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===Liver Biopsy===
===Liver Biopsy===
* The [[Gold standard (test)|gold standard]] for diagnosis of cirrhosis is [[liver biopsy]], through a [[percutaneous]], transjugular, [[laparoscopic]], or fine-needle approach.  
Features of liver biopsy are as follows:<ref name="pmid9683971">{{cite journal |vauthors=Williams EJ, Iredale JP |title=Liver cirrhosis |journal=Postgrad Med J |volume=74 |issue=870 |pages=193–202 |year=1998 |pmid=9683971 |pmc=2360862 |doi= |url=}}</ref><ref name="pmid12865280">{{cite journal |vauthors=Blomley MJ, Lim AK, Harvey CJ, Patel N, Eckersley RJ, Basilico R, Heckemann R, Urbank A, Cosgrove DO, Taylor-Robinson SD |title=Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study |journal=Gut |volume=52 |issue=8 |pages=1188–93 |year=2003 |pmid=12865280 |pmc=1773750 |doi= |url=}}</ref><ref name="pmid11211142">{{cite journal |vauthors=Kim CK, Lim JH, Lee WJ |title=Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients |journal=J Ultrasound Med |volume=20 |issue=2 |pages=99–104 |year=2001 |pmid=11211142 |doi= |url=}}</ref><ref name="pmid443970">{{cite journal |vauthors=Abdi W, Millan JC, Mezey E |title=Sampling variability on percutaneous liver biopsy |journal=Arch. Intern. Med. |volume=139 |issue=6 |pages=667–9 |year=1979 |pmid=443970 |doi= |url=}}</ref><ref name="pmid14647056">{{cite journal |vauthors=Bedossa P, Dargère D, Paradis V |title=Sampling variability of liver fibrosis in chronic hepatitis C |journal=Hepatology |volume=38 |issue=6 |pages=1449–57 |year=2003 |pmid=14647056 |doi=10.1016/j.hep.2003.09.022 |url=}}</ref><ref name="pmid12385448">{{cite journal |vauthors=Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER |title=Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection |journal=Am. J. Gastroenterol. |volume=97 |issue=10 |pages=2614–8 |year=2002 |pmid=12385448 |doi=10.1111/j.1572-0241.2002.06038.x |url=}}</ref><ref name="pmid11172192">{{cite journal |vauthors=Bravo AA, Sheth SG, Chopra S |title=Liver biopsy |journal=N. Engl. J. Med. |volume=344 |issue=7 |pages=495–500 |year=2001 |pmid=11172192 |doi=10.1056/NEJM200102153440706 |url=}}</ref><ref name="pmid19243014">{{cite journal |vauthors=Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD |title=Liver biopsy |journal=Hepatology |volume=49 |issue=3 |pages=1017–44 |year=2009 |pmid=19243014 |doi=10.1002/hep.22742 |url=}}</ref>
* Cirrhosis is primarily a histological diagnosis. The [[Gold standard (test)|gold standard]] for diagnosis of cirrhosis is [[liver biopsy]].
* Sample of the liver is obtained by:<ref name="pmid16636018">{{cite journal |vauthors=Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK |title=Transjugular liver biopsy: how good is it for accurate histological interpretation? |journal=Gut |volume=55 |issue=12 |pages=1789–94 |year=2006 |pmid=16636018 |pmc=1856467 |doi=10.1136/gut.2005.090415 |url=}}</ref>
**Percutaneous
**Transjugular 
**Laparoscopic radiographically- guided fine-needle approach
* Percutaneous biopsy of focal lesions may be performed in combination with either ultrasound or CT imaging.<ref name="pmid15278290">{{cite journal |vauthors=Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP |title=[Bioptic diagnosis of chronic hepatitis. Results of an evidence-based consensus conference of the German Society of Pathology, of the German Society for Digestive and Metabolic Diseases and of Compensated Hepatitis (HepNet)] |language=German |journal=Pathologe |volume=25 |issue=5 |pages=337–48 |year=2004 |pmid=15278290 |doi=10.1007/s00292-004-0692-7 |url=}}</ref>
* Percutaneous liver biopsy remains the cornerstone of diagnosis. It is quick and simple to perform liver biopsy in a patient with normal platelet count and INR.<ref name="pmid22833761">{{cite journal |vauthors=Tannapfel A, Dienes HP, Lohse AW |title=The indications for liver biopsy |journal=Dtsch Arztebl Int |volume=109 |issue=27-28 |pages=477–83 |year=2012 |pmid=22833761 |pmc=3402072 |doi=10.3238/arztebl.2012.0477 |url=}}</ref>
* 
* Histologically, cirrhosis may be classified as micronodular, macronodular, or mixed, but this classification is nonspecific to the etiology.  
* Histologically, cirrhosis may be classified as micronodular, macronodular, or mixed, but this classification is nonspecific to the etiology.  
* Histology of the liver may change as the disease progresses, and serological markers are much more specific, however, a biopsy is not necessary if the clinical, laboratory, and radiologic data suggest cirrhosis.
* Histology of the liver may change as the disease progresses, and serological markers are much more specific.
* There is a small but significant risk of liver biopsy, and cirrhosis itself predisposes for complications due to liver biopsy.<ref>{{cite journal |last=Grant |first=A |coauthors=Neuberger J |year=1999 | title=Guidelines on the use of liver biopsy in clinical practice |journal=Gut |volume=45 |issue=Suppl 4 |pages=1-11 |id=PMID 10485854 |url=http://gut.bmj.com/cgi/content/full/45/suppl_4/IV1|quote=The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding. }}</ref>
* A biopsy is not necessary if the clinical, laboratory, and radiologic data suggest cirrhosis.
 
* Liver biopsy may be suggestive of etiology:
* [[Alcoholic liver disease]] : [[Liver biopsy]] may show hepatocyte necrosis, presence of mallory bodies, neutrophilic infiltration and perivenular inflammation.
* [[Alcoholic liver disease]] : [[Liver biopsy]] may show hepatocyte necrosis, presence of mallory bodies, neutrophilic infiltration and perivenular inflammation.
* [[Primary biliary cirrhosis]] : Gold standard diagnostic modality is the detection of antimitochondrial antibodies along  liver biopsy as confirmation if florid bile duct lesions.
* [[Primary biliary cirrhosis]] : Gold standard diagnostic modality is the detection of antimitochondrial antibodies along  liver biopsy as confirmation if florid bile duct lesions.  
 
* Hereditary hemochromatosis
 
* Nonalcoholic steatohepatitis
'''Liver biopsy:''' <ref name="pmid9683971">{{cite journal |vauthors=Williams EJ, Iredale JP |title=Liver cirrhosis |journal=Postgrad Med J |volume=74 |issue=870 |pages=193–202 |year=1998 |pmid=9683971 |pmc=2360862 |doi= |url=}}</ref><ref name="pmid12865280">{{cite journal |vauthors=Blomley MJ, Lim AK, Harvey CJ, Patel N, Eckersley RJ, Basilico R, Heckemann R, Urbank A, Cosgrove DO, Taylor-Robinson SD |title=Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study |journal=Gut |volume=52 |issue=8 |pages=1188–93 |year=2003 |pmid=12865280 |pmc=1773750 |doi= |url=}}</ref><ref name="pmid11211142">{{cite journal |vauthors=Kim CK, Lim JH, Lee WJ |title=Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients |journal=J Ultrasound Med |volume=20 |issue=2 |pages=99–104 |year=2001 |pmid=11211142 |doi= |url=}}</ref><ref name="pmid443970">{{cite journal |vauthors=Abdi W, Millan JC, Mezey E |title=Sampling variability on percutaneous liver biopsy |journal=Arch. Intern. Med. |volume=139 |issue=6 |pages=667–9 |year=1979 |pmid=443970 |doi= |url=}}</ref><ref name="pmid14647056">{{cite journal |vauthors=Bedossa P, Dargère D, Paradis V |title=Sampling variability of liver fibrosis in chronic hepatitis C |journal=Hepatology |volume=38 |issue=6 |pages=1449–57 |year=2003 |pmid=14647056 |doi=10.1016/j.hep.2003.09.022 |url=}}</ref><ref name="pmid12385448">{{cite journal |vauthors=Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER |title=Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection |journal=Am. J. Gastroenterol. |volume=97 |issue=10 |pages=2614–8 |year=2002 |pmid=12385448 |doi=10.1111/j.1572-0241.2002.06038.x |url=}}</ref><ref name="pmid11172192">{{cite journal |vauthors=Bravo AA, Sheth SG, Chopra S |title=Liver biopsy |journal=N. Engl. J. Med. |volume=344 |issue=7 |pages=495–500 |year=2001 |pmid=11172192 |doi=10.1056/NEJM200102153440706 |url=}}</ref><ref name="pmid19243014">{{cite journal |vauthors=Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD |title=Liver biopsy |journal=Hepatology |volume=49 |issue=3 |pages=1017–44 |year=2009 |pmid=19243014 |doi=10.1002/hep.22742 |url=}}</ref>
* Wilson disease
*Cirrhosis is primarily a histological diagnosis.
* Alpha-1 antitrypsin deficiency
*Percutaneous liver biopsy remains the cornerstone of diagnosis.
*There is a small but significant risk of liver biopsy, and cirrhosis itself predisposes for complications due to liver biopsy.<ref>{{cite journal |last=Grant |first=A |coauthors=Neuberger J |year=1999 | title=Guidelines on the use of liver biopsy in clinical practice |journal=Gut |volume=45 |issue=Suppl 4 |pages=1-11 |id=PMID 10485854 |url=http://gut.bmj.com/cgi/content/full/45/suppl_4/IV1|quote=The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding. }}</ref> Risks of liver biopsy include:
* quick and simple to perform in a cooperative patient with a normal INR and platelet count.
**Haemorrhage
*The gold standard for diagnosing cirrhosis is:
**Biliary peritonitis
**Examination of an explanted liver, either at autopsy or following liver transplantation, because the architecture of the entire liver can be appreciated.
**Hematoma
 
**Perforation of other viscera
*Cirrhosis is diagnosed with a liver biopsy <ref name="pmid22833761">{{cite journal |vauthors=Tannapfel A, Dienes HP, Lohse AW |title=The indications for liver biopsy |journal=Dtsch Arztebl Int |volume=109 |issue=27-28 |pages=477–83 |year=2012 |pmid=22833761 |pmc=3402072 |doi=10.3238/arztebl.2012.0477 |url=}}</ref><ref name="pmid15278290">{{cite journal |vauthors=Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP |title=[Bioptic diagnosis of chronic hepatitis. Results of an evidence-based consensus conference of the German Society of Pathology, of the German Society for Digestive and Metabolic Diseases and of Compensated Hepatitis (HepNet)] |language=German |journal=Pathologe |volume=25 |issue=5 |pages=337–48 |year=2004 |pmid=15278290 |doi=10.1007/s00292-004-0692-7 |url=}}</ref>
**Mortality rates of between 0.01% and 0.1%
 
*Sample of the liver is obtained by:<ref name="pmid16636018">{{cite journal |vauthors=Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK |title=Transjugular liver biopsy: how good is it for accurate histological interpretation? |journal=Gut |volume=55 |issue=12 |pages=1789–94 |year=2006 |pmid=16636018 |pmc=1856467 |doi=10.1136/gut.2005.090415 |url=}}</ref>
**Percutaneous
**Transjugular 
**Laparoscopic radiographically-guided fine-needle approach.
 
*Liver biopsy is not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis and if the results would not alter the patient's management.
 
*Patient with a history of heavy alcohol use who has ascites, severe coagulopathy, and a shrunken, nodular-appearing liver on ultrasonography.
 
*Liver biopsy may be suggestive of etiology:
*Metabolic causes of cirrhosis include:
**Hereditary hemochromatosis
**Nonalcoholic steatohepatitis
**Wilson disease
**Alpha-1 antitrypsin deficiency
 
*Risks:
**haemorrhage
**biliary peritonitis
**haematoma
**perforation of other viscera
**mortality rates of between 0.01% and 0.1%
 
*Percutaneous biopsy of focal lesions may be performed in combination with either ultrasound or CT imaging.
 
*Prerequisites:
**normal INR and platelet count.


*May be performed in combination with either ultrasound or CT.
* Patients with moderate coagulopathy: 
*Patients with moderate coagulopathy: 
**Plugged liver biopsy : injection of gelatin sponges or metal coils down the tract after biopsy
**Plugged liver biopsy : injection of gelatin sponges or metal coils down the tract after biopsy
**Laparoscopic liver biopsy  performed on a sedated patient with moderate coagulopathy
**Laparoscopic liver biopsy  performed on a sedated patient with moderate coagulopathy
Line 70: Line 49:
===NT-proBNP (N Terminal pro Brain Natriuretic Peptide)===
===NT-proBNP (N Terminal pro Brain Natriuretic Peptide)===
* N Terminal pro Brain Natriuretic peptide is an important factor for evaluating the complications of cirrhosis.<ref name="pmid22911531">{{cite journal |author=Ljubicic N, Gomercic M, Zekanovic D, Bodrozic-Dzakic T, Djuzel A |title=New insight into the role of NT-proBNP in alcoholic liver cirrhosis as a noninvasive marker of esophageal varices |journal=[[Croatian Medical Journal]] |volume=53 |issue=4 |pages=374–8 |year=2012 |pmid=22911531 |pmc=3428825 |doi= |url=http://www.cmj.hr/2012/53/4/22911531.htm |accessdate=2012-09-06}}</ref>
* N Terminal pro Brain Natriuretic peptide is an important factor for evaluating the complications of cirrhosis.<ref name="pmid22911531">{{cite journal |author=Ljubicic N, Gomercic M, Zekanovic D, Bodrozic-Dzakic T, Djuzel A |title=New insight into the role of NT-proBNP in alcoholic liver cirrhosis as a noninvasive marker of esophageal varices |journal=[[Croatian Medical Journal]] |volume=53 |issue=4 |pages=374–8 |year=2012 |pmid=22911531 |pmc=3428825 |doi= |url=http://www.cmj.hr/2012/53/4/22911531.htm |accessdate=2012-09-06}}</ref>
* High levels of NT-proBNP ( >101 pg/ml) is the marker of esophageal varices.
* High levels of NT-proBNP ( >101 pg/ml) serve as a marker of esophageal varices.
* NT-proBNP is not a marker of cirrhosis progression.


==References==
==References==

Revision as of 15:42, 14 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

The gold standard diagnostic test for cirrhosis is liver biopsy, although it is rarely necessary for diagnosis or treatment. NT-proBNP can be used to evaluate the complications of cirrhosis.

Other Diagnostic Studies

Liver Biopsy

Features of liver biopsy are as follows:[1][2][3][4][5][6][7][8]

  • Cirrhosis is primarily a histological diagnosis. The gold standard for diagnosis of cirrhosis is liver biopsy.
  • Sample of the liver is obtained by:[9]
    • Percutaneous
    • Transjugular 
    • Laparoscopic radiographically- guided fine-needle approach
  • Percutaneous biopsy of focal lesions may be performed in combination with either ultrasound or CT imaging.[10]
  • Percutaneous liver biopsy remains the cornerstone of diagnosis. It is quick and simple to perform liver biopsy in a patient with normal platelet count and INR.[11]
  • Histologically, cirrhosis may be classified as micronodular, macronodular, or mixed, but this classification is nonspecific to the etiology.
  • Histology of the liver may change as the disease progresses, and serological markers are much more specific.
  • A biopsy is not necessary if the clinical, laboratory, and radiologic data suggest cirrhosis.
  • Liver biopsy may be suggestive of etiology:
  • Alcoholic liver disease : Liver biopsy may show hepatocyte necrosis, presence of mallory bodies, neutrophilic infiltration and perivenular inflammation.
  • Primary biliary cirrhosis : Gold standard diagnostic modality is the detection of antimitochondrial antibodies along liver biopsy as confirmation if florid bile duct lesions.
  • Hereditary hemochromatosis
  • Nonalcoholic steatohepatitis
  • Wilson disease
  • Alpha-1 antitrypsin deficiency
  • There is a small but significant risk of liver biopsy, and cirrhosis itself predisposes for complications due to liver biopsy.[12] Risks of liver biopsy include:
    • Haemorrhage
    • Biliary peritonitis
    • Hematoma
    • Perforation of other viscera
    • Mortality rates of between 0.01% and 0.1%
  • Patients with moderate coagulopathy: 
    • Plugged liver biopsy : injection of gelatin sponges or metal coils down the tract after biopsy
    • Laparoscopic liver biopsy  performed on a sedated patient with moderate coagulopathy
      • Advantage: allows direct visualisation of the liver
  • Patients with severe clotting disorders:
  • Transjugular liver biopsy :
    • risk of intraperitoneal bleed is  less
    •  Disadvantages:
      •  biopsies are small: multiple biopsies required 
      •  taken 'blindly'

NT-proBNP (N Terminal pro Brain Natriuretic Peptide)

  • N Terminal pro Brain Natriuretic peptide is an important factor for evaluating the complications of cirrhosis.[13]
  • High levels of NT-proBNP ( >101 pg/ml) serve as a marker of esophageal varices.

References

  1. ↑ Williams EJ, Iredale JP (1998). "Liver cirrhosis". Postgrad Med J. 74 (870): 193–202. PMC 2360862. PMID 9683971.
  2. ↑ Blomley MJ, Lim AK, Harvey CJ, Patel N, Eckersley RJ, Basilico R, Heckemann R, Urbank A, Cosgrove DO, Taylor-Robinson SD (2003). "Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study". Gut. 52 (8): 1188–93. PMC 1773750. PMID 12865280.
  3. ↑ Kim CK, Lim JH, Lee WJ (2001). "Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients". J Ultrasound Med. 20 (2): 99–104. PMID 11211142.
  4. ↑ Abdi W, Millan JC, Mezey E (1979). "Sampling variability on percutaneous liver biopsy". Arch. Intern. Med. 139 (6): 667–9. PMID 443970.
  5. ↑ Bedossa P, Dargère D, Paradis V (2003). "Sampling variability of liver fibrosis in chronic hepatitis C". Hepatology. 38 (6): 1449–57. doi:10.1016/j.hep.2003.09.022. PMID 14647056.
  6. ↑ Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER (2002). "Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection". Am. J. Gastroenterol. 97 (10): 2614–8. doi:10.1111/j.1572-0241.2002.06038.x. PMID 12385448.
  7. ↑ Bravo AA, Sheth SG, Chopra S (2001). "Liver biopsy". N. Engl. J. Med. 344 (7): 495–500. doi:10.1056/NEJM200102153440706. PMID 11172192.
  8. ↑ Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD (2009). "Liver biopsy". Hepatology. 49 (3): 1017–44. doi:10.1002/hep.22742. PMID 19243014.
  9. ↑ Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK (2006). "Transjugular liver biopsy: how good is it for accurate histological interpretation?". Gut. 55 (12): 1789–94. doi:10.1136/gut.2005.090415. PMC 1856467. PMID 16636018.
  10. ↑ Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP (2004). "[Bioptic diagnosis of chronic hepatitis. Results of an evidence-based consensus conference of the German Society of Pathology, of the German Society for Digestive and Metabolic Diseases and of Compensated Hepatitis (HepNet)]". Pathologe (in German). 25 (5): 337–48. doi:10.1007/s00292-004-0692-7. PMID 15278290.
  11. ↑ Tannapfel A, Dienes HP, Lohse AW (2012). "The indications for liver biopsy". Dtsch Arztebl Int. 109 (27–28): 477–83. doi:10.3238/arztebl.2012.0477. PMC 3402072. PMID 22833761.
  12. ↑ Grant, A (1999). "Guidelines on the use of liver biopsy in clinical practice". Gut. 45 (Suppl 4): 1–11. PMID 10485854. The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding. Unknown parameter |coauthors= ignored (help)
  13. ↑ Ljubicic N, Gomercic M, Zekanovic D, Bodrozic-Dzakic T, Djuzel A (2012). "New insight into the role of NT-proBNP in alcoholic liver cirrhosis as a noninvasive marker of esophageal varices". Croatian Medical Journal. 53 (4): 374–8. PMC 3428825. PMID 22911531. Retrieved 2012-09-06.

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