Liver biopsy: techniques, clinical applications, and complications

A comprehensive clinical and microbiological study on the diagnosis and management of cholangitis in patients with biliary atresia undergoing kasai portoenterostomy

BACKGROUND AND OBJECTIVES

Kasai-portoenterostomy (KPE) is the initial attempt to restore the bile flow and salvage the native liver in biliary atresia (BA) patients. Cholangitis is a frequent complication after KPE and adequate treatment impacts the long-term outcome. The aim of our study is to assess the severity of cholangitis episodes in a cohort of BA patients post KPE, identify the causative agents, using several diagnostic methods, as well as to assess the tolerability and efficacy of our antimicrobial protocol.

METHODS

This analytical retrospective observational study, conducted at Pediatric Hepatology Unit, Cairo University Pediatric Hospital, included infants and children with cholangitis post-KPE enrolled over 30 months. Clinical data collection, basic laboratory investigations inflammatory markers, B-D glucan, blood culture, 16SrDNA, 18SrDNA were performed in all enrolled patients. Cholangitis episodes were treated with intravenous antibiotics according to our antimicrobial protocol that has been implemented in conjunction with the antimicrobial stewardship committee.

RESULTS

This study included 30 post-KPE patients, who experienced 47 episodes of cholangitis. Twenty-five episodes of cholangitis were culture positive cholangitis (positive blood culture and/or PCR results and/or liver biopsy). Klebsiella Variicola and Klebsiella pneumoniae were the most prevalent pathogens in 13 and seven cultures, respectively. Meropenem was the most successful antibiotic in the eradication of infection in 11(23.4%) episodes. Culture positive cholangitis showed increased incidence of sepsis and worse outcome in comparison to culture negative cholangitis. The severity of cholangitis was classified into 16 patients (34%) with infection, 28 (60%) sepsis, one (2%) severe sepsis and two (4%) septic shock.

CONCLUSION

Almost half of cholangitis episodes were culture-positive; the commonest pathogen was Klebsiella, showing more severe sepsis and worse outcome.

A lethal case of massive hemorrhage after percutaneous liver biopsy in a patient with thrombasthenia

Percutaneous needle liver biopsy is an important procedure in the diagnosis of and assessment of the severity of liver diseases. Although liver biopsy is considered to be a relatively safe procedure, there are occasional cases of death due to massive bleeding after liver biopsy. Thrombasthenia is a disease in which bleeding occurs in the mucosa and skin due to platelet dysfunction. A 60-year-old female was admitted for a liver biopsy for further investigation after an abnormal liver function test. She was diagnosed with thrombasthenia and was being treated with oral tranexamic acid and carbazochrome. Blood tests showed little decrease of platelet count and no abnormalities of blood coagulability. Approximately ten hours after the liver biopsy, the patient complained of nausea and lightheadedness, followed by decreased blood pressure and decreased consciousness. An emergent abdominal CT scan showed a large amount of blood in the abdominal cavity. The patient died despite multidisciplinary treatment, and a forensic autopsy was performed. At internal examination, approximately 2,620 mL of dark red blood was accumulated in the abdominal cavity. A puncture wound led 1.8 cm into the liver from the surface of the liver, and no major vascular damage was observed. The cause of death was considered to be blood loss due to bleeding from the puncture wound. Even if the platelet count is normal, such as in a case of thrombasthenia, the risk of bleeding should not be underestimated. Careful attention should be paid when performing liver biopsy in a patient with risk factors.

Magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF) is a viable alternative to liver biopsy for steatosis quantification in living liver donor transplantation

This study aimed to investigate whether magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF) can be a viable noninvasive alternative to liver biopsy for the quantification of living liver donor steatosis. Hepatic steatosis for 143 donors was graded by MRI-PDFF. Study endpoints included liver volume regeneration in donors, recipient outcomes including length of hospital stay, deaths, primary non-function (PNF), early allograft dysfunction (EAD), and small for size syndrome (SFSS). Correlation between MRI-PDFF determined donor steatosis and endpoints were analyzed. Donors had lower steatosis grade than non-donors. Donor remnant liver regenerated to an average of 82% of pre-donation volume by 101 ± 24 days with no complications. There was no correlation between percent liver regeneration and steatosis severity. Among recipients, 4 underwent redo-transplantation and 6 died, with no association with degree of steatosis. 52 recipients (36%) fulfilled criteria for EAD (driven by INR), with no difference in hepatic steatosis between groups. MRI-PDFF reliably predicted donor outcomes. Living donors with no or mild steatosis based on MRI-PDFF (ie, <20%) and meeting other criteria for donation can expect favorable post-surgical outcomes, including liver regeneration. Recipients had a low rate of death or retransplantation with no association between mild hepatic steatosis and EAD.

The Synergistic Effect of TNFα -308 G/A and TGFβ1 -509 C/T Polymorphisms on Hepatic Fibrosis Progression in Hepatitis C Virus Genotype 4 Patients

Tumor necrosis factor-alpha (TNFα) and transforming growth factor-beta (TGFβ1) cytokines are highly implicated in liver fibrosis. Polymorphisms in these cytokines affect their expression, secretion, and activity. This study aimed to evaluate the influence of TNFα -308 G/A and TGFβ1 -509 C/T polymorphism on hepatic fibrosis progression in Egyptian patients with hepatitis C virus (HCV) genotype 4. Genotyping of TNFα -308 G/A and TGFβ1 -509 C/T was performed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis in 122 subjects (50 healthy controls and 72 HCV patients). Also, serum TNFα and TGFβ1 levels were detected by enzyme-linked immunosorbent assay (ELISA). The genotyping results of early (F0-F1, n = 36) and late (F2-F4, n = 36) HCV fibrosis patients showed that late fibrosis patients had higher TNFα -308 AA genotype and TGFβ1 -509 TT genotype than early fibrosis patients (p = 0.016, 0.028, respectively). Moreover, the TNFα and TGFβ1 serum levels were significantly higher in HCV patients with TNFα A containing genotypes (GA+AA) (p = 0.004) and patients with TGFβ1 T containing genotypes (CT+TT) (p = 0.001), respectively. The combined unfavorable TNFα (GA/AA) and TGFβ1 (CT/TT) genotypes were highly associated with abnormal liver function parameters and were significantly higher in high activity (A2-A3) and late fibrosis (F2-F4) HCV patients (p = 0.023, 0.029). The multivariate analysis results confirmed that the combined TNFα-308 (AA) and TGFβ1 -509 (TT) unfavorable genotypes increased the risk of hepatic fibrosis progression by 6.4-fold than combined favorable genotypes (odds ratio: 6.417, 95% confidence interval [1.490-27.641], p = 0.013). In conclusion, both TNFα -308 G/A and TGFβ1 -509 C/T polymorphisms synergistically influence the hepatic fibrosis progression and can be used as potential biomarkers to predict hepatic disease progression in chronic hepatitis C patients.

Clinical value and safety of liver biopsies in patients transplanted for hepatitis C virus-related end-stage liver disease

BACKGROUND

Hepatitis C is the leading indication for liver transplantation. Differentiation between recurrent graft hepatitis C (RGH-C) and graft rejection (GR) is challenging. Liver biopsy is standard to diagnose both conditions; however, little information is available regarding this procedure in hepatitis C virus (HCV)-infected liver transplant recipients.

METHODS

Liver biopsies (n = 211) from all consecutive patients (n = 138) transplanted for hepatitis C at Hannover Medical School between January 2000 and October 2011 were screened, and a final cohort of 96 patients with 196 biopsies was included. Indications, histopathological findings, and biopsy-related complications were documented. Modifications in the treatment based on the biopsy result and the biochemical outcome were analyzed.

RESULTS

Most biopsies (196/211, 93%) were representative. Five patients (2.5%) developed non-fatal biopsy-related complications. Biopsy results were GR (35%), RGH-C (31%), and other diagnoses (34%). GR was independently associated with lower albumin (P = 0.025) and higher bilirubin levels (P = 0.011). Treatment was modified based on the biopsy result in 25% of cases. Alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), and bilirubin levels improved in 41%, 25%, and 31% of cases 4 weeks post biopsy respectively. ALT improvements were more significant in patients with GR than in those with RGH-C.

CONCLUSION

Liver biopsy in HCV-infected liver transplant recipients is safe and representative in >90% of cases. GR is independently associated with lower albumin and higher bilirubin levels.

Liver biopsy: Analysis of results of two specialist teams

AIM: To analyze the safety and the adequacy of a sample of liver biopsies (LB) obtained by gastroenterologist (G) and interventional radiologist (IR) teams.

METHODS: Medical records of consecutive patients evaluated at our GI unit from 01/01/2004 to 31/12/2010 for whom LB was considered necessary to diagnose and/or stage liver disease, both in the setting of day hospital and regular admission (RA) care, were retrieved and the data entered in a database. Patients were divided into two groups: one undergoing an ultrasonography (US)-assisted procedure by the G team and one undergoing US-guided biopsy by the IR team. For the first group, an intercostal approach (US-assisted) and a Menghini modified type needle 16 G (length 90 mm) were used. The IR team used a subcostal approach (US-guided) and a semiautomatic modified Menghini type needle 18 G (length 150 mm). All the biopsies were evaluated for appropriateness according to the current guidelines. The number of portal tracts present in each biopsy was assessed by a revision performed by a single pathologist unaware of the previous pathology report. Clinical, laboratory and demographic patient characteristics, the adverse events rate and the diagnostic adequacy of LB were analyzed.

RESULTS: During the study period, 226 patients, 126 males (56%) and 100 females (44%), underwent LB: 167 (74%) were carried out by the G team, whereas 59 (26%) by the IR team. LB was mostly performed in a day hospital setting by the G team, while IR completed more procedures on inpatients (P < 0.0001). The groups did not differ in median age, body mass index (BMI), presence of comorbidities and coagulation parameters. Complications occurred in 26 patients (16 G team vs 10 IR team, P = 0.15). Most gross samples obtained were considered suitable for basal histological evaluation, with no difference among the two teams (96.4% G team vs 91.5% IR, P = 0.16). However, the samples obtained by the G team had a higher mean number of portal tracts (G team 9.5 ± 4.8; range 1-29 vs IR team 7.8 ± 4.1; range 1-20) (P = 0.0192) and a longer mean length (G team 22 mm ± 8.8 vs IR team 15 ± 6.5 mm) (P = 0.0001).

CONCLUSION: LB can be performed with similar outcomes both by G and IR. Use of larger dimension needles allows obtaining better samples, with a similar rate of adverse events.

Glycogen storage disease type III in Egyptian children: a single centre clinico-laboratory study

BACKGROUND AND STUDY AIMS

Glycogen storage disease type III (GSD III) is an autosomal recessive disorder caused by deficiency of glycogen debrancher enzyme and is characterised by clinical variability.

PATIENTS AND METHODS

We herein describe the clinical and laboratory findings in 31 Egyptian patients with GSD III presenting to the Paediatric Hepatology Unit, Cairo University, Egypt.

RESULTS

Eighteen patients (58%) were males. Their ages ranged between 6 months to 12 years. The main presenting complaint was progressive abdominal distention in 55%. Twelve patients (38.7%) had a history of recurrent attacks of convulsions; four had an erroneous diagnosis of hypocalcaemia and epilepsy. Doll-like facies was noted in 90%. Abdominal examination of all cases revealed abdominal distention and soft hepatomegaly which had bright echogenicity by ultrasound. Hypertriglyceridaemia was present in 93.6%, hyperlactacidaemia in 51.6% and hyperuricaemia in 19.4%. Liver biopsy showed markedly distended hepatocytes with well distinct cytoplasmic boundaries and 32% had macrovesicular fatty changes. Serum creatine kinase was elevated in 64.6% of patients and correlated positively and significantly with age (r=0.7 and P=<0.001), while serum triglycerides correlated negatively with age (r=-0.4 and P=0.05).

CONCLUSION

Blood glucose assessment and search for hepatomegaly in an infant with recurrent seizures may prevent delay in the diagnosis. A huge soft liver reaching the left midclavicular line that appears echogenic on ultrasonography is characteristic of GSD III. A distended hepatocyte with rarified cytoplasm is pathognomonic but not diagnostic. Hypertriglyceridaemia correlates negatively with age, in contrary to CK level.

Ultrasonography as a non-invasive tool for detection of nonalcoholic fatty liver disease in overweight/obese Egyptian children

INTRODUCTION

Liver biopsy, although a gold standard in diagnosis of nonalcoholic fatty liver disease (NAFLD), is an invasive and expensive tool.

AIM

To assess the diagnostic accuracy of abdominal ultrasound in detecting NAFLD among a group of overweight/obese children having one or more liver abnormality (clinical hepatomegaly, raised ALT or echogenic liver parenchyma by ultrasound).

METHODS

Seventy-eight overweight/obese children were referred to the Pediatric Hepatology Unit, Cairo University Pediatric Hospital, Egypt, for assessment for hepatic abnormalities. Out of the 78 children, 34 had one or more abnormality in the form of clinical hepatomegaly, raised alanine aminotransferase (ALT) and/or echogenic liver parenchyma by ultrasound. All 34 cases underwent liver biopsy for evaluation for NAFLD.

RESULTS

Histological NAFLD was detected in 15 cases; 8 simple steatosis and 7 nonalcoholic steatohepatitis (NASH). Sonographic evaluation of hepatic parenchymal echogenicity revealed: 11 with grade 1 echogenicity, 12 with grade 2 and 9 with grade 3 while only 2 had normal liver echopattern. Ultrasonography was 100% sensitive and 100% specific in detecting histological NAFLD, while the positive predictive value (PPV) was 47% and negative predictive value (NPV) was 11%. After consolidating the included children into 2 groups: the first including normal and grade 1 echogenicity and the second including grades 2 and 3, the sensitivity of ultrasonography in detecting histological NAFLD was still 100%, while negative predictive value increased to 100% with an accuracy of 82%.

CONCLUSION

We conclude that ultrasonography is an important non invasive tool in assessment for NAFLD. Normal or grade 1 hepatic echogenicity can soundly exclude histological NAFLD and obviates the need for liver biopsy.

Significant clinical risks and the benefits of liver biopsies in Srinagarind Hospital, Khon Kaen University, Thailand: Lessons learned from the past to the present

Aim:To evaluate risks and benefits of percutaneous liver biopsies in Srinagarind Hospital, Khon Kaen, Thailand.Methods:We retrospectively reviewed all patients who had performed liver biopsies between January 2005 and September 2009 from the data of the Srinagarind Memorial Building, Khon Kaen University, Thailand.Results:A total of 1038 liver biopsies were reviewed. The 927 liver biopsies performed were blind (89.3%), 110 were ultrasound guided (10.6%) and one was both (0.1%). The essential biopsies were conducted in cases of chronic hepatitis B or C (68.9%), chronic hepatitis (22.9%) and liver mass (5%). The liver biopsies established definite diagnosis 99.5% of the time. The most common complication of liver biopsies was pain (4.8%). There were no reported cases of biopsy-related mortality.Conclusion:Liver biopsies performed by trained physicians are safe, rarely have complications, and are highly useful. The fibrotic staging and abnormal liver function tests are common indications. Nonalcoholic steatohepatitis is the common finding for chronic hepatitis.

Effects of percutaneous needle liver biopsy on dairy cow behaviour

In cattle, percutaneous needle liver biopsy is used for scientific examination of liver metabolism. The impact of the biopsy procedure is, however, poorly investigated. Our aim was to examine the behaviour of dairy cows during and after liver biopsy. Data were collected from 18 dry cows. Percutaneous needle liver biopsies (after administration of local anaesthesia (2% Procaine)) and blood samples were taken during restraining. During the control treatment, animals were restrained and blood sampled. During the biopsy procedure, cows showed increased restlessness (P=0.008), frequency of head shaking (P=0.016), and decreased rumination (P=0.064). After biopsies, tail pressing (P=0.016) and time spent perching (P=0.058) increased. Time spent upright (P=0.10) and number of leg movements (P=0.033) increased during the night as compared to controls. Thus, liver biopsy induced behavioural changes for up to 19 h--and particularly for behaviour previously associated with pain. Even though the exact welfare impact of percutaneous needle liver biopsies in cows is not known, and the magnitude of the behavioural changes was limited, pain always has negative effects on animal welfare. Therefore, if the present biopsy procedure--involving several biopsy passes--is to be used, improvement of the anaesthetic protocol as well as the inclusion of analgesics should be considered.

Unusual complication after left-lobe liver biopsy for diffuse liver disease: severe bleeding from the superior epigastric artery

OBJECTIVE

Imaging-guided parenchymal liver biopsy for diffuse liver disease is increasingly performed via an epigastric route from the left lobe, as opposed to the more traditional intercostal right-sided approach.

MATERIALS AND METHODS

We conducted a retrospective analysis of all liver biopsies performed at our department for 3 years (July 2007 through June 2010). A total of 1028 liver biopsies were performed during this period. Of these, 776 biopsies were performed for diffuse medical liver disease. Electronic medical records were reviewed for any documented complications.

RESULTS

We identified six cases (0.8%) of documented significant bleeding after 776 biopsies. All bleeding complications were associated with the left-sided epigastric approach. No documented case of major bleeding from the right-sided approach was recorded during the same period. We describe four patients with severe bleeding complications in which classic imaging features were noted on CT, pointing to injury of the superior epigastric artery as the possible cause of the bleeding.

CONCLUSION

It is important to recognize the subtle CT signs of superior epigastric artery bleeding because the traditional femoral approach with angiography of the hepatic and portal vessels may not reveal active bleeding. The superior epigastric artery, rather than the hepatic arteries, should be evaluated. A brachial approach for the angiogram may be the more optimal technique.

Splenomegaly: investigation, diagnosis and management

Splenomegaly is a feature of a broad range of diseases, and presents to clinicians in many fields. This review examines the aetiology of splenomegaly in the developed world, and describes a logical approach to the patient with splenomegaly. In some patients, extensive radiological and laboratory investigations will fail to yield a diagnosis: these cases of "isolated" splenomegaly are not uncommon and can be particularly challenging to manage. The risks of serious underlying disease must be balanced against the risks of invasive investigations such as splenic biopsy and diagnostic splenectomy. We discuss the options in isolated splenomegaly and their evidence base, and incorporate them into a management strategy to aid the clinician in cases of diagnostic difficulty.

Acute ischemic injury due to a giant intrahepatic hematoma: A complication of percutaneous liver biopsy

We present the case of a patient with chronic hepatitis B who developed an extensive intrahepatic hematoma, associated with a 30-fold elevation in serum alanine aminotransferase levels, following percutaneous liver biopsy. The patient was hypertensive but without hemorrhagic diathesis by routing tests done before biopsy. There was no concomitant intraperitoneal hemorrhage and no blood transfusions were required, despite a 9% drop in hematocrit. The complication was associated with short-lived, mild-to-moderate abdominal pain, easily relieved by paracetamol analgesics. The intrahepatic hematoma, as followed by computed tomography, resolved within 8 months. This case indicates that extensive intrahepatic hematoma and associated ischemic injury may infrequently complicate a liver biopsy and that hypertension may be a predisposing factor.

Correlation of percutaneous liver biopsy fragmentation with the degree of fibrosis

BACKGROUND

Although fragmentation of a liver biopsy specimen has been considered to be suggestive of cirrhosis, the evidence for this is difficult to find in the published literature.

AIM

To determine whether fragmentation of percutaneous liver biopsy specimens correlates with the degree of fibrosis.

METHODS

One hundred and eighty-six patients underwent percutaneous liver biopsy prospectively. The specimens were measured for the length and number of fragments. The extent of fibrosis was scored by a pathologist blind to the clinical data. Length and fragmentation data were compared between the different stages.

RESULTS

The overall median fragment length was 1.85 cm and the median fragment number was four. Specimens with advanced fibrosis (stages III-IV) had more fragments than those with no or mild fibrosis (stages 0-II) (P < 0.0001). The aggregate fragment length decreased with increasing stage of fibrosis (P < 0.0001). Specimens with greater than 12 fragments were seen only with advanced fibrosis.

CONCLUSIONS

Fragmentation of percutaneous liver biopsy specimens is common and increases with progression from early to advanced fibrosis. Fibrotic specimens fragment more often and more extensively.

Serum bile acids in liver transplantation--early indicator for acute rejection and monitor for antirejection therapy

We studied the course of serum bile acids to investigate its reliability in the diagnosis of acute rejection after liver transplantation in relation to pathohistological findings. Serum bile acid concentration, bilirubin and transaminases were measured in 41 patients who underwent liver transplantation. Their course was correlated to liver biopsy. Group I (n = 19) patients were without acute rejection, whereas group II (n = 22) patients showed acute rejection. Bile acid concentrations in group II showed a statistically highly significant (P < or = 0.001) threefold increase 3 days prior to biopsy. Successful antirejection treatment was correlated with a statistically significant (P = 0.008) decrease of serum bile acid 1 day after initiation of therapy. Patients without acute rejection showed a baseline bile acid concentration at the time of biopsy. Bilirubin and transaminases did not show any statistically significant correlation to acute rejection. Infection did not lead to a significant bile acid increase. Our study shows that serum bile acids monitored after liver transplantation can easily be used to detect acute rejection and at the same time they reflect the success of antirejection therapy.

Interpretation of the international normalised ratio in patients with liver disease

Wide acceptance of the international normalised ratio (INR) and thromboplastins with low international sensitivity indices (ISIs) has inadvertently led to the application of the INR to patients other than those on anticoagulation treatment. I examined the degree of factor deficiency for a given INR in patients with liver disease and controls receiving stable-dose warfarin. The degree of factor V and VII, but not prothrombin, deficiencies for a given INR were greater in liver patients than controls. The INR measured with a low-ISI thromboplastin can quantify the coagulation status of patients with liver disease, but should not be interpreted as having the same meaning as the INR in patients receiving warfarin.

Percutaneous liver biopsy: what is the current approach? Results of a questionnaire survey

The technique of performing liver biopsy varies among physicians, even within the same practice. In an attempt to determine whether gastroenteroogists/hepatologists differ in their approach compared to radiologists, we surveyed a nearly equal number of physicians in the Washington, DC, USA, metropolitan area with respect to 26 variables. While the technique can vary considerably, relatively few differences were seen between the groups. Only about half of gastroenterologists and hepatologists use ultrasound guidance, a biopsy, gun, and conscious sedation; radiologists routinely used a biopsy gun and conscious sedation and rarely require an overnight stay.

Liver biopsy: complications and risk factors

AIM: To study the complications and the risk factors of percutaneous liver biopsy, and to compare the complication rate between the periods o f 1987-1993 and 1994-1996.

METHODS: Medical records of all patients undergoing percutaneous liver biopsy between January 1, 1987 to September 31, 1996 in Songklanagarind Hospital were reviewed retrospectively.

RESULTS: There were 484 percutaneous liver biopsies performed. The total complication rate was 6.4%, of which 4.5% were due to major bleeding; the death rate was 1.6%. The important risk factors correlated with bleeding complications and deaths were a platelet count of 70 × 10⁹/L or less, a prolonged prothrombin time of > 3 s over control, or a prolonged activated partial thromboplastin time of > 10 s over control. Although physician inexperience was not statistically significantly associated with bleeding complications and deaths, there was a reduction of death rate from 2.2% in 1987-1993 to 0% in 1993-1996. This reduction is thought to result from both increased experience o f senior staff and increased supervision of residents.

CONCLUSIONS: Screening of platelet count, prothrombin time, and activated partial thromboplastin time should be done and need to be corrected in case of abnormality before liver biopsy. Percutaneous liver biopsy should be performed or supervised by an expert in gastrointestinal diseases, especially in high risk cases.

Diagnostic usefulness of percutaneous liver biopsy in HIV-infected patients with fever of unknown origin

OBJECTIVES

to determine the value of percutaneous liver biopsy (PLB) in the diagnosis of fever of unknown origin (FUO) in HIV-infected patients and establish a prediction model for its usefulness to enable diagnosis of FUO in these patients to be standardized.

METHODS

a total of 58 HIV-infected patients who underwent PLB for the evaluation of FUO were studied at 'Carlos Haya' Hospital in Malaga, Spain. The patients were classified into three groups, according to the results of the PLB: (a) diagnostic PLB (when a definitive diagnosis was obtained); (b) helpful PLB (the tissue sample showed suggestive, but not definitive, findings); and (c) normal or non-specific PLB (no contribution to diagnosis, the findings being normal or irrelevant). Multivariate analysis was made to establish a prediction model for the diagnostic usefulness of PLB, calculating the positive (PPV) and negative (NPV) predictive values.

RESULTS

PLB was carried out in 58 HIV-infected patients during diagnosis of FUO. Risk factors for HIV infection included intravenous drug use (72.4%), homosexual or bisexual activities (12.1%), and heterosexual transmission (15.5%). Fifty-two out of 58 patients (89.6%) had previous AIDS-defining illnesses. The mean CD4 lymphocyte count +/-SD was 56.4+/-80.9/mm3. The mean duration of fever was 43 days. Diagnosis could be established in 51 (87.9%) patients, with tuberculosis (50%) and leishmaniasis (20.7%) being the most common. The PLB was diagnostic in 25 cases (43.1%), helpful in 13 (22.4%), and normal or non-specific in the remaining 20 (34.5%). Biopsy-associated complications occurred in two cases. The presence of hepatomegaly or splenomegaly were the most useful factors in predicting the usefulness of the PLB, with a PPV of 86.1% and NPV of 68.2%. In patients with tuberculosis, an increased alkaline phosphatase and hepatomegaly had a PPV of 86.4% and a NPV of 71.4%.

CONCLUSIONS

PLB is a useful technique for the diagnosis of FUO in HIV-infected persons. Early PLB should be considered in those patients with hepatosplenomegaly and increased alkaline phosphatase levels.

Use of bile cytology for early diagnosis of complications in orthotopic liver transplantation

We conducted a daily analysis of bile cellularity in 25 patients undergoing 29 orthotopic liver transplants (OLT) and correlated the cytological parameters with the clinical outcome of each patient. The 16 patients without complications only showed slides with cells during the first 4-5 postoperative days. The four patients with primary non-function (PNF) of the graft had a high cell density up to the time of the retransplant, with a preponderance of polymorphonuclear (PMN) leucocytes (59.2%) and epithelial cells (29.2%). During the episodes of sepsis (n = 3) and rejection (n = 7) we noted the sudden appearance of high cellularity, almost exclusively PMN leucocytes (96.5%), and a preponderance of PMN leucocytes (84.2%) with appreciable percentages of mononuclear cells and macrophages as well as the early appearance of lymphoblasts in the rejection episodes. Our results show that bile cytology can be a useful method for diagnosing graft complications in liver transplantation.

Influence of chronic alcohol abuse and liver disease on hepatic aldehyde dehydrogenase activity

Alcohol metabolism results in the production of acetaldehyde, a compound that is much more toxic than ethanol itself. Hepatic aldehyde dehydrogenase (ALDH) is the main enzymatic system responsible for acetaldehyde clearance from the hepatocyte. The objective of this study was to determine the modifications in ALDH activity due to chronic alcohol abuse and liver disease. ALDH activity was determined in samples of liver tissue from 69 alcoholic and 82 nonalcoholic subjects, with and without liver disease. According to the results of liver pathology examination, alcoholic patients were classified into the following groups: controls, with no liver disease (group 1), noncirrhotic liver disease patients (group 2), and cirrhotics (group 3). Nonalcoholic subjects were categorized, using the same criteria, into groups 4, 5, and 6, respectively. ALDH activity was determined spectrophotometrically at two substrate concentrations: 18 mM for total activity and 180 microM for low Km activity. High Km activity was calculated by subtracting the low Km activity value from that of total ALDH activity. Results obtained in each group were expressed as the mean +/- SD of mU of g of wet weight. There were no significant differences when the total ALDH activity from the alcoholic and the nonalcoholic patients with a similar degree of liver pathology were compared: group 1, 1257 +/- 587 vs. group 4, 1328.1 +/- 546.2 (p: NS); group 2, 919.1 +/- 452.4 vs. group 5, 753.5 +/- 412 (p: NS); and group 3, 430.2 +/- 162.4 vs. group 6, 473.2 +/- 225.3 (p: NS). On the other hand, total ALDH activity was significantly lower in cirrhotics than in controls, both among alcoholics (p < 0.01) and among nondrinkers (p < 0.05). The low Km activity was severely reduced in cirrhotics, both alcoholics and nonalcoholics (p < 0.01). High Km activities in cirrhotic patients were low, compared to controls, both in alcoholics and nonalcoholics, although the difference was nonsignificant. The results of the present study suggests that chronic alcohol abuse does not depress ALDH activity. A reduction in the ALDH activity detected in patients with severe liver disease (cirrhotics) was clearly a consequence of liver damage. This reduction was due mainly to a decrease of the low Km ALDH activity, but a trend to a decrease in the high Km ALDH activity was also detected.

Accuracy of clinical diagnosis of cirrhosis among alcohol-abusing men

There is a considerable variation among specialists in the use of liver biopsy for the diagnosis of alcoholic cirrhosis, which is often based solely on clinical findings, sometimes supplemented with blood tests. To assess the diagnostic accuracy that may be achieved by this approach, we related items of the history, symptoms and signs, and routine blood tests to the presence/absence of cirrhosis in a unique, previously established, consecutive series of 303 alcohol-abusing men, in whom liver biopsy was performed irrespective of the clinical and biochemical findings. Using logistic regression analyses, we created a clinical, a combined clinical and biochemical, and a pure biochemical diagnostic model. The probability of cirrhosis in patients with the specified characteristics was estimated, the diagnostic accuracy was assessed as functions of diagnostic thresholds for cirrhosis defined by the probability of cirrhosis varying between 0 and 1,and confidence intervals were estimated by bootstrap sampling. The clinical model, including facial teleangiectasia, vascular spiders, white nails, abdominal veins, fatness, and peripheral edema, could be used with high diagnostic accuracy and it was clearly superior to the biochemical model. Adding biochemical findings to the clinical model improved the accuracy of the clinical model only slightly. We conclude that cirrhosis may be diagnosed in alcohol-abusing men with a high accuracy using selected, properly weighted clinical observations only.

Polymerase chain reaction for the early diagnosis of cytomegalovirus hepatitis in liver transplant patients

BACKGROUND

In liver transplant (LTX) patients, cytomegalovirus (CMV) hepatitis as a cause of graft dysfunction occurs in 15-25% of the patients. Polymerase chain reaction (PCR), applied to liver biopsy specimens, may increase the ability to detect CMV DNA at a local site. In this study, PCR was used to compare its relation to the development of clinical CMV hepatitis.

STUDY DESIGN

Nested polymerase chain reaction (nPCR), derived from a conserved region of the CMV major immediate-early gene, was used to examine 141 frozen liver biopsies from 61 LTX patients for the presence of CMV DNA. 134 biopsies were obtained from 54 patients with pathological liver function tests within four months after transplantation. The remaining seven patient biopsies were derived from the one-year investigation after LTX and served as controls. The results were compared to virus isolation, antigen detection by immunohistology and in situ hybridization for CMV DNA of the biopsy specimens. Histological examination was performed to verify a diagnosis of viral hepatitis.

RESULTS

CMV DNA was amplified in 11% (15/134) of the biopsies, corresponding to 20% (11/54) of the patients. Virus isolation revealed CMV in 5% (7/134) of the samples. None of the nPCR-negative biopsies was virus culture positive. CMV genomes were detected by nPCR more frequently than CMV hepatitis was diagnosed by using the combination of CMV-specific histopathology and/or immunohistology and/or CMV-positive virus isolation (p < 0.01). However, when this comparison was performed within individual patients, the difference was not significant (p > 0.05). If the results of in situ hybridization were included in the diagnostic criteria of CMV hepatitis, the nPCR was comparable to these, both at the biopsy and the patient levels (p > 0.1 and p > 0.05, respectively). For the diagnosis of CMV hepatitis the negative predictive value of CMV-nPCR was 1.0. The positive predictive value ranged from 0.55 to 0.82 depending on the criteria of CMV hepatitis. The nPCR also detected signs of CMV infection in the liver graft earlier than virus isolation, 11 versus 21 days, respectively, after transplantation.

CONCLUSION

The frequency of CMV DNA positivity, measured by nPCR, was similar to that revealed by other combined methods. We suggest that the combined findings of histological cholangitis and/or lobulitis together with nPCR for CMV DNA can be used as a diagnostic criterion for initiation of antiviral treatment against CMV hepatitis.

Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London

The liver section of the British Society of Gastroenterology and the research unit of the Royal College of Physicians collaborated to set up a nationwide audit to investigate the practice of percutaneous liver biopsy in England and Wales. Each of 189 health districts in England and Wales was approached to provide a list of 10 consecutive percutaneous biopsies performed during 1991, and details of demographic data, indications, suspected diagnosis, investigations, biopsy technique, outcome, and influence on patient management were collected. Data were retrieved on 1500 (79%). The age distribution showed 6% of biopsies were done in those over 80 years of age and as many over 90 as under 10 years of age. Suspected malignancy and chronic liver disease each contributed one third of the indications. In 34% the procedure was carried out by radiologists under ultrasound image control. The remainder were done by general physicians and gastroenterologists, with the operator in the second group being more senior and experienced. The Trucut biopsy needle accounted for two thirds of biopsies, the remainder being the Menghini type. For both needles the samples were recorded as excellent or satisfactory in 83% and inadequate in only 5%. Bleeding complicated 26 procedures (1.7%), requiring transfusion in 11, and was commoner when clotting was impaired or serum bilirubin raised. There were two definite and three possible procedure related, given an overall mortality of 0.13-0.33%. The diagnosis made before biopsy was confirmed in 63% of patients, and the clinician found the biopsy helpful in treatment in 75%. Day case biopsy and techniques to reduce the risk of bleeding were surprisingly rare in this series, which has given a unique opportunity to examine everyday practice across a wide range of hospitals.

The value of a baseline liver biopsy prior to methotrexate treatment

Two patients with severe disabling psoriasis were treated with methotrexate (MTX). As a short course of treatment was envisaged, a pretreatment liver biopsy was not performed. Although both patients developed similarly abnormal levels of hepatic enzymes after low cumulative doses of MTX (440 and 450 mg), subsequent liver biopsies revealed contrasting findings. In one patient the histological features were normal. However, in the second, there was hepatic fibrosis, and the absence of a pretreatment biopsy led to problems with interpretation of these histological findings. As a liver biopsy is by far the most reliable method of detecting liver disease, we suggest that it is still of value to include a baseline liver biopsy in the pretreatment assessment of patients even when only a short course of MTX is planned.

Daily determination of individual serum bile acids allows early detection of hepatic allograft dysfunction

Acute graft rejection is still a major cause of morbidity after orthotopic liver transplantation, and its diagnosis necessitates an invasive liver biopsy. Our aim has been to determine whether changes in individual serum bile acid levels after engraftment are sensitive, specific and reliable indicators of graft function and whether these changes can antedate other biochemical indicators of hepatic allograft rejection. Individual bile acids in 200 serum samples taken serially from eight adult liver transplant patients were measured. Patients with biopsy-confirmed graft dysfunction due to rejection or nonrejection causes (n = 6 episodes) had significantly higher serum concentrations of glycocholate plus glycochenodeoxycholate and taurocholate/taurochenodeoxycholate ratios than did noncomplicated grafts (n = 3). These changes antedated any other conventional biochemical parameters by at least 48 hr and were 100% sensitive and specific. None of the conventional liver function tests could match this. Acute rejection episodes (n = 3) were then compared with nonrejection causes of graft dysfunction (n = 3). In acute rejection we noted a significant increase in the concentration of glycodeoxycholate plus deoxycholate and a significant decrease in the cholate/chenodeoxycholate ratio compared with that in nonrejection graft malfunction. Both of these changes antedated any other biochemical parameters by 24 hr. In conclusion, individual serum bile acid assays, after orthotopic liver transplantation, can detect graft dysfunction resulting from any cause at an earlier time than routine biochemical tests, and they are sensitive, specific and reliable for early detection of graft dysfunction. In addition, acute rejection can be distinguished from other causes of graft dysfunction.

Transjugular liver biopsy: comparison with percutaneous liver biopsy

A transjugular liver biopsy was performed on 60 patients. Specimens were successfully obtained from 57 (95%) patients. Specimens obtained from cirrhotic patients were frequently small-sized/fragmented. The wedge hepatic venous pressure and hepatic venous pressure gradient were higher in patients with small-sized/fragmented specimens than those with non-fragmented specimens (16.3 +/- 6.4 vs 12.3 +/- 4.9 and 10.9 +/- 6.2 vs 7.3 +/- 3.4 mmHg, P < 0.05, respectively). During the same period of time, percutaneous liver biopsies were consecutively performed on 277 patients. The liver specimens by transjugular method were generally smaller (0.63 +/- 0.58 vs 1.50 +/- 0.86 cm, P < 0.001) and more fragmented (63% vs 16%, P < 0.01) than those obtained by percutaneous method. Biopsy specimens obtained for diagnosis by the former method were inadequate from 6 (10%) patients and by the latter route were inadequate from 7 (2%) patients. Subcapsular haematoma in one patient was associated with the transjugular liver biopsy. Minor complications occurred in three patients: neck haematoma in two and paroxysmal supraventricular tachycardia during the procedure in one. In comparison, percutaneous liver biopsy was followed by minor complications in 20 patients and major complications in four patients. It is concluded that transjugular liver biopsy is a safe, valuable and alternative procedure to obtain liver specimens, especially in patients who were contraindicated for percutaneous liver biopsy.

Pediatric liver disease in the eastern province of Saudi Arabia: A clinicopathological study

This prospective study analyzes the clinical features and histopathological findings in liver biopsies of pediatric patients presenting to the hospital with liver disease during a 10 year period. Only those patients in whom liver biopsy was performed for a tissue diagnosis were included. Fifty patients were investigated, all below the age of 12 years, of whom 36 were male and 14 female. Thirty-two were of neonatal-infantile group, 11 had a diagnosis of neonatal giant cell he hepatitis of infections origin and an intact biliary tree. Two had septic shock and one had leishmaniasis. The remaining 18 patients of the neonatal-infantile group constituted five case of glycogen storage disease, six of infantile obstructive cholangiopathy (biliary atreasia), four of fatty change and one each of congenital hepatic fibrosis, neuroblastoma and nonspecific reactive hepatitis. The eighteen older children had the following diagnoses: thalassemia in five, sickle cell disease in four, two each of Reye syndrome and hepatoblastoma. The remaining were one each of glycogen storage disease, Rotor syndrome, cirrhosis, fatty change and non-Hodgkin lymphoma (NHL). These findings are presented and discussed.

Practice and complications of liver biopsy. Results of a nationwide survey in Switzerland

Studies on the complication rate of liver biopsy have hitherto been conducted in referral hospital centers. They are therefore not representative for general practice where liver biopsy is performed by specialists and nonspecialists. In a postal nationwide survey, we approached all gastroenterologists and hospital internists to assess the complication rate and practice (setting, needle type, use of ultrasonography) of percutaneous liver biopsy performed in 1989 in Switzerland for diffuse liver disease. Two hundred eighty questionnaires were mailed and 252 were returned (response rate 90.0%) 165 respondents (65.5%) performed 3501 biopsies while 87 respondents (34.5%) did not practice liver biopsy; 67.7% of biopsies were executed blindly and 32.3% were guided. Eight nonfatal and three fatal complications occurred. Hemorrhage was the most frequent complication (five cases) and was responsible for all three fatal outcomes. The overall complication rate was 0.31%, being distinctly lower in the group of gastroenterologists (0.11%) as compared to the group of internists (0.55%; P = 0.031). The complication rate was 1.68% in the group of internists performing fewer than 12 biopsies per year, while there was no complication in the group of internists performing more than 50 biopsies per year (P = 0.036). Complications were not related to the needle diameter or to the absence of ultrasonography before biopsy. In conclusion, this representative survey in Switzerland shows that the complication rate of liver biopsy is mainly related to the experience and training of the operator.

Atypical liver alcohol dehydrogenase in the Spanish population: its relation with the development of alcoholic liver disease

The presence of atypical liver alcohol dehydrogenase (ADH) was determined in samples of liver tissue from 222 alcoholic and nonalcoholic subjects to determine its prevalence in the Spanish population, and to evaluate the possible relationship between the presence of this isoenzyme and the development of alcoholism and alcoholic liver disease. Alcoholic patients were classified into the following groups: control subjects, with normal liver pathology (group 1), patients with noncirrhotic liver disease (group 2), and patients with cirrhosis of the liver (group 3). Nonalcoholic subjects were also divided, following the same criteria, into groups 4, 5, and 6, respectively. The prevalence of atypical ADH in the population analyzed was 16.2%. Atypical ADH was present in 14.9% of alcoholics and in 17.4% of nonalcoholics (p = NS). There were no significant differences when the prevalence of atypical ADH of alcoholic and nonalcoholic patients with similar degrees of liver pathology was compared (group 1 vs. 4, group 2 vs. 5, and group 3 vs. 6). The prevalence of atypical ADH was also similar in cirrhotic patients with respect to those of noncirrhotic liver disease and control patients, either in alcoholic or nonalcoholic groups. Our findings indicate that the prevalence of atypical ADH in the Spanish population is similar to that reported for other Caucasian groups. Moreover, the presence of atypical ADH does not play a role in the development of alcoholism nor in the development of alcoholic liver disease in the population analyzed.

Dynamic hepatic scintigraphy in the screening of psoriatic patients for methotrexate-induced hepatotoxicity

We report the use of dynamic hepatic scintigraphy in the assessment of the hepatic status of psoriatic patients before and during methotrexate therapy. Eighty-seven paired dynamic scans and percutaneous liver biopsies were performed in 63 patients. The liver biopsies were graded according to Warin et al. with fibrosis of grade 2 or worse being a strong indication for withdrawal of methotrexate. The sensitivity of dynamic hepatic scintigraphy in detecting fibrosis of grade 2 or worse was 83.3% and the specificity was 81.5%. The predictive value of a normal scan for fibrosis of grade 0-1 was high (98.5%) although the predictive value of an abnormal scan for fibrosis of grade 2 or worse was low (25%). Dynamic hepatic scintigraphy may therefore offer a means to reduce the number of liver biopsies necessary in patients receiving methotrexate for psoriasis.

Transjugular and plugged liver biopsies

When a liver biopsy is indicated the transabdominal approach using either a Menghini or Tru-Cut needle has been shown to be an extremely safe procedure with very low morbidity and mortality rates in patients with normal or only mildly disturbed coagulation. When the coagulation status is severely deranged, however, several methods of obtaining a liver biopsy have been devised to circumvent the increased risk of bleeding. The transjugular approach has been shown to be both successful and relatively safe. The less cumbersome technique of plugging the needle track after percutaneous transabdominal biopsy has been reported relatively recently. Although it is likely that the latter method will produce good biopsy samples in the majority of cases (and in this regard it may prove to be better than the transjugular route), considerably more experience is required before its true complication rate is known. In a hospital where large numbers of transjugular biopsies are performed by experienced radiologists and in which skilled pathologists are used to interpreting the histological appearances of small, crushed liver samples, there is no compelling reason to change to the plugged biopsy technique. The more difficult question is whether hospitals in which the radiological and histological skills necessary for consistent success with the transjugular approach are not available should adopt the plugged biopsy method. The answer to this question is probably in the affirmative, but will depend on the confidence and interventional experience of the local operator and on more detailed factual information concerning the safety of the plugged method. With regard to the latter point, the publication of a large controlled study on the safety and efficacy of plugged liver biopsy would be a valuable contribution to the world literature on the subject.

Pre-operative radiological and clinical assessment of hepatic tumours--is biopsy necessary?

The pre-operative investigations of 72 consecutive patients who underwent liver resection for hepatic tumours have been reviewed. A combination of clinical, biochemical and radiological findings correctly predicted histology in 93% of cases (the benign or malignant nature in 97%). Biopsy was performed in only 20 patients. Five of the biopsy reports were incorrect (75% accuracy, benign or malignant nature accuracy 90%). Although guided biopsy can be performed during radiological assessment of focal hepatic lesions we argue that it is rarely indicated and can be misleading in patients proceeding to hepatic resection.

'Tru-Cut' needle biopsy of the liver: importance of the correct technique

In order to determine which technique would provide adequate tissue for histological examination when the 'Tru-Cut' needle is used for liver biopsy, the livers of cadavers were biopsied by a single operator, under direct vision, using a 'Tru-Cut' needle. The modified breast biopsy technique either preceded or followed one of two alternative methods, one of which was recommended by the manufacturer, in a random manner. Thereafter, the biopsies were repeated using the alternative sequence. The mean length of the liver biopsy specimens that were obtained using the modified breast biopsy technique was 16.3 mm (range: 8-20 mm). The corresponding figures for the manufacturerer's method were 7.7 mm (range: 2-14 mm) and for the third technique were 2.7 mm (range: 0.5-8 mm). Three of the 40 specimens (7.5%) obtained using the latter technique fragmented when placed in formalin; this did not occur in any of the 40 specimens taken using the modified breast biopsy technique. This investigation indicates that the modified breast biopsy technique should be used when 'Tru-Cut' needle biopsy of the liver is performed. This provides specimens which are adequate for histological diagnosis. In addition, the safety of liver biopsy, which is compromised by poor technique, is improved. The alternative methods, including that recommended by the manufacturer, must be avoided.

Hepatic alcohol dehydrogenase activity in alcoholic subjects with and without liver disease

Alcohol dehydrogenase activity was measured in samples of liver tissue from a group of alcoholic and non-alcoholic subjects to determine whether decreased liver alcohol dehydrogenase activity is a consequence of ethanol consumption or liver damage. The alcoholic patients were classified further into the following groups: control subjects with no liver disease (group 1), subjects with non-cirrhotic liver disease (group 2), and subjects with cirrhotic liver disease (group 3). The non-alcoholic subjects were also divided, using the same criteria, into groups 4, 5, and 6, respectively. The analysis of the results showed no significant differences when mean alcohol dehydrogenase activities of alcoholic and non-alcoholic patients with similar degrees of liver pathology were compared (groups 1 v 4, 2 v 5, and 3 v 6. Alcohol dehydrogenase activity was, however, severely reduced in patients with liver disease compared with control subjects. Our findings suggest that alcohol consumption does not modify hepatic alcohol dehydrogenase activity. The reduction in specific alcohol dehydrogenase activity in alcoholic liver disease is a consequence of liver damage.

Liver biopsy complications monitored by ultrasound

Ultrasound (US) was performed in 96 patients (on 108 occasions) 2-4 h after diagnostic liver puncture with a modified Menghini needle. Serious complications (major haemorrhages: one intraparenchymal and one into the abdominal cavity) were seen in two patients, while seven presented with minor bleedings though without any registered clinical abnormality (slight pain in one). On 11 occasions (10 patients) slight to moderate pain was observed though in combination with a normal US. Findings on US and clinical observations showed poor correlation and the number of bleeding complications discovered by US examination seems to depend upon when the study is performed. US does not replace the clinical follow-up but may be helpful in the presence of adverse clinical reactions in order to establish the type of lesion: profuse parenchymal haemorrhage versus bleeding into the abdominal cavity. This information may be helpful in the choice between conservative and surgical therapy.

The accuracy of aspiration cytology in the diagnosis of rejection following orthotopic liver transplantation

The role of aspiration cytology (AC) and the total corrected increment (TCI) in the diagnosis of hepatic rejection was assessed in 30 patients following 36 liver transplants. A total of 174 AC specimens were "blindly" evaluated. Patients underwent protocol AC twice weekly and when biochemical or clinical parameters suggested rejection. Hepatic rejection was only confirmed when clinical and biochemical changes were accompanied by positive histological diagnosis. In all, 103 specimens were matched against histology, the remainder assessed against retrospective clinical and biochemical diagnoses. There were 80 cytological diagnoses of rejection, confirmed in 69 specimens, and 94 diagnoses of no rejection, confirmed in 73 specimens. These figures give a sensitivity of 76.7%, a specificity of 86.9% and a positive predictive value of 86.3%. Overall, 39.7% of specimens taken more than 2 months after grafting proved to be incorrectly diagnosed. However, the accuracy was higher in 145 specimens taken within 8 weeks of transplantation, with a sensitivity of 81.3%, a specificity of 90%, a positive predictive value of 89.7% and an accuracy of 85.5%. Although histology remains the gold standard in the diagnosis of acute rejection after hepatic grafting, AC using a TCI with a positive predictive value of 86.3% may prove to be of value in monitoring liver transplant patients in the first 2 months after grafting.

Aminoterminal propeptide of type III procollagen in methotrexate-induced liver fibrosis and cirrhosis

Twenty-four psoriatic patients on methotrexate were studied with liver biopsies and serum measurements of aminoterminal propeptide of type III procollagen (PIII NP). All but one of nine patients with serum levels of PIII NP above the normal range had liver fibrosis or cirrhosis and no normal liver biopsies were obtained in this group. In contrast, nine normal liver biopsies and two biopsies with minimal fibrosis were found among the 15 patients with normal serum levels of PIII NP. The study indicates that aminoterminal propeptide of type III procollagen can be utilized as a valuable non-invasive marker of fibrogenesis in the liver. This analysis is not specific for the liver, but it seems that the number of liver biopsies probably can be reduced in psoriatics on methotrexate who have normal levels of PIII NP.

Ultrasound-assisted percutaneous liver biopsy: superiority of the Tru-Cut over the Menghini needle for diagnosis of cirrhosis

A total of 1192 consecutive patients with diffuse liver disease were randomized to have percutaneous liver biopsy specimens taken with the Menghini or the Tru-Cut needle, to compare tissue yield, safety, and accuracy of the two needles for diagnosing cirrhosis. The sites of puncture were determined by prebiopsy ultrasound scans. Adequate samples were obtained from 94% with the Tru-Cut needle and from 79.2% with the Menghini needle (p less than 0.001). Accuracy in diagnosing cirrhosis was 89.5% for the Tru-Cut needle and 65.5% for the Menghini needle (p less than 0.05). Complication rates were very low and similar for both needles. Under these conditions, the Tru-Cut needle is superior to the Menghini needle for diagnosing cirrhosis.

Failure of percutaneous liver biopsy: anatomical variation

Anatomical variation may result in failure to obtain hepatic tissue at liver biopsy. A patient is reported in whom routine liver biopsy was unsuccessful. Subsequent computed tomography (CT) showed that the right lobe of the liver was partially deficient anteriorly and that the biopsy had caused an intraabdominal haematoma. A technically successful biopsy was subsequently carried out under radiological (CT) guidance. Variations in hepatic anatomy are considered and some conclusions are offered which may both improve the success rate and further reduce the morbidity of routine percutaneous needle biopsy of the liver.

A comparison of liver ultrasound with liver biopsy histology in psoriatics receiving long-term methotrexate therapy

A comparison of liver ultrasound and liver biopsy histology was made on 54 paired investigations from 28 patients about to receive or already receiving methotrexate for severe psoriasis. Ultrasound scans were reported as normal, or abnormal showing either fatty change or fibrosis. Eighteen of the scans were reported as normal and in no instance did the simultaneously-obtained liver biopsy show significant fibrosis. Thirty-one of the scans were reported as showing fatty change without fibrosis; in 12 cases the liver histology showed mild but significant fibrosis and in four cases fibrosis was of sufficient severity to necessitate methotrexate withdrawal. Five of the scans were reported as showing fibrosis and in all the biopsy showed significant fibrosis. This was of sufficient degree to necessitate methotrexate withdrawal in two cases. No patient with a normal ultrasound scan showed significant fibrosis and thus we concluded that such patients may be spared liver biopsy and safely continue with methotrexate therapy. Ultrasound cannot reliably distinguish between fatty change and fibrosis, so all patients with abnormal scans require liver biopsy.

Computed tomography of the liver after biopsy

Angiographic studies suggest that needle biopsy of the liver is invariably associated with some degree of haemorrhage (Wallace et al., 1972). The appearances of the liver on computed tomography after percutaneous biopsy have not been described. As an aid to the interpretation of scans in patients referred because of clinical complications of biopsy, we performed unenhanced computed tomography of the liver in 30 patients within 72 h of biopsy. None of these patients would ordinarily have been referred for computed tomography. Only one of the scans showed a parenchymal abnormality attributable to biopsy. We conclude that post-biopsy changes on unenhanced computed tomography scans of the liver are uncommon and that the needle tracks and vascular anomalies commented on by angiographers are not usually shown.

Wash off liver cytology: a complementary diagnostic tool to liver biopsy

Parenchymal and non-parenchymal cells were harvested by washing the liver tissue core and needle after percutaneous biopsy. The cytological material obtained was suitable for morphological analysis, including showing the presence of surface and cytoplasmic antigens using labelled antibody techniques. This technique provides a combined cytological and histological approach to the diagnosis of liver disease.

Sampling variability and its influence on the diagnostic yield of percutaneous needle biopsy of the liver

In an investigation to determine the influence of sampling variability on the diagnostic yield of liver biopsy, 3 consecutive samples were obtained from each of 75 patients by redirecting the biopsy needle through a single entry site. In 14.7% of patients all 3 specimens were normal, and in 36% there were similar abnormalities in all 3 specimens. In the other patients, sampling variability between specimens was present. In those patients with cirrhosis, hepatocellular carcinoma, metastatic carcinoma, or hepatic granulomas the histological abnormality was present in all 3 biopsy specimens in only 50%, 54.5%, 50%, and 18.8% of patients, respectively. No complications were recorded. These findings show that important pathology can be overlooked if only a single biopsy specimen is taken, and that the method of obtaining 3 consecutive specimens improves the diagnostic yield of liver biopsy without an associated increase in complications.

Apparent dose dependency of the hepatic (S)-acenocoumarol clearance in the rat: a study using open liver biopsies

Saturable hepatic uptake processes may account for the apparent dose-dependent clearance of 4-hydroxycoumarins. We investigated the dose dependent clearance and dose dependent liver distribution of the (S)-enantiomer of acenocoumarol (4-hydroxy-3-[1-4-nitrophenyl)-3-oxobutyl]coumarin) in the rat applying the in situ liver biopsy technique. The drug was administered by constant-rate infusion. At infusion rates below 0.6 microgram/min, blood clearance appeared to be dose dependent, i.e., clearance of (S)-acenocoumarol declined gradually from 6.5 mL/min at a 0.15 microgram/min infusion rate to 3.9 mL/min at a 0.6 micrograms/min infusion rate. From 0.6 microgram/min up to the highest input tested, i.e., 15 micrograms/min, clearance was almost constant, 3.5 mL/min. At low infusion rates the steady-state liver concentration of (S)-acenocoumarol rose steeply in a convex way with infusion. Scatchard analysis of steady-state liver concentrations in relation to steady-state blood concentrations revealed a hepatic binding site for (S)-acenocoumarol, exhibiting a capacity of 1.4 microgram/g of liver tissue.

Ultrasound as a screening procedure for methotrexate-induced hepatic damage in severe psoriasis

Methotrexate has been of proven value in the management of patients with severe psoriasis. Its long-term use, however, can be complicated by progressive hepatic damage which has necessitated regular liver biopsies. We have looked into the efficacy of liver ultrasonography as a non-invasive screening procedure to select those patients who may be developing liver changes. Eighty-seven investigations on 82 patients were performed, comparing liver ultrasound results with liver biopsy. Eight of these showed a degree of hepatic damage which was sufficient to indicate cessation of methotrexate, and all of these were detected by ultrasonography. Our results indicate that patients whose last liver biopsy was normal could be allowed an extended interval between biopsies provided their intervening ultrasound scans remained normal.