Review article: the evolving role of liver biopsy

Survey of liver pathologists to assess attitudes towards digital pathology and artificial intelligence

AIMS

A survey of members of the UK Liver Pathology Group (UKLPG) was conducted, comprising consultant histopathologists from across the UK who report liver specimens and participate in the UK National Liver Pathology External Quality Assurance scheme. The aim of this study was to understand attitudes and priorities of liver pathologists towards digital pathology and artificial intelligence (AI).

METHODS

The survey was distributed to all full consultant members of the UKLPG via email. This comprised 50 questions, with 48 multiple choice questions and 2 free-text questions at the end, covering a range of topics and concepts pertaining to the use of digital pathology and AI in liver disease.

RESULTS

Forty-two consultant histopathologists completed the survey, representing 36% of fully registered members of the UKLPG (42/116). Questions examining digital pathology showed respondents agreed with the utility of digital pathology for primary diagnosis 83% (34/41), second opinions 90% (37/41), research 85% (35/41) and training and education 95% (39/41). Fatty liver diseases were an area of demand for AI tools with 80% in agreement (33/41), followed by neoplastic liver diseases with 59% in agreement (24/41). Participants were concerned about AI development without pathologist involvement 73% (30/41), however, 63% (26/41) disagreed when asked whether AI would replace pathologists.

CONCLUSIONS

This study outlines current interest, priorities for research and concerns around digital pathology and AI for liver pathologists. The majority of UK liver pathologists are in favour of the application of digital pathology and AI in clinical practice, research and education.

How Successful Are APRI and FIB-4 Scores in Predicting Liver Fibrosis in Chronic Hepatitis B Patients?

Objective

We aimed to evaluate the correlation of fibrosis severity in liver biopsies, the gold standard for the diagnosis of patients with chronic hepatitis B (CHB), using noninvasive methods such as the aspartate aminotransferase (AST)-to-platelet ratio index (APRI) and fibrosis-4 score (FIB-4).

Materials and Methods

The study included patients who were followed and treated for CHB in 2018-2023. Biochemical markers and liver biopsy findings of the cases were retrospectively, and their correlations with APRI and FIB-4, which are noninvasive scores, were compared.

Results

The study included 202 patients. The biochemical markers and liver biopsy findings of the cases were examined retrospectively, and their correlations with the noninvasive scores APRI and FIB-4 were compared. According to liver biopsy results, 109 (54.0%) cases had no fibrosis (stage 0.1), 85 (42.1%) cases had mild fibrosis (stage 2, 3), and 8 (4%) cases had severe fibrosis (stage 4, 5, 6). The median FIB-4 score was 0.79 (0.25 -11.74), and the median APRI score was 0.29 (0.10-29.40). When the predictive power of the APRI score to discriminate between "without fibrosis" and "with fibrosis (mild and severe)" was evaluated by receiver operating characteristic (ROC) curve analysis, for the APRI score >0.408 as the ideal cut-off point, the sensitivity and specificity were found to be 34% and 79%, respectively. When the cut-off point for the FIB-4 score was >0.701, the sensitivity and specificity were 71% and 46%, respectively. Although the area under the curve (AUC) ratios ranged between 52% and 64% in the ROC analyses, the sensitivity ratios of the cut-off points calculated for FIB-4 were higher. The likelihood ratios of the cut-off point we found for the APRI score (1.61 and 1.75, respectively) were relatively better than those for FIB-4 (1.31 and 1.41, respectively).

Conclusion

Noninvasive tests used to detect liver fibrosis in individuals with CHB do not eliminate the need for liver biopsy but may provide insight into the fibrosis status of patients.

Advances in Endoscopic Ultrasound (EUS)-Guided Liver Biopsy

Recent years have seen the emergence of endoscopic-ultrasound-guided liver biopsy (EUS-LB) as an effective alternative to traditional (percutaneous or transjugular) liver biopsy techniques. Comparative studies have demonstrated that both endoscopic and non-endoscopic approaches are similar in terms of diagnostic adequacy, accuracy, and adverse events; however, EUS-LB offers the advantage of reduced recovery time. Additionally, EUS-LB enables the sampling of both lobes of the liver as well as the advantage of portal pressure measurements. However, EUS-LB may be argued to have a high cost, although this procedure can be cost-effective if bundled with other endoscopic procedures. Approaches utilizing EUS-guided liver therapy, such as the administration of chemotherapeutic agents and EUS elastography, are in development, and their optimal integration into clinical care is likely to emerge in the coming years. In the present review, we evaluate the available literature on EUS-LB indications, contraindications, variations in needle biopsy techniques, comparative outcomes, advantages and disadvantages, and future trends and perspectives.

Combination Treatment of Omega-3 Fatty Acids and Vitamin C Exhibited Promising Therapeutic Effect against Oxidative Impairment of the Liver in Methotrexate-Intoxicated Mice

Drug-induced liver injury (DILI) is the main cause of liver damage mediated by the excretion of toxic active drug metabolites. Omega-3 fatty acids and vitamin C have potent antioxidant, anti-inflammatory, and antiapoptotic effects that could offer protection against oxidative stress and liver damage. This study evaluated the hepatoprotective effect of omega-3 and vitamin C alone as well as in a combined form in methotrexate- (MTX-) induced acute liver injury in mice. Male ICR mice of seven groups (7 mice per group) were used. Groups 1 (control group) and 2 (MTX) received 0.9% saline/day (po) for 9 days. Groups 3 and 4 received 100 and 200 mg/kg bw/day omega-3 (po), respectively, for 9 days. Groups 5 and 6 received 100 and 200 mg/kg bw/day vitamin C (po), respectively, for 9 days, while group 7 received omega-3 (100 mg/kg bw/day) and vitamin C (100 mg/kg bw/day) (po) for 9 days. All animals in groups 2 to 7 received 20 mg/kg/day MTX (I.P.) once on the 10th day. Our results revealed that MTX significantly induced the elevation of transaminases, alkaline phosphates (ALP), lactate dehydrogenase (LDH), and malonaldehyde (MDA) while depleting the levels of superoxide dismutase (SOD) and glutathione (GSH) when compared to the control group. Treatment with omega-3 fatty acids or vitamin C significantly attenuated the antioxidants and biochemical alterations in a dose-independent manner. Our molecular docking study of ligand-receptor interaction revealed that both ascorbic acid and omega-3 docked well to the binding cavity of LDH with high binding affinities of -5.20 and -4.50 kcal/mol, respectively. The histopathological features were also improved by treatment with omega-3 and vitamin C. The combined form of omega-3 and vitamin C showed a remarkable improvement in the liver enzymes, oxidative stress biomarkers, and the histopathological architecture of the mice. Conclusively, the combination of omega-3 and vitamin C demonstrated a synergistic therapeutic effect against MTX-intoxicated mice, hence representing a potential novel strategy for the management of drug-induced liver disorders.

Histologic Analysis of Transjugular Liver Biopsy Specimens for Early Prediction of Prognosis in Acute Liver Failure

Background and Aims

The prognosis of acute liver failure (ALF) treated with conservative therapy is extremely poor. Histologic diagnosis at the time ALF occurs provides important clues for determining the prognosis, including indications for liver transplant. Transjugular liver biopsy (TJLB), which helps clarify the pathology of ALF, may be an effective clinical parameter that contributes to prognosis prediction, including indications for liver transplant.

Methods

In this prospective study, 79 patients who underwent TJLB with ALF were enrolled between May 2002 and March 2021. The relationships between prognosis and the extent of tissue necrosis on TJLB specimens, serum parameters related to the cause, and clinical parameters were investigated.

Results

Model for end-stage liver disease-sodium, hepatic encephalopathy predicting, total bilirubin, hepatocyte growth factor, ammonia, coma rate, and histologic diagnosis were identified as prognostic factors on univariate analysis. Histologically, 13 of 16 patients with massive hepatic necrosis died or had a liver transplant. On multivariate analysis, the only prognostic factor was massive hepatic necrosis. There were no treatment-related complications, and TJLB was technically successful in all patients.

Conclusion

In diagnosing the cause of ALF and understanding its pathology, TJLB contributes to predicting the prognosis of ALF based on histologic findings together with liver function tests and imaging findings, and it is an important diagnostic technique for determining diagnostic and treatment eligibility, including indications for liver transplant. When determining the best timing for patient selection and liver transplant, the finding of massive hepatic necrosis on TJLB specimens at the time ALF occurred was the most important prognostic factor.

Using FibroScan to Assess for the Development of Liver Fibrosis in Arthritis Patients on Methotrexate: A Single-Centre Experience

Objective

Methotrexate (MTX) is often the primary medication to treat various rheumatic diseases, due to its low cost and its demonstrated efficacy in controlling disease activity. However, a concern has been the potential for hepatic fibrosis associated with long term MTX usage. This study investigated the association between cumulative MTX intake and development of liver fibrosis by utilizing non-invasive transient elastography (FibroScan).

Methods

All patients with inflammatory arthritis treated with MTX were offered screening with FibroScan. A certified technician measured liver stiffness after patients adhered to a fast. Relevant clinical information was obtained by patient survey and medical records review. The population was divided into quartiles based on participant's cumulative dosage of MTX.

Results

520 rheumatologic patients were included in this study. The prevalence of stages F3 or F4 liver fibrosis was 13.3% in the control group, and 12.7% in the entire sample. Compared with subgroup 1 (control with cumulative MTX exposure of < 500mg), MTX subgroups 2-4 were not significantly correlated with higher FS scores (p-values 0.82, 0.59, and 0.18 respectively). In multivariable linear regression analysis, statistically significant factors for liver stiffness were BMI, waist circumference, male sex, and age.

Conclusion

No significant correlation between the cumulative MTX dosage and liver stiffness even at high MTX doses was observed. The analyses showed significant correlations between the FibroScan score and BMI. The findings were reassuring in that current rheumatology practice appears to be safe and effective in screening for liver fibrosis in patients on long term low dose MTX therapy.

Clinical Usefulness of Transjugular Liver Biopsy in Patients With Hematological Diseases With Liver Dysfunction

Introduction

Transjugular liver biopsy (TJLB) is indicated for patients in whom percutaneous liver biopsy is contraindicated, such as those with hematological diseases complicated by liver dysfunction. However, the clinical utility of TJLB in this group of patients has not been thoroughly investigated. The objective of this study is to evaluate the clinical efficacy of TJLB in patients with hematological diseases complicated by liver dysfunction.

Methods

We analyzed the data of patients who developed liver disorders during treatment for hematological diseases at our hospital and required tissue diagnosis via TJLB. The clinical features of patients were analyzed.

Results

Twenty-seven patients (mean age, 60.07 years; 12 men, 15 women) requiring tissue diagnoses via TJLB after developing liver disorders while undergoing treatment for hematological diseases were enrolled. One patient with autoimmune hemolytic anemia was diagnosed with drug-induced liver injury; two patients with amyloidosis had nonalcoholic steatohepatitis; one patient with acute promyelocytic leukemia had a drug-induced liver injury; one patient with chronic myelomonocytic leukemia had liver infiltration caused by an underlying disease; three patients with idiopathic thrombocytopenic purpura had autoimmune hepatitis; four patients with malignant lymphoma had liver infiltration by the underlying disease, and one patient with multiple myeloma had liver disorder caused by disseminated intravascular coagulation. Moreover, one patient had hepatitis B reactivation, another had hepatitis E, and six patients had a drug-induced liver injury. The treatment regimen was altered in cases of liver infiltration caused by the underlying disease, and the drug was changed for patients with drug-induced liver injury.

Conclusion

The etiology of liver disorders in patients with hematological diseases varies widely. Therefore, histological diagnosis using TJLB is useful to determine an appropriate therapeutic strategy for underlying hematological diseases.

Prevalence of liver fibrosis by Fibroscan in patients on long-term methotrexate therapy for rheumatoid arthritis

INTRODUCTION

Data on the long-term use of methotrexate (MTX) causing liver fibrosis in patients with rheumatoid arthritis (RA) is sparse. Liver biopsy is the gold standard to assess fibrosis but is an invasive procedure. Transient elastography (TE) by Fibroscan is a noninvasive validated tool to detect and quantify liver fibrosis. The present study aimed to assess the prevalence of liver fibrosis by Fibroscan in patients with RA on long-term MTX therapy and its correlation with cumulative dose of MTX.

METHODS

This cross-sectional study included adult patients (≥ 18 years age) of RA who had been on MTX for ≥ 3 years. The patients' records were reviewed, and the cumulative dose of MTX was calculated. Liver fibrosis was assessed by TE method, and the cutoff value of 7.1 kPa (kilopascal) was considered abnormal (liver fibrosis). Spearman's rank test was used to assess the correlation between the cumulative dose of MTX and Fibroscan score.

RESULTS

Seventy-five patients were enrolled of which 69 were females (92%). The mean age was 47.2 ± 11.3 years. The mean body mass index and waist circumference were 24.8 ± 3.9 kg/m² and 91.6 ± 9.9 cm, respectively. The median duration and cumulative dose of MTX were 336 weeks (interquartile range,144-912 weeks) and 6300 mg (interquartile range, 2400-22,000 mg), respectively. The mean liver stiffness was 5.22 ± 2.03 kPa. Twelve patients (16%) had Fibroscan score ≥ 7.1 kPa, of which 3 patients had severe liver stiffness (9.5 to 12.5 kPa) and one patient had liver stiffness in the range of cirrhosis (> 12.5 kPa). Fibroscan scores significantly correlated with cumulative dose of MTX (r= 0.30, p = 0.008).

CONCLUSIONS

Long-term MTX therapy in RA was associated with increased liver stiffness on Fibroscan. Key Points • Fibroscan is a useful tool for monitoring MTX-induced liver fibrosis. • Liver fibrosis as evidenced by increased liver stiffness on Fibroscan is prevalent among patients on long-term MTX therapy for RA.

Comparison of tru-cut biopsy and fine-needle aspiration cytology in an experimental alcoholic liver disease model

INTRODUCTION

Liver biopsies such as tru-cut (sharp needle) and fine-needle aspiration cytology (FNAC) are the most commonly preferred techniques to detect the grade and stage of certain liver diseases. In this study, we aimed to compare the efficiency of USG-guided tru-cut biopsy and fine-needle aspiration cytology in an experimental alcoholic liver disease model.

METHODS

Thirty-six female Wistar albino rats, 4-6 months old, and weighing from 190 to 250 g, were used in this study. The animals were randomly divided into six equal groups: G1 (control), G2 (tru-cut control), G3 (FNAC control), G4 (Alcoholic liver disease model), G5 (Alcoholic liver disease model + FNAC), and G6 (Alcoholic liver disease model + tru-cut biopsy). After a histopathological evaluation by light microscopy, the sensitivity, specificity, positive and negative predictive values of FNAC and tru-cut biopsy for the diagnosis of liver lesions were calculated.

RESULTS

No pathology was detected in G1 except for mild congestion. On the other hand, hepatocyte damage, periportal inflammation, congestion, and fatty changes were detected in all liver tissues of the alcoholic liver disease groups. The sensitivity of hepatocyte damage, inflammation, congestion, and fatty change parameters for FNAC were 33.3%, 80%, 0%, and 0%, respectively, while the sensitivity of the same variables for tru-cut were 66.7%, 40%, 100%, and 20%, respectively.

DISCUSSION

Both techniques were superior in some aspects. FNAC can be an attractive alternative to tru-cutbiopsy and applied in routine practice in the diagnosis of non-tumoral liver diseases.

Ultrasound-Guided Percutaneous Liver Biopsy: A Review on Obtaining Adequate Specimens

This literature review was conducted to evaluate liver biopsy adequacy, including total core length (TCL), number of portal tracts (PT), fragmentation, and complication rates, as a function of needle type and gauge. A systematic electronic search was performed in the Web of Science and Google Scholar databases, according to the PRISMA statement. Eligible data, describing in vivo percutaneous ultrasound-guided human liver biopsy quality outcomes, were compared to adequacy criteria of the American Association for the Study of Liver Diseases (AASLD, TCL ≥ 20 mm, PT ≥ 11). An adequate mean number of PTs was found in 83% of biopsy needles assessed between 2012 and 2019, compared to 0% between 1998 and 2004. For TCL, this was 44% and 33%, respectively. Increasing the needle diameter enhanced TCL (result in 50% of included studies) and PT count (100%), and reduced fragmentation rates (75%), whereas no effect on pain or complications was found (83%). In total, five needle types achieved adequate PT counts, using 16 G (3×), 17 G (1×), or 18 G (1×) needles. Adequacy was reached using either a core needle biopsy (CNB, 3×) approach with one pass, or a fine needle aspiration (FNA, 2×) approach with two passes. The recommendations for biopsy adequacy can be met using 16/17 G FNA or 16/18 G CNB needles. Currently, many publications still present substandard liver biopsy quality outcomes. Although minimizing biopsy invasiveness is desirable, a decreased diameter or number of passes is ill-judged when reliability of biopsy outcomes is at stake.

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.

The role of elastography in the assessment of chronic liver disease in children

Background

Conventional ultrasonography is a method preferred for the investigation of chronic liver diseases in pediatric groups, as it is non-invasive, cheap, feasible and available. The purpose of this study is to present the role of Share-wave Elastography (SWE) in terms of diagnostic value in children diagnosed with “chronic liver disease.”

Methods

We studied patients who had been diagnosed with chronic liver disease between March 2012-September 2015, and who had undergone liver biopsy and had their pathology results, compared with 26 healthy subjects. Statistical analysis was performed with IBM SPSS Statistics for Windows, Version 20.0. “Pearson Correlation Analysis” was performed in order to measure the relationship between elastography values and Brunt level.

Results

This study had 107 subjects in total, consisting of 81 patients between 0–204 months of age Pearson correlation coefficient level was determined as r = 0.644. Since the correlation coefficient is positive, there is a same-directional relationship between Elastography level and Brunt degree. This means that while one of the variables is increasing, the other one will also increase.

Conclusion

Since it is known that development of hepatic fibrosis is a dynamic process, and that many hepatic fibrosis etiologies are known to continue throughout the course of life, the application of Real time SWE method instead of repeated liver biopsies on patients is a much simpler and smart method. Increasing the clinical use of Real Time SWE method with future studies might provide an opportunity for preventing unnecessary liver biopsies since the patients are evaluated in a shorter time and in a cost-effective manner.

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.

Adiposity May Moderate the Link Between Choline Intake and Non-alcoholic Fatty Liver Disease

Background: In animal models, histological and biochemical changes are observed in response to choline deficiency. It is unclear whether dietary choline is linked to non-alcoholic fatty liver disease (NAFLD). Objective: We examined the link among liver tests, fatty liver index (FLI), and choline consumption. Furthermore, we evaluated the impact of adiposity on this association. Method: The National Health and Nutrition Examination Survey (NHANES) was used to obtain data on choline intake and liver function biomarkers. Masked variance and weighting methodology were performed to account for the complex NHANES data. Results: Of the 20,643 participants, 46.8% were men and 45.6% had NAFLD (defined as United States FLI ≥30). In a fully adjusted model (for demographic, dietary, and clinical factors), a significant negative association was found between FLI and choline consumption (β = -0.206, p < 0.001). Participants in the highest quartile (Q4) of choline intake had a 14% lower risk of NAFLD compared with those in the first quartile (Q1). This link was stronger for postmenopausal women; women in Q4 had a 26% lower risk of NAFLD compared with those in Q1. Body mass index (BMI) strongly moderated the link between FLI and choline intake. For example, when choline consumption increased from low (272 mg/d) to high (356 mg/d), FLI decreased from 79.3 to 74.1 in the low BMI category (mean BMI = 22.1 kg/m²) and from 32.1 to 20.6 in the high BMI category (mean BMI =35.9 kg/m²). Conclusions: Our results suggest the presence of a reverse significant association between choline intake and risk of NAFLD. Furthermore, BMI was shown to mediate this relationship since changes in FLI, in relation to choline consumption, were more pronounced in participants with a higher BMI.

Diagnostic histochemistry in hepatic pathology

Histochemistry has an important, continuing role in the current assessment of hepatic biopsies and resection specimens. The evaluation of connective tissue elements in the liver can be accomplished with such methods as the Masson trichrome, Snook reticulin, Vierhoff van Gieson, orcein, and Victoria blue stains. The results contribute to the diagnosis of acute and chronic hepatitis, submassive necrosis, venous outflow obstruction, steatohepatitis, and cirrhosis. Fat stains done on frozen sections of liver tissue are routinely performed in the evaluation of donor liver allograft biopsies. Iron stains such as Perls' method and the Prussian blue technique contribute to the recognition of hemochromatosis and hemosiderosis. The rhodanine, orcein, and Timm stains for copper are used in the characterization of chronic cholestatic liver disease and Wilson's disease. Labeling of carbohydrate-based moieties in various disorders is accomplished with the digested and undigested periodic acid-Schiff method, and Congo red or crystal violet stains can be employed to detect amyloid deposition. Lastly, evaluations of the thickness of the cell plates and continuity of the reticulin framework, as seen with the Snook reticulin stain, can contribute to the diagnostic separation of benign from malignant hepatocellular neoplasms.

A higher flavonoid intake is associated with less likelihood of nonalcoholic fatty liver disease: results from a multiethnic study

Limited information exists on the impact of flavonoid intake on nonalcoholic fatty liver disease (NAFLD). We evaluated the link between flavonoid intake, liver tests and risk of NAFLD in a randomly selected sample of US adults (from the National Health and Nutrition Examination Survey, NHANES, 2005-2010). Of the 17,685 participants, 46.9% were men and 45.4% had NAFLD. NAFLD patients had a significantly lower mean flavonoid intake than healthy individuals (111.3±3.6 vs. 201.3±2.3 mg/d, respectively; P<.001). Fatty liver index (FLI) and serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were significantly higher in the first tertile (T1) of flavonoid intake compared with the highest tertile (T3: with the highest flavonoid intake) (FLI: 67.1 vs. 36.2, AST: 31.2 VS 26.8 U/L and, ALT: 34.2 vs. 24.2 U/L, respectively; P<.001 for all comparisons). Adjusted linear regression displayed significant and negative associations between FLI, AST, ALT and flavonoid intake (P<.001 for all comparisons). Multivariable logistic regression showed that the risk for NAFLD significantly decreased as flavonoid intake tertiles increased in a stepwise manner (odds ratio: 0.81, 95% confidence interval: 0.78-0.86). Moderation analysis revealed that C-reactive protein (CRP) strongly modulated the impact of flavonoid intake on FLI; participants with higher CRP levels benefited less from flavonoid intake compared with those with lower CRP concentrations. In conclusions, our results suggest a reverse significant association between flavonoid consumption, liver tests and the risk for NAFLD. Furthermore, CRP was shown to essentially moderate this relationship. These findings support recommendations for consumption of flavonoid-rich foods to prevent cardiometabolic diseases.

Monitoring methotrexate-induced liver fibrosis in patients with psoriasis: utility of transient elastography

Increasingly, existing evidence indicates that methotrexate-associated liver injury is related to comorbid risk factors such as diabetes, alcoholism, and obesity, rather than to methotrexate itself. Despite this fact, significant effort continues to be expended in the monitoring of low-dose methotrexate in patients with psoriasis. The gold standard investigation has been liver biopsy, but this is associated with significant morbidity and mortality. As methotrexate-induced liver injury is uncommon, the risk/benefit ratio of liver biopsy has been questioned. Fortunately, a number of new technologies have been developed for the diagnosis of chronic liver disease, including transient elastography (TE). TE is a type of shear wave ultrasound elastography, which measures the speed of shear waves used to estimate hepatic tissue stiffness. Several meta-analyses show very high pooled sensitivity and specificity for the diagnosis of hepatic cirrhosis (87% and 91%, respectively) in a variety of chronic liver disorders. It has a negative predictive value for cirrhosis of >90% and a positive predictive value of 75%. Recent European guidelines now advocate the use of TE as the first-line test for the assessment of fibrosis in alcohol- or hepatitis-related liver disease, including nonalcoholic fatty liver disease (NAFLD). As the prevalence of obesity and metabolic syndrome, including NAFLD, is significantly elevated in patients with psoriasis, TE may be worth considering as a routine investigation for any patient with psoriasis. Although high-quality studies comparing TE with standard liver biopsy in the monitoring of psoriatics on low-dose methotrexate are lacking, the evidence from multiple small cohort studies and case series demonstrates its effectiveness. A recent Australasian position statement recommends that TE should be considered as a routine investigation for monitoring methotrexate therapy, repeated every 3 years if kPa <7.5 and yearly if kPa >7.5. Liver biopsy should be considered for patients with a kPa >9.5.

Risk of liver disease in methotrexate treated patients

Methotrexate is the first line drug treatment for a number of rheumatic and non-rheumatic diseases. It is effective in controlling disease activity and preventing disease-related damage, and significantly cheaper than many alternatives. Use in rheumatoid arthritis infers a significant morbidity and mortality benefit. Methotrexate is generally well tolerated but can cause symptomatic adverse events. Multiple serious adverse events have been attributed to methotrexate, based largely on older reports using high or daily doses, and subsequent case reports and circumstantial evidence. The risk with modern dosing regimens: Lower doses, weekly schedules, and concomitant folic acid is less clear. Clarification and dissemination of the actual risk is crucial so appropriate judgements can be made for patients who may benefit from this treatment. Methotrexate has been associated with a range of liver related adverse events ranging from asymptomatic transaminase elevations to fibrosis and fatal hepatic necrosis. Concern over potential liver toxicity has resulted in treatment avoidance, cessation, or recommendations for investigations which may be costly, invasive and unwarranted. Modern laboratory monitoring of liver blood tests may also influence the risk of more serious complications. The majority of present day studies report an approximate doubling of the relative risk of elevated transaminases in methotrexate treated patients but no increased risk of symptomatic or severe liver related adverse events. In this article we will review the evidence around methotrexate and liver related adverse events.

Prevalence of hepatic steatosis in apparently healthy medical students: a transient elastography study on the basis of a controlled attenuation parameter

OBJECTIVE

Despite the increasing burden of nonalcoholic fatty liver disease (NAFLD) in modern societies, the optimal screening method to detect hepatic steatosis in the general population remains to be established. Controlled attenuation parameter (CAP) measured with transient elastography (TE) has recently emerged as a reliable imaging tool for the screening and diagnosis of NAFLD. Here, we sought to investigate the prevalence of TE-defined hepatic steatosis in a sample of apparently healthy medical students. We also assessed the relationships between CAP and traditional NAFLD risk factors.

MATERIALS AND METHODS

A total of 112 Turkish medical students (48 women and 64 men, mean age 20.5±1.1 years) underwent TE. On the basis of previous studies, a cut-off value of 238 dB/m for CAP was used for the diagnosis of hepatic steatosis.

RESULTS

On the basis of the selected cut-off for CAP, we identified 26 students (23.2%) with TE-defined NAFLD. Univariate correlation analyses showed that CAP values were significantly associated with BMI (r=0.40, P<0.001), waist circumference (r=0.39, P<0.001), and hip circumference (r=0.34, P<0.001). In multivariable analysis, only BMI retained its independent association with CAP (β=0.36, t=3.4, P<0.001).

CONCLUSION

NAFLD is highly prevalent even in apparently healthy young individuals. CAP assessment with TE may be useful for an early, noninvasive identification of hepatic steatosis.

The common PNPLA3 variant p.I148M is associated with liver fat contents as quantified by controlled attenuation parameter (CAP)

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is becoming the most prevalent liver disorder. The PNPLA3 (adiponutrin) variant p.I148M has been identified as common genetic modifier of NAFLD. Our aim was to assess the relationships between genetic risk and non-invasively measured liver fat content.

METHODS

Hepatic steatosis was quantified by transient elastography, using the controlled attenuation parameter (CAP) in 174 patients with chronic liver diseases (50% women, age 18-77 years). In addition, a cohort of 174 gender-matched healthy controls (50% women, age 32-77 years) was recruited. The PNPLA3 mutation as well as the novel NAFLD-predisposing genetic variant (TM6SF2 p.E167K) were genotyped with allele-specific probes.

RESULTS

The PNPLA3 genotype correlated significantly (P = 0.001) with hepatic CAP measurements. The p.148M risk allele increased the odds of developing liver steatosis (OR = 2.39, P = 0.023). In multivariate models, BMI and PNPLA3 mutation were both independently associated with CAP values (P < 0.001 and P = 0.007, respectively). Carriers of the TM6SF2 risk allele presented with increased aminotransferase activities (ALT: P = 0.007, AST: P = 0.004), but the presence of this variant did not affect CAP values.

CONCLUSIONS

The PNPLA3 p.I148M variant represents the most important prosteatotic genetic risk factor. NAFLD carriers of this variant should be followed up carefully, with elastography and CAP being ideally suited for this purpose.

Evaluation of Percutaneous Liver Biopsy Complications in Patients with Chronic Viral Hepatitis

OBJECTIVE

Liver biopsy is still the gold standard for the determination of liver fibrosis and necroinflammatory activity. It is an invasive method and may lead to severe complications. The aim of this study was to determine the evaluation of percutaneous liver biopsy complications in patients with chronic viral hepatitis.

MATERIALS AND METHODS

1165 patients, who were followed with the diagnosis of chronic viral hepatitis and who were applied percutaneous liver biopsy between January 2000 and February 2013 at the out-patient clinic of Infectious Diseases and Clinical Microbiology, were included in the study.

RESULTS

Of 1165 patients who underwent liver biopsy, 196 (86 male, 110 female) were diagnosed with chronic hepatitis C, 969 (559 male, 410 female) were diagnosed with chronic hepatitis B. The mean age was 43.3 and 55.4% were male. 11% of the patients were diagnosed with chronic renal failure and underwent haemodialysis. Minor complication rate was about 20% (severe pain required usage of analgesic drugs in 19.8%, abdominal pain in 22.6%) whereas major complication rate was 1.15% (pneumothorax in 0.17%, heamobilia in 0.08%, hematoma in 0.9%). We did not observe severe complications such as fever, abscess, anaphylaxis, bacteraemia, organ perforations, sepsis or death.

CONCLUSION

Despite being an invasive procedure, percutaneous liver biopsy can be considered a safe method because of the low rates of severe complications observed in our patients.

Detecting minimal hepatic encephalopathy in an endemic country for hepatitis B: the role of psychometrics and serum IL-6

BACKGROUND & AIMS

It remains unknown what the prevalence of minimal hepatic encephalopathy is in Taiwan, a highly endemic country for chronic viral hepatitis infection. It is also unclear whether abnormal serum cytokine levels can be indicative of the presence of minimal hepatic encephalopathy. We aimed to standardize the tests of psychometric hepatic encephalopathy score and predictive value of proinflammatory cytokines in minimal hepatic encephalopathy in Taiwan.

METHODS

180 healthy subjects and 94 cirrhotic patients without a history of overt hepatic encephalopathy from a tertiary center were invited to participate in this cross-sectional study. Blood sampling for determination of serum levels of interleukin 6 and 18 and tumor necrosis factor-α was performed. Based on the normogram of psychometric hepatic encephalopathy score from healthy volunteers, patients with minimal hepatic encephalopathy were identified from the cirrhotic patients using the criterion of a psychometric hepatic encephalopathy score less than -4.

RESULTS

In the healthy subjects, age and education were predictors of subtests of psychometric hepatic encephalopathy score. Minimal hepatic encephalopathy was identified in 27 (29%) cirrhotic patients. Serum interleukin 6 level (OR = 6.50, 95% CI = 1.64-25.76, P = 0.008) was predictive of the presence of minimal hepatic encephalopathy after multivariate analysis.

CONCLUSIONS

The psychometric hepatic encephalopathy score can be a useful tool for detecting patients with minimal hepatic encephalopathy in Taiwan and around one third of cirrhotic outpatients fulfill this diagnosis. A high serum interleukin 6 level is predictive of the presence of minimal hepatic encephalopathy.

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.

A review of methotrexate-associated hepatotoxicity

Methotrexate is effective not only in treating psoriasis and rheumatoid arthritis but also various other disorders. The use of methotrexate has been somewhat limited by concerns regarding its adverse effects, including its potential for hepatotoxicity. The purpose of this article is to provide an overview of methotrexate-associated hepatotoxicity, including risk factors, pathogenesis and recommendations for monitoring it by US, UK and European guidelines, as well as providing a brief overview of its mechanism of action and of high-dose methotrexate.

Open and laparoscopic resection of hepatocellular adenoma: trends over 23 years at a specialist hepatobiliary unit

BACKGROUND

Hepatocellular adenoma (HCA) is a rare benign liver epithelial tumour that can require surgery. This retrospective study reports a 23-year experience of open and laparoscopic resections for HCA.

METHODS

Patients with a histological diagnosis of HCA were included in this analysis. Surgical resection was performed in all symptomatic patients and in those with lesions measuring >5 cm.

RESULTS

Between 1989 and 2012, 62 patients, 59 of whom were female, underwent surgery for HCA (26 by open surgery and 36 by laparoscopic surgery). Overall, 96.6% of female patients had a history of contraceptive use; 54.8% of patients presented with abdominal pain and 11.2% with haemorrhage; the remaining patients were asymptomatic. Patients who underwent laparoscopy had smaller lesions (mean ± standard deviation diameter: 68.3 ± 35.2 mm versus 91.9 ± 42.5 mm; P = 0.022). Operatively, laparoscopic and open liver resection did not differ except in the number of pedicle clamps, which was significantly lower in the laparoscopic group (27.8% versus 57.7% of patients; P = 0.008). Postoperative variables did not differ between the groups. Mortality was nil. Two surgical specimens were classified as HCA/borderline hepatocellular carcinoma. At the 3-year follow-up, all patients were alive with no recurrence of HCA.

CONCLUSIONS

Open and laparoscopic liver resections are both safe and feasible approaches for the surgical management of HCA. However, laparoscopic liver resections may be limited by lesion size and location and require advanced surgical skills.

Evaluation of the utility of serum prolidase as a marker for liver fibrosis

BACKGROUND

Liver dysfunction is common and often unrecognized. Liver biopsy is the gold standard in the assessment of liver fibrosis, but has disadvantages. We assessed the diagnostic accuracy of serum prolidase enzyme activity (SPA) in predicting the presence and degree of liver fibrosis, as compared with liver biopsy. Further, we evaluated the effect of hemolysis on measured SPA levels.

METHODS

We undertook a prospective case control study. Thirty eight outpatients without apparent liver illness and 20 patients with liver pathology scheduled to undergo liver biopsy had their SPA levels measured.

RESULTS

Patients undergoing liver biopsy had higher SPA levels (361 (268) IU/l [median (interquartile range)]) compared with controls (169 (160) (P < 0.001)). A SPA cutoff value of 200 IU/l yielded a sensitivity of 89%, specificity of 59%, an odds ratio of 11.5, negative predictive value of 92%, and a positive predictive value of 50%. Hemolysis causes an apparent increase in SPA levels.

CONCLUSION

Higher SPA levels in patients undergoing liver biopsies compared with controls may reflect the presence of liver fibrosis. SPA levels could not be used to stage the degree of fibrosis. SPA measurement may be useful in the diagnostic workup of suspected liver disease.

Detection of hepatic steatosis using the controlled attenuation parameter: a comparative study with liver biopsy

OBJECTIVE

Measurements of controlled attenuation parameter (CAP) with transient elastography (FibroScan®; EcoSens SA, Paris, France) may provide an accurate noninvasive assessment of hepatic steatosis. Herein, we prospectively determined the accuracy of liver fat quantification with CAP values in patients with chronic liver diseases and compare the results with those of histological assessment of steatosis as reference standard.

MATERIALS AND METHODS

We enrolled 50 Turkish patients with various forms of chronic liver diseases. All patients underwent both CAP assessment and ultrasonography-guided liver biopsy.

RESULTS

On liver biopsy, 16 (32%) patients had S0, 12 (24%) had S1, 9 (18%) had S2, and 13 (26%) had S3. The CAP values increased significantly (p<0.001) for each steatosis stage on liver biopsy: S0, 222 dB/m; S1, 250 dB/m; S2, 270 dB/m; and S3, 318 dB/m. A cutoff value of 257 dB/m could distinguish significant steatosis (S2-S3) from S0 (Sn 89%, Sp 83%, positive likelihood ratio 5.33, negative likelihood ratio 0.13, AUROC=0.93). Multivariable analysis indicated that neither liver fibrosis (p=0.58) nor disease etiology (p=0.96) had a significant impact on the association between CAP and the stage of steatosis.

CONCLUSION

The determination of CAP using transient elastography can represent an important step forward toward the goal of an "imaging liver biopsy".

Evaluation of the relation between hepatic fibrosis and basic laboratory parameters in patients with chronic hepatitis B fibrosis and basic laboratory parameters

BACKGROUND

The hepatitis B virus is an important healthcare problem. According to current clinical practice, a liver biopsy is required for the diagnosis and treatment of chronic liver disease. However, a liver biopsy is an invasive, inconvenient procedure, which requires an expert pathologist opinion. Therefore requirement of biochemical tests, which are considered to indicate hepatic fibrosis and may be repeated easily, increases gradually today.

OBJECTIVES

This study evaluated the correlation between hepatic fibrosis and routine laboratory values in patients with chronic hepatitis B.

PATIENTS AND METHODS

The files of 456 patients with CHB (chronic hepatitis B) who were referred to the infectious diseases and clinical microbiology clinic between January 2009 and March 2012 were screened retrospectively. Liver biopsy samples were examined according to Ishak scoring. Laboratory parameters and histopathology reports were recorded, and correlations between the fibrosis grade and laboratory parameters were analyzed.

RESULTS

There were 320 male and 136 female patients, with a mean age 36.7 ± 12.1 years. According to liver biopsy results, a low fibrosis score (stage 0-2) was detected in 281 patients (61.6%), and a high fibrosis score (stage 3-5) was detected in 175 patients (38.4%). Patients with a high fibrosis score had significantly higher ALT (alanine amino transferase), AST (aspartate aminotransferase), and HBV-DNA values and a significantly lower platelet count compared with those with a low fibrosis score (P = 0.001, 0.001, 0.025, and 0.001, respectively). A positive correlation was detected between the fibrosis score and age, BMI, HAI, ALT, and AST values, and a negative correlation was detected between the fibrosis score and albumin and platelet counts. In the regression analysis performed to evaluate the factors associated with high-stage fibrosis, fibrosis was determined to be associated with thrombosis, ALT, and gender. The results of the regression analysis demonstrated that the risk of fibrosis was 4.6 fold higher in men.

CONCLUSIONS

According to the results obtained in our study, advanced age, higher BMI, AST, ALT, and HBV-DNA levels, and low albumin and platelet levels are correlated with advanced fibrosis in patients with CHB.

Noninvasive detection of hepatic steatosis in patients without ultrasonographic evidence of fatty liver using the controlled attenuation parameter evaluated with transient elastography

OBJECTIVE

Although ultrasound is a useful technique for detecting hepatic steatosis, it cannot provide a precise determination of hepatic fat content. A novel attenuation parameter named controlled attenuation parameter (CAP) has been developed to process the raw ultrasonic signals acquired by Fibroscan. The aim of this study was to determine the percentage of hepatic steatosis in apparently healthy Turkish individuals using the proposed diagnostic cut-off points for CAP. In addition, we sought to investigate the association of CAP with the traditional risk factors for nonalcoholic fatty liver disease in a screening setting.

MATERIALS AND METHODS

In the present study, 102 Turkish individuals without evidence of fatty liver on ultrasound and normal aminotransferase levels underwent CAP measurements by means of Fibroscan.

RESULTS

The mean (SD), median (minimum-maximum), and 5th and 95th percentile values of CAP values in this cohort of 102 individuals were 206.99 (48.12), 210.5 (100.0-314.0), 113.4 and 280.2 dB/m, respectively. Using the cut-offs of 222, 238, and 283 dB/m for CAP, there were 39 (38.2%), 23 (22.5%), and five (4.9%) individuals out of 102 who had at least 10% steatosis despite normal liver findings on ultrasound. After allowance for potential confounders, CAP was independently associated with BMI (β=0.39, t=3.5, P<0.001) and the number of metabolic syndrome criteria (β=0.24, t=2.1, P<0.05).

CONCLUSION

These results hold promise for early noninvasive detection of hepatic steatosis on the basis of CAP assessment.

Fine needle aspirating and cutting is superior to Tru-cut core needle in liver biopsy

BACKGROUND

Liver biopsy is the "gold standard" for evaluating liver disorders, but controversies over the potential risk of complications and patient discomfort still exist. Using a 21G fine needle, we developed a new biopsy procedure, fine needle aspirating and cutting (FNAC). Our procedure obtains enough tissue for pathological examination and meanwhile, reduces the risk of biopsy complications. The present study was to determine the safety and efficiency of 21G FNAC compared with 18G Tru-cut core needle (TCN) in liver tumor biopsies.

METHODS

Ninety-four patients with unresectable malignant tumors were included in this study. Patients were divided into 2 groups: 18G TCN and 21G FNAC. The total positive rate (TPR) and safety of both groups were compared.

RESULTS

TPR was not different between the two groups. Liver puncture track subcapsular hemorrhage and arteriovenous shunt were reported with 18G TCN but not with 21G FNAC. The incidence of pain caused by biopsy was higher for the 18G TCN group compared to the 21G FNAC group (P<0.05). About 82.6% of the patients in the 18G TCN group had a sample length >0.5 cm, but 52.1% in the 21G FNAC group (P<0.05). More than 50% of patients in both groups had sufficient tissue for immunohistochemical examination.

CONCLUSIONS

TPR is not different between the 21G FNAC and 18G TCN biopsy procedures, but the safety of 21G FNAC is superior to that of 18G TCN. Tissues obtained by either of these two procedures are sufficient for a pathological diagnosis.

Percutaneous liver biopsies guided with ultrasonography: a case series

Background

Although liver biopsy is an easy procedure for hospitalized patients and outpatients, some complications may occur.

Objectives

To evaluate the efficiency, complications, safety and clinicopathological utility of ultrasonographic-guided percutaneous liver biopsy in diffuse liver disease.

Patients and Methods

In our retrospective study, we evaluated ultrasound-assisted needle biopsies that were performed in outpatients from October 2006 to July 2010. The liver biopsies were performed following one-night fasting using the tru-cut biopsy gun (18-20 gauge) after marking the best seen and hypovascular part of the liver, distant enough from the adjacent organs.

Results

A total of 1018 patients were referred to our radiology department. Most of the patients had hepatitis B (60.6%). The biopsy specimens were recorded and sent to our pathology department for histopathological examination.

Conclusion

According to the results of our series, percutaneous liver biopsy using the tru-cut biopsy gun guided by ultrasonography can be performed safely. We resolve that routine ultrasound of the puncture site is a quick, effective and safe procedure. The complication rate is very low. The US-assisted percutaneous liver biopsy should be used for all cases.

Transient elastography: Kill two birds with one stone?

Assessment of liver fibrosis and steatosis is crucial in chronic liver diseases in order to determine the prognosis, the need of treatment, as well as monitor disease progression and response to treatment. Liver biopsy is limited by its invasiveness and patient acceptability. Transient elastography (TE, Fibroscan^®) is a non-invasive tool with satisfactory accuracy and reproducibility to estimate liver fibrosis and steatosis. TE has been well validated in major liver diseases including chronic hepatitis B and C, non-alcoholic fatty liver disease, alcoholic liver disease, primary biliary cirrhosis, and primary sclerosing cholangitis. As alanine aminotransferase (ALT) is one of the major confounding factors of liver stiffness in chronic hepatitis B, an ALT-based algorithm has been developed and higher liver stiffness measurements (LSM) cutoff values for different stages of liver fibrosis should be used in patients with elevated ALT levels up to 5 times of the upper limit of normal. Otherwise falsely-high LSM results up to cirrhotic range may occur during ALT flare. TE is also useful in predicting patient prognosis such as development of hepatocellular carcinoma (HCC), portal hypertension, post-operative complications in HCC patients, and also survival. Unfortunately, failed acquisition of TE is common in obese patients. Furthermore, obese patients may have higher LSM results even in the same stage of liver fibrosis. The new XL probe, a larger probe with lower ultrasound frequency and deeper penetration, increases the success rate of TE in obese patients. The median LSM value with XL probe was found to be lower than that by the conventional M probe, hence cutoff values approximately 1.2 to 1.3 kPa lower than those of M probe should be adopted. Recent studies revealed a novel ultrasonic controlled attenuation parameter (CAP) of the machine is a useful parameter to detect even low-grade steatosis noninvasively. CAP may also be used to quantify liver steatosis by applying different cutoff values. As both LSM and CAP results are instantly available at same measurement, this makes TE a very convenient tool to assess any patients who are suspected or confirmed to suffer from chronic liver diseases.

Tolerance of liver biopsy in a tertiary care center: comparison of the percutaneous and the transvenous route in 143 prospectively followed patients

BACKGROUND

Transjugular liver biopsy (TJLB) is usually performed when a percutaneous liver biopsy (PLB) is contraindicated. TJLB is an invasive procedure and the patient's tolerance may be variable.

AIM

To compare patient tolerance and quality of the biopsy sample between PLB and TJLB.

PATIENTS AND METHODS

A total of 143 patients underwent a liver biopsy; of these, 75 underwent TJLB and 68 underwent PLB. To evaluate patient tolerance, we used a visual analog scale that scored the intensity of the symptoms. The length of the biopsy sample and the total number of portal tracts per biopsy were also determined for assessment of biopsy quality.

RESULTS

The biopsy sample length was similar in both groups (18.88 ± 8.83 mm on PLB vs. 18.26 ± 10.30 mm on TJLB). No differences were found in the number of portal tracts between the two groups (10.43 ± 8.25 on TJLB vs. 12 ± 10.09 on PLB). Fewer complications were observed in the TJLB group compared with the PLB group (P=0.002).Further, higher degree of pain was reported by patients who underwent PLB compared with patients who underwent TJLB (3.18 ± 3.17 vs. 1.19 ± 2.07); as such, there was a greater need for analgesics on PLB.

CONCLUSION

TJLB and PLB techniques provide similar quality of tissue samples; however, TJLB is less painful and therefore better tolerated by patients.

Ultrasonography (US) and non-invasive diagnostic methods for non-alcoholic fatty liver disease (NAFLD) and early vascular damage. Possible application in a population study on the metabolic syndrome (MS)

Abdominal ultrasonography (US) represents the first-line imaging examination in chronic liver diseases; in most cases, US, laboratory findings and the clinical context are generally sufficient to guide the diagnosis. Thanks to the considerable diffusion of US, we have seen an increased diagnosis of NAFLD in recent years, although this condition is generally silent from a clinical point of view. We have to identify the metabolic syndrome in the general population and to promptly recognize NAFLD to prevent its development into non-alcoholic steatohepatitis, cirrhosis and hepatocellular carcinoma. Among the non-invasive diagnostic techniques for NAFLD and for early vascular damage, ultrasonography represents the method of choice. In fact, besides the traditional semiotics of fundamental US of the liver, new US techniques have recently been proposed (contrast enhancement US, acoustic structure characterization), with respect to serum biomarkers and Fibroscan, for the study of liver fibrosis. Similarly, also as concerns the US measurement of carotid intima-media thickness, new automated methods with sophisticated software and radio-frequency signal have recently been introduced. Finally, we report the preliminary results of a personal experience on liver and carotid US in the epidemiology of the metabolic syndrome.

Implications of rapid virological response in hepatitis C therapy in the US veteran population

BACKGROUND

Early predictors of response to hepatitis C virus (HCV) therapy, such as rapid virological response, are valuable for the identification of patients with a higher likelihood of treatment success.

AIM

To identify predictors of rapid virological response in a real world setting.

METHODS

Using the VA Clinical Case Registry, we identified patients with HCV mono-infection, without liver transplantation, who initiated peginterferon (PEG-IFN) and ribavirin (RBV) in 2007 or 2008 and had HCV RNA testing for RVR. Significant baseline characteristics from genotype specific univariate analyses were used in backwards stepwise models to identify significant independent predictors of RVR.

RESULTS

The final cohort consisted of 2424 patients with genotype 1 (G1), 666 patients with genotype 2 (G2), and 419 patients with genotype 3 (G3). Rapid virological response rates were 15% for G1, 71% for G2 and 57% for G3. Sustained virological response rates were significantly higher in patients with rapid virological response than without, increasing from 18% to 52% in G1, 39% to 71% in G2, and 40% to 60% in G3 (P < 0.0001). A baseline HCV RNA < 500,000 IU/mL positively predicted RVR across all genotypes studied. In addition, for G1, Black race, Hispanic ethnicity, aspartate aminotransferase/alanine aminotransferase (AST/ALT) ≥ 0.6, ferritin ≥ 350 ng/mL, LDL< 100 mg/dL and diabetes; for G2, BMI ≥ 30 kg/m(2), platelets < 150 K/μL, LDL< 100 mg/dL and the use of PEG-IFN alfa-2b; and for G3, AST/ALT ≥ 1.0, all negatively predicted rapid virological response.

CONCLUSION

We found several novel independent predictors of rapid virological response, including BMI, AST/ALT ratio, ferritin, platelets, LDL, diabetes and type of PEG-IFN prescribed, which may be useful in guiding treatment decisions in routine medical practice.

Obesity, Visceral Fat, and NAFLD: Querying the Role of Adipokines in the Progression of Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of clinicopathologic conditions ranging from steatosis alone to nonalcoholic steatohepatitis (NASH), with varying risks for progression to cirrhosis and hepatocellular carcinoma. There is mounting evidence that NAFLD not only complicates obesity, but also perpetuates its metabolic consequences. Critical event that leads to progressive liver injury in NAFLD is unknown. Obesity reflects a generalized proinflammatory state with its increased inflammatory markers like C reactive protein, IL-6, IL-8, IL-10, PAI-1, TNF-α, and hepatocyte growth factor. The elevated production of these adipokines is increasingly considered to be important in the development of diseases linked to obesity and the metabolic syndrome. Disordered cytokine production is likely to play a role in the pathogenesis of NAFLD. There is no effective treatment for NAFLD, though weight loss may halt disease progression and revert histological changes, the underlying mechanism remaining elusive. All stages of the disease pathway from prevention, early identification/diagnosis, and treatment require an understanding of the pathogenesis of liver injury in NAFLD.

Liver lesions in children and adolescents: cytopathologic analysis and clinical correlates in 44 cases

The role of fine needle aspiration (FNA) as a first-line diagnostic modality is well-established for neoplastic and nonneoplastic liver masses in adults. However, cytopathologic analysis of such lesions in children and adolescents has not been well studied. An 18-year retrospective review of the cytopathology archives at The Johns Hopkins Hospital identified 44 cases of hepatic FNA in children and adolescents (i.e., 21 years and younger). The cytopathologic material was reviewed and correlated with subsequent surgical pathology diagnoses and/or clinical follow-up. Among the 44 FNAs studied, 40 (90.9%) were deemed diagnostic for evaluation and 4 (9.1%) were nondiagnostic. Twenty four (60%) of the diagnostic FNAs were neoplasms, 10 (25%) were nonneoplastic lesions, and 6 (15%) were "atypical" or "suspicious." There were 21 (87.5%) malignant and 3 (12.5%) benign tumors. Among the malignant cases, metastases/secondary tumors accounted for 12 (54.5%) followed by hepatocellular carcinoma (HCC)--7 (38.1%). The types of metastatic/secondary neoplasms were Wilms tumor (2), germ cell tumor (2), acute leukemias (2), and miscellaneous others (6). Among the nonneoplastic lesions focal nodular hyperplasia was most common--4 (40%). Among the "atypical" cases, 4 (66.6%) turned out to be benign on follow-up, 2 were HCC, and 1 was Hodgkin lymphoma. Immunoperoxidase (IPOX) studies were done in 20 (45.5%) cases to confirm the cytopathologic diagnoses. Overall, FNA showed a sensitivity of 95.2% and a specificity of 100% for a malignant diagnosis.

Noncirrhotic human nonalcoholic fatty liver disease induces portal hypertension in relation to the histological degree of steatosis

INTRODUCTION

We earlier showed in an animal model that steatosis, in the absence of fibrosis or inflammation, induces a significant rise in portal pressure. The relevance of these findings for human pathology is unknown till date.

AIMS

To study portal pressure in nonalcoholic fatty liver disease patients and to identify factors possibly related to steatosis-induced changes in liver haemodynamics.

MATERIALS AND METHODS

Patients presenting with a problem of overweight and with noninvasive signs of liver involvement were proposed for transjugular liver biopsy. The biopsy was scored according to the Nonalcoholic Steatohepatitis Clinical Research Network scoring system.

RESULTS

Fifty consecutive patients were studied. Mean age was 47.9 ± 13.6 years; 31 (62%) of them were female. Hepatic venous pressure gradient (HVPG) was normal in 27 patients (54%), borderline (5 mmHg) in nine (18%) and elevated in 14 patients (28%). For further analysis those with a HVPG of 5 mmHg were considered normal (group 1). HVPG was 8.8 ± 2.6 mmHg in those with an elevated HVPG (group 2) versus 3.4 ± 1.2 mmHg in group 1 (P < 0.0001). In both the groups, only one patient had cirrhosis; 26 of 36 (group 1) and nine of 14 patients (group 2) had fibrosis score 0. Fibrosis score was not significantly different (P = 0.530). Perisinusoidal fibrosis score was not significantly different (P = 0.186). Steatosis was the only histological feature that significantly differed between the groups (P = 0.016). The degree of steatosis (P = 0.010) was the only independent predictor of the presence of portal hypertension.

CONCLUSION

Human nonalcoholic fatty liver disease can, even in the absence of significant fibrosis, induce portal hypertension, correlated with the severity of the steatosis.

Visceral adiposity and insulin resistance are independent predictors of the presence of non-cirrhotic NAFLD-related portal hypertension

INTRODUCTION

We previously demonstrated in an animal model that steatosis, in the absence of fibrosis, induces a significant rise in portal pressure, indicating substantial changes in liver hemodynamics. As assessment of portal pressure is an invasive procedure, non-invasive parameters are needed to identify patients at risk.

AIMS

To study the portal pressure in nonalcoholic fatty liver disease patients and to identify factors that are possibly related to steatosis-induced changes in liver hemodynamics.

MATERIALS AND METHODS

Patients presenting with a problem of overweight or obesity, and in whom non-invasive investigations showed signs of liver involvement, were proposed for transjugular hepatic vein catheterization and liver biopsy. The biopsy was scored according to the Nonalcoholic Steatohepatitis Clinical Research Network Scoring System.

RESULTS

A total of 50 consecutive patients were studied. Their mean age was 47.9 ± 1.8 years; 31 (62%) were female. Hepatic venous pressure gradient was normal in 36 (72%) and elevated in 14 (28%) patients. The degree of steatosis was the only histological parameter that differed significantly between the two groups (P=0.016), and was a predictor of the presence of portal hypertension (PHT) in regression analysis (P=0.010). Comparing normal versus portal hypertensive patients, waist circumference (117 ± 2 versus 128 ± 4 cm, P=0.005), waist-hip ratio (0.96 ± 0.06 versus 1.04 ± 0.03, P=0.003), visceral fat (229 ± 15 versus 292 ± 35 cm(2), P=0.022), fasting insulin (15.4 ± 1.7 versus 21.8 ± 2.4 μU ml(-1), P=0.032), fasting c-peptide (1.22 ± 0.06 versus 1.49 ± 0.09 nmol l(-1), P=0.035) and homeostasis model assessment-insulin resistance (HOMA IR) (3.28 ± 0.29 versus 4.81 ± 0.57, P=0.019) were significantly higher. Age, gender, liver enzymes, ferritin and high-sensitive C-reactive protein were not significantly different. In regression analysis, waist circumference (P=0.008) and HOMA IR (P=0.043) were independent predictors of PHT.

CONCLUSIONS

Estimates of both visceral adiposity and IR are predictors for the presence of PHT, related to the degree of steatosis, and may help in identifying patients who are at risk of developing steatosis-related complications.

Practice guidelines for the diagnosis and management of nonalcoholic fatty liver disease. A decalogue from the Italian Association for the Study of the Liver (AISF) Expert Committee

We report the evidence-based Italian Association for the Study of Liver guidelines for the appropriate diagnosis and management of patients with nonalcoholic fatty liver disease in clinical practice and its related research agenda. The prevalence of nonalcoholic fatty liver disease varies according to age, gender and ethnicity. In the general population, the prevalence of nonalcoholic fatty liver disease is about 25% and the incidence is of two new cases/100 people/year. 2-3% of individuals in the general population will suffer from nonalcoholic steatohepatitis. Uncomplicated steatosis will usually follow a benign course. Individuals with nonalcoholic steatohepatitis, however, have a reduced life expectancy, mainly owing to vascular diseases and liver-related causes. Moreover, steatosis has deleterious effects on the natural history of HCV infection. Nonalcoholic fatty liver disease is usually diagnosed in asymptomatic patients prompted by the occasional discovery of increased liver enzymes and/or of ultrasonographic steatosis. Medical history, complete physical examination, etiologic screening of liver injury, liver biochemistry tests, serum lipids and insulin sensitivity tests should be performed in every patient. Occult alcohol abuse should be ruled out. Ultrasonography is the first-line imaging technique. Liver biopsy, the gold standard in diagnosis and prognosis of nonalcoholic fatty liver disease, is an invasive procedure and its results will not influence treatment in most cases but will provide prognostic information. Assessment of fibrosis by composite scores, specific laboratory parameters and transient elastography might reduce the number of nonalcoholic fatty liver disease patients requiring liver biopsy. Dieting and physical training reinforced by behavioural therapy are associated with improved nonalcoholic fatty liver disease. Diabetes and the metabolic syndrome should be ruled out at timed intervals in nonalcoholic fatty liver disease. Nonalcoholic steatohepatitis patients should undergo periodic evaluation of cardiovascular risk and of advancement of their liver disease; those with nonalcoholic steatohepatitis-cirrhosis should be evaluated for early diagnosis of hepatocellular carcinoma.

Nonalcoholic fatty liver disease: a review and update

The spectrum of nonalcoholic fatty liver disease (NAFLD) ranges from asymptomatic steatosis to nonalcoholic steatohepatitis (NASH) and cirrhosis. Hepatic steatosis occurs when free fatty acids, released in the setting of insulin resistance and the metabolic syndrome, are taken up by the liver. Additional biochemical insults, including oxidative stress, upregulation of inflammatory mediators, and dysregulated apoptosis, can result in inflammation (producing NASH) and fibrosis. Noninvasive methods (e.g., abdominal ultrasonography) are safe ways to support a diagnosis of hepatic steatosis, but advanced liver histopathologic findings including NASH and fibrosis cannot be identified without pursuing liver biopsy. Recent advances in serologic and imaging methods aim to determine severity of inflammation and fibrosis noninvasively. Currently, therapeutic options for NAFLD are limited to medications that reduce risk factors, but the future holds promise for therapies that might slow the progression of this increasingly prevalent disorder.

Clinical relevance of transjugular liver biopsy in comparison with percutaneous and laparoscopic liver biopsy

BACKGROUND

Transjugular liver biopsy (TJLB) is frequently used to obtain liver specimens in high-risk patients. However, TJLB sample size possibly limits their clinical relevance.

METHODS

102 patients that underwent TJLB were included. Clinical parameters and outcome of TJLB were analyzed. Control samples consisted of 112 minilaparoscopic liver biopsies (mLLBs) and 100 percutaneous liver biopsies (PLBs).

RESULTS

Fewer portal tracts were detected in TJLB (4.3 +/- 0.3) in comparison with PLB (11.7 +/- 0.5) and mLLB (11.0 +/- 0.6). No difference regarding the specification of indeterminate liver disease and staging/grading of chronic hepatitis was observed. In acute liver failure (n = 32), a proportion of hepatocellular necrosis beyond 25% was associated with a higher rate of death or liver transplantation.

CONCLUSIONS

Despite smaller biopsy samples the impact on the clinical decision process was found to be comparable to PLB and mLLB. TJLB represents a helpful tool to determine hepatocellular necrosis rates in patients with acute liver failure.

Outpatient percutaneous liver biopsy: still a good option

OBJECTIVE

To assess security of "blind" percutaneous liver biopsy as an ambulatory procedure.

MATERIAL AND METHODS

Defining inclusion criteria, surveillance protocol, data from ultrasonography done 6 h after procedure and complications.

RESULTS

We analysed 192 percutaneous liver biopsies done between 2000-2007. There were no major complications and only a small number of minor complications. There were no deaths related to the procedure.

CONCLUSION

It is possible to perform percutaneous liver biopsy as an ambulatory procedure not expecting to find threatening complications.

Reversal of liver fibrosis

Hepatic fibrosis is a scarring process associated with an increased and altered deposition of extracellular matrix in the liver. It is caused by a variety of stimuli and if fibrosis continues unopposed, it would progress to cirrhosis which poses a significant health problem worldwide. At the cellular and molecular level, this progressive process is characterized by cellular activation of hepatic stellate cells and aberrant activity of transforming growth factor-beta with its downstream cellular mediators. Liver biopsy has been the reference test for assessment of hepatic fibrosis, but because of its limitations, noninvasive markers of liver fibrosis were developed. Liver fibrosis or cirrhosis was considered irreversible in the past but progress of research on the molecular pathogenesis of liver fibrosis has shown that hepatic cellular recovery is possible. Currently, no acceptable therapeutic strategies exist, other than removal of the fibrogenic stimulus, to treat this potentially devastating disease.

Noninvasive monitoring of hepatitis C fibrosis progression

Noninvasive approaches in the diagnosis and monitoring of fibrosis are still evolving. Transient elastography is an inexpensive, rapid, and relatively accurate form of noninvasive monitoring, especially in severe fibrosis It is a nascent technology, however, and there is no clear indication that elastography is better than biopsy for less severe fibrosis. With improved resolution and longer term data, it may become a vital supplement. The combined use of transient elastography and biochemical markers seems to be the most promising noninvasive technique.