**2. Contraindications to percutaneous liver biopsy**

**Absolute contraindications:** the main contraindication to percutaneous liver biopsy is significant coagulopathy, others are: uncooperative patient, history of unexplained bleed‐ ing, prothrombin time 3–5 seconds more than control, platelet count less than 50,000/ mm3 , the use of a non-steroidal anti-inflammatory drugs, (unless discontinued 7 to 10 days previously), blood for transfusion unavailable, suspected hemangioma, another vas‐ cular tumor or echinococcal cysts in the liver, and the inability to identify an appropriate site for biopsy.

**Relative contraindications:** Morbid obesity, ascites, hemophilia, infection in the right pleu‐ ral cavity or below the right hemidiaphragm.

**Accepted indications:** Given the new developments that have proved the efficacy of liver biopsy, its role in the management of patients with chronic liver diseases has much evolved in recent years and will continue to evolve as new non invasive technologies are developed.


**Table 1.** Indications and contraindications for liver biopsy

Its importance in diagnosis, staging and prognosis largely depends on the indication and the clinical question relying on an answer from the histological result.

#### **2.1. Is liver biopsy always necessary?**

With regards to the technique used to carry out the liver biopsy there has also been a major change, it used to be performed blindly by clinicians, specialists in gastroenterology or hep‐ atology at the patient's bed whereas at present, percutaneous biopsies are performed pri‐

Currently, a liver biopsy can be obtained either transvenously or transcutaneously, or by combining imaging modalities such as ultrasound, computed tomography, and laparosco‐ py. The choice of one technique over another is based on availability, personal preference,

**•** Percutaneous liver biopsy can be transthoracic, with an intercostal liver access or subcos‐ tal, when the patient has an enlarged liver extending below the costal margin. Clinicians

**•** Transjugular or transvenous liver biopsy was first described in 1964. It is a technique used in order to avoid percutaneous liver biopsy in patients who are at a higher risk of bleed‐ ing. However, it has its limitations and is considered an inferior biopsy due to the frag‐ mentation of the obtained specimen, which may reduce the accuracy of the diagnosis. It is performed in a vascular catheterisation laboratory by a radiologist with special training in interventional radiology. Videofluoroscopy equipment and cardiac monitoring are man‐ datory due to the risk of cardiac arrhythmia as the catheter passes through the right at‐ rium. With this method, hepatic venography, wedged hepatic venous pressure, caval pressure and atrial pressure measurements can also be obtained during the procedure. The most frequent indications for the transjugular route are: severe coagulopathy, ascites,

**•** Laparoscopic liver biopsy. This technique is well established and its use varies between centers. It is indicated in centers where access to transvenous liver biopsy is not available, and in patients with focal liver lesions and coagulopathy for whom obtaining histology is

The decision to use a particular technique is based on the risk profile of the patient. If he or she has advanced liver failure with coagulopathy and ascites, liver biopsy is unnecessary, but the diagnosis of the underlying disease is crucial in specific circumstances in order to determine a therapy, for example in cases of liver transplant. Before a liver biopsy it is nec‐ essary to carry out an ultrasound to quantify vascular permeability and because it may rule out anatomical abnormalities and can identify mass lesions that are clinically silent. When cirrhosis is suspected on clinical grounds, or by non-invasive methods liver biopsy is usual‐

**Absolute contraindications:** the main contraindication to percutaneous liver biopsy is significant coagulopathy, others are: uncooperative patient, history of unexplained bleed‐

have now discarded blind liver biopsies in favour of ultrasound-guided biopsies.

Liver biopsy techniques: Percutaneous, transjugular or laparoscopic

obesity, suspected vascular tumour or peliosis hepatis.

**2. Contraindications to percutaneous liver biopsy**

essential for their management.

ly avoided.

marily by radiologists.

34 Liver Biopsy – Indications, Procedures, Results

and the clinical situation.

The utility of routine liver biopsy has been the subject of debate in recent years. Due to liver biopsy being associated with a small but definite risk, a biopsy should only be performed when the findings contribute to a better management of the patient. It is argued that for the purposes of management, liver biopsy is neither needed in cases with advanced fibrosis nor those diagnosed with cirrhosis by other methods, nor in patients with mild disease, for whom a therapeutic decision is not urgent. Until recently, liver biopsy played a key role in the evaluation of chronic liver disease, but now in the presence of better diagnostic tests on disease etiologies and treatments its role has to be re-evaluated. Recognition and confirma‐ tion of the pattern of injury (chronic hepatitic, chronic cholestatic, steatohepatitic, etc.) is the pathologist's priority when evaluating the liver biopsy.

Moreover, liver biopsy provides information on the severity and distribution of lesions (co‐ dified in the staging and grading of chronic liver disease), the presence of confounding pat‐ terns of injury (such as steatohepatitis coexisting with chronic viral hepatitis), and the presence of additional findings such as steatosis or iron accumulation that may have prog‐ nostic or therapeutic relevance.

**•** In cholestatic liver diseases: primary biliary cirrhosis, primary sclerosing cholangitis and

Rethinking the Role of Liver Biopsy in the Era of Personalized Medicine

http://dx.doi.org/10.5772/53120

37

**•** Evaluation of abnormal results of biochemical tests of the liver in association with a sero‐

**•** Evaluation of the efficacy or the adverse effects of treatment regimens (e.g.,methotrexate

**•** Alcohol related disease. Non-alcoholic fatty liver disease (NAFLD) or Non-alcoholic stea‐

**•** Evaluation of the status of the liver post transplantation or of the donor liver pre trans‐

Liver samples should be fixed in 10% neutral buffered formalin because this enables all rou‐ tine histochemical and immunohistochemical staining to be carried out. A small portion of the sample could be snap-frozen for adjunctive molecular studies for diagnostic or research

As for stains, a good collagen stain to assess fibrosis is mandatory. Perls' stain for iron is rec‐ ommended and the Periodic Acid-Schiff (PAS) stain with and without diastase digestion is

Special stains for special circumstances are ordered if indicated by the clinical situation. For instance, the Ziehl-Nielsen is ordered for mycobacteria, and Grocott's silver methanamine stain is used when granulomas are observed or when fungi infection is suspected. The Con‐ go Red stain is requested when amyloid is suspected to be present Rhodamine stain, Victo‐ ria blue or orcein stain is used to detect copper deposition when there is clinical suspicion of Wilson's disease. Immunohistochemistry is used to confirm the presence of Hepatitis B sur‐

The pathological report that used to be too descriptive now has to include etiology, aspects

In order to promote the clinico-pathological diagnostic correlation with the intention of im‐ proving communication and clarifying individual cases, regular meetings between clinicians

**•** Diagnosis of a liver mass, in selected cases, when image tests are inconclusive. **•** Evaluation of fever of unknown origin, with an eventual culture of liver tissue.

purposes, particularly when multiple etiologies are clinically suspected.

Cultures could be indicated in selected cases such as Mycobacterias [11].

useful for assessing hepatocyte cytoplasm glucogen content.

**5. Histologic diagnosis and clinical correlation**

face antigen and Hepatitis B core antigen [10].

related to prognosis and possible therapy [12,13].

overlap syndromes.

therapy for psoriasis).

tohepatitis (NASH).

plantation.

logic workup that is negative or inconclusive

**4. Methods: How to handle a liver biopsy**

#### **2.2. Who should be biopsied?**

As a rule patients with standard clinical and radiological features are not biopsied. Howev‐ er, in the presence of non concordant or atypical results, a biopsy may be recommended. The decision whether to perform a liver biopsy in some patients is clear, however in cases with a suspected concomitant diagnosis or when results from other methods are non conclu‐ sive confirmation is needed [8,9].


**Table 2.** Patterns of liver cell injury found in liver biopsies and clinical differential diagnosis
