Liver biopsy

[Guest guest]

What You Need to Know: Jayna H. Maxwell Liver biopsy is usually the most

specific test to assess the nature and severity of liver diseases. In addition,

it can be useful in monitoring the efficacy of various treatments. There are

currently several methods available for obtaining liver tissue, each with its

own advantages and disadvantages. These methods will be explained in some detail

later in this article. The size of the biopsy specimen, which varies between 1

and 3 centimeters in length and between 1.2 and 2 millimeters in diameter,

represents 1/50,000 of the total mass of the liver. Usually, for evaluation of

diffuse liver disease (that is, disease which occurs throughout the liver, such

as in hepatitis C), a specimen of 1.5 centimeters in length is adequate for a

diagnosis to be made. A liver biopsy can give valuable information regarding

staging, prognosis, and management. For example, in patients with chronic

hepatitis C infection, not only is there a poor

correlation between symptoms or levels of serum alanine aminotransferase (ALT –

a liver enzyme which, at elevated levels, is indicative of liver-cell

destruction) and histologic features of the liver (that is, whether the tissue

and architecture of the liver are intact or damaged), but also patients with

completely normal levels of liver enzymes may be found to have clinically

significant fibrosis or cirrhosis on biopsy. If the patient has mild disease and

is infected with genotype 1a or 1b of the hepatitis C virus, a decision may be

made to defer treatment, since these genotypes are relatively resistant to

interferon. If a decision is made to treat such a patient with a combination of

interferon and ribavirin and there are adverse effects, the treatment can be

stopped. Conversely, if the patient has moderate-to-advanced disease, treatment

will most likely be offered. If the patient has a virologic response (that is,

the viral count decreases markedly) and tolerable side

effects with treatment, continued therapy would be strongly encouraged. The

finding of cirrhosis on liver biopsy will determine the need for further

examinations, such as upper endoscopy to rule out esophageal varices (swollen

veins in the esophagus which may hemohorrage) and screening for cancer with

blood tests for the presence of alpha-fetoprotein (AFP) and ultrasound of the

liver. In alcoholic liver disease, the severity of the clinical symptoms and

the degree of liver-enzyme elevation correlate poorly with the extent of liver

damage, particularly in patients who continue to drink alcohol. The long-term

prognosis depends on the severity of hepatic, or liver, injury determined upon

biopsy. Liver biopsy provides an accurate diagnosis in approximately 90 percent

of patients with unexplained abnormalities revealed on liver-function tests.

The various methods for performing a biopsy of the liver are as follows: (1)

Percutaneous Liver Biopsy – this type of biopsy is

done directly through the skin into the liver. Needles for percutaneous liver

biopsy are broadly categorized as suction needles, cutting needles, and

spring-loaded cutting needles that have a triggering mechanism. The cutting

needles, except for the spring-loaded variety, require a longer time in the

liver during the biopsy, which may increase the risk of bleeding. A greater

incidence of bleeding after biopsy has sometimes been observed with

large-diameter needles. If cirrhosis is suspected on clinical grounds, a cutting

needle is preferred over a suction needle, since fibrotic tissue tends to

fragment with the use of suction needles. This would render the tissue sample

less useful or even useless for diagnostic purposes. Ultrasonography performed

before a liver biopsy identifies mass lesions (defined areas of suspicious or

diseased tissue) that may not present symptoms and defines the anatomy of the

liver and the relative positions of the gallbladder, lungs, and

kidneys. Most hepatologists agree that all patients should undergo

ultrasonography of the liver before a percutaneous biopsy is performed. However,

it is debatable whether the routine use of ultrasonography to guide the biopsy

reduces the rate of complications, provides a higher diagnostic yield, or is

cost effective. It is now standard practice to perform liver biopsy on an

outpatient basis, provided that various criteria are met. The Patient Care

Committee of the American Gastroenterological Association has published practice

guidelines for outpatient liver biopsy. The patient must be able to return to

the hospital in which the procedure was performed within 30 minutes after the

onset of any adverse symptoms. Reliable persons must stay with the patient

during the first night after the biopsy to provide care and transportation, if

necessary. The patient should have no serious medical problems that increase the

risk associated with the biopsy. The facility in which the

biopsy is performed should have an approved laboratory, a blood-banking unit,

an easily accessible inpatient bed, and personnel to monitor the patient for at

least 6 hours after the biopsy. The patient should be hospitalized after the

biopsy is performed if there is evidence of bleeding, a bile leak, pneumothorax

(air or gas in the pleural space), or other organ puncture, or if the patient’s

pain requires more than one dose of analgesics in the first 4 hours after the

biopsy. Liver biopsy is a safe procedure when performed by experienced

operators. Froehlich et al. noted a lower complication rate for physicians who

performed more than 50 biopsies a year. Prior localization of the biopsy site

via ultrasound may decrease the rate of complications for physicians who perform

liver biopsies infrequently. “Blind” liver biopsies (i.e., without the aid of

prior ultrasound localization) should be performed by experienced

gastroenterologists, hepatologists, or transplantation

surgeons and not by general internists. Although the liver has a rich

vascular supply, complications associated with percutaneous liver biopsy are

rare. Sixty percent of complications occur within 2 hours and 96 percent within

24 hours after the procedure. Approximately 1 to 3 percent of patients requires

hospitalization for complications after a liver biopsy, especially if the

procedure was performed with a Tru-cut biopsy needle. Pain and hypotension

(dangerously low blood pressure) are the predominant complications for which

patients are hospitalized. Minor complications after percutaneous liver biopsy

include transient, localized discomfort at the biopsy site; pain requiring

analgesia; and mild, transient hypotension. Approximately one-fourth of patients

has pain in the right upper quadrant or right shoulder after liver biopsy. The

pain is usually dull, mild, and brief. Ongoing, severe pain in the abdomen

should alert the physician to the possibility of a more serious

complication, such as bleeding or peritonitis (inflammation of the membrane

lining the walls of the abdominal and pelvic cavities). Although very rare,

clinically significant intraperitoneal hemorrhage (bleeding within the membrane

surrounding the stomach and pelvis) is the most serious bleeding complication of

percutaneous liver biopsy; it usually becomes apparent within the first 2 to 3

hours after the procedure. Risk factors for hemorrhage after liver biopsy are

older age, more than 3 passes with the needle during biopsy, and the presence of

cirrhosis or liver cancer. The patient may then require intravenous fluids

and/or blood products. The mortality rate among patients after percutaneous

liver biopsy is approximately 1 in 10,000 to 1 in 12,000. Mortality is highest

among patients who undergo biopsies of malignant lesions. Cirrhosis is another

risk factor for fatal bleeding after liver biopsy. (2) Transjugular Liver

Biopsy – With transjugular liver biopsy, the

liver tissue is obtained from within the vascular system rather than directly

through the skin into the liver. This minimizes the risk of bleeding. The

procedure involves percutaneous puncturing of the right internal jugular vein

located in the neck area, the introduction, with the use of fluoroscopy (a type

of x-ray), of a catheter (a flexible tube) into the right hepatic vein (a major

vein carrying blood from the liver), and a needle biopsy of the liver performed

through the catheter. The duration of the procedure is between 30 and 60

minutes. Electrocardiographic monitoring is required to detect arrhythmias

induced by passage of the catheter through the heart. Samples are retrieved from

a needle passed through the catheter into the liver while suction is maintained.

The samples obtained are small and fragmented, a disadvantage of the technique

that may be improved with newer-generation technology. Adequate tissue for

histologic diagnosis can be obtained from 80 to 97

percent of patients in centers where a large number of transjugular biopsies

are performed. In various studies, the rate of complications associated with

transjugular liver biopsy ranges from 1.3 percent to 20.2 percent, and mortality

ranges from 0.1 percent to 0.5 percent. (3) Laparoscopic Liver Biopsy –

Diagnostic laparoscopy is especially useful in the diagnosis of diseases of the

cavities enclosing the stomach and pelvis, the evaluation of ascites (the

accumulation of fluid in the abdominal cavity) of unknown origin, and the

staging of abdominal cancer. It can be performed safely under local anesthesia

with conscious sedation. However, the use of laparoscopic liver biopsy by

gastroenterologists has declined in favor of less invasive radiologic

procedures, and very few gastroenterology training programs now provide

instruction in the procedure, which is usually performed by surgeons because of

their growing experience with laparoscopic surgery. (4) Fine-Needle

Aspiration Biopsy – Fine-needle aspiration biopsy of the liver is performed

under ultrasonographic or CT guidance. Patients with a history of cancer and

liver lesions are good candidates for fine-needle aspiration biopsy. The

diagnostic accuracy ranges from 80 to 95 percent and is substantially affected

by the expertise of the pathologist. Cytologic findings (microscopic examination

of the extracted cells) that are negative for cancer do not rule it out.

Although ultrasound-guided or CT-guided biopsy is usually reserved for focal

hepatic lesions (defined areas of suspicious or diseased tissue), limited data

suggests that diagnostically useful material can be obtained with automatic

spring-loaded biopsy needles guided by ultrasound in over 95 percent of

patients, including those with diffuse liver disease (i.e., disease which occurs

throughout the liver, such as in hepatitis C). Fine-needle aspiration biopsy is

associated with a low risk of seeding of the needle tract

with malignant cells and is generally a very safe procedure. Source

Information: From the Liver Center, Division of Gastroenterology, Beth Israel

Deaconess Medical Center, Harvard Medical School, Boston

http://www.hcvets.com/data/hcv_liver/liver_biopsy.htm

Debra wrote:

Where does the doctor get this number from anyway.. I have my biopsy

report and all I remember it saying is Cirrhosis, with bridging

fibrosis. Does that alone determine the stage or grade, or is it also

determined by liver function, portal hypertention, ascites.. etc..

Who assigns this number.. I dont believe it on my biopsy report but I

will find it and read it later.. Debra

>

> I think some are confusing the progression of liver disease which

has

> three stages with liver biopsy readings which also has different

> stages for inflammation, fibrosis, cirrhosis. Different pathologists

> may also give different biopsy readings. Also, a 1 " needle biopsy

may

> have different results than a wedge biopsy.

>

> Liver Disease progresses in the following stages.

> Inflammation (regardless of the cause, I.e, NASH, NALD or alcohol).

> This is also called hepatitis especially when the cause is

undetermined.

> Then Fibrosis and unless treated or the progression stopped can lead

> to cirrhosis.

> http://www.liverfoundation.org/education/info/progression/

> http://www.emedicine.com/med/topic3183.htm

>

> A biopsy reading will show inflammation, necrosis, fibrosis etc.

> Grading and Staging of hepatitis by assigning scores for severity

are

> helpful in managing patients with chronic hepatitis. The degree of

> inflammation and necrosis can be assessed as none, minimal, mild,

> moderate, or severe.

> The degree of fibrosis can be similarly assessed. Scoring systems

are

> particularly helpful in clinical studies on chronic hepatitis.

>

> So grades and staging may also be labeled differently from hospital

to

> hospital. So you may have severe inflammation with slow or minimal

> progression based on the type of fibrosis. Like fibrosis without

bridging.

>

> http://www.hcvets.com/data/hcv_liver/liver_biopsy.htm

> http://www.emedicine.com/med/topic2969.htm

>

> MaC

>

Group Email: livercirrhosissupport

web address:

http://groups.yahoo.com/group/livercirrhosissupport/

[Guest guest]

A liver biopsy is an invasive medical procedure that obtains a small sample of

liver tissue, which

provides information about liver injury and disease progression.

Liver biopsy is not a new procedure. The first liver biopsy was performed by

Ehrlich in

Germany in 1883, and in the late 1950s, Menghini developed a " 1-second

technique, " which led

to wider use of the procedure.

Currently, biopsies are performed primarily by specialists in gastroenterology /

hepatology or by

radiologists.

Why Do Liver Biopsy?

The data provided by liver biopsy, when combined with information from a history

and physical

examination, is useful for diagnosing and treating liver disease.

Since many liver diseases have similar symptoms, an examination of a liver

biopsy specimen can

may be used to identify or rule out possible causes for abnormal physical or

laboratory findings.

For example, finding that fat has accumulated in the liver tissue suggests

diseases due to alcohol

abuse, hepatitis C, diabetes, and/or obesity, and although blood cultures can

usually identify the

type of organism in cases of infectious disease, not all infectious organsims

can be identified by

laboratory tests.

In these cases, liver biopsy may assist in identifying the organism. Examples

include intrahepatic

tuberculosis and Mycobacterium avium complex (MAC).

Liver biopsy also permits the assessment of changes in liver tissue due to

illness, by applying

scoring systems for inflammation and fibrosis noted by the pathologist to the

biopsy specimen.

Many scoring systems report the degree of inflammation as the grade of the

disease and the

amount of fibrosis as the stage, commonly rating both on a 1 to 4 scale, with 4

being the most

advanced.

Liver biopsy can allow monitoring of the progression of hepatitis infection (or

other liver

diseases) disease or the effect of treatment. Although not as common in diseases

such as primary

biliary cirrhosis, chronic hepatitis C, or alcoholic liver disease, liver biopsy

is also used to

evaluate and treat rejection following liver transplantation.

Biopsy Methods

There are several methods for performing a liver biopsy. The physician may use a

" blind "

approach, locating the liver by percussing (thumping) the chest wall.

The biopsy may be guided by ultrasound or computer tomography (CT) guidance, or

a tissue

specimen may be obtained by intravascular sampling via the hepatic vein.

Two other methods for doing a liver biopsy are sometimes used: laparoscopic

biopsy and

transvenous biopsy. For a laparoscopic liver biopsy, the doctor inserts a

lighted tube

(laparoscope) through a small incision in the abdomen.

The doctor can see images of the liver on a monitor screen and can use

instruments through the

laparoscope to remove tissue samples from specific parts of the liver.

A transvenous biopsy, also called trans-jugular, is used when a person has a

problem with

bleeding (blood-clotting problem) or fluid in the abdomen (ascites).

In this procedure, the doctor inserts a catheter into a vein in the neck, then

puts a biopsy needle

into the catheter and advances it thrrough the vein to the liver where a tissue

sample is retrieved.

When NOT to get a Liver Biopsy (Contraindications)

There are not many conditions that absolutely prohibit a percutaneous ( " through

the skin " ) liver

biopsy, but there are conditions that can increase the probability of

complications. These include:

Prolonged bleeding times (increased prothrombin time, international normalized

ratio (INR)

greater than 1.6)

Thrombocytopenia (platelet count less than 60,000)

Ascites (in this case the transjugular route preferred)

Having a body shape not conducive to the procedure (in this case the

transjugular route

preferred)

Suspected abnormal blood vessel formation in the liver (hepatic hemangioma)

Suspected echinococcal infection (infection by the tapeworm of the genus

Echinococcus).

The Biopsy Experience

This description applies to percutaneous liver biopsy. Other forms of biopsy

will be different.

Patients typically are advised not to eat or drink anything for 8 hours before

the biopsy, and to

arrive at the hospital about an hour or more before the scheduled time of the

procedure.

The physician may have additional instructions about other medications during

the fasting period

and may have other special instructions.

A local anesthetic is administered prior to the liver biopsy procedure. This may

be above the site

of the liver (on the right side of your abdomen and below the ribs) or between

the lower ribs on

the right side.

Some physicians may choose to administer a sedative, while others may not.

Sedated or not, the

patient must be able to cooperate with the physician during the procedure.

When the local anesthetic has started to work, the patient will be positioned on

their back or side,

depending on where the physician decides to insert the biopsy needle.

The biopsy needle is a long, thin tube that is either inserted through the

numbed skin by hand or

by a mechanical device. The patient will be instructed to take a few deep

breaths prior to the

needle being inserted and then to hold their breath.

The biopsy instrument is inserted and quickly withdrawn, removing a small sample

of liver

tissue.

After the procedure an adhesive bandage will be applied and the patient will be

positioned on the

right side. This applies pressure to the wound and helps to prevent bleeding.

The patient will remain in bed, lying in this position for 6 to 8 hours. During

this time the patient

will be regularly monitored to the development of any post-procedure

complications.

Patients who are given sedatives will usually not be allowed to drive, and will

need to make the

necessary arrangements to get home.

Typically, the patient is instructed to rest in bed at home for 8 to 12 hours,

and the patient should

avoid exertion for about a week after the procedure so that the incision and

liver can heal.

Soreness and pain is not uncommon. Pain may radiate to the right shoulder. This

is usually

caused by irritation of the diaphragm and should disappear within a few hours or

days.

Patients should not take aspirin or ibuprofen for the first week after surgery.

These medicines

decrease blood clotting, increasing the probability of bleeding complications.

Complications of Liver Biopsy

Complications of liver biopsy are uncommon but can be very serious. Most

complications occur

within the first 2 hours, and nearly all occur within 24 hours after the

procedure.

Only about 2 out 100 people undergoing biopsy require hospitalization for the

management of an

adverse event.

Pain. Pain occurs in about one-third of patients undergoing a liver biopsy. It

often is described as

a dull ache in the right upper abdomen or shoulder and typically lasts less than

2 hours.

Treatment with analgesic pain medication is usually effective. Unrelenting,

severe abdominal

pain is abnormal, suggesting a serious complication such as internal bleeding or

leaking bile.

Bleeding. Bleeding within the liver or inside the membrane surrounding the liver

are common

complications, noted on approximately 23% of ultrasound images obtained

following biopsy.

This bleeding may not produce any clinical symptoms. Large hematomas (a mass of

blood,

sometimes clotted) may cause obstruction of the bile ducts in rare instances.

Hemobilia. Hemobilia (bleeding into the bile ducts and gallbladder) is a very

rare complication

of liver biopsy. It may cause symptoms of biliary colic (sudden, intermittent

abdominal pain),

gastrointestinal bleeding and jaundice.

Intraperitoneal hemorrhage. Massive internal bleeding in the abdomen is the most

serious of the

bleeding complications.

This uncommon complication is most often seen during the first few hours

following the

procedure, although reports of this complication as long as 24 hours after the

procedure have

been noted. This complication requires aggressive medical management.

Factors associated with bleeding include increased age, hepatic malignancy,

multiple needle

insertions during the procedure, and cirrhosis.

Abdominal pain, increased heart rate and decreased blood pressure are signs of

significant

bleeding.

Understanding Your Biopsy Results

The following terms are often used to describe the changes in liver tissue

associated with HCV

infection:

Portal Inflammation. The portal areas are tiny tracts of connective tissue

within the liver that

contain branches of the portal vein, the hepatic artery and bile ducts.

Piecemeal Necrosis. This term describes necrosis (cellular death) and

inflammation around the

portal areas.

Fibrosis. Fibrosis is the deposition of specialized fibers in the cell structure

of the liver, forming

scar tissue. The early stages of fibrosis are confined to the portal tracts.

The intermediate stages of fibrosis are characterized by expansion of fibrous

tissue to the portal

tracts and bridging between portal areas (known as bridging fibrosis).

Cirrhosis. A term used to describe significant deformation of the structure of

the liver due to

scarring.

Grade. Grading describes the degree of inflammation and necrosis that has

occurred in the liver.

Stage. Staging describes the degree of fibrosis (scarring) that has occurred.

There are several systems for describing the amount and type of inflammation and

fibrosis you

may have. When receiving biopsy results, the physician should specify which

system is being

used for grading and staging.

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