**2. Indications for LB**

Indications for liver biopsy in chronic liver disease have evolved (Tables 1,2). The main ad‐ vantages of LB with respect to the etiology of liver disease are shown in Table 2 and will be detailed later. The indication for liver biopsy is appropriate when the treatment or prognosis will be modified by results of histopathological examination of the liver. However, liver bi‐ opsy is not appropriate when the therapeutic decision and/or establishment of a diagnosis does not depend on histological findings [1].

**Etiology 1997 Study [31]**

Cholestatic disease of the

cholestasis)

liver (primary biliary cirrhosis. primary sclerosing cholangitis. chronic

**2.1. Chronic hepatitis C**

**of 2,084 biopsies**

4.3 3.7

Liver biopsy has long been the only reference for assessing necroinflammatory lesions and fibrosis in hepatitis C. Liver biopsy is most useful for evaluating the existence of co-morbidi‐ ties: alcoholic liver disease, non alcoholic fatty liver disease and iron overload, which are es‐ pecially common in patients with chronic hepatitis C. In 2002, the French consensus conference no longer recommended systematic liver biopsy in patients with consistently normal transaminases [2]. At that time, for patients recently contaminated with genotype 2 or 3 infection, without co-morbidity and/or when the indication was viral eradication inde‐ pendently of fibrosis data, then antiviral treatment could be undertaken without requiring LB [2]. Furthermore, liver biopsy is not useful when diagnosis of cirrhosis is obvious [2]. While abdominal ultrasonography is satisfactory for assessing the existence of steatosis, liv‐ er biopsy is needed in order to evaluate the existence of steatohepatitis, iron overload or al‐ coholic liver disease associated with hepatitis C. Such lesions are associated with more rapid fibrosis progression and a less favorable response to treatment. The major development over the last ten years, spurred by French teams, of non-invasive assessment of fibrosis during the course of hepatitis C has significantly reduced indications for liver biopsy in patients with chronic hepatitis C. Several serum tests (FibroTest®, FibroMeter®, Hepascore®) are currently being validated by the French High Authority of Health for establishing extent of fibrosis in patients with untreated chronic hepatitis C and no co-morbidity [3-5]. The FibroT‐ est has been validated by numerous studies and several independent teams [6]. The FibroM‐ eter ® virus [9] has also been the subject of independent validations by different teams. FibroScan ® is useful for confirming or ruling out the presence of cirrhosis [7, 8], and for patients with HIV-HCV co-infection. In a recent survey, the use of liver biopsy was reduced by 50 % for chronic hepatitis C patients [9]. Most hepatologists in France no longer recom‐

**2009 Study [13] of 8,580 biopsies**

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105

Current Trends in Liver Biopsy Indications for Chronic Liver Diseases

**(%)**

**(%)**

Hepatitis C 54.1 33.6 Delta hepatitis B 5.8 14.4 Hereditary hemochromatosis 4.3 1

Autoimmune hepatitis 1 3.5 Liver transplantation 3 12. Miscellaneous 17.6 12.2 Metabolic steatopathy unlisted 8.9

**Table 3.** Indications for liver biopsy. Evolutionary trend in France.


\* After complete check-up, according to (2)

#### **Table 1.** Indications for liver biopsy


**Table 2.** Utility of liver biopsy in clinical practice for diffuse parenchymal damage


**Table 3.** Indications for liver biopsy. Evolutionary trend in France.

#### **2.1. Chronic hepatitis C**

**2. Indications for LB**

104 Liver Biopsy - Indications, Procedures, Results

**Indications**

does not depend on histological findings [1].

\* After complete check-up, according to (2)

**Table 1.** Indications for liver biopsy

Autoimmune hepatitis In particular, seronegative

NA: not applicable

syndrome

Primary biliary cirrhosis / overlap


For research purposes - Development of treatments related to results of histological analysis

For prognostic purposes - Assessment of known parenchymal liver diseases.

**Cause of liver disease Diagnosis Evaluation of**

Hepatitis C - +++

Indications for liver biopsy in chronic liver disease have evolved (Tables 1,2). The main ad‐ vantages of LB with respect to the etiology of liver disease are shown in Table 2 and will be detailed later. The indication for liver biopsy is appropriate when the treatment or prognosis will be modified by results of histopathological examination of the liver. However, liver bi‐ opsy is not appropriate when the therapeutic decision and/or establishment of a diagnosis

For diagnostic purposes - Combination of several parenchymal liver diseases - Abnormal liver tests of unknown origin \*.

**fibrosis**

of fibrosis)

(Non-invasive markers

+++ +++ + ++++

++ +++ +++ ++

**Prognosis Management**

+ (+) ++++


Hepatitis B - +++ + (+) +++

Hemochromatosis +/- +++ + (+) + Wilson's disease ++ +++ + α-1 Antitrypsin deficiency + +++ Depends on lung status +

Primary sclerosing cholangitis ++ +/0 0 + Alcoholic liver disease +/- ++ ++ + Severe acute alcoholic hepatitis +++ NA NA + Steatosis / steatohepatitis +++ +++ + + Infiltrative lesions of the liver ++++ NA NA + Medicinal cause ++ NA NA + Follow-up after liver transplantation ++++ +++ + +

**Table 2.** Utility of liver biopsy in clinical practice for diffuse parenchymal damage

Liver biopsy has long been the only reference for assessing necroinflammatory lesions and fibrosis in hepatitis C. Liver biopsy is most useful for evaluating the existence of co-morbidi‐ ties: alcoholic liver disease, non alcoholic fatty liver disease and iron overload, which are es‐ pecially common in patients with chronic hepatitis C. In 2002, the French consensus conference no longer recommended systematic liver biopsy in patients with consistently normal transaminases [2]. At that time, for patients recently contaminated with genotype 2 or 3 infection, without co-morbidity and/or when the indication was viral eradication inde‐ pendently of fibrosis data, then antiviral treatment could be undertaken without requiring LB [2]. Furthermore, liver biopsy is not useful when diagnosis of cirrhosis is obvious [2]. While abdominal ultrasonography is satisfactory for assessing the existence of steatosis, liv‐ er biopsy is needed in order to evaluate the existence of steatohepatitis, iron overload or al‐ coholic liver disease associated with hepatitis C. Such lesions are associated with more rapid fibrosis progression and a less favorable response to treatment. The major development over the last ten years, spurred by French teams, of non-invasive assessment of fibrosis during the course of hepatitis C has significantly reduced indications for liver biopsy in patients with chronic hepatitis C. Several serum tests (FibroTest®, FibroMeter®, Hepascore®) are currently being validated by the French High Authority of Health for establishing extent of fibrosis in patients with untreated chronic hepatitis C and no co-morbidity [3-5]. The FibroT‐ est has been validated by numerous studies and several independent teams [6]. The FibroM‐ eter ® virus [9] has also been the subject of independent validations by different teams. FibroScan ® is useful for confirming or ruling out the presence of cirrhosis [7, 8], and for patients with HIV-HCV co-infection. In a recent survey, the use of liver biopsy was reduced by 50 % for chronic hepatitis C patients [9]. Most hepatologists in France no longer recom‐ mend first-line liver biopsy for chronic hepatitis C (Table 4). Discrepancy between results of serum fibrosis markers and FibroScan®, when performed simultaneously, is an indication for liver biopsy.

tis and if extensive fibrosis or cirrhosis is suspected, then the Fibrotest® [16]and FibroScan®

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In patients with hepatic steatosis as part of the metabolic syndrome, liver biopsy is useful for differentiating fatty lesions from steatohepatitis (NASH), the evolutionary potential of which is much more severe (risk of cirrhosis and hepatocellular carcinoma ). The presence of body mass index > 30 kg/m², AST/ALT ratio > 1, hypertriglyceridemia > 1.7 mmol/L, age > 50 years and a syndrome of insulin resistance are predictors of steatohepatitis and fibrotic le‐ sions. When elements of metabolic syndrome exist with or without steatosis visualized on ultrasonography, then LB performed for what is referred to as "unexplained" cytolysis leads to a diagnosis of steatosis and steatohepatitis lesions in 60% of the cases [18]. Liver biopsy enables accurate diagnosis of lesions and evaluation of the degree of fibrosis [1]. It should be noted, however, that in this setting, steatosis FibroMeter ® [19] and Fibromax® [20] can pro‐

Diagnosis of primary biliary cirrhosis is based on identification of cholestasis associated with antimitochondrial M2 antibodies. Liver biopsy is not useful for diagnosis of primary biliary cirrhosis [21], but is very useful for assessing the activity and extent of fibrotic le‐ sions. FibroScan® in this indication can assess the presence or absence of cirrhosis [22]. Liver biopsy is useful in case of a poor response to ursodeoxycholic acid and/or in case of a drastic increase of transaminases. Liver biopsy is able to reveal moderate to severe lymphocytic piecemeal necrosis that may fit into the context of overlap syndrome, requiring a change in therapy and the addition of corticosteroids. During the course of autoimmune hepatitis [1, 23] , liver biopsy is necessary to assess piecemeal necrotic lesions and fibrosis stage. It is es‐ pecially helpful in the absence of antibodies. In autoimmune hepatitis, no method of noninvasive evaluation of fibrosis has been developed. Liver biopsy is also necessary prior to discontinuation of immunosuppressive therapy, since the presence of histological piecemeal necrotic lesions is associated with almost constant recurrence of outbreaks of cytolysis dele‐ terious to the liver [24]. When confronted with possible chronic cholestasis, the diagnosis of primary sclerosing cholangitis is based on data from the magnetic resonance cholangiopan‐ creatography (MRCP)[21]. Liver biopsy often confirms the diagnosis, but can appear normal in 25% of the cases. When MRCP is normal, liver biopsy enables diagnosis of cholangitis of

small bile ducts and, in all cases, helps to clarify lesions due to hepatic fibrosis [1, 21].

Diagnosis of hereditary HFE-gene-related hemochromatosis is based on the association of hyperferritinemia with elevated saturation of transferrin and presence of the C282Y muta‐ tion in the homozygous state. Thus, liver biopsy is not mandatory for diagnosis. It is still indicated, however, when serum ferritin is higher than 1,000 µg/L, and/or when the AST are increased and/or if hepatomegaly is present [25]. Simple markers (platelet count and

vide evidence of the existence of fibrosis and can predict the existence of NASH.

**2.5. Cholestatic liver diseases, and autoimmune diseases of the liver**

[17] give satisfactory diagnostic performances.

**2.4. Non alcoholic fatty liver disease**

**2.6. Genetic hemochromatosis**


**Table 4.** Contraindications to transjugular and transparietal liver biopsy

#### **2.2. Hepatitis B and hepatitis B-delta**

Serum markers of non-invasive necroinflammatory lesions and fibrosis in hepatitis B and Bdelta have not been fully validated, nor has the FibroScan [10, 11]. Scientific institutions rec‐ ommend that liver biopsy be performed prior to any treatment decision in the context of chronic hepatitis B or B-delta. Liver biopsy is the best means of assessing necroinflammatory lesions and fibrosis in chronic hepatitis B [12]. The evolutionary trend in indications for liver biopsy for hepatitis C and B has been inverted over the last twelve years: the number of liver biopsies for hepatitis C in 2009 represented 33.6%, compared to 54.1% in 1997, this trend be‐ ing related to development of non-invasive measures for assessing fibrosis; however, the number of liver biopsies for hepatitis B and delta-B has tripled in France [13] (Table 4). This is probably related to the increased number of patients with hepatitis B in France and the emergence of more effective treatment, along with insufficient validation of non-invasive fibrosis assessment methods.

#### **2.3. Alcoholic liver disease**

Liver biopsy remains essential in case of severe acute alcoholic hepatitis with Maddrey func‐ tion above 32. In this situation, lesions of acute alcoholic hepatitis are absent in 20% of cases [14], while the benefit of corticosteroids in the absence of alcoholic hepatitis lesions has not been demonstrated with an increased risk of bacterial infection. However, this point has been debated by some authors [15]. When there are no signs of severe acute alcoholic hepati‐

tis and if extensive fibrosis or cirrhosis is suspected, then the Fibrotest® [16]and FibroScan® [17] give satisfactory diagnostic performances.

#### **2.4. Non alcoholic fatty liver disease**

mend first-line liver biopsy for chronic hepatitis C (Table 4). Discrepancy between results of serum fibrosis markers and FibroScan®, when performed simultaneously, is an indication

Serum markers of non-invasive necroinflammatory lesions and fibrosis in hepatitis B and Bdelta have not been fully validated, nor has the FibroScan [10, 11]. Scientific institutions rec‐ ommend that liver biopsy be performed prior to any treatment decision in the context of chronic hepatitis B or B-delta. Liver biopsy is the best means of assessing necroinflammatory lesions and fibrosis in chronic hepatitis B [12]. The evolutionary trend in indications for liver biopsy for hepatitis C and B has been inverted over the last twelve years: the number of liver biopsies for hepatitis C in 2009 represented 33.6%, compared to 54.1% in 1997, this trend be‐ ing related to development of non-invasive measures for assessing fibrosis; however, the number of liver biopsies for hepatitis B and delta-B has tripled in France [13] (Table 4). This is probably related to the increased number of patients with hepatitis B in France and the emergence of more effective treatment, along with insufficient validation of non-invasive

Liver biopsy remains essential in case of severe acute alcoholic hepatitis with Maddrey func‐ tion above 32. In this situation, lesions of acute alcoholic hepatitis are absent in 20% of cases [14], while the benefit of corticosteroids in the absence of alcoholic hepatitis lesions has not been demonstrated with an increased risk of bacterial infection. However, this point has been debated by some authors [15]. When there are no signs of severe acute alcoholic hepati‐

Hydatid cyst Cholangitis Bile duct dilatation

Uncorrected hemostasis deficits

**Transparietal liver biopsy Transjugular liver biopsy**

for liver biopsy.

Hydatid cyst

Morbid obesity Ascites

Suspicion of amyloidosis

Relative contraindications

Infection of the right pleural cavity

fibrosis assessment methods.

**2.3. Alcoholic liver disease**

**2.2. Hepatitis B and hepatitis B-delta**

Absolute contraindications: Absence of patient cooperation Clotting abnormalities (see text)

106 Liver Biopsy - Indications, Procedures, Results

Need to maintain anticoagulants or antiplatelets Vascular lesion along the puncture route Non-percussive or non-identifiable liver

**Table 4.** Contraindications to transjugular and transparietal liver biopsy

In patients with hepatic steatosis as part of the metabolic syndrome, liver biopsy is useful for differentiating fatty lesions from steatohepatitis (NASH), the evolutionary potential of which is much more severe (risk of cirrhosis and hepatocellular carcinoma ). The presence of body mass index > 30 kg/m², AST/ALT ratio > 1, hypertriglyceridemia > 1.7 mmol/L, age > 50 years and a syndrome of insulin resistance are predictors of steatohepatitis and fibrotic le‐ sions. When elements of metabolic syndrome exist with or without steatosis visualized on ultrasonography, then LB performed for what is referred to as "unexplained" cytolysis leads to a diagnosis of steatosis and steatohepatitis lesions in 60% of the cases [18]. Liver biopsy enables accurate diagnosis of lesions and evaluation of the degree of fibrosis [1]. It should be noted, however, that in this setting, steatosis FibroMeter ® [19] and Fibromax® [20] can pro‐ vide evidence of the existence of fibrosis and can predict the existence of NASH.

#### **2.5. Cholestatic liver diseases, and autoimmune diseases of the liver**

Diagnosis of primary biliary cirrhosis is based on identification of cholestasis associated with antimitochondrial M2 antibodies. Liver biopsy is not useful for diagnosis of primary biliary cirrhosis [21], but is very useful for assessing the activity and extent of fibrotic le‐ sions. FibroScan® in this indication can assess the presence or absence of cirrhosis [22]. Liver biopsy is useful in case of a poor response to ursodeoxycholic acid and/or in case of a drastic increase of transaminases. Liver biopsy is able to reveal moderate to severe lymphocytic piecemeal necrosis that may fit into the context of overlap syndrome, requiring a change in therapy and the addition of corticosteroids. During the course of autoimmune hepatitis [1, 23] , liver biopsy is necessary to assess piecemeal necrotic lesions and fibrosis stage. It is es‐ pecially helpful in the absence of antibodies. In autoimmune hepatitis, no method of noninvasive evaluation of fibrosis has been developed. Liver biopsy is also necessary prior to discontinuation of immunosuppressive therapy, since the presence of histological piecemeal necrotic lesions is associated with almost constant recurrence of outbreaks of cytolysis dele‐ terious to the liver [24]. When confronted with possible chronic cholestasis, the diagnosis of primary sclerosing cholangitis is based on data from the magnetic resonance cholangiopan‐ creatography (MRCP)[21]. Liver biopsy often confirms the diagnosis, but can appear normal in 25% of the cases. When MRCP is normal, liver biopsy enables diagnosis of cholangitis of small bile ducts and, in all cases, helps to clarify lesions due to hepatic fibrosis [1, 21].

#### **2.6. Genetic hemochromatosis**

Diagnosis of hereditary HFE-gene-related hemochromatosis is based on the association of hyperferritinemia with elevated saturation of transferrin and presence of the C282Y muta‐ tion in the homozygous state. Thus, liver biopsy is not mandatory for diagnosis. It is still indicated, however, when serum ferritin is higher than 1,000 µg/L, and/or when the AST are increased and/or if hepatomegaly is present [25]. Simple markers (platelet count and transaminases, possibly combined with the dosage of hyaluronic acid and/or use of Fibro‐ Scan) can indicate the existence or absence of extensive fibrosis and help to guide indica‐ tions for liver biopsy.

**3. Limitations**

Liver biopsy has remained the "gold standard" for years. However, it is imperfect since a large biopsy is required to make an accurate assessment of fibrotic stage and inflammatory grade. Pathologists estimated that a 25 mm-long fragment obtained with a 16-G needle was necessary to accurately determine the grade of chronic liver disease [27]. Colloredo et al. showed that eleven to fifteen complete portal tracts was the minimal number below which disease stage was significantly underestimated [28]. In a large review of the literature including 10,027 LB, Cholongitas et al. showed that the mean ± SD length was 17.7±5.8 mm and the mean ± SD num‐ ber of portal tract was 7.5±5.8 [29]. This implies that at least two passes would be necessary to

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109

Methods for performing LB will not be detailed here, but are available in practical guide‐

When all conditions are met, then "ambulatory" liver biopsy may be performed [30]. In the study published in 2000 (completed in 1997) [31], 27% of liver biopsies were performed on an outpatient basis, most often for chronic hepatitis C; this figure is currently at 45% [13]. Several French teams have shown that outpatient liver biopsy is a safe and effective proce‐ dure and that liver biopsy performed on an outpatient basis reduces discomfort and increas‐ es the acceptability of subsequent examination conducted under the same conditions. If all conditions are not met and/or if organizational arrangements do not permit it, then liver bi‐

LB is carried out by hepatogastroenterologists, radiologists and occasionally by surgeons. Currently, liver biopsy is performed in France by a hepatogastroenterologist in 63.5% of cas‐ es, by a radiologist in 34.8% of cases and by a surgeon in 1.7% of cases [13]. The increasing number of liver biopsies performed by radiologists in France is linked to an increased num‐ ber of biopsies performed using ultrasound guidance or guided real-time ultrasonography [30] and by the development of the transvenous route as compared to the transparietal route. Indeed, in 1997, 9% of liver biopsies were performed via the transvenous route com‐ pared to 22.4% in 2009 [13]. In the US, 50% of biopsies are performed by radiologists. In that country, it is felt that the number of LB performed in order to gain sufficient expertise is at

Absolute and relative contraindications for LB depend on the surgical approach recom‐ mended. Contraindications for liver biopsy using the transjugular or transparietal route [1,

obtain a 2.5 cm long specimen, thus potentially increasing the risk of complications.

**4. Optimal methods for carrying out lb in 2012**

opsy should be performed via traditional hospitalization.

least 40, carried out in the presence of an experienced radiologist [1].

**5. Absolute and relative contraindications for LB**

30] are summarized in Table 4.

lines [30]. Several issues will be addressed:

#### **2.7. Unexplained abnormal liver tests**

Liver biopsy is often proposed in case of unexplained abnormal liver tests, when physical examination, biochemical and serological tests, imaging investigation could not establish a diagnosis. In one study including 354 patients, non alcoholic fatty liver disease was the defi‐ nite diagnosis in 64 % of the cases. Other lesions included drug induced liver injury, alcoholrelated liver disease, auto-immune hepatitis, primary sclerosing cholangitis,primary and secondary biliary cirrhosis, hemochromatosis, amyloid and glycogen storage disease, and cryptogenic hepatitis [26]. In another study including 272 patients, NAFLD represented 59.5 % of the cases [18].

#### **2.8. Other indications (Table 3)**

Liver biopsy is essential for the diagnosis of rare diseases of the liver such as Wilson's dis‐ ease, wherein the hepatic copper concentration has to be measured, a deficiency in al‐ pha-1 antitrypsin with evidence of PAS-positive cells, overload diseases such as Gaucher's disease, and amyloidosis, when there exists no other alternative [2]. In case of amyloido‐ sis, liver biopsy should be performed via the transjugular route, since there is a major risk of bleeding in case of LBP performed via the transparietal route. Liver biopsy also helps in diagnosing rare diseases (nodular regenerative hyperplasia, congenital hepatic fibrosis) in case of prolonged abnormal liver function tests [1]. In case of severe acute hepatitis, emergency liver biopsy performed via the transjugular route may be particularly useful for diagnosing seronegative autoimmune hepatitis, infiltrative lesions of the liver, hepati‐ tis or herpes [1]. Liver biopsy is essential for diagnosis of abnormalities in liver function tests when monitoring patients after liver transplantation in order to give a positive differ‐ ential diagnosis of the following anomalies: rejection, infection, drug-induced liver injury, bile duct injury and viral reinfection. In case of hepatitis C virus recurrence in the liver transplant, liver biopsy is indicated; however, the FibroScan® is currently being assessed for evaluating damage from hepatic fibrosis. In case of suspected drug-induced hepatitis, liver biopsy may be useful if biochemical abnormalities persist beyond 3 months after ces‐ sation of treatment or if there is evidence suggesting injury to the bile ducts, such as a prolonged cholestatic syndrome.

It is essential that the pathologist be provided with relevant and complete clinical and bio‐ logical information. Such information should be available before performing liver biopsy in suspected cases of rare diseases of the liver, or when bacteriological seeding or special stain‐ ing has to be performed [1], so that the fresh liver fragment is immediately transmitted to the pathology or microbiology laboratory.
