HCC should be performed in all patients with chronic HBV

infection, even in the absence of cirrhosis.[1,2]

http://www.medscape.com/viewarticle/566961?src=mp

_________________________________________________________________

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From Medscape Gastroenterology

Ask the Experts about Liver Disease

Role of Liver Biopsy in Chronic Hepatitis B

Posted 01/07/2008

F. Balistreri, MD

Question

What is the role of grade of inflammation found on liver biopsy in starting

antiviral therapy in hepatitis B virus (HBV) infection with or without

considering the stage of disease?

Response from F. Balistreri, MD

Dorothy M. M. Kersten Professor of Pediatrics, University of Cincinnati College

of Medicine, Cincinnati, Ohio; Medical Director, Liver Transplantation Program,

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

The major value of a liver biopsy in a patient with chronic hepatitis B

infection is to rule out other causes of liver disease, assess the degree of

liver damage, and provide information regarding disease progression. The issue

is not always clearcut -- liver histology can improve significantly in patients

who have spontaneous hepatitis B e antigen (HBeAg) seroconversion or sustained

response to antiviral therapy. Likewise, liver histology can worsen rapidly in

patients who have recurrent exacerbations or reactivation of hepatitis B.

In practice, the issue of whether to initiate treatment in a patient with

chronic hepatitis B does not depend on histologic findings, such as the grade of

inflammation. The liver biopsy is of limited value in predicting response to

interferon therapy and the data are limited regarding the value in predicting

response to any of the oral antiviral agents. The best candidates for treatment

are those individuals with positive predictors of response -- these patients can

be identified on the basis of serum HBV DNA levels, hepatic biochemical tests,

and serologic studies. The best indicators of sustained virologic response are

low pre-treatment serum HBV DNA titers and elevated alanine aminotransferase

(ALT) levels. The decision as to whether to obtain a liver biopsy should take

into consideration age, the upper limits of normal (ULN) for serum ALT level,

HBeAg status, HBV DNA levels, and other clinical features suggestive of chronic

liver disease. The American Association for the Study of Liver Diseases (AASLD)

guidelines suggest that " patients who remain HBeAg positive with HBV DNA levels>

20,000 IU/mL after a 3-6 month period of elevated ALT levels between 1-2x ULN,

or who remain HBeAg positive with HBV DNA levels> 20,000 IU/mL and are>40 years

old, should be considered for liver biopsy, and treatment should be considered

if biopsy shows moderate/severe inflammation or significant fibrosis. " [1]

Therefore, liver biopsy is most useful in persons who do not meet clearcut

guidelines for treatment.

One could argue that a biopsy could indicate cirrhosis and that the presence of

cirrhosis increases the risk for hepatocellular carcinoma (HCC). However,

periodic screening for HCC should be performed in all patients with chronic HBV

infection, even in the absence of cirrhosis.[1,2]

http://www.medscape.com/viewarticle/566961?src=mp

_________________________________________________________________

Helping your favorite cause is as easy as instant messaging.  You IM, we give.

http://im.live.com/Messenger/IM/Home/?source=text_hotmail_join

[Guest guest]

From Medscape Gastroenterology

Ask the Experts about Liver Disease

Role of Liver Biopsy in Chronic Hepatitis B

Posted 01/07/2008

F. Balistreri, MD

Question

What is the role of grade of inflammation found on liver biopsy in starting

antiviral therapy in hepatitis B virus (HBV) infection with or without

considering the stage of disease?

Response from F. Balistreri, MD

Dorothy M. M. Kersten Professor of Pediatrics, University of Cincinnati College

of Medicine, Cincinnati, Ohio; Medical Director, Liver Transplantation Program,

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

The major value of a liver biopsy in a patient with chronic hepatitis B

infection is to rule out other causes of liver disease, assess the degree of

liver damage, and provide information regarding disease progression. The issue

is not always clearcut -- liver histology can improve significantly in patients

who have spontaneous hepatitis B e antigen (HBeAg) seroconversion or sustained

response to antiviral therapy. Likewise, liver histology can worsen rapidly in

patients who have recurrent exacerbations or reactivation of hepatitis B.

In practice, the issue of whether to initiate treatment in a patient with

chronic hepatitis B does not depend on histologic findings, such as the grade of

inflammation. The liver biopsy is of limited value in predicting response to

interferon therapy and the data are limited regarding the value in predicting

response to any of the oral antiviral agents. The best candidates for treatment

are those individuals with positive predictors of response -- these patients can

be identified on the basis of serum HBV DNA levels, hepatic biochemical tests,

and serologic studies. The best indicators of sustained virologic response are

low pre-treatment serum HBV DNA titers and elevated alanine aminotransferase

(ALT) levels. The decision as to whether to obtain a liver biopsy should take

into consideration age, the upper limits of normal (ULN) for serum ALT level,

HBeAg status, HBV DNA levels, and other clinical features suggestive of chronic

liver disease. The American Association for the Study of Liver Diseases (AASLD)

guidelines suggest that " patients who remain HBeAg positive with HBV DNA levels>

20,000 IU/mL after a 3-6 month period of elevated ALT levels between 1-2x ULN,

or who remain HBeAg positive with HBV DNA levels> 20,000 IU/mL and are>40 years

old, should be considered for liver biopsy, and treatment should be considered

if biopsy shows moderate/severe inflammation or significant fibrosis. " [1]

Therefore, liver biopsy is most useful in persons who do not meet clearcut

guidelines for treatment.

One could argue that a biopsy could indicate cirrhosis and that the presence of

cirrhosis increases the risk for hepatocellular carcinoma (HCC). However,

periodic screening for HCC should be performed in all patients with chronic HBV

infection, even in the absence of cirrhosis.[1,2]

http://www.medscape.com/viewarticle/566961?src=mp

_________________________________________________________________

Helping your favorite cause is as easy as instant messaging.  You IM, we give.

http://im.live.com/Messenger/IM/Home/?source=text_hotmail_join

[Guest guest]

From Medscape Gastroenterology

Ask the Experts about Liver Disease

Role of Liver Biopsy in Chronic Hepatitis B

Posted 01/07/2008

F. Balistreri, MD

Question

What is the role of grade of inflammation found on liver biopsy in starting

antiviral therapy in hepatitis B virus (HBV) infection with or without

considering the stage of disease?

Response from F. Balistreri, MD

Dorothy M. M. Kersten Professor of Pediatrics, University of Cincinnati College

of Medicine, Cincinnati, Ohio; Medical Director, Liver Transplantation Program,

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

The major value of a liver biopsy in a patient with chronic hepatitis B

infection is to rule out other causes of liver disease, assess the degree of

liver damage, and provide information regarding disease progression. The issue

is not always clearcut -- liver histology can improve significantly in patients

who have spontaneous hepatitis B e antigen (HBeAg) seroconversion or sustained

response to antiviral therapy. Likewise, liver histology can worsen rapidly in

patients who have recurrent exacerbations or reactivation of hepatitis B.

In practice, the issue of whether to initiate treatment in a patient with

chronic hepatitis B does not depend on histologic findings, such as the grade of

inflammation. The liver biopsy is of limited value in predicting response to

interferon therapy and the data are limited regarding the value in predicting

response to any of the oral antiviral agents. The best candidates for treatment

are those individuals with positive predictors of response -- these patients can

be identified on the basis of serum HBV DNA levels, hepatic biochemical tests,

and serologic studies. The best indicators of sustained virologic response are

low pre-treatment serum HBV DNA titers and elevated alanine aminotransferase

(ALT) levels. The decision as to whether to obtain a liver biopsy should take

into consideration age, the upper limits of normal (ULN) for serum ALT level,

HBeAg status, HBV DNA levels, and other clinical features suggestive of chronic

liver disease. The American Association for the Study of Liver Diseases (AASLD)

guidelines suggest that " patients who remain HBeAg positive with HBV DNA levels>

20,000 IU/mL after a 3-6 month period of elevated ALT levels between 1-2x ULN,

or who remain HBeAg positive with HBV DNA levels> 20,000 IU/mL and are>40 years

old, should be considered for liver biopsy, and treatment should be considered

if biopsy shows moderate/severe inflammation or significant fibrosis. " [1]

Therefore, liver biopsy is most useful in persons who do not meet clearcut

guidelines for treatment.

One could argue that a biopsy could indicate cirrhosis and that the presence of

cirrhosis increases the risk for hepatocellular carcinoma (HCC). However,

periodic screening for HCC should be performed in all patients with chronic HBV

infection, even in the absence of cirrhosis.[1,2]

http://www.medscape.com/viewarticle/566961?src=mp

_________________________________________________________________

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