Evaluation of liver test abnormalities in a patient-centered medical home: do liver test patterns matter?

The Utility of Liver Biopsy in the Evaluation of Liver Disease and Abnormal Liver Function Tests

OBJECTIVES

We aimed to assess the value of liver biopsy in the evaluation of abnormal liver tests.

METHODS

We analyzed consecutive liver biopsy specimens performed for evaluation of unexplained abnormal liver tests from 2014 to 2018. Diagnoses were categorized histologically and clinically. We determined whether histologic examination led to a specific diagnosis and whether prebiopsy laboratory variables predicted the underlying etiology.

RESULTS

Among the 383 liver biopsy specimens included, chronic hepatitis was the most common histologic (25%) and clinical (17%) diagnosis. Liver biopsy led to a clinical diagnosis in 87% of patients. The most likely clinical diagnoses were autoimmune hepatitis, nonalcoholic fatty liver disease, and drug-induced liver injury (38, 33, and 32 patients, respectively). Using sensitivity, specificity, and positive and negative predictive values, we found that liver tests were not predictive of a specific diagnosis. In patients with no history of liver disease or clinical features of portal hypertension, biopsy specimens revealed histologic cirrhosis in 5% of patients.

CONCLUSIONS

Histopathologic diagnoses were made in 85% of patients undergoing liver biopsy for investigation of unexplained liver tests, leading to a clinical diagnosis in 87% of patients. However, neither liver tests themselves nor their patterns were useful in predicting histologic or clinical diagnoses.

Evaluation of liver function tests in the paediatric patient

INTRODUCTION

Although changes in liver function tests can be non-specific in numerous clinical conditions, they can be the first sign of a potentially serious disease in an asymptomatic patient.

MATERIAL AND METHODS

Retrospective cohort study, performed by reviewing the records of children of a reference hospital central laboratory with alanine aminotransferase enzyme (ALT) elevation during a 6-month aleatory period.

RESULTS

572 blood tests with serum ALT elevation corresponding to 403 patients have been assessed during the period studied. 98 patients were excluded for presenting abnormal liver test before the study period of comorbidity that could produce ALT elevation. The remaining 305 patients, 22.6% were diagnosed with a medical condition during the first blood test that explained the ALT elevation, although only 33.3% of them were followed up until verifying their normalisation. Final study sample consists of 236 patients with abnormal liver test without apparent liver disease. Adequate follow-up was found only in 29% of them. From this group, 9 patients (13%) were diagnosed with liver disease. The rest of the samples were not properly monitored. In patients with higher serum ALT levels, follow-up was early and more appropriate.

CONCLUSIONS

In our area, most children without apparent liver disease are no properly monitored. Therefore, an opportunity to diagnosis and treat a potential liver disease was lost in a great number of children. All children with unexplained hypertransaminasaemia must be studied.

The utility of liver biopsy in 2020

PURPOSE OF REVIEW

Over the past decade, imaging modalities and serological tests have emerged as important tools in the evaluation of liver diseases, in many cases supplanting the use of liver biopsy and histological examination. Nonetheless, the accuracy and diagnostic value of these methods may not always be conclusive and the assessment of liver histology often remains the gold standard for diagnostic evaluation. The purpose of this review is to summarize the current role of liver biopsy in contemporary hepatology practice.

RECENT FINDINGS

Technical factors were found to influence the diagnostic value of liver biopsy and histological examination of the liver, including specimen number and size (preferably ≥3 nonfragmented specimens of >20 mm in length), needle diameter (1.6 mm Menghini), number of passes (mean 2.5), imaging-guidance, and operator experience. Liver biopsy was demonstrated to be diagnostically valuable in the evaluation of persistently abnormal liver tests of unclear cause, with histology pointing to a specific diagnosis in 84% of patients. Although coagulation abnormalities continue to be an important concern when performing liver biopsy, their influence on complication risk remains unclear. Implementation of less stringent preprocedural coagulation thresholds decreased preprocedural transfusions without increasing the bleeding rate. Serious complications associated with percutaneous liver-biopsy (PLB) and transjugular liver-biopsy are similar, but pain appears to be more common with PLB.

SUMMARY

Histopathological evaluation continues to be fundamentally important in assessing hepatic disease, and liver histology remains the most accurate approach to assess fibrosis and assign prognosis.

When Do Clinicians Follow-up Abnormal Liver Tests in Primary Care?

BACKGROUND

Many guidelines addressing the approach to abnormal liver chemistries, including bilirubin, transaminases and alkaline phosphatase, recommend repeating the tests. However, when clinicians repeat testing is unknown.

MATERIAL AND METHODS

This retrospective study followed adult patients with abnormal liver chemistries in a patient-centered medical home (PCMH) from 2007 to 2016. All PCMH patients possessing at least 1 abnormal liver test (total bilirubin, aminotransferases and alkaline phosphatase) were included. Patients were followed from the index abnormal liver chemistry until the next liver test result, or the end of the study period. The primary predictor variable of interest was the number of abnormal chemistries (out of 4) on index testing. Demographic and clinical variables served as other potential predictors of outcome. A Cox proportional hazards model was applied to investigate associations between the predictor variables and the time to repeat liver chemistry testing.

RESULTS

Of 9,545 patients with at least 2 PCMH visits and 1 liver test abnormality, 6,489 (68%) obtained repeat testing within 1 year, and 80% of patients had follow-up tests within 2 years. Patients with multiple abnormal liver tests and those with higher degrees of abnormality were associated with shorter time to repeat testing.

CONCLUSIONS

A large proportion of patients with abnormal liver tests still lack repeat testing at 1 year. The number of liver abnormal liver tests and degree of elevation were inversely associated with the time to repeat testing.