Ultrasound-guided liver biopsy in real life: comparison of same-day prebiopsy versus real-time ultrasound approach

BACKGROUND AND AIM: Currently, an increasing number of liver biopsies are performed by radiologists under real-time ultrasound control. A routine ultrasound assessment of a puncture site before performing percutaneous biopsy is reported to increase diagnostic yield and decrease complication rates. It is not clear if real-time ultrasound is superior to marking the puncture site before biopsy as regards reducing biopsy size and avoiding fragmentation and complications. The aim of this study was to compare ultrasound assessment of the puncture site before performing percutaneous liver biopsy with real-time ultrasound liver biopsy for suspected diffuse liver disease. METHODS: Consecutive percutaneous liver biopsies (n = 631) for diffuse liver disease were evaluated. Group A consisted of patients who had real-time guided-ultrasound biopsy performed by radiologists (241 patients; M/F, 35/106; median age 48 year [range, 17-76]; needle 18 G). Group B patients were assessed by radiologists using ultrasound of the puncture site on the same day that biopsies were performed by experienced gastroenterologists/hepatologists on the ward using the marked site (390 patients; M/F, 276/114; median age 43 year [range, 15-75]; needle 16 G). RESULTS: There were no differences in severity of liver disease, establishing a diagnosis (OR, 1.92 [95% CI, 0.84-4.34]; P = 0.12), length of liver biopsy specimens, number of fragments or complications. Two independent variables were significantly associated with a histological diagnosis: longer biopsy length (P < 0001) and fragment number of two or less (P < 0.001). CONCLUSION: Real-time ultrasound did not improve diagnostic yield or result in fewer complications. Marking the puncture site seems adequate and has the practical advantage that it takes up less of the radiologists' time.     

Liver biopsy in cirrhotic patients

Liver biopsy remains an important tool for the evaluation of patients with hepatic disease. However, clinicians utilize a variety of biopsy techniques including automated cutting needle devices, manual cutting needles, and aspiration needles. Using a large study cohort of patients with advanced fibrosis/cirrhosis we sought to evaluate practices and outcomes of the biopsy technique used by study investigators across the United States. All biopsy samples were from patients with suspected advanced fibrosis or cirrhosis because of hepatitis C virus (HCV) infection. Individual study investigators were permitted to use any biopsy technique. Biopsy specimens were centrally evaluated for tissue adequacy and fragmentation, and were histologically scored using accepted criteria. We evaluated a total of 923 liver biopsy specimens from 502 patients performed at 62 clinical sites. The average duration of HCV infection was 27.9 +/- 0.46 yr. Automated cutting needles were significantly more likely to provide adequate specimens for evaluation than aspiration needles (P < 0.005). Automated cutting needles produced significantly longer biopsies than other techniques (P < 0.05), except for a limited number of cases in which a surgical wedge biopsy was obtained. Tissue fragmentation was observed in 39.2% of liver biopsies obtained using an aspiration technique, but in only 4.7% of samples collected using an automated cutting needle (P < 0.001). We conclude that automated cutting needles provide superior liver biopsy specimens compared with aspiration techniques in subjects with advanced fibrosis/cirrhosis. No specific safety issues attributable to a particular biopsy method were identified.     

肝硬化的诊断和评估

肝硬化是各种慢性肝病的终末阶段,如何早期诊断肝硬化及对肝硬化进行分期并进行有效病情评估,在临床工作中尤为重要。介绍了肝脏穿刺病理学检查、血清学检查及影像学检查在肝硬化的临床诊断中的应用,以及肝脏储备功能评估、并发症评估和预后评估的研究进展。指出随着分子生物学及影像学诊断技术的发展,必将大力提高无创诊断的准确性和特异性,并深入完善疾病的评估体系。     

A prospective study about the usefulness of ultrasonographic monitoring after invasive liver procedures--liver biopsy and fine-needle aspiration (FNA)]

OBJECTIVE: To determine the need to perform ultrasound scans to all patients after liver biopsy or fine-needle aspiration (FNA) in order to detect complications with or without symptoms. MATERIAL AND METHODS: After liver biopsy or FNA using a regular protocol the patient is observed for 24 hours at the hospital, and all patients undergo an abdominal sonography at that time even in the absence of evident complications. RESULTS: 298 liver biopsies and 98 FNAs were performed. There were complications in 37 patients (9.34%): 36 (9.09%) were minor complications such as pain, vasovagal episodes, or small bleeding, and 1 (0.25%) was a major complication with severe hemorrhage. Only 1 out of all 396 procedures had a complication detected by ultrasounds (intrahepatic hematoma) while the patient was asymptomatic. CONCLUSIONS: The low incidence of complications occurring without symptoms, and their favorable course suggest that routine ultrasonography is not necessary after these techniques, and that it should be only performed when a complication is suspected.     

Liver fibrosis in non-alcoholic fatty liver disease-diagnostic challenge with prognostic significance

Non-alcoholic fatty liver disease(NAFLD) is the mostcommon liver disease in the Western world, with a prevalence of 20%. In a subgroup of patients, inflammation, ballooning degeneration of hepatocytes and a varying degree of fibrosis may develop, a condition named non-alcoholic steatohepatitis. Advanced liver fibrosis(stage F3) and cirrhosis(stage F4) are histologic features that most accurately predict increased mortality in both liver-related and cardiovascular diseases. Patients with advanced fibrosis or cirrhosis are at risk for complications such as hepatocellular carcinoma and esophageal varices and should therefore be included in surveillance programs. However, liver disease and fibrosis are often unrecognized in patients with NAFLD, possibly leading to a delayed diagnosis of complications. The early diagnosis of advanced fibrosis in NAFLD is therefore crucial, and it can be accomplished using serum biomarkers(e.g., the NAFLD Fibrosis Score, Fib-4 Index or BARD) or non-invasive imaging techniques(transient elastography or acoustic radiation force impulse imaging). The screening of risk groups, such as patients with obesity and/or type 2 diabetes mellitus, for NAFLD development with these non-invasive methods may detect advanced fibrosis at an early stage. Additionally, patients with a low risk for advanced fibrosis can be identified, and the need for liver biopsies can be minimized. This review focuses on the diagnostic challenge and prognostic impact of advanced liver fibrosis in NAFLD.     

Noninvasive tools to assess hepatic fibrosis: ready for prime time?

Often regarded as the gold standard for fibrosis assessment, liver biopsy carries associated risks; however, it is less than ideal. The need for noninvasive assessment of hepatic fibrosis for disease staging, prognosis, progression, and treatment response is clear. Advances in serologic testing and conventional imaging techniques have reduced the need for liver biopsy. Areas of research include defining cutoff values for specific diseases, further head-to-head comparisons of noninvasive modalities, examination of algorithms using both serum markers and imaging, and the cost-effectiveness of these various tests for diagnostic as well as screening purposes.     

Value of ultrasound-guided cytopuncture in the diagnosis of tumors in cirrhosis. Study of 29 cases

Ultrasonically guided fine needle aspiration biopsy is known to be of great value in the diagnosis of malignant liver disease, with an overall accuracy rate of 73-94 p. 100. However, investigators have essentially reported cases of liver metastases. In this report, we examined the diagnostic value of this method in the specific case of tumors associated with cirrhosis. Twenty-seven patients with cirrhosis (20 alcoholic, 4 post-hepatitis, 3 hemochromatosis) with ultrasonically suspected hepatic malignancy were studied. They all presented severe blood clotting disturbances and/or ascites. At the end of the study, all patients had proven malignancy (by post mortem biopsy in 14 cases and/or serum AFP greater than 500 microgram/l in 17 cases). There were 25 primary and 2 metastatic tumors. Twenty-nine fine needle aspiration biopsies were performed under ultrasonic guidance. material suitable for cytologic evaluation was obtained in 25 patients. In 14 cases, a diagnosis of malignant involvement of the liver was firmly established by cytological examination; it was suggested in 4 other cases. Tumor typing was possible in 12 primary and 2 metastatic tumors, in agreement with the proven diagnosis. The present study shows that fine needle aspiration biopsy under ultrasound guidance is a safe and accurate diagnostic procedure in malignant liver disease associated with cirrhosis.     

Dilemmas in managing prostate carcinoma. (Part I): Localized disease

Since we cannot predict which patients have biologically significant prostate carcinoma, except in the face of other known, significantly life-limiting disease, all palpable abnormalities should be considered for a diagnostic procedure. Negative core needle biopsy, fine needle aspiration, open perineal biopsy, transurethral biopsy, or urinary and prostatic fluid cytology results do not exclude cancer. If cancer is suspected, repeat biopsies and careful, frequent follow-up are mandatory.     

Liver fibrosis in paediatric liver diseases

Numerous paediatric liver diseases from different origins may be complicated by development of liver fibrosis and progression to cirrhosis. Although fibrogenesis, which represents a major driving force for the development of liver fibrosis, has common tracts whatever the aetiology, liver fibrosis has different histopathological patterns in paediatric liver disease. In these diseases management choices may depend upon the stage of liver fibrosis. Thus, the accurate estimation of histological pattern of liver fibrosis is important for the prevention of the subsequent complications. Liver biopsy has long been considered as a gold standard diagnostic method for assessing liver fibrosis. However, due to its several disadvantages, in the last decades alternative and accurate non-invasive means to estimate fibrosis are developed. In this review, we characterised the most frequent histological patterns of liver fibrosis in paediatric liver diseases. Furthermore, we describe use of liver biopsy in diagnosis and staging of liver fibrosis, list the alternative non-invasive techniques that have an emerging role in the assessment of liver fibrosis, and propose a management algorithm.     

The value of Chiba fine-needle aspiration biopsy in the diagnosis of hepatic malignancy: a comparison with Menghini needle biopsy

The detection or exclusion of metastatic liver involvement is critical in the management and prognosis of patients with malignant disease. Noninvasive imaging modalities such as computed tomography, ultrasound, and technetium colloid liver scan are highly sensitive but nonspecific. Serum alkaline phosphatase is of similar value. A blind liver biopsy by the Menghini technique is often done to confirm the diagnosis, but its yield is low. We prospectively evaluated 74 patients using blind Menghini needle biopsy and concurrent Chiba fine-needle aspiration biopsy (FNAB) techniques. A positive diagnosis of malignancy was made in 30 patients (41%). In only 25 (34%) was the diagnosis made by Menghini biopsy, while Chiba FNAB confirmed the diagnosis in all 30 patients. Thus, concurrent use of both needles increased the diagnostic accuracy by 7%. Seven additional patients, considered to have one or more contraindications for the Menghini biopsy, underwent Chiba FNAB alone; the diagnosis was confirmed in all without complication. We conclude that FNAB alone or in combination with Menghini biopsy is valuable and safe in the diagnosis of metastatic liver disease.     

Endoscopic ultrasound guided liver biopsy for parenchymal liver disease

Liver biopsy plays an essential role in the diagnosis, evaluation and management of a vast proportion of liver diseases. Conventionally, percutaneous and transjugular approaches have been used to obtain liver biopsies. Endoscopic ultrasound guided liver biopsy(EUS-LB) has emerged as a safe and effective alternate in the past two decades. EUS-LB carries a role in evaluation of both benign and malignant diseases of the liver. It can offer higher resolution imaging of the liver and can detect smaller lesions than computed tomography scan of the abdomen or ultrasound scans with the option for doppler assistance to reduce complications. Current evidence demonstrates the superiority of EUS-LB for a targeted approach of focal lesion and there is also evidence of less sampling variability in heterogeneous parenchymal pathologies. These advantages combined with an improved safety profile had led to the rapid progress in the development of new techniques, equipment and procedures for EUS-LB. We provide a comprehensive review of EUS-LB for parenchymal liver disease.     

Identifying contraindications to resection in patients with pancreatic carcinoma: the role of endoscopic ultrasound.

OBJECTIVE: To present recently published material comparing the performance of endosonography relative to other imaging modalities when evaluating the patient with a suspected or known pancreas carcinoma. METHODS: Medline was searched using the terms "endosonography" and "pancreas neoplasms". References from retrieved papers were reviewed to identify other reports. Emphasis was placed on peer-reviewed material published within the past three years that included comparison with other imaging modalities. RESULTS: Despite advances in cross-sectional imaging modalities, endosonography remains the most sensitive and specific method for identifying pancreatic mass lesions. The resectability of pancreatic carcinoma is best determined with dual-phase helical computed tomography, although endosonography may be slightly more accurate for lymph node assessment. Endoscopic ultrasound-guided fine needle aspiration biopsy has a high sensitivity (93%) and specificity (100%) when used in patients with masses in whom pancreatic cancer is suspected but prior biopsies have been negative. CONCLUSIONS: Endosonography helps in the diagnosis of pancreatic neoplasms through definitive inclusion or exclusion of a mass lesion as well as biopsy confirmation of malignancy. The role of endosonography in the determination of resectability has been eclipsed by dual-phase helical computed tomography. However, endoscopic ultrasound with fine needle aspiration of nonperitumoral lymph nodes may identify advanced disease with sufficient frequency to justify its routine use in patients with lesions that are thought to be resectable based on helical computed tomography.     

Ultrasound-assisted percutaneous liver biopsy performed by a physician assistant

OBJECTIVE: Percutaneous liver biopsy is an essential diagnostic tool utilized in the management of patients with liver disease. This procedure is generally performed by a physician and has a small but well-defined complication rate. We report on the complication rate and efficiency of ultrasound-assisted percutaneous liver biopsy performed by an experienced physician assistant. METHODS: One thousand eighty-six consecutive outpatient liver biopsies (847 hepatic allografts and 239 native livers) were performed at a single center by a physician assistant between June, 1996 and June, 2000. Patients with hepatic mass lesions, unusual hepatic anatomy, and uncorrectable coagulopathy (international normalized ratio > 1.7, platelet count < 50 x 10(9)/L) were excluded. Bedside ultrasonography was used to determine the optimal site for the liver biopsy. Liver biopsies were performed with a 15-gauge Jamshidi aspiration biopsy needle. Patients were observed for 3 h after biopsy, followed by dismissal with subsequent contact in 24 h to assess outcome and complications. RESULTS: Adequate tissue was obtained in 1084 cases (99.8%), with a mean tissue length of 3.2 cm. After the procedure, narcotic analgesia was necessary in 116 (10%) of the patients undergoing liver biopsies. The overall complication rate requiring hospitalization was 0.6%. Major complications requiring intervention occurred in four patients (0.4%). There were no deaths resulting from liver biopsies. CONCLUSION: We conclude that outpatient percutaneous liver biopsy can be safely and effectively performed by a trained physician assistant.     

Serial Percutaneous Liver Biopsies in Laboratory Rats

The percutaneous liver biopsy is an essential tool that provides histological assessment of the liver for diagnostic, therapeutic, and prognostic purposes. To date, this procedure has not been described in the laboratory setting for studies with small laboratory animals. The aim of the present study was to assess the feasibility and diagnostic value of performing serial percutaneous liver biopsies in a rat model of chronic liver disease. Adult male Sprague-Dawley rats (N = 27) were exposed to thioacetamide (TAA) for six months, throughout which serial liver biopsies were performed at baseline and two, four, and six months. An additional group of isocaloric-fed rats (N = 6) not exposed to TAA served as controls. Following the biopsies at each time point, a subset of rats was killed to determine whether the histologic findings seen in the biopsies were consistent with the histology of the entire organ. Seven rats (21%) died from complications of the procedure (one from anaesthetic overdose and six from postbiopsy bleeding). A total of 72 biopsies were performed, resulting in a procedural mortality of 8%. In the remaining rats, biopsies were well tolerated with no overt signs of pain or discomfort. Histologic activity and fibrosis in the biopsy specimens reflected the results observed in wedge sections of liver tissue at all stages of TAA-induced liver disease. The results of this study indicate that serial percutaneous liver biopsies can be successfully performed and reflect the extent of hepatic injury in a common model of chronic liver disease.     

Limitations of liver biopsy and non-invasive diagnostic tests for the diagnosis of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis

It is estimated that 30%of the adult population in Japan is affected by nonalcoholic fatty liver disease(NAFLD).Fatty changes of the liver are generally diagnosed using imaging methods such as abdominal ultrasonography(US)and computed tomography(CT),but the sensitivity of these imaging techniques is low in cases of mild steatosis.Alanine aminotransferase levels may be normal in some of these patients,warranting the necessity to establish a set of parameters useful for detecting NAFLD,and the more severe form of the disease,nonalcoholic steatohepatitis(NASH).Although liver biopsy is currently the gold standard for diagnosing progressive NASH,it has many drawbacks,such as sampling error,cost,and risk of complications.Furthermore,it is not realistic to perform liver biopsies on all NAFLD patients.Diagnosis of NASH using various biomarkers,scoring systems and imaging methods,such as elastography,has recently been attempted.The NAFIC score,calculated from the levels of ferritin,fasting insulin,and typeⅣcollagen 7S,is useful for the diagnosis of NASH,while the NAFLD fibrosis score and the FIB-4 index are useful for excluding NASH in cases of advanced fibrosis.This article reviews the limitations and merits of liver biopsy and noninvasive diagnostic tests in the diagnosis of NAFLD/NASH.     

Abdominelle Sonographie

Ultrasound is the first and most important imaging method used for suspected liver disease both for confirming (e.g. metastatic disease) and excluding pathological alterations. It is the single best tool in the evaluation of focal liver lesions (FLL) and is unrivalled by any other imaging modality owing to its real-time, dynamic nature, high resolution and good safety record. It is invaluable in the differential diagnosis of jaundice, in describing complications in liver cirrhosis and in all forms of ultrasound-guided intervention. In summary ultrasound is an indispensable tool in clinical hepatology. Ultrasound is also the imaging method of choice for the evaluation of splenomegaly. Focal splenic lesions in general are not frequent and can be found in <?1?% of ultrasound investigations. From a diagnostic point of view they can be divided into neoplastic and non-neoplastic lesions. The latter include, for example ischemic, traumatic and infectious lesions as well as hematomas. This review summarizes the current knowledge and challenges of transabdominal ultrasound techniques for the diagnostic approach to hepatic and splenic diseases.     

Controversies in liver biopsy: Who,where, when,how, why?

Liver biopsy continues to have a central role in the evaluation of patients with suspected liver disease. The procedure is often indicated to evaluate otherwise unexplained liver biochemical test abnormalities, but the precise degree of serum aminotransferase elevations that should prompt a liver biopsy is controversial, as is the need for liver biopsy in all patients with suspected nonalcoholic fatty liver disease and chronic hepatitis C. Standard liver biopsy is contraindicated in patients with severe coagulopathy and ascites, although the degree of coagulopathy that contraindicates a liver biopsy is controversial. A transjugular approach is an alternative in patients with coagulopathy or ascites. Controversy surrounds all the technical aspects of liver biopsy, particularly the choice of needle (cutting vs suction) and the use of ultrasound to mark or guide the biopsy site. Bleeding is the major complication of liver biopsy, with a risk of 0.3%; cutting needles are more likely to cause hemorrhage than are suction needles. Traditionally, liver biopsy has been the province of the hepatologist/ gastroenterologist. However, an increasing number of liver biopsies are performed by radiologists. The implications of this trend with respect to patient outcome, safety, and training of fellows is unclear.     

Liver biopsy: evolving role in the new millennium

Since the origination of the liver biopsy, the technique has evolved into an essential diagnostic tool, with very few complications. In addition to the percutaneous approach, a liver biopsy can also be obtained via transjugular, laparoscopic, or intraoperative approach. While in the early 1960s and 1970s the liver biopsy was used for making a diagnosis in cases of clinically suspected medical liver disease, today it is more often performed to assess disease prognosis and evaluate therapeutic strategies. As a result, indications for the liver biopsy have evolved over the past 2 decades. However with advances in serologic diagnosis of viral/autoimmune hepatitis and laboratory tests for genetic disorders, the role of liver biopsy in certain clinical settings is currently debated. This review discusses the technique, indications, contraindications, and the changing role of liver biopsy in some of the common disorders and the associated controversies.     

Non-invasive diagnosis of liver fibrosis and cirrhosis

The evaluation and follow up of liver fibrosis and cirrhosis have been traditionally performed by liver biopsy. However, during the last 20 years, it has become evident that this "gold-standard" is imperfect; even according to its proponents, it is only "the best" among available methods. Attempts at uncovering non-invasive diagnostic tools have yielded multiple scores, formulae, and imaging modalities. All are better tolerated, safer, more acceptable to the patient, and can be repeated essentially as often as required. Most are much less expensive than liver biopsy. Consequently, their use is growing, and in some countries the number of biopsies performed, at least for routine evaluation of hepatitis B and C, has declined sharply. However, the accuracy and diagnostic value of most, if not all, of these methods remains controversial. In this review for the practicing physician, we analyze established and novel biomarkers and physical techniques. We may be witnessing in recent years the beginning of the end of the first phase for the development of non-invasive markers. Early evidence suggests that they might be at least as good as liver biopsy. Novel experimental markers and imaging techniques could produce a dramatic change in diagnosis in the near future.     

Liver assessment and biopsy in patients with marked coagulopathy: value of mini-laparoscopy and control of bleeding

OBJECTIVE: Evaluation of liver disease in patients with a high risk of postbiopsy bleeding presents a diagnostic challenge. Mini-laparoscopy offers the possibility of coagulation of biopsy site and the additional advantage of macroscopic liver assessment. We wished to assess the value and safety of mini-laparoscopy with guided biopsy as a diagnostic approach in patients in whom percutaneous liver biopsy is considered contraindicated because of a marked coagulopathy. METHODS: We investigated 61 consecutive patients with marked coagulopathy (prolonged international normalized ratio > 1.5, thrombocytopenia < 50/nl, or both; von Willebrand's disease/hemophilia). Diagnostic mini-laparoscopy with visually guided liver biopsy was undertaken for the evaluation of liver disease. Biopsy sites were coagulated prophylactically (n = 4) or therapeutically (n = 52). Safety, diagnostic yield, and therapeutic consequences were assessed. RESULTS: Macroscopic assessment of the liver was possible in 60/61 high-risk patients and was considered diagnostic in 1/61. In 58 of the remaining 60 patients, liver biopsy was technically feasible. There was no persistent postbiopsy bleeding. One patient with fulminant hepatic failure had self-limiting bleeding from the abdominal wall. Ninety-seven percent of the biopsies were of adequate size for diagnostic histological evaluation. CONCLUSIONS: Mini-laparoscopy with guided liver biopsy allows reliable and safe evaluation of liver disease in patients with severe coagulopathy.