**8. Conclusions**

LB continues to play a central role in the evaluation of patients with suspected liver disease, but many aspects of the procedure remain controversial. For example, the precise degree of serum ALT elevations that should prompt a LB is debated, as is the need for LB in all pa‐ tients with suspected NAFLD and chronic hepatitis C. The importance of LB in arriving at a diagnosis of diffuse parenchymal liver disease is being diminished by accurate blood testing strategies for chronic viral hepatitis, autoimmune hepatitis, and primary biliary cirrhosis. Further, imaging tests are superior to LB in the diagnosis of primary sclerosing cholangitis. However, many cases remain in which diagnostic confusion exists even after suitable labo‐ ratory testing and imaging studies. Diagnosing infiltrative disease (eg, amyloidosis, sarcoi‐ dosis), separating benign fatty liver disease from steatohepatitis, and evaluating liver parenchyma after liver transplantation are best accomplished by LB.

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Percutaneous LB is contraindicated in patients with severe coagulopathy and ascites, but the degree of coagulopathy that contraindicates a LB is controversial. Also controversial are the technical aspects of LB, particularly the choice of needle (cutting vs. suction) and the use of US to mark or guide the biopsy site. Bleeding is the major complication of LB, with a risk of 0.3%; cutting needles are more likely to cause hemorrhage than are suction needles. While needle biopsy is still the mainstay in diagnosing hepatic fibrosis, its days of dominance seem limited as technology improves. When physical examination or standard laboratory tests reveal clear-cut signs of portal hypertension, LB will seldom add useful information. Similarly, when imaging studies provide compelling evidence of cirrhosis and portal hypertension, needle biopsy is not warranted. The combination algo‐ rithms warrant further evaluation in all chronic liver diseases, as they may help decrease the number of liver biopsies required. Moreover, transient elastography is playing an ev‐ er-increasing role in the assessment of hepatic fibrosis and will significantly reduce the need for biopsy in patients with liver disease.

Clearly, as our knowledge of various liver disorders advances and new especially non-inva‐ sive diagnostic tests are developed, the role of LB in medical practice will continue to evolve. Emergence of better imaging techniques, surrogate serological markers of liver fibro‐ sis are among the many new and exciting developments that hold promise for the future.
