**7. Use of liver biopsy in clinical practice**

Here we will discuss some of the most prominent findings of liver biopsy in the following clinical settings:


and pathologists are necessary. It is not only important to hold formal conferences but also to increase daily exchanges. To facilitate the communication between pathologists, radiologists, surgeons and clinicians it is desirable, when feasible, for the same teams to work together.

In order to produce a clinically relevant liver histology report pathologists should follow the

**1.** The adequacy of the biopsy should be assessed by measuring the length of the speci‐ men and counting the number of portal tracts. The data should be written up in the fi‐ nal report to make clinicians aware of any potential sampling error in the grading and staging. To reduce sampling error the amount of tissue required is usually 1 to 4 cm

**2.** The type and severity of necroinflammation and fibrosis should be described in words. By only using numbers to report the presence or not of bridging necrosis for example, some clinically useful information might be omitted. A validated scoring system should

**3.** As well as being described, the existence of adjunt data should be scored subjectively, such as steatosis graded on a scale of 0-3 and siderosis graded on a scale of 0-4.

**•** Differentiating viral hepatitis from other chronic disorders, such as cell dysplasia and

**•** Using immunostaining when appropriate, for example Hepatitis B Virus antigens

**5.** Chronic viral hepatitis, primary biliary cirrhosis and autoimmune hepatitis have typical histological lesions and it is advisable to consider the characteristics of: portal tract in‐ flammation, interface hepatitis, lobular necrosis and bile duct damage, separately [15]. **6.** Concomitant histological features in liver specimens of hepatitis C cases: auto-immuni‐ ty, co-infections, steatosis, hemosiderosis, malignancy –related changes, hepatitis due to drugs and/or vascular problems. Furthermore, biopsy frequently detects associated le‐ sions such as steatosis or steatohepatitis providing information related to management

**7.** Finally the conclusions should be written in order to make the histological diagnosis, stating whether the pathological findings are consistent with chronic hepatitis or not, whether a specific viral etiology may be suspected or whether there are changes related

**6. Writing the histology report**

38 Liver Biopsy – Indications, Procedures, Results

internationally accepted guidelines.

[14].

long and needs to include at least four portal tracts.

be used for grade of activity and stage of fibrosis.

**•** Searching for any concomitant diseases.

and prognosis of patients with chronic hepatitis C.

to concomitant diseases, specifying which.

**4.** Other diagnostic criteria may be useful in differential diagnoses:

thus separately reporting the presence of cell changes.


#### **7.1. Chronic viral hepatitis C and B**

In the past the majority of liver biopsies were performed in chronic hepatitis C patients. However, recently this has changed, due to a better understanding of the etiology, patho‐ genesis, the natural history of the disease and available therapies.

As the ability to treat hepatitis C effectively improves, the value of information gained from a liver biopsy decreases. The most effective therapy currently available, a combination of pegy‐ lated interferon α and ribavirin, can induce sustained viral clearance, implying a definitive cure and improved long term prognosis. This occurs, after anti-viral treatment in up to 80% of patients infected with genotypes 2 and 3. In patients with genotype 1 receiving recently ap‐ proved telaprevir and boceprevir, triple therapy constituents, an average of 70-75% can ach‐ ieve sustained viral clearance. Due to the high percentage of positive response in persons with genotypes 2 and 3, the need for a liver biopsy in such cases has been questioned.

breakpoints between grades. Although the intrinsic mechanism and involved factors for ac‐ celerated fibrosis are unclear, steatosis has been associated with increased inflammation,

**Utility of biopsy in hepatitis C.** Nowadays, the majority of Hepatitis C patients can be man‐ aged without having to undergo a liver biopsy since liver biopsy rarely identifies unsuspect‐ ed etiology and hepatitis C diagnosis relies on blood antibody and HCV RNA determinations. However, a biopsy allows to identify patients most in need of therapy or to find clinically unsuspected cirrhosis, which when found it is necessary to screen for varices

Moreover clinical and laboratory surrogates for biopsy may be useful in identifying cirrho‐ sis and biopsy is not necessary if clinical, image and analytical data concur. Post-treatment biopsy is not needed, nevertheless a new liver biopsy, could be performed if new treatments

**METAVIR, 1994**

Enlargement of portal tracts

5 Marked bridging with

6 Cirrhosis probable or

**Table 4.** Comparison of commonly used scoring systems for fibrosis staging in chronic Hepatitis C

**Batts and Ludwig, 1995**

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

Periportal fibrosis

**Ishak et al. 1995 [20]**

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

41

some portal areas, with or without short fibrous

Fibrous expansion of most portal areas, with or without short septa

most portal areas with occasional portal to portal bridging

portal areas with marked bridging (portal to portal as well as portal to

occasional nodules (incomplete cirrhosis)

Portal fibrosis Fibrous expansion of

septa

Septal fibrosis Fibrous expansion of

Cirrhosis Fibrous expansion of

central)

definite

**[19]**

**[18]**

0 No Fibrosis No Fibrosis No Fibrosis No Fibrosis No Fibrosis

hepatocellular apoptosis and the presence of perisinusoidal fibrosis [22].

or clinical trials arrive in order to stratify patients by prognosis.

**Scheuer, 1991**

Enlarged fibrotic portal tracts

portal-portal septa but intact architecture

Fibrosis with architectural distortion but no obvious cirrhosis

definite cirrhosis

**[17]**

and hepatocellular carcinoma.

**Fibrosis stage Knodell et al.**

1 Fibrous portal

3 Bridging

**1981 [16]**

expansion

2 Periportal or

Fibrosis (portalportal or portalcentral linkage

4 Cirrhosis Probable or

The terminology used to assess the appearance of liver biopsies with chronic viral hepatitis has also evolved.

The first classification of chronic hepatitis based on histological criteria was published in 1968. At that time, only three diseases causing chronic hepatitis could be diagnosed, hepati‐ tis B, non A-non B (hepatitis C, since 1989) and autoimmune hepatitis. This classification which also had prognostic implications only had two categories, namely "chronic persistent hepatitis" and "chronic active hepatitis". Three years later, the term chronic lobular hepatitis was added to represent findings similar to those observed in acute hepatitis.

During the 1990s, there were great changes in the understanding of chronic viral hepatitis by pathologists and hepatologists. The new concepts recognized that the traditional catego‐ rization of pathologic changes (chronic persistent hepatitis, chronic lobular hepatitis, and chronic active hepatitis) was inadequate for assessing histological changes during clinical trials. Pathologic processes were separated rather than considered as part of a continuum of pathologic changes that occur in chronic hepatitis C. Pathologists introduced the idea of staging for fibrosis and grading for the inflammatory component to the pathological evalua‐ tion of chronic hepatitis C.

#### *7.1.1. Grading and staging of chronic hepatitis C Scoring Systems (Table 4) [16-20]*

Grading is the assessment of the activity of a disease, which may increase and decrease as a disease flares and subsides, or may remain static throughout the disease.

Grade and stage evaluation is a standard part of the pathologic assessment of liver biopsies in chronic hepatitis. Pathological staging has focused on the assessment of fibrosis as the best surrogate marker of the disease process. Staging divides the fibrotic continuum into discrete categories and all of the existing staging systems have cirrhosis as their highest stage. Several systems exist for grading and staging of chronic hepatitis and all have been used effectively to assess changes in pathology following therapeutic intervention. These systems include the methods of Scheuer, Desmet, Batts and Ludwig,and the METAVIR system used to score indi‐ vidual features of inflammation and fibrosis semi-quantitatively in clinical studies [14-20].

Steatosis and Steatohepatitis in chronic hepatitis C Steatosis in hepatitis C is mainly macro‐ vesicular and a common finding in genotype 3 [21] it is also related to a high body mass in‐ dex and older age. More recently, steatosis has been recognized as a feature worthy of study, from an etiologic standpoint and especially in terms of its clinical significance. Esti‐ mation of the degree of steatosis has been hampered by the lack of standard definitions and breakpoints between grades. Although the intrinsic mechanism and involved factors for ac‐ celerated fibrosis are unclear, steatosis has been associated with increased inflammation, hepatocellular apoptosis and the presence of perisinusoidal fibrosis [22].

As the ability to treat hepatitis C effectively improves, the value of information gained from a liver biopsy decreases. The most effective therapy currently available, a combination of pegy‐ lated interferon α and ribavirin, can induce sustained viral clearance, implying a definitive cure and improved long term prognosis. This occurs, after anti-viral treatment in up to 80% of patients infected with genotypes 2 and 3. In patients with genotype 1 receiving recently ap‐ proved telaprevir and boceprevir, triple therapy constituents, an average of 70-75% can ach‐ ieve sustained viral clearance. Due to the high percentage of positive response in persons with

The terminology used to assess the appearance of liver biopsies with chronic viral hepatitis

The first classification of chronic hepatitis based on histological criteria was published in 1968. At that time, only three diseases causing chronic hepatitis could be diagnosed, hepati‐ tis B, non A-non B (hepatitis C, since 1989) and autoimmune hepatitis. This classification which also had prognostic implications only had two categories, namely "chronic persistent hepatitis" and "chronic active hepatitis". Three years later, the term chronic lobular hepatitis

During the 1990s, there were great changes in the understanding of chronic viral hepatitis by pathologists and hepatologists. The new concepts recognized that the traditional catego‐ rization of pathologic changes (chronic persistent hepatitis, chronic lobular hepatitis, and chronic active hepatitis) was inadequate for assessing histological changes during clinical trials. Pathologic processes were separated rather than considered as part of a continuum of pathologic changes that occur in chronic hepatitis C. Pathologists introduced the idea of staging for fibrosis and grading for the inflammatory component to the pathological evalua‐

Grading is the assessment of the activity of a disease, which may increase and decrease as a

Grade and stage evaluation is a standard part of the pathologic assessment of liver biopsies in chronic hepatitis. Pathological staging has focused on the assessment of fibrosis as the best surrogate marker of the disease process. Staging divides the fibrotic continuum into discrete categories and all of the existing staging systems have cirrhosis as their highest stage. Several systems exist for grading and staging of chronic hepatitis and all have been used effectively to assess changes in pathology following therapeutic intervention. These systems include the methods of Scheuer, Desmet, Batts and Ludwig,and the METAVIR system used to score indi‐ vidual features of inflammation and fibrosis semi-quantitatively in clinical studies [14-20].

Steatosis and Steatohepatitis in chronic hepatitis C Steatosis in hepatitis C is mainly macro‐ vesicular and a common finding in genotype 3 [21] it is also related to a high body mass in‐ dex and older age. More recently, steatosis has been recognized as a feature worthy of study, from an etiologic standpoint and especially in terms of its clinical significance. Esti‐ mation of the degree of steatosis has been hampered by the lack of standard definitions and

genotypes 2 and 3, the need for a liver biopsy in such cases has been questioned.

was added to represent findings similar to those observed in acute hepatitis.

*7.1.1. Grading and staging of chronic hepatitis C Scoring Systems (Table 4) [16-20]*

disease flares and subsides, or may remain static throughout the disease.

has also evolved.

40 Liver Biopsy – Indications, Procedures, Results

tion of chronic hepatitis C.

**Utility of biopsy in hepatitis C.** Nowadays, the majority of Hepatitis C patients can be man‐ aged without having to undergo a liver biopsy since liver biopsy rarely identifies unsuspect‐ ed etiology and hepatitis C diagnosis relies on blood antibody and HCV RNA determinations. However, a biopsy allows to identify patients most in need of therapy or to find clinically unsuspected cirrhosis, which when found it is necessary to screen for varices and hepatocellular carcinoma.

Moreover clinical and laboratory surrogates for biopsy may be useful in identifying cirrho‐ sis and biopsy is not necessary if clinical, image and analytical data concur. Post-treatment biopsy is not needed, nevertheless a new liver biopsy, could be performed if new treatments or clinical trials arrive in order to stratify patients by prognosis.


**Table 4.** Comparison of commonly used scoring systems for fibrosis staging in chronic Hepatitis C

#### *7.1.2. Natural history*

The degree of inflammation, fibrosis stage, and steatosis seen on liver biopsy are key histo‐ logical predictors of progression to cirrhosis. (Table 5) (see page 28).

biopsy that help to predict etiology chronic hepatitis B may show some of the changes described previously, as well as a ground-glass change to the cell cytoplasm. This change reflects accumulation of hepatitis B surface antigen within the endoplasmic retic‐

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

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

43

Chronic hepatitis C may be associated with prominent lymphoid aggregates within portal tracts, sometimes including germinal centers and, occasionally, bile duct damage, although not to the degree seen in line primary biliary disorders. In addition, biopsies may show fo‐

**Patterns of liver cell injury found in liver biopsy and differential diagnosis**. Chronic viral hepatitis have no unique histopathologic features, it is therefore necessary to consider vari‐ ous causes. In addition to viral infection, chronic hepatitis may be autoimmune or drug re‐ lated. Histological features of chronic cholestatic disease, including PBC, primary sclerosing cholangitis (PSC), autoimmune cholangitis, as well as metabolic diseases including Wilson disease and α1-antitrypsin deficiency, may overlap with some of the findings with "so

Many rare diseases originate in the liver, either affecting the liver directly or causing extrahepatic disease [31]. For example, liver histology is usually normal in primary hyperoxaluria while the kidneys and other organs may be irreparably damaged; however, cure is only pos‐ sible with a liver transplant. In other inherited disorders, the liver disease may remain asymptomatic until precipitous acute liver failure develops; the classic example is Wilson

*7.2.1. Hematochromatosis: The role of liver biopsy in the diagnosis of hepatic iron overload in the era*

Hemochromatosis is an autosomal recessive disorder that leads to massive deposits of iron in many organs, including liver, pancreas, heart, joints, and skin. The gene responsible for hereditary hemochromatosis, HFE, is located on chromosome 6. The two most common mu‐ tations are C282Y (present in up to 80% of cases) and H63D. The defining characteristic of this disease is the failure to prevent unneeded iron from entering the circulatory pool as a result of genetic changes compromising the synthesis or activity of hepcidin, the iron hor‐ mone.Hemochromatosis results from the interaction between genetic and acquired factors. Depending on the underlying mutation, the coinheritance of modifier genes, the presence of nongenetic hepcidin inhibitors, and other host-related factors, clinical manifestation may vary from simple biochemical abnormalities to severe multiorgan disease [33]. The indica‐ tion of a liver biopsy in the era of genetic testing is being questioned. But, in our opinion, liver biopsy continues to play an important role in the diagnosis, prognosis and manage‐ ment of patients with elevated serum ferritin and abnormal liver function test results in gen‐ eral hepatology practice. Genetic tests for HFE mutations (C282Y, H63D) and liver biopsies

disease. Here we present the diseases most frequently observed in adult patients.

ulum of the hepatocytes [29].

called" chronic hepatitis.

*of genetic testing [32]*

are complementary in the workup of these patients.

**7.2. Metabolic liver diseases**

cal, nonzonal macrovesicular steatosis [30].

Based on retrospective data, it has been shown that most patients with moderate inflamma‐ tion on initial liver biopsy developed cirrhosis after 20 years, and nearly all patients with se‐ vere inflammation or bridging fibrosis developed cirrhosis in 10 years. Patients with mild inflammation and/or minimal fibrosis have a low risk of progression to cirrhosis. Hepatic steatosis is also an emerging risk factor for fibrosis progression in hepatitis C [22]. Clinical information may help to refine prognosis, but cannot substitute the valuable information ob‐ tained from a liver biopsy. Poynard's group showed three clinical factors which are inde‐ pendently associated with faster progression of fibrosis: male, aged over 40 at the time of infection, and having a daily alcohol consumption of 50 grams or more [23]. Other factors predicting progression to cirrhosis include immunosuppression and co-infection with hepa‐ titis B or HIV [24].

Utility of biopsy in hepatitis B Liver biopsy is not mandatory but may show moderate or severe inflammation which is why before starting antivirals, usually for a long period, our protocol is to perform a liver biopsy and to individualize the therapeutic decision [25]. It has been proved that long-term therapy may improve histology but the role of serial liver biop‐ sies has yet to be established outside of clinical trials. Fibroscan has yet to be validated for patients with chronic hepatitis B but research on this is ongoing [26].

It is important to identify cirrhosis to indicate anti-hepatitis B therapy and hepatocellular carcinoma screening is also recommended for all hepatitis B surface antigen-positive (HBsAg+) patients, cirrhotic or not. New guidelines on anti-HBV treatment say that it is ad‐ visable to treat patients with elevated DNA-HBV and minimally elevated or fluctuating ala‐ nine aminotransferase (ALT), [27, 28].

Features typical of chronic viral hepatitis inflammation, like fibrosis, is considered to be one of the key characteristics of chronic viral hepatitis. It is a chronic necroinflammatory process in which hepatocytes are preferentially injured compared with bile ducts. The grade of in‐ flammation is a stratification of the overall necroinflammatory changes into mild, moderate, and marked categories. Unlike the fibrosis systems, which are based on distinctive architec‐ tural changes that can be highlighted with special stains, assessment of inflammation is more subjective and hence shows more interobserver variations. Usually varying degrees of portal and periportal inflammation(with lymphocytes, plasma cells, and macrophages), lo‐ bulillar hepatitis, and fibrosis are to be individually considered and scored.

Interface hepatitis occurs when the inflammatory infiltrate crosses the limiting plate; it is usually associated with local hepatocyte damage, piecemeal necrosis, and inflammation.

Lobular inflammation is accompanied by some hepatocellular necrosis (acidophilic or Councilman bodies). Chronic hepatitis leads to progressive fibrosis and, without treat‐ ment, to cirrhosis. The fibrosis begins in portal areas, extends to periportal areas, bridg‐ ing also other portal tracts and central veins. Histopathological findings in the liver biopsy that help to predict etiology chronic hepatitis B may show some of the changes described previously, as well as a ground-glass change to the cell cytoplasm. This change reflects accumulation of hepatitis B surface antigen within the endoplasmic retic‐ ulum of the hepatocytes [29].

Chronic hepatitis C may be associated with prominent lymphoid aggregates within portal tracts, sometimes including germinal centers and, occasionally, bile duct damage, although not to the degree seen in line primary biliary disorders. In addition, biopsies may show fo‐ cal, nonzonal macrovesicular steatosis [30].

**Patterns of liver cell injury found in liver biopsy and differential diagnosis**. Chronic viral hepatitis have no unique histopathologic features, it is therefore necessary to consider vari‐ ous causes. In addition to viral infection, chronic hepatitis may be autoimmune or drug re‐ lated. Histological features of chronic cholestatic disease, including PBC, primary sclerosing cholangitis (PSC), autoimmune cholangitis, as well as metabolic diseases including Wilson disease and α1-antitrypsin deficiency, may overlap with some of the findings with "so called" chronic hepatitis.

#### **7.2. Metabolic liver diseases**

*7.1.2. Natural history*

42 Liver Biopsy – Indications, Procedures, Results

titis B or HIV [24].

nine aminotransferase (ALT), [27, 28].

The degree of inflammation, fibrosis stage, and steatosis seen on liver biopsy are key histo‐

Based on retrospective data, it has been shown that most patients with moderate inflamma‐ tion on initial liver biopsy developed cirrhosis after 20 years, and nearly all patients with se‐ vere inflammation or bridging fibrosis developed cirrhosis in 10 years. Patients with mild inflammation and/or minimal fibrosis have a low risk of progression to cirrhosis. Hepatic steatosis is also an emerging risk factor for fibrosis progression in hepatitis C [22]. Clinical information may help to refine prognosis, but cannot substitute the valuable information ob‐ tained from a liver biopsy. Poynard's group showed three clinical factors which are inde‐ pendently associated with faster progression of fibrosis: male, aged over 40 at the time of infection, and having a daily alcohol consumption of 50 grams or more [23]. Other factors predicting progression to cirrhosis include immunosuppression and co-infection with hepa‐

Utility of biopsy in hepatitis B Liver biopsy is not mandatory but may show moderate or severe inflammation which is why before starting antivirals, usually for a long period, our protocol is to perform a liver biopsy and to individualize the therapeutic decision [25]. It has been proved that long-term therapy may improve histology but the role of serial liver biop‐ sies has yet to be established outside of clinical trials. Fibroscan has yet to be validated for

It is important to identify cirrhosis to indicate anti-hepatitis B therapy and hepatocellular carcinoma screening is also recommended for all hepatitis B surface antigen-positive (HBsAg+) patients, cirrhotic or not. New guidelines on anti-HBV treatment say that it is ad‐ visable to treat patients with elevated DNA-HBV and minimally elevated or fluctuating ala‐

Features typical of chronic viral hepatitis inflammation, like fibrosis, is considered to be one of the key characteristics of chronic viral hepatitis. It is a chronic necroinflammatory process in which hepatocytes are preferentially injured compared with bile ducts. The grade of in‐ flammation is a stratification of the overall necroinflammatory changes into mild, moderate, and marked categories. Unlike the fibrosis systems, which are based on distinctive architec‐ tural changes that can be highlighted with special stains, assessment of inflammation is more subjective and hence shows more interobserver variations. Usually varying degrees of portal and periportal inflammation(with lymphocytes, plasma cells, and macrophages), lo‐

Interface hepatitis occurs when the inflammatory infiltrate crosses the limiting plate; it is usually associated with local hepatocyte damage, piecemeal necrosis, and inflammation.

Lobular inflammation is accompanied by some hepatocellular necrosis (acidophilic or Councilman bodies). Chronic hepatitis leads to progressive fibrosis and, without treat‐ ment, to cirrhosis. The fibrosis begins in portal areas, extends to periportal areas, bridg‐ ing also other portal tracts and central veins. Histopathological findings in the liver

logical predictors of progression to cirrhosis. (Table 5) (see page 28).

patients with chronic hepatitis B but research on this is ongoing [26].

bulillar hepatitis, and fibrosis are to be individually considered and scored.

Many rare diseases originate in the liver, either affecting the liver directly or causing extrahepatic disease [31]. For example, liver histology is usually normal in primary hyperoxaluria while the kidneys and other organs may be irreparably damaged; however, cure is only pos‐ sible with a liver transplant. In other inherited disorders, the liver disease may remain asymptomatic until precipitous acute liver failure develops; the classic example is Wilson disease. Here we present the diseases most frequently observed in adult patients.

#### *7.2.1. Hematochromatosis: The role of liver biopsy in the diagnosis of hepatic iron overload in the era of genetic testing [32]*

Hemochromatosis is an autosomal recessive disorder that leads to massive deposits of iron in many organs, including liver, pancreas, heart, joints, and skin. The gene responsible for hereditary hemochromatosis, HFE, is located on chromosome 6. The two most common mu‐ tations are C282Y (present in up to 80% of cases) and H63D. The defining characteristic of this disease is the failure to prevent unneeded iron from entering the circulatory pool as a result of genetic changes compromising the synthesis or activity of hepcidin, the iron hor‐ mone.Hemochromatosis results from the interaction between genetic and acquired factors. Depending on the underlying mutation, the coinheritance of modifier genes, the presence of nongenetic hepcidin inhibitors, and other host-related factors, clinical manifestation may vary from simple biochemical abnormalities to severe multiorgan disease [33]. The indica‐ tion of a liver biopsy in the era of genetic testing is being questioned. But, in our opinion, liver biopsy continues to play an important role in the diagnosis, prognosis and manage‐ ment of patients with elevated serum ferritin and abnormal liver function test results in gen‐ eral hepatology practice. Genetic tests for HFE mutations (C282Y, H63D) and liver biopsies are complementary in the workup of these patients.

Liver biopsy allows a quantitative iron concentration study and the identification of the grade of hepatic iron overload, localization pattern and associated liver pathology for diag‐ nosis and management of patients [34].

*7.2.3. The role of liver biopsy in determining the diagnosis of Wilson disease*

a severe hepatic failure that may require an urgent liver transplant [40].

*7.2.4. Alfa1 -antitrypsin (A1-AT) deficiency on liver biopsy*

son clinical correlation is required [41].

tients of all ages, sexes, and races [42].

**7.3. Autoimmune Hepatitis (AIH)**

mortality above 50%.

Wilson disease is an autosomal recessive disorder of copper metabolism, characterized by excessive accumulation of copper in the liver and other organs. Genetic evaluation is diffi‐ cult because most patients are compound heterozygotes. For patients with Wilson disease the norm is to perform a liver biopsy with a quantitative copper testing of the liver; levels are typically greater than 250 mg/g dry weight liver (normal level, 38 mg/g) [39].When the diagnosis of Wilson disease is considered prior to liver biopsy other tests are undertaken. - Serum ceruloplasmin (less than 20 mg/dL in patients with Wilson disease; normal levels, 23 to 50 mg/dL). - 24-hour urinary copper (greater than 100 mg/dL; normal, less than 30 mg/ dL). -Kayser-Flescher ring has to be studied by ophthalmologic testing. The liver biopsy in this disease can present differently, depending on the patient's age. In children and young adolescents, the most common finding may be fatty change. In older adolescents and young adults, a liver biopsy may show chronic hepatitis with piecemeal necrosis. Adults tend to show cirrhosis, and Mallory bodies\*. In adolescents or adults, confluent necrosis may lead to

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

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

45

A1-AT is the major circulating inhibitor of serine proteases (Pi). Its primary target is the po‐ tent elastase found in polymorphonuclear cells (PMNs). It is a glycoprotein synthesized in the liver. Many of the Pi variants are associated with fairly normal serum concentrations and function and thus are of little clinical significance. However, a few, result in low circulating levels of α1-AT (i.e., PiZZ) and are of pathologic significance. Liver biopsies from affected patients demonstrate classic PAS-positive, diastase-resistant globules within periportal hep‐ atocytes. Portal fibrosis and chronic hepatitis may also be present. Liver cell dysplasia may be seen, and patients older than 50, especially men, are at risk of developing hepatocellular carcinoma. The presence of PAS-positive, diastase-resistant globules is not always diagnos‐ tic for A1-AT deficiency because various inflammatory conditions may be associated with overproduction of the enzyme, as is the case in cardiac congestion or hypoxia. For this rea‐

Autoimmune hepatitis (AIH) is an inflammatory condition of the liver that can affect pa‐

Timely diagnosis and immunosuppressive therapy may control disease activity in almost all affected patients and various case series have reported near normal or normal life expectan‐ cy in patients diagnosed and treated adequately [43]. Untreated AIH, however, has 5-year

It was first described as a form of chronic hepatitis in young women, showing jaundice, ele‐ vated gammaglobulins and amenorrhea, which eventually leads to cirrhosis. There is not a single test to diagnose AIH but a set of diagnostic criteria has been suggested in order to

classify patients as having probable or definite AIH depending on a score.

Liver biopsies may be relatively normal or show bridging fibrosis or even micronodular cir‐ rhosis. Untreated, hemochromatosis leads to the development of micronodular cirrhosis. Prior to the availability of genetic testing, the diagnosis of hemochromatosis was always de‐ termined with liver biopsy and quantitation of tissue iron. With the availability of genetic testing for the C282Y and/or H63D mutations, liver biopsy is more often reserved for evalu‐ ation of clinical status or complications (i.e. degree of fibrosis, development of hepatocellu‐ lar carcinoma) rather than for primary diagnosis [35]. A biopsy can also help determine if other disease processes are present, such as hepatitis C or fatty liver disease [36].

We suggest that patients with suspected hemochromatosis undergo genetic testing for the C282Y and H63D mutations, especially if they have a family history of hemochromatosis,in order to establish the genotype of the patient and permit genetic counseling. A liver biopsy may not be necessary in young C282Y homozygotes or in heterozygotes without evidence of liver disease.

Disorders that have to be considered in the clinical differential diagnosis of hemochromatosis

The list of disorders associated with increased hepatic iron is long. The majority of patients with hepatic iron accumulation from any cause do not have hepatic iron concentration (HIC) that is above the upper limit of normal (approximately 1100 mg/µg dry liver weight). Fur‐ thermore the pattern of distribution of the iron in the liver may be of some help in establish‐ ing the diagnosis [37]:


#### *7.2.2. Porphyria Cutanea Tarda (PCT)*

It is the most common form of porphyria across the world. PCT is usually an acquired liver disease caused by exogenous factors, such as excess alcohol intake, iron overload, chronic hepatitis C and oestrogen therapy.

The pathogenesis of PCT is varied; it may be hereditary or acquired, leading to hepatic iron loading and to an increase of oxidative stress. Iron loading is usually only mild or moderate in degree. However, in patients with excessive alcohol intake and/or chronic hepatitis C in‐ fection, hepcidin production by hepatocytes decreases. This decrease is responsible for in‐ creased iron absorption from the gut. The important role that PCT often plays in the hepatitis C virus setting has recently been emphasized [38].

#### *7.2.3. The role of liver biopsy in determining the diagnosis of Wilson disease*

Liver biopsy allows a quantitative iron concentration study and the identification of the grade of hepatic iron overload, localization pattern and associated liver pathology for diag‐

Liver biopsies may be relatively normal or show bridging fibrosis or even micronodular cir‐ rhosis. Untreated, hemochromatosis leads to the development of micronodular cirrhosis. Prior to the availability of genetic testing, the diagnosis of hemochromatosis was always de‐ termined with liver biopsy and quantitation of tissue iron. With the availability of genetic testing for the C282Y and/or H63D mutations, liver biopsy is more often reserved for evalu‐ ation of clinical status or complications (i.e. degree of fibrosis, development of hepatocellu‐ lar carcinoma) rather than for primary diagnosis [35]. A biopsy can also help determine if

We suggest that patients with suspected hemochromatosis undergo genetic testing for the C282Y and H63D mutations, especially if they have a family history of hemochromatosis,in order to establish the genotype of the patient and permit genetic counseling. A liver biopsy may not be necessary in young C282Y homozygotes or in heterozygotes without evidence of

Disorders that have to be considered in the clinical differential diagnosis of hemochromatosis

The list of disorders associated with increased hepatic iron is long. The majority of patients with hepatic iron accumulation from any cause do not have hepatic iron concentration (HIC) that is above the upper limit of normal (approximately 1100 mg/µg dry liver weight). Fur‐ thermore the pattern of distribution of the iron in the liver may be of some help in establish‐

**•** predominantly hepatocellular distribution of iron leads to a diagnosis of genetic hemo‐

**•** predominant presence of iron in Kupffer cells, may be the result of multiple transfusions

**•** a mixed distribution of iron may be a sign of megaloblastic anemia or anemia secondary

It is the most common form of porphyria across the world. PCT is usually an acquired liver disease caused by exogenous factors, such as excess alcohol intake, iron overload, chronic

The pathogenesis of PCT is varied; it may be hereditary or acquired, leading to hepatic iron loading and to an increase of oxidative stress. Iron loading is usually only mild or moderate in degree. However, in patients with excessive alcohol intake and/or chronic hepatitis C in‐ fection, hepcidin production by hepatocytes decreases. This decrease is responsible for in‐ creased iron absorption from the gut. The important role that PCT often plays in the

chromatosis, alcoholic liver disease and/or porphyria cutanea tarda.

other disease processes are present, such as hepatitis C or fatty liver disease [36].

nosis and management of patients [34].

44 Liver Biopsy – Indications, Procedures, Results

liver disease.

ing the diagnosis [37]:

and/or hemolytic anemias.

*7.2.2. Porphyria Cutanea Tarda (PCT)*

hepatitis C and oestrogen therapy.

hepatitis C virus setting has recently been emphasized [38].

to chronic infection.

Wilson disease is an autosomal recessive disorder of copper metabolism, characterized by excessive accumulation of copper in the liver and other organs. Genetic evaluation is diffi‐ cult because most patients are compound heterozygotes. For patients with Wilson disease the norm is to perform a liver biopsy with a quantitative copper testing of the liver; levels are typically greater than 250 mg/g dry weight liver (normal level, 38 mg/g) [39].When the diagnosis of Wilson disease is considered prior to liver biopsy other tests are undertaken. - Serum ceruloplasmin (less than 20 mg/dL in patients with Wilson disease; normal levels, 23 to 50 mg/dL). - 24-hour urinary copper (greater than 100 mg/dL; normal, less than 30 mg/ dL). -Kayser-Flescher ring has to be studied by ophthalmologic testing. The liver biopsy in this disease can present differently, depending on the patient's age. In children and young adolescents, the most common finding may be fatty change. In older adolescents and young adults, a liver biopsy may show chronic hepatitis with piecemeal necrosis. Adults tend to show cirrhosis, and Mallory bodies\*. In adolescents or adults, confluent necrosis may lead to a severe hepatic failure that may require an urgent liver transplant [40].

### *7.2.4. Alfa1 -antitrypsin (A1-AT) deficiency on liver biopsy*

A1-AT is the major circulating inhibitor of serine proteases (Pi). Its primary target is the po‐ tent elastase found in polymorphonuclear cells (PMNs). It is a glycoprotein synthesized in the liver. Many of the Pi variants are associated with fairly normal serum concentrations and function and thus are of little clinical significance. However, a few, result in low circulating levels of α1-AT (i.e., PiZZ) and are of pathologic significance. Liver biopsies from affected patients demonstrate classic PAS-positive, diastase-resistant globules within periportal hep‐ atocytes. Portal fibrosis and chronic hepatitis may also be present. Liver cell dysplasia may be seen, and patients older than 50, especially men, are at risk of developing hepatocellular carcinoma. The presence of PAS-positive, diastase-resistant globules is not always diagnos‐ tic for A1-AT deficiency because various inflammatory conditions may be associated with overproduction of the enzyme, as is the case in cardiac congestion or hypoxia. For this rea‐ son clinical correlation is required [41].

#### **7.3. Autoimmune Hepatitis (AIH)**

Autoimmune hepatitis (AIH) is an inflammatory condition of the liver that can affect pa‐ tients of all ages, sexes, and races [42].

Timely diagnosis and immunosuppressive therapy may control disease activity in almost all affected patients and various case series have reported near normal or normal life expectan‐ cy in patients diagnosed and treated adequately [43]. Untreated AIH, however, has 5-year mortality above 50%.

It was first described as a form of chronic hepatitis in young women, showing jaundice, ele‐ vated gammaglobulins and amenorrhea, which eventually leads to cirrhosis. There is not a single test to diagnose AIH but a set of diagnostic criteria has been suggested in order to classify patients as having probable or definite AIH depending on a score.

Clinical appearance ranges from an absence of symptoms to a severe fulminant presenta‐ tion. It is usually clinically associated with other autoimmune diseases such as rheumatoid arthritis, ulcerative colitis, autoimmune thyroiditis, or diabetes mellitus. A family history has been reported [44].

bile ductules (cholangioles) may also be present along the edges of the portal tracts. These changes are associated with features of chronic cholestasis, including feathery degeneration within the cytoplasm of hepatocytes, accumulation of bile pigment, periportal accumulation

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47

**- Stage 3** is associated with increasing fibrosis and bridging between portal areas, with de‐

**- Stage 4** represents biliary cirrhosis, usually micronodular. In the past the diagnosis was

Primary sclerosing cholangitis (PSC) is a disease with a variable clinical course, with obliter‐ ation of the biliary tree that leads to biliary cirrhosis and its complications such as portal hy‐ pertension and liver failure. The term "primary" is used to distinguish this condition from the bile duct strictures that are secondary to bile duct injury, cholelithiasis or ischaemia [50].

Patients may present with increased alkaline phosphatase and positive perinuclear anti‐ neutrophil cytoplasmic antibodies (pANCAs). In this disease, liver biopsy does not have a crucial role in the diagnosis. Ultrasound is used for the initial investigation and may show bile duct dilatation and liver and splenic changes; however, it is unspecific for PSC. [51,52]. The classic lesion of PSC in the histological study is onionskin or concentric periductular fibrosis, with damage to the ductal epithelium, but it is rarely seen on per‐ cutaneous biopsy. The most common findings on a biopsy in early-stage disease are non‐ specific [46], fibrosis with inflammation of portal tracts and paucity of normal bile ducts. In addition, in patients with extrahepatic obstruction, proliferation and dilatation of inter‐ lobular ducts and an increased number of periportal PMNs can be observed. Endoscopic retrograde cholangiopancreatography (ERCP) is the next choice test for diagnosis, but it is invasive, for this reason its role is under debate [53]. Transhepatic cholangiography can be used if ERCP is unsuccessful, but again is invasive. Non-invasive alternatives to ERCP are: magnetic resonance cholangiopancreatography (MRCP), which is increasingly used and is useful for excluding other disease and evaluating the biliary system [54]. Transient elastography (FibroScan®) has potential as a non-invasive method for detection

PSC shares many clinical biochemical and pathologic features with primary biliary cirrhosis, although PSC, can affect both intrahepatic and extrahepatic ducts. PSC is strongly associated with inflammatory bowel disease, particularly ulcerative colitis. Due to its major morbidity and mortality the diagnosis has to be confirmed. At the time of diagnosis, PSC typically in‐ volves both intra and extrahepatic bile ducts in the majority of cases. The most dismal se‐ quel of PSC is the development of colangio carcinoma (CC) in 14% of patients (which may

A wide spectrum of disease severity exists, ranging from patients who present with ad‐ vanced liver disease requiring liver transplantation within a short time to those who remain

not be demonstrable radiographically with the usual diagnostic methods) [56].

of copper (not generalized as in Wilson disease), and, occasionally, Mallory bodies\*.

done in very advanced disease, biliary cirrhosis, hence its name.

of cirrhosis in patients with more advanced liver disease [55].

creased amounts of inflammation.

*7.3.2. Primary Sclerosing Cholangitis (PSC)*

A liver biopsy should be obtained at first diagnosis before therapy for grading, staging and confirmation of the diagnosis. Histological appearance is not characteristic, although typical features such as periportal hepatitis with lymphocytic infiltrates, plasma cells and piecemeal necrosis, with more advanced disease bridging necrosis, are frequent. Variable degrees of portal fibrosis are present [45]. In non treated patients or in non-responsive to corticosteroid therapy cirrhosis eventually occurs.

Differential diagnosis which has been revisited recently by the International Autoimmune Hepatitis Group comprises: chronic hepatitis not caused by other etiologies (viral, drug-in‐ duced), acute hepatitis alone or acute hepatitis superimposed on underlying chronic liver disease and autoimmune diseases with associated duct damage and duct loss [47].

Early diagnosis may be difficult because the clinical picture is heterogeneous and the liver histology sometimes shows atypical features.

A simple and accurate diagnostic scoring system for AIH has been established but not totally validated yet. In 1993, the International Autoimmune Hepatitis Group (IAIHG) proposed specific diagnostic criteria, which were revised in 1999. These criteria were made by expert consensus and introduced to allow comparison of studies from different centers [46]. Some of the items were of questionable value which is why in 2008 the IAIHG published a new simplified scoring system for wider applicability in routine clini‐ cal practice, based on the data of patients with well-established diagnoses and validated in another group of patients [47].The new score includes autoantibodies, immunoglobu‐ lin G, histology, and exclusion of viral hepatitis, allowing a reliable diagnosis of AIH ap‐ plying simple scores.

#### *7.3.1. Primary Biliary Cirrhosis (PBC)*

PBC is a chronic progressive cholestatic liver disease that occurs in middle-aged patients, usually women, and is often associated with other autoimmune diseases. Patients may present with jaundice and pruritus in advanced cases. Laboratory testing reveals serum an‐ ti–mitochondrial antibody (AMA) as well as increased alkaline phosphatase, bilirubin, and γ-glutamyl transpeptidase [48]. The histological staging of PBC considers the degree of bile duct damage and fibrosis [49].

**- Stage 1** early disease is characterized by damage to septal and larger interlobular bile ducts, reflected by biliary epithelial damage with infiltration of the duct by lymphocytes, plasma cells, eosinophils, and rare polymorphs. The inflammatory infiltrate confined within the portal tract, may include granulomas and lymphoid follicles (florid duct lesion).

**- Stage 2** the inflammatory process extends beyond the portal tract, and changes of interface hepatitis (piecemeal necrosis) may be seen. Bile ducts begin to disappear and proliferation of

bile ductules (cholangioles) may also be present along the edges of the portal tracts. These changes are associated with features of chronic cholestasis, including feathery degeneration within the cytoplasm of hepatocytes, accumulation of bile pigment, periportal accumulation of copper (not generalized as in Wilson disease), and, occasionally, Mallory bodies\*.

**- Stage 3** is associated with increasing fibrosis and bridging between portal areas, with de‐ creased amounts of inflammation.

**- Stage 4** represents biliary cirrhosis, usually micronodular. In the past the diagnosis was done in very advanced disease, biliary cirrhosis, hence its name.

### *7.3.2. Primary Sclerosing Cholangitis (PSC)*

Clinical appearance ranges from an absence of symptoms to a severe fulminant presenta‐ tion. It is usually clinically associated with other autoimmune diseases such as rheumatoid arthritis, ulcerative colitis, autoimmune thyroiditis, or diabetes mellitus. A family history

A liver biopsy should be obtained at first diagnosis before therapy for grading, staging and confirmation of the diagnosis. Histological appearance is not characteristic, although typical features such as periportal hepatitis with lymphocytic infiltrates, plasma cells and piecemeal necrosis, with more advanced disease bridging necrosis, are frequent. Variable degrees of portal fibrosis are present [45]. In non treated patients or in non-responsive to corticosteroid

Differential diagnosis which has been revisited recently by the International Autoimmune Hepatitis Group comprises: chronic hepatitis not caused by other etiologies (viral, drug-in‐ duced), acute hepatitis alone or acute hepatitis superimposed on underlying chronic liver

Early diagnosis may be difficult because the clinical picture is heterogeneous and the liver

A simple and accurate diagnostic scoring system for AIH has been established but not totally validated yet. In 1993, the International Autoimmune Hepatitis Group (IAIHG) proposed specific diagnostic criteria, which were revised in 1999. These criteria were made by expert consensus and introduced to allow comparison of studies from different centers [46]. Some of the items were of questionable value which is why in 2008 the IAIHG published a new simplified scoring system for wider applicability in routine clini‐ cal practice, based on the data of patients with well-established diagnoses and validated in another group of patients [47].The new score includes autoantibodies, immunoglobu‐ lin G, histology, and exclusion of viral hepatitis, allowing a reliable diagnosis of AIH ap‐

PBC is a chronic progressive cholestatic liver disease that occurs in middle-aged patients, usually women, and is often associated with other autoimmune diseases. Patients may present with jaundice and pruritus in advanced cases. Laboratory testing reveals serum an‐ ti–mitochondrial antibody (AMA) as well as increased alkaline phosphatase, bilirubin, and γ-glutamyl transpeptidase [48]. The histological staging of PBC considers the degree of bile

**- Stage 1** early disease is characterized by damage to septal and larger interlobular bile ducts, reflected by biliary epithelial damage with infiltration of the duct by lymphocytes, plasma cells, eosinophils, and rare polymorphs. The inflammatory infiltrate confined within

**- Stage 2** the inflammatory process extends beyond the portal tract, and changes of interface hepatitis (piecemeal necrosis) may be seen. Bile ducts begin to disappear and proliferation of

the portal tract, may include granulomas and lymphoid follicles (florid duct lesion).

disease and autoimmune diseases with associated duct damage and duct loss [47].

has been reported [44].

46 Liver Biopsy – Indications, Procedures, Results

plying simple scores.

*7.3.1. Primary Biliary Cirrhosis (PBC)*

duct damage and fibrosis [49].

therapy cirrhosis eventually occurs.

histology sometimes shows atypical features.

Primary sclerosing cholangitis (PSC) is a disease with a variable clinical course, with obliter‐ ation of the biliary tree that leads to biliary cirrhosis and its complications such as portal hy‐ pertension and liver failure. The term "primary" is used to distinguish this condition from the bile duct strictures that are secondary to bile duct injury, cholelithiasis or ischaemia [50].

Patients may present with increased alkaline phosphatase and positive perinuclear anti‐ neutrophil cytoplasmic antibodies (pANCAs). In this disease, liver biopsy does not have a crucial role in the diagnosis. Ultrasound is used for the initial investigation and may show bile duct dilatation and liver and splenic changes; however, it is unspecific for PSC. [51,52]. The classic lesion of PSC in the histological study is onionskin or concentric periductular fibrosis, with damage to the ductal epithelium, but it is rarely seen on per‐ cutaneous biopsy. The most common findings on a biopsy in early-stage disease are non‐ specific [46], fibrosis with inflammation of portal tracts and paucity of normal bile ducts. In addition, in patients with extrahepatic obstruction, proliferation and dilatation of inter‐ lobular ducts and an increased number of periportal PMNs can be observed. Endoscopic retrograde cholangiopancreatography (ERCP) is the next choice test for diagnosis, but it is invasive, for this reason its role is under debate [53]. Transhepatic cholangiography can be used if ERCP is unsuccessful, but again is invasive. Non-invasive alternatives to ERCP are: magnetic resonance cholangiopancreatography (MRCP), which is increasingly used and is useful for excluding other disease and evaluating the biliary system [54]. Transient elastography (FibroScan®) has potential as a non-invasive method for detection of cirrhosis in patients with more advanced liver disease [55].

PSC shares many clinical biochemical and pathologic features with primary biliary cirrhosis, although PSC, can affect both intrahepatic and extrahepatic ducts. PSC is strongly associated with inflammatory bowel disease, particularly ulcerative colitis. Due to its major morbidity and mortality the diagnosis has to be confirmed. At the time of diagnosis, PSC typically in‐ volves both intra and extrahepatic bile ducts in the majority of cases. The most dismal se‐ quel of PSC is the development of colangio carcinoma (CC) in 14% of patients (which may not be demonstrable radiographically with the usual diagnostic methods) [56].

A wide spectrum of disease severity exists, ranging from patients who present with ad‐ vanced liver disease requiring liver transplantation within a short time to those who remain asymptomatic for decades. The natural course of PSC is determined by interindividual vari‐ ability, the rate of progression and the development of CC, which can occur at any time.

and portal tracts. When cirrhosis is fully developed, most of the native central veins have been obliterated. Alcoholic cirrhosis is micronodular and the scarring is relatively uniform throughout the liver. With complete alcohol abstinence, the nodules can regener‐ ate to a larger size, but the central veins are decreased in number and the nodules may

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

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49

**7.5. Non-Alcoholic Fatty Liver Disease, (NAFLD) and Non-Alcoholic Steatohepatitis,**

logical grounds alone. Clinical correlations are basic for its diagnosis [63].

The histological appearance in these disorders may be very similar to the injury related to alcohol. In non-alcoholic steatohepatitis, the liver exhibits fat and perivenular sinusoidal col‐ lagen deposition and may be indistinguishable from alcoholic perivenular fibrosis on histo‐

Sometimes a biopsy shows a pattern which looks like alcoholic hepatitis, but the patient de‐ nies alcohol use. A differential diagnosis for alcoholic hepatitis has to be done, and non-alco‐ holic fatty liver disease, (NALDF) and non-alcoholic steatohepatitis, (NASH) should be

For many decades, typical "alcoholic hepatitis" was often diagnosed with liver biopsy, and in some patients' medical records were completed with somewhat judgmental comments about their persistent denial of alcohol intake. Now, there are other known causes for Mallo‐ ry bodies (\*) and steatosis found in liver biopsies which, in the past, were classified as alco‐ hol related liver injury. In retrospect, we now know that many patients with "alcoholic

It is clear that similar patterns of injury can be seen in non-alcoholics, especially in the set‐ ting of diabetes and obesity, referred to as nonalcoholic steatohepatitis (NASH) or nonal‐ coholic fatty liver disease (NAFLD). This represents a significant form of chronic liver disease in both adults and children, with a spectrum ranging from indolent to end-stage liver disease. It may be an underlying cause of cryptogenic cirrhosis and has been report‐ ed to recur after a liver transplant. Other conditions associated with NASH include acute starvation, accelerated weight loss, intestinal bypass, disorders of lipid metabolism, and various drugs. Careful clinicopathologic correlation is required to determine the cause. Liver biopsy evaluation allows us to establish the degree of steatosis, inflammation, and

The diagnosis of liver steatosis has several implications in chronic liver diseases.

**•** Liver steatosis is associated with liver fibrosis progression and a decreased rate of sus‐

**•** Donor liver macrovesicular steatosis is independently associated with graft failure at one

**•** After major hepatic resection, liver steatosis induces an increased risk of post-operative

lack some portal tracts [62].

**(NASH)**

considered [63].

fibrosis stage [65]. **Liver steatosis**

hepatitis" were treated unfairly [64].

tained viral response in chronic hepatitis C.

complications and elevated risk of death.

year after liver transplantation.

The differential diagnosis has to be established among : autoimmune hepatitis, overlap syn‐ dromes, infectious hepatitis, other bile duct diseases presenting as acute or chronic cholangi‐ tis, and biliary strictures, cholangiocarcinoma, gallstones, hepatomegaly and primary biliary cirrhosis.

Liver biopsy in PSC is only needed to diagnose small-duct PSC or to exclude other diseases that may be associated with PSC or with similar features and confounding aspects. Liver bi‐ opsy also may be useful for staging the disease. However, serial liver biopsy in monitoring the disease is not indicated [57].

Recently some authors have developed the Mayo clinic risk score, a multivariate statistical survival model, on the basis of the long-term course of the disease in 486 PSC patients seen at three centers in United States. In this score, the need for liver biopsy has been eliminated. This scoring system has its advantages; it is non-invasive and was found to be well correlat‐ ed to actual survival. It also performs better than the Child-Pugh classification for cirrhosis, which does not predict survival with PSC [58].

#### *7.3.3. Autoimmune Hepatitis (AIH) with overlap variants*

Overlap syndromes of AIH are not uncommon but are not well defined. Histology, clinical and serological indicators imply more than one liver disease at the same time.

The diagnosis of an overlap syndrome relies on the biochemical profile, either cholestatic or hepatitic in addition to the auto-antibodies pattern and elevated gamma globulins. The his‐ topathology can show portal inflammation with or without involvement of bile ducts [59].

In adult patients with an overlap of PBC and AIH, which is the the most common, antinu‐ clear as well as antimitochondrial antibodies are present. Chronic hepatitis C may trigger autoimmune activation, with concomitant positive autoimmune antibodies. AIH may be as‐ sociated with Ig G4 autoimmune cholangitis (IAC). In contrast to PSC, IAC-IgG4, has no as‐ sociated intestinal bowel disease and pancreatitis [60].

The value of a biopsy in liver diseases such as PSC or suspected metastatic disease, which is characterized by a zonal affection of the liver has to be dealt with individually and complet‐ ed with other imaging techniques.

Liver biopsy is advisable if diagnostic tests show abnormal liver function results which may be indicative of many etiologies e.g. nonalcoholic steatohepatitis with strongly elevated anti‐ nuclear antibodies and abnormal iron studies, or co-infection with HIV and hepatitis C in a patient with abnormal liver function tests taking hepatotoxic drugs etc.

#### **7.4. Alcohol: Fibrous progression related to alcohol injury**

Many patients with ethanol injury show initial scarring around central veins with deli‐ cate fibrosis along the sinusoids [61]. Eventually, bridging fibrosis connects central veins and portal tracts. When cirrhosis is fully developed, most of the native central veins have been obliterated. Alcoholic cirrhosis is micronodular and the scarring is relatively uniform throughout the liver. With complete alcohol abstinence, the nodules can regener‐ ate to a larger size, but the central veins are decreased in number and the nodules may lack some portal tracts [62].

#### **7.5. Non-Alcoholic Fatty Liver Disease, (NAFLD) and Non-Alcoholic Steatohepatitis, (NASH)**

The histological appearance in these disorders may be very similar to the injury related to alcohol. In non-alcoholic steatohepatitis, the liver exhibits fat and perivenular sinusoidal col‐ lagen deposition and may be indistinguishable from alcoholic perivenular fibrosis on histo‐ logical grounds alone. Clinical correlations are basic for its diagnosis [63].

Sometimes a biopsy shows a pattern which looks like alcoholic hepatitis, but the patient de‐ nies alcohol use. A differential diagnosis for alcoholic hepatitis has to be done, and non-alco‐ holic fatty liver disease, (NALDF) and non-alcoholic steatohepatitis, (NASH) should be considered [63].

For many decades, typical "alcoholic hepatitis" was often diagnosed with liver biopsy, and in some patients' medical records were completed with somewhat judgmental comments about their persistent denial of alcohol intake. Now, there are other known causes for Mallo‐ ry bodies (\*) and steatosis found in liver biopsies which, in the past, were classified as alco‐ hol related liver injury. In retrospect, we now know that many patients with "alcoholic hepatitis" were treated unfairly [64].

It is clear that similar patterns of injury can be seen in non-alcoholics, especially in the set‐ ting of diabetes and obesity, referred to as nonalcoholic steatohepatitis (NASH) or nonal‐ coholic fatty liver disease (NAFLD). This represents a significant form of chronic liver disease in both adults and children, with a spectrum ranging from indolent to end-stage liver disease. It may be an underlying cause of cryptogenic cirrhosis and has been report‐ ed to recur after a liver transplant. Other conditions associated with NASH include acute starvation, accelerated weight loss, intestinal bypass, disorders of lipid metabolism, and various drugs. Careful clinicopathologic correlation is required to determine the cause. Liver biopsy evaluation allows us to establish the degree of steatosis, inflammation, and fibrosis stage [65].

#### **Liver steatosis**

asymptomatic for decades. The natural course of PSC is determined by interindividual vari‐ ability, the rate of progression and the development of CC, which can occur at any time.

The differential diagnosis has to be established among : autoimmune hepatitis, overlap syn‐ dromes, infectious hepatitis, other bile duct diseases presenting as acute or chronic cholangi‐ tis, and biliary strictures, cholangiocarcinoma, gallstones, hepatomegaly and primary biliary

Liver biopsy in PSC is only needed to diagnose small-duct PSC or to exclude other diseases that may be associated with PSC or with similar features and confounding aspects. Liver bi‐ opsy also may be useful for staging the disease. However, serial liver biopsy in monitoring

Recently some authors have developed the Mayo clinic risk score, a multivariate statistical survival model, on the basis of the long-term course of the disease in 486 PSC patients seen at three centers in United States. In this score, the need for liver biopsy has been eliminated. This scoring system has its advantages; it is non-invasive and was found to be well correlat‐ ed to actual survival. It also performs better than the Child-Pugh classification for cirrhosis,

Overlap syndromes of AIH are not uncommon but are not well defined. Histology, clinical

The diagnosis of an overlap syndrome relies on the biochemical profile, either cholestatic or hepatitic in addition to the auto-antibodies pattern and elevated gamma globulins. The his‐ topathology can show portal inflammation with or without involvement of bile ducts [59].

In adult patients with an overlap of PBC and AIH, which is the the most common, antinu‐ clear as well as antimitochondrial antibodies are present. Chronic hepatitis C may trigger autoimmune activation, with concomitant positive autoimmune antibodies. AIH may be as‐ sociated with Ig G4 autoimmune cholangitis (IAC). In contrast to PSC, IAC-IgG4, has no as‐

The value of a biopsy in liver diseases such as PSC or suspected metastatic disease, which is characterized by a zonal affection of the liver has to be dealt with individually and complet‐

Liver biopsy is advisable if diagnostic tests show abnormal liver function results which may be indicative of many etiologies e.g. nonalcoholic steatohepatitis with strongly elevated anti‐ nuclear antibodies and abnormal iron studies, or co-infection with HIV and hepatitis C in a

Many patients with ethanol injury show initial scarring around central veins with deli‐ cate fibrosis along the sinusoids [61]. Eventually, bridging fibrosis connects central veins

patient with abnormal liver function tests taking hepatotoxic drugs etc.

**7.4. Alcohol: Fibrous progression related to alcohol injury**

and serological indicators imply more than one liver disease at the same time.

cirrhosis.

the disease is not indicated [57].

48 Liver Biopsy – Indications, Procedures, Results

which does not predict survival with PSC [58].

*7.3.3. Autoimmune Hepatitis (AIH) with overlap variants*

sociated intestinal bowel disease and pancreatitis [60].

ed with other imaging techniques.

The diagnosis of liver steatosis has several implications in chronic liver diseases.


**•** Finally, liver steatosis is the main lesion observed in non-alcoholic fatty liver disease (NAFLD) which, as a consequence of the worldwide burden of visceral obesity, is now an important cause of chronic liver disease in western countries.

discordance rate for steatosis would have been missed in 24% of cases if only one biopsy had been done and a difference of one stage of fibrosis or more was seen in 41% of

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51

Drug and toxin induced liver injury is a common cause for abnormal liver tests in humans [72]. Liver injury related to drugs can be subdivided into intrinsic and idiosyncratic injury. Intrinsic injury is produced through direct or indirect mechanisms and idiosyncratic injury

Drug induced liver cell injuries have different morphological patterns such as, hepatocellu‐ lar injury, cholestatic injury, bile duct injury, vascular injury, portal fibrosis, neoplasia or

The list of implicated products is very long and in some cases mixed lesions can be found. Drug "signature" is a well-known concept which implies that the drugs responsi‐ ble for the injury can be identified from the different lesions it causes to the liver. For example, diclofenac and minocyline produce a chronic hepatitis pattern, steatohepatitis can be induced by amiodarone and tamoxifen, vascular toxicity may be associated with

Histological changes that suggest drug- or toxin-related liver injury are atypical therefore, in some cases, depending on the findings, it is worth the pathologist asking the clinician specif‐

Is the patient's blood analysis compatible with hepatitis? Has viral injury been excluded?

**•** Granulomas (\*\*) may also be part of the inflammatory reaction in drug injury [76].

If granulomas have been found, have other causes of granulomas been excluded? (see

If significant fatty change is found is there any possibility that it could be related to toxic

If an abundance of eosinophils is observed in a liver biopsy, a hypersensitivity reaction is suspected which may resemble viral hepatitis. Eosinophils may also be present nonspecifi‐ cally in viral hepatitis, in connective tissue disorders, and in some neoplasms (usually in Hodgkin's disease infiltrates). However, when eosinophils are a striking feature, it is advisa‐ ble that the clinician search for a drug, a toxin, or even a nutritional supplement ("natural

If numerous liver cell mitotic figures show up in the liver biopsy, this may suggest that a

ic questions in order to do a differential diagnosis and to identify the drug [75]:

**•** What are the patient's toxic exposures at work, home, or play?

**•** Has every drug been sought and disclosed?

short episode of drug exposure is to blame.

may be mediated by hypersensitivity or by metabolic toxic metabolites [73].

paired biopsies [71].

azathioprine etc. [74].

below) [77]

ethanol injury?

medicines").

**7.6. Liver injury caused by drugs**

miscellaneous (pigments and inclusions).

At present, the histological examination of a liver biopsy continues to be the reference for evaluating liver steatosis despite its limitations. The procedure is invasive and impaired by sampling bias, which results in imperfect reproducibility and only allows for a semiquantitative grading of steatosis [66]. The non-invasive diagnosis of liver steatosis is done by imaging techniques and blood tests, but diagnostic accuracy remains to be validated and their use in clinical practice has yet to be recommended. Ultrasonography is consid‐ ered the imaging technique of choice for steatosis screening, but its sensitivity in detecting fatty liver is only 60–94% and is operator dependent. Other techniques, such as computed tomography, proton magnetic resonance spectroscopy and magnetic resonance imaging offer high accuracy for quantification of liver fat but have low availability, high cost and lack standardization [67].

The diagnosis of hepatic steatosis and steatohepatitis or non-alcoholic steatohepatitis (NASH) is not yet possible without liver biopsy. Therapeutic targets of drug development are in early stages. As regards the study of factors most likely associated with disease pro‐ gression, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has sponsored the NASH Clinical Research Network (CRN) who has developed a histological scoring system, which is used for clinical trials for NASH [68].

The histological lesions for the diagnosis of NASH are: zone 3 macrosteatosis, hepatocyte ballooning and mixed lobular inflammation. Other findings that are common include mildmoderate portal inflammation, acidophil bodies, glycogenated nuclei, lipogranulomas and perisinusoidal fibrosis. In addition, the following may be present: Mallory's hyaline (\*) in hepatocytes, megamitochondria and mild siderosis.

(\*) Mallory bodies or Mallory's hyaline are irregular, rope-like eosinophilic intracytoplasmic strings that represent aggregates of cytokeratin filaments. The cytokeratins form a filamen‐ tous support network within the hepatocytes. Cellular damage is due, for example, to etanol producing hepatocyte ballooning degeneration, which can cause the keratins to misfold and aggregate. Mallory bodies may be found in alcoholic, nonalcoholic steatohepatitis, and Wil‐ son disease, cholestatic conditions such as primary biliary cirrhosis (PBC) and with certain drugs, such as amiodarone. Although the fat and neutrophils can resolve relatively quickly after alcohol abstinence, hyaline can take up to 6 weeks to disappear [69].

The histological severity of NAFLD is determined by the Non-alcoholic fatty liver disease Activity Score (NAS) and the Fibrosis Score, developed and validated by the CRN [68]. This scoring system is very useful for assessing change in clinical trials but it is not meant to re‐ place a full interpretation of histological findings by a pathologist [70].

Some investigators have observed that there is significant sampling variability and that the histological lesions of NASH are unevenly distributed throughout the liver parenchy‐ ma and can lead to substantial misdiagnosis and staging inaccuracies. For example, Rat‐ ziu et al. reported that on 51 patients with NAFLD who underwent paired biopsies, the discordance rate for steatosis would have been missed in 24% of cases if only one biopsy had been done and a difference of one stage of fibrosis or more was seen in 41% of paired biopsies [71].

### **7.6. Liver injury caused by drugs**

**•** Finally, liver steatosis is the main lesion observed in non-alcoholic fatty liver disease (NAFLD) which, as a consequence of the worldwide burden of visceral obesity, is now an

At present, the histological examination of a liver biopsy continues to be the reference for evaluating liver steatosis despite its limitations. The procedure is invasive and impaired by sampling bias, which results in imperfect reproducibility and only allows for a semiquantitative grading of steatosis [66]. The non-invasive diagnosis of liver steatosis is done by imaging techniques and blood tests, but diagnostic accuracy remains to be validated and their use in clinical practice has yet to be recommended. Ultrasonography is consid‐ ered the imaging technique of choice for steatosis screening, but its sensitivity in detecting fatty liver is only 60–94% and is operator dependent. Other techniques, such as computed tomography, proton magnetic resonance spectroscopy and magnetic resonance imaging offer high accuracy for quantification of liver fat but have low availability, high cost and

The diagnosis of hepatic steatosis and steatohepatitis or non-alcoholic steatohepatitis (NASH) is not yet possible without liver biopsy. Therapeutic targets of drug development are in early stages. As regards the study of factors most likely associated with disease pro‐ gression, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has sponsored the NASH Clinical Research Network (CRN) who has developed a histological

The histological lesions for the diagnosis of NASH are: zone 3 macrosteatosis, hepatocyte ballooning and mixed lobular inflammation. Other findings that are common include mildmoderate portal inflammation, acidophil bodies, glycogenated nuclei, lipogranulomas and perisinusoidal fibrosis. In addition, the following may be present: Mallory's hyaline (\*) in

(\*) Mallory bodies or Mallory's hyaline are irregular, rope-like eosinophilic intracytoplasmic strings that represent aggregates of cytokeratin filaments. The cytokeratins form a filamen‐ tous support network within the hepatocytes. Cellular damage is due, for example, to etanol producing hepatocyte ballooning degeneration, which can cause the keratins to misfold and aggregate. Mallory bodies may be found in alcoholic, nonalcoholic steatohepatitis, and Wil‐ son disease, cholestatic conditions such as primary biliary cirrhosis (PBC) and with certain drugs, such as amiodarone. Although the fat and neutrophils can resolve relatively quickly

The histological severity of NAFLD is determined by the Non-alcoholic fatty liver disease Activity Score (NAS) and the Fibrosis Score, developed and validated by the CRN [68]. This scoring system is very useful for assessing change in clinical trials but it is not meant to re‐

Some investigators have observed that there is significant sampling variability and that the histological lesions of NASH are unevenly distributed throughout the liver parenchy‐ ma and can lead to substantial misdiagnosis and staging inaccuracies. For example, Rat‐ ziu et al. reported that on 51 patients with NAFLD who underwent paired biopsies, the

after alcohol abstinence, hyaline can take up to 6 weeks to disappear [69].

place a full interpretation of histological findings by a pathologist [70].

important cause of chronic liver disease in western countries.

scoring system, which is used for clinical trials for NASH [68].

hepatocytes, megamitochondria and mild siderosis.

lack standardization [67].

50 Liver Biopsy – Indications, Procedures, Results

Drug and toxin induced liver injury is a common cause for abnormal liver tests in humans [72]. Liver injury related to drugs can be subdivided into intrinsic and idiosyncratic injury. Intrinsic injury is produced through direct or indirect mechanisms and idiosyncratic injury may be mediated by hypersensitivity or by metabolic toxic metabolites [73].

Drug induced liver cell injuries have different morphological patterns such as, hepatocellu‐ lar injury, cholestatic injury, bile duct injury, vascular injury, portal fibrosis, neoplasia or miscellaneous (pigments and inclusions).

The list of implicated products is very long and in some cases mixed lesions can be found. Drug "signature" is a well-known concept which implies that the drugs responsi‐ ble for the injury can be identified from the different lesions it causes to the liver. For example, diclofenac and minocyline produce a chronic hepatitis pattern, steatohepatitis can be induced by amiodarone and tamoxifen, vascular toxicity may be associated with azathioprine etc. [74].

Histological changes that suggest drug- or toxin-related liver injury are atypical therefore, in some cases, depending on the findings, it is worth the pathologist asking the clinician specif‐ ic questions in order to do a differential diagnosis and to identify the drug [75]:

Is the patient's blood analysis compatible with hepatitis? Has viral injury been excluded?


If granulomas have been found, have other causes of granulomas been excluded? (see below) [77]

If significant fatty change is found is there any possibility that it could be related to toxic ethanol injury?

If an abundance of eosinophils is observed in a liver biopsy, a hypersensitivity reaction is suspected which may resemble viral hepatitis. Eosinophils may also be present nonspecifi‐ cally in viral hepatitis, in connective tissue disorders, and in some neoplasms (usually in Hodgkin's disease infiltrates). However, when eosinophils are a striking feature, it is advisa‐ ble that the clinician search for a drug, a toxin, or even a nutritional supplement ("natural medicines").

If numerous liver cell mitotic figures show up in the liver biopsy, this may suggest that a short episode of drug exposure is to blame.

#### *7.6.1. Drug Induced Liver Injury (DILI) examples*

The American Association of Reumatology has provided guidelines for monitoring pa‐ tients receiving Methotrexate therapy as there is a known relation between this treatment and hepatotoxicity [78].

fection with cytomegalovirus or Epstein-Barr virus as well as with drug (allopurinol)

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

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53

**•** Lipogranulomas are composed of lipid deposits and vacuolated macrophages. They are

**•** Microgranulomas may be a nonspecific finding, they are usually subtle and composed of

There are many causes of hepatic granulomas, including local irritants, infections, infesta‐ tions and hypersensitivity to drugs. The constituents of these lesions, depending on the eti‐ ology and inflammatory cytokines produced include large epithelioid cells, multinucleated giant cells, varied numbers of mononuclear cells and eosinophils. The causes vary in fre‐ quency from one country to another. Although the etiology may be determined from the histological features, from special stains for micro-organisms, from culture of part of the bi‐ opsy specimen or polymerase chain reaction of the paraffin-embedded specimen, or from clinical and serological data, the cause of hepatic granulomas remains unknown in one third of cases. It is likely that approximately one third of granulomatous liver reactions are caused by drugs, including allopurinol, carbamazepine, procainamide, diphenylhydantoin, quini‐

Although the usefulness of liver biopsy in the diagnosis of fever of unknown origin is still controversial, a review of the literature shows that liver biopsy can be effective in confirm‐

Based on the findings of a liver biopsy evaluating Fever of Unknown Origin (FUO), we can conclude that abnormal liver biopsy is helpful in determining the cause of the FUO. The most common cause of fever was of an infectious origin. Other causes were neoplastic disor‐

Liver biopsy was performed after routine studies were negative. Therefore results such as histoplasmosis and tuberculosis indicate that, despite advances in diagnostic technology, liver biopsy continues to be useful in the diagnosis of FUO. In endemic areas, histoplasmosis

Cirrhosis is pathologically defined as a diffuse process in which the normal anatomical lo‐ bules are replaced by architecturally abnormal nodules separated by fibrous tissue. There‐ fore, focal scarring, even if significant and associated with nodules, is not cirrhosis because the process is not diffuse [86]. In the past the description of a liver as "cirrhotic" implied an ominous prognosis in a patient with liver disease. In chronic hepatitis, the most important goal is to delay or to stop the development of cirrhosis. Nowadays, treatments to prevent its progression are available. At present there are many known stages as opposed to before

and tuberculosis should be considered in the differential diagnosis of FUO [85].

toxicity and in association with systemic lupus erythematosus.

small, round clusters of plump Kupffer cells.

dine, isoniazid, and sulphanilamide.

ders or inflammatory [87].

**7.8. Cirrhosis**

formed in the presence of exogenous or endogenous fat accumulation.

**7.7. The role of liver biopsy in infections and pyrexia of unknown origin**

ing histopathological diagnosis and microbiological analysis [83].

A few years ago methotrexate was used for treating reumathoid arthritis. Now patients with psoriasis are also treated with this drug, albeit at a lower dose. Many potentially hepatotoxic medications, used in such cases are worth investigating [78].

Amoxi-clavulanic acid is one of the examples of a broadly used antibiotic which has been implicated in liver toxicity. Typically the patient with this toxicity presents with jaundice. After excluding other causes, such as viral hepatitis, autoimmunity, or other etiologies, and in presence of a normal biliary tree, a liver biopsy is recommended, which may show a cholestatic hepatitis pattern. After discontinuation of the drug the evolution is usually favourable [79].

#### *7.6.2. Granulomas in liver biopsies*

Granuloma is defined as an aggregate of histiocytes and can only be diagnosed through his‐ topathological examination.

Causes of granulomas in the liver: most systemic granulomatous diseases involve the liver to some extent; tuberculosis and sarcoidosis are the most common causes [80]. Other infec‐ tious agents include bacteria (brucellosis, nocardiosis, tularemia, Q fever [*Coxiella burnetii*], spirochetes), various fungi, protozoa, and viruses (cytomegalovirus, Epstein-Barr virus). Noninfectious causes in addition to sarcoidosis include PBC, drug reaction, extrahepatic in‐ flammatory disease, such as chronic inflammatory bowel disease, rheumatoid arthritis), neo‐ plasms (Hodgkin disease) and foreign substances (talc, mineral oil) .

#### *7.6.3. Can negative stains for fungi and acid-fast bacilli exclude infection in patients with fever of unknown origin?*

Definitely not. Cultures for these organisms are more sensitive than special histological stains. If infection is a possibility, a core of liver should be submitted with sterile precautions and without fixative to the microbiology laboratory. In addition, tissue in formalin should be sent to the pathology laboratory for microscopic sections. A tissue sample may also be sent for molecular analysis to determine whether an infectious agent is present, depending on the possibilities [82, 83].

#### *7.6.4. Different types of granulomas useful in determining specific diagnosis*


fection with cytomegalovirus or Epstein-Barr virus as well as with drug (allopurinol) toxicity and in association with systemic lupus erythematosus.


There are many causes of hepatic granulomas, including local irritants, infections, infesta‐ tions and hypersensitivity to drugs. The constituents of these lesions, depending on the eti‐ ology and inflammatory cytokines produced include large epithelioid cells, multinucleated giant cells, varied numbers of mononuclear cells and eosinophils. The causes vary in fre‐ quency from one country to another. Although the etiology may be determined from the histological features, from special stains for micro-organisms, from culture of part of the bi‐ opsy specimen or polymerase chain reaction of the paraffin-embedded specimen, or from clinical and serological data, the cause of hepatic granulomas remains unknown in one third of cases. It is likely that approximately one third of granulomatous liver reactions are caused by drugs, including allopurinol, carbamazepine, procainamide, diphenylhydantoin, quini‐ dine, isoniazid, and sulphanilamide.

### **7.7. The role of liver biopsy in infections and pyrexia of unknown origin**

Although the usefulness of liver biopsy in the diagnosis of fever of unknown origin is still controversial, a review of the literature shows that liver biopsy can be effective in confirm‐ ing histopathological diagnosis and microbiological analysis [83].

Based on the findings of a liver biopsy evaluating Fever of Unknown Origin (FUO), we can conclude that abnormal liver biopsy is helpful in determining the cause of the FUO. The most common cause of fever was of an infectious origin. Other causes were neoplastic disor‐ ders or inflammatory [87].

Liver biopsy was performed after routine studies were negative. Therefore results such as histoplasmosis and tuberculosis indicate that, despite advances in diagnostic technology, liver biopsy continues to be useful in the diagnosis of FUO. In endemic areas, histoplasmosis and tuberculosis should be considered in the differential diagnosis of FUO [85].

#### **7.8. Cirrhosis**

*7.6.1. Drug Induced Liver Injury (DILI) examples*

medications, used in such cases are worth investigating [78].

plasms (Hodgkin disease) and foreign substances (talc, mineral oil) .

*7.6.4. Different types of granulomas useful in determining specific diagnosis*

and hepatotoxicity [78].

52 Liver Biopsy – Indications, Procedures, Results

evolution is usually favourable [79].

*7.6.2. Granulomas in liver biopsies*

topathological examination.

*unknown origin?*

on the possibilities [82, 83].

The American Association of Reumatology has provided guidelines for monitoring pa‐ tients receiving Methotrexate therapy as there is a known relation between this treatment

A few years ago methotrexate was used for treating reumathoid arthritis. Now patients with psoriasis are also treated with this drug, albeit at a lower dose. Many potentially hepatotoxic

Amoxi-clavulanic acid is one of the examples of a broadly used antibiotic which has been implicated in liver toxicity. Typically the patient with this toxicity presents with jaundice. After excluding other causes, such as viral hepatitis, autoimmunity, or other etiologies, and in presence of a normal biliary tree, a liver biopsy is recommended, which may show a cholestatic hepatitis pattern. After discontinuation of the drug the

Granuloma is defined as an aggregate of histiocytes and can only be diagnosed through his‐

Causes of granulomas in the liver: most systemic granulomatous diseases involve the liver to some extent; tuberculosis and sarcoidosis are the most common causes [80]. Other infec‐ tious agents include bacteria (brucellosis, nocardiosis, tularemia, Q fever [*Coxiella burnetii*], spirochetes), various fungi, protozoa, and viruses (cytomegalovirus, Epstein-Barr virus). Noninfectious causes in addition to sarcoidosis include PBC, drug reaction, extrahepatic in‐ flammatory disease, such as chronic inflammatory bowel disease, rheumatoid arthritis), neo‐

*7.6.3. Can negative stains for fungi and acid-fast bacilli exclude infection in patients with fever of*

Definitely not. Cultures for these organisms are more sensitive than special histological stains. If infection is a possibility, a core of liver should be submitted with sterile precautions and without fixative to the microbiology laboratory. In addition, tissue in formalin should be sent to the pathology laboratory for microscopic sections. A tissue sample may also be sent for molecular analysis to determine whether an infectious agent is present, depending

**•** Epithelioid granulomas are nodular aggregates of plump macrophages, often associated with multinucleated giant cells, lymphocytes, and plasma cells. They are typically seen in

**•** Fibrin-ring granulomas are formed by a fibrin band encircling a lipid droplet, with associ‐ ated inflammation. They were first described with Q fever but may also be seen after in‐

sarcoidosis. The presence of central caseating necrosis suggests tuberculosis.

Cirrhosis is pathologically defined as a diffuse process in which the normal anatomical lo‐ bules are replaced by architecturally abnormal nodules separated by fibrous tissue. There‐ fore, focal scarring, even if significant and associated with nodules, is not cirrhosis because the process is not diffuse [86]. In the past the description of a liver as "cirrhotic" implied an ominous prognosis in a patient with liver disease. In chronic hepatitis, the most important goal is to delay or to stop the development of cirrhosis. Nowadays, treatments to prevent its progression are available. At present there are many known stages as opposed to before when there only one was considered, G Garcia-Tsao in the article "In search of a pathophy‐ siological classification of cirrhosis." [86].

the liver disease better [95]. The present debate questioning the need for liver biopsy versus

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

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

55

Micronodular cirrhosis (nodules of 3 mm or less), which may develop as a result of ethanol injury, biliary tract disease, or hemochromatosis, is usually uniform throughout the liver, and nodules may be identified on a needle specimen. However, macronodular cirrhosis (nodules greater than 3 mm), due most commonly to chronic viral hepatitis, constitutes a

**7.9. Hepatocellular Carcinoma (HCC) and other benign or malignant focal lesions: The**

Liver biopsy is useful for diagnosis of a diffused disease and guided liver biopsy remains

This technique has a crucial role in the evaluation of focal liver lesions or localized lesions. Liver tumors appear as nodular or localized lesions which can be malignant or non-malig‐ nant and can be either primary from the liver or metastasic. If clinical, biochemical and radi‐ ologic findings are inconclusive, some phases of the diagnostic process may require a liver

**Malignant lesions. Hepatocellular carcinoma (HCC),** the most frequent malignant liver cancer, is usually discovered during screening programs in cirrhotic patients. Regarding treatment, the only curative option is surgery, both limited hepatectomy of the tumor or liv‐

In liver lesions with typically recognized features of HCC, defined by using advanced radio‐ logical methods, liver biopsy has no place. However, a liver biopsy will be performed in pa‐ tients with atypical liver tumors suggestive of a possible colangiocarcinoma. These cases

Besides, when surgery is indicated in a patient with suspected liver cirrhosis, a liver biopsy has to be performed in the non-neoplasic liver. Pathological diagnosis may help to asses the

Metastasis of the liver with an unknown primary tumor should be biopsied to obtain infor‐

Concern has been expressed about the risk of spreading malignant cells via the needle tract, but this rarely occurs when using needles with a diameter of less than 1.3 mm, which also

functional capacity, specific prognosis and whether surgery could be performed.

minimizes the risk of bleeding. The procedure is simple, safe and painless [101].

biopsy in order to establish the diagnosis and their staging and management [99].

*7.8.2. A needle biopsy specimen does not always permit the diagnosis of cirrhosis*

non invasive tests will be discussed below.

**role of Fine Needle Aspiration Biopsy (FNAB) [97]**

essential for the diagnosis of localized lesions.

*7.9.1. Fine needle aspiration biopsy (FNAB)*

er transplant in very select cases [100].

Indications of liver biopsy with regards to diffused or local lesions

require another form of therapy and the prognosis is worse [99].

mation of the primary tumor in order to determine therapy.

less uniform pattern [96].

#### *7.8.1. Fibrosis progression*

One of the most crucial developments is the reformulation of the concept of cirrhosis from a static to a dynamic process. This concept is likely to be even better defined in the future.

As fibrotic scars advance and extend the normal architecture changes and nodules are formed [88]. Moreover, the angiogenic process that naturally accompanies scar formation permits the creation of abnormal channels between central hepatic veins and portal ves‐ sels, resulting in the shunting of blood around the regenerating parenchyma. Normal vascular structures, along with sinusoidal channels, may be obliterated, leading to portal hypertension. Some authors describe cirrhosis as a vascular disease [89]. Clinical conse‐ quences of cirrhosis result from the decreased ability of the parenchyma to synthesize clotting factors and other substances combined with the complications related to portal hypertension [90].

Knowledge on the level of fibrotic progression between normal histology to cirrhosis has considerable prognostic weight. Patients with bridging fibrosis on biopsy are much closer to end-stage liver disease than those with minimal or no fibrosis. Fibrosis is not an autono‐ mous feature, but rather a tissue progressive lesion resulting from other pathologic mecha‐ nisms such as inflammatory, degenerative or dystrophic processes [91].

The first transition in this process occurs between the normal, non-fibrotic state and the ex‐ pansion of the portal area by fibrosis, to the extension of short, incomplete septations around the portal area, change that gives to the portal areas an irregular stellate shape.

In the next transition, development of bridges between vascular structures, portal-portal bridging fibrosis and portal-central bridging, occur. Gradually, more and more bridges are formed, accompanied by distortion of the architecture due to hepatocellular regeneration and contraction of fibrotic scars. When these changes diffusely involve the biopsy, it is clas‐ sified as cirrhosis [92].

Progressive fibrosis leads to cirrhosis and it is now known that cirrhosis can be reversible. There was a lot of controversy surrounding this issue a few years ago [93]. For patients in a precirrhotic stage of fibrosis, liver biopsy remains the gold standard of assessment. Prior to 1995, there was no published system which subdivided advanced stages of cirrhosis. Only the Ishak modification of the Histologic Activity Index (HAI) subdivided cirrhosis into three categories [94].

Nowadays, since Garcia-Tsao et al.reported compensated and decompensated phases in the clinical evolution of liver cirrhosis, many prophylactic measures and controls have been im‐ plemented in order to improve survival and quality of life [87]. Cirrhosis is usually clinically evident. Once the pathologic stage of cirrhosis has been reached, clinical scales such as the Child-Pugh score have to be used because they represent the prognosis and the staging of the liver disease better [95]. The present debate questioning the need for liver biopsy versus non invasive tests will be discussed below.

#### *7.8.2. A needle biopsy specimen does not always permit the diagnosis of cirrhosis*

Micronodular cirrhosis (nodules of 3 mm or less), which may develop as a result of ethanol injury, biliary tract disease, or hemochromatosis, is usually uniform throughout the liver, and nodules may be identified on a needle specimen. However, macronodular cirrhosis (nodules greater than 3 mm), due most commonly to chronic viral hepatitis, constitutes a less uniform pattern [96].

#### **7.9. Hepatocellular Carcinoma (HCC) and other benign or malignant focal lesions: The role of Fine Needle Aspiration Biopsy (FNAB) [97]**

Indications of liver biopsy with regards to diffused or local lesions

Liver biopsy is useful for diagnosis of a diffused disease and guided liver biopsy remains essential for the diagnosis of localized lesions.

#### *7.9.1. Fine needle aspiration biopsy (FNAB)*

when there only one was considered, G Garcia-Tsao in the article "In search of a pathophy‐

One of the most crucial developments is the reformulation of the concept of cirrhosis from a static to a dynamic process. This concept is likely to be even better defined in the future.

As fibrotic scars advance and extend the normal architecture changes and nodules are formed [88]. Moreover, the angiogenic process that naturally accompanies scar formation permits the creation of abnormal channels between central hepatic veins and portal ves‐ sels, resulting in the shunting of blood around the regenerating parenchyma. Normal vascular structures, along with sinusoidal channels, may be obliterated, leading to portal hypertension. Some authors describe cirrhosis as a vascular disease [89]. Clinical conse‐ quences of cirrhosis result from the decreased ability of the parenchyma to synthesize clotting factors and other substances combined with the complications related to portal

Knowledge on the level of fibrotic progression between normal histology to cirrhosis has considerable prognostic weight. Patients with bridging fibrosis on biopsy are much closer to end-stage liver disease than those with minimal or no fibrosis. Fibrosis is not an autono‐ mous feature, but rather a tissue progressive lesion resulting from other pathologic mecha‐

The first transition in this process occurs between the normal, non-fibrotic state and the ex‐ pansion of the portal area by fibrosis, to the extension of short, incomplete septations around the portal area, change that gives to the portal areas an irregular stellate shape.

In the next transition, development of bridges between vascular structures, portal-portal bridging fibrosis and portal-central bridging, occur. Gradually, more and more bridges are formed, accompanied by distortion of the architecture due to hepatocellular regeneration and contraction of fibrotic scars. When these changes diffusely involve the biopsy, it is clas‐

Progressive fibrosis leads to cirrhosis and it is now known that cirrhosis can be reversible. There was a lot of controversy surrounding this issue a few years ago [93]. For patients in a precirrhotic stage of fibrosis, liver biopsy remains the gold standard of assessment. Prior to 1995, there was no published system which subdivided advanced stages of cirrhosis. Only the Ishak modification of the Histologic Activity Index (HAI) subdivided cirrhosis into three

Nowadays, since Garcia-Tsao et al.reported compensated and decompensated phases in the clinical evolution of liver cirrhosis, many prophylactic measures and controls have been im‐ plemented in order to improve survival and quality of life [87]. Cirrhosis is usually clinically evident. Once the pathologic stage of cirrhosis has been reached, clinical scales such as the Child-Pugh score have to be used because they represent the prognosis and the staging of

nisms such as inflammatory, degenerative or dystrophic processes [91].

siological classification of cirrhosis." [86].

*7.8.1. Fibrosis progression*

54 Liver Biopsy – Indications, Procedures, Results

hypertension [90].

sified as cirrhosis [92].

categories [94].

This technique has a crucial role in the evaluation of focal liver lesions or localized lesions. Liver tumors appear as nodular or localized lesions which can be malignant or non-malig‐ nant and can be either primary from the liver or metastasic. If clinical, biochemical and radi‐ ologic findings are inconclusive, some phases of the diagnostic process may require a liver biopsy in order to establish the diagnosis and their staging and management [99].

**Malignant lesions. Hepatocellular carcinoma (HCC),** the most frequent malignant liver cancer, is usually discovered during screening programs in cirrhotic patients. Regarding treatment, the only curative option is surgery, both limited hepatectomy of the tumor or liv‐ er transplant in very select cases [100].

In liver lesions with typically recognized features of HCC, defined by using advanced radio‐ logical methods, liver biopsy has no place. However, a liver biopsy will be performed in pa‐ tients with atypical liver tumors suggestive of a possible colangiocarcinoma. These cases require another form of therapy and the prognosis is worse [99].

Besides, when surgery is indicated in a patient with suspected liver cirrhosis, a liver biopsy has to be performed in the non-neoplasic liver. Pathological diagnosis may help to asses the functional capacity, specific prognosis and whether surgery could be performed.

Metastasis of the liver with an unknown primary tumor should be biopsied to obtain infor‐ mation of the primary tumor in order to determine therapy.

Concern has been expressed about the risk of spreading malignant cells via the needle tract, but this rarely occurs when using needles with a diameter of less than 1.3 mm, which also minimizes the risk of bleeding. The procedure is simple, safe and painless [101].

#### *7.9.2. Non-malignant lesions*

In cases of Hemangioma or Focal Nodular Hyperplasia (FNH), diagnosed and confirmed by radiology, biopsy is usually not necessary.

Distinguishing recurrent hepatitis from acute allograft rejection, which can overlap, is diffi‐

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

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

57

**•** Graft reinfection (from 0 to 3 months post-transplant). HCV-related inflammation is rare‐ ly seen at this time. Liver biopsies may show mild lobular disarray, few necrotic hepato‐

**•** Established graft infection (from 3 to 6 months), acute hepatitis including ballooning de‐ generation of hepatocytes, acidophil bodes, and Kupffer cell prominence can be observed.

**•** Progressive liver damage (after 6 months), features related to chronic HCV infection such as, mononuclear portal infiltrates and interface hepatitis are observed. Bile duct damage, although mild, may occur, and granulomas may be detected. Up to half of patients will

*The role of liver biopsy in the evaluation of abnormal liver tests after the first year post transplanta‐ tion* Common causes after the first year include acute rejection, opportunistic infection, re‐ current viral hepatitis, chronic rejection, steatohepatitis, or recurrent diseases. Chronic rejection occurs as a consequence of repeated episodes of acute rejection that are unrespon‐ sive to immunosuppression. The main histological abnormalities are loss of small bile ducts (ductopenic rejection) and/or obliterative vasculopathy (affecting large and medium-sized arteries). Unlike acute allograft rejection, the degree of bile duct damage is typically out of

Complications of liver transplantation are not limited to acute and chronic rejection and re‐ currence of original disease, but include surgical complications, most commonly hepatic ar‐ tery occlusion, infections, and development of de novo malignancies. In the early post transplantation period preservation injury, damage to the graft during harvesting and im‐ plantation, may lead to significant graft dysfunction. In post-perfusion biopsies, heavy neu‐ trophilic infiltrate and hepatocyte necrosis may be predictive of initial poor graft function. Ischemic complications, such as hepatic artery thrombosis, are one of the most serious com‐ plications and may lead to early graft loss or biliary stricture. In these patients liver biopsy is

Infectious complications that generally occur after transplantation, cytomegalovirus(CMV) for example, remains common and is frequently associated with parenchymal microabscess‐

A liver biopsy is effective in the evaluation of a bone marrow transplant recipient with ele‐ vated liver tests [106]. Known complications of bone marrow transplantation include venoocclusive disease (VOD) and graft-versus-host disease (GVHD). A biopsy is necessary to diagnose VOD. It develops within 1 to 4 weeks after transplantation and is characterized by occlusion of central veins, sinusoidal fibrosis, and pericentral hepatocyte necrosis. Acute GVHD develops within 6 weeks after transplantation and affects the skin, gastrointestinal

cult. There are usually three main phases to recurrent HCV:

Varying degrees of portal tract inflammation may also be present.

cytes (acidophil bodies), and fatty change.

have histological evidence after 1 year.

proportion to the degree of inflammation.

es which are found in the liver biopsy of CMV patients.

usually not performed.

*7.10.2. Bone marrow transplantation*

FNH and hepatic adenoma are benign tumors and are less frequently observed than HCC. Their diagnosis is done using imaging techniques (ultrasound or helicoidal scanner). How‐ ever, differential diagnosis is necessary because, although FNH only requires radiological follow-up, in some cases, higher risk circumstances have been recognized and surgery is recommended [102].

#### *7.9.3. Most prevalent mass lesions [102, 103]*


#### **7.10. New evolving fields for liver biopsy: Liver transplantation, Bone marrow transplantation, Living donors and Morbid obesity**

#### *7.10.1. Liver transplantation*

With regards to liver transplantation, liver biopsy remains very useful in the management of transplanted patients. In this clinical situation, if a rejection is suspected and other complica‐ tions have been ruled out, a guided biopsy will be performed. This procedure can be of great value in order to confirm the specific diagnosis and to indicate treatment [104].

In the first few weeks and months after transplantation, the major causes of abnormal liver tests include preservation injury, acute rejection, opportunistic infections (e.g., cytomegalo‐ virus, hepatitis), vascular compromise, and/or biliary stricture. Of these, acute allograft re‐ jection is the most common and results from direct alloantigenic stimulation of recipient T cells by donor dendritic cells (antigen-presenting cells). The effector T cells can then prefer‐ entially injure biliary epithelial cells of both interlobular and septal bile ducts as well as en‐ dothelial cells of intrahepatic arteries and veins.

*The main histological features of acute rejection* Acute rejection is characterized by an infiltration of mixed, predominantly mononuclear cells within portal tracts. The inflammatory infil‐ trates include lymphocytes, macrophages, plasma cells, polymorphonuclear neutrophils and eosinophils. The inflammatory cells typically infiltrate the bile duct epithelium and are asso‐ ciated with bile duct damage. Subendothelial inflammation (endothelialitis), which may in‐ volve both portal and central veins, is also a typical feature. The most common grading system is the Banff schema, a consensus document proposed by an international panel of pathologists and liver transplant physicians [105]. Criteria helping to distinguish recurrent hepatitis C after transplantation from allograft rejection; Hepatitis C (HCV) recurs in virtual‐ ly all patients transplanted for that disease.

Distinguishing recurrent hepatitis from acute allograft rejection, which can overlap, is diffi‐ cult. There are usually three main phases to recurrent HCV:


*The role of liver biopsy in the evaluation of abnormal liver tests after the first year post transplanta‐ tion* Common causes after the first year include acute rejection, opportunistic infection, re‐ current viral hepatitis, chronic rejection, steatohepatitis, or recurrent diseases. Chronic rejection occurs as a consequence of repeated episodes of acute rejection that are unrespon‐ sive to immunosuppression. The main histological abnormalities are loss of small bile ducts (ductopenic rejection) and/or obliterative vasculopathy (affecting large and medium-sized arteries). Unlike acute allograft rejection, the degree of bile duct damage is typically out of proportion to the degree of inflammation.

Complications of liver transplantation are not limited to acute and chronic rejection and re‐ currence of original disease, but include surgical complications, most commonly hepatic ar‐ tery occlusion, infections, and development of de novo malignancies. In the early post transplantation period preservation injury, damage to the graft during harvesting and im‐ plantation, may lead to significant graft dysfunction. In post-perfusion biopsies, heavy neu‐ trophilic infiltrate and hepatocyte necrosis may be predictive of initial poor graft function.

Ischemic complications, such as hepatic artery thrombosis, are one of the most serious com‐ plications and may lead to early graft loss or biliary stricture. In these patients liver biopsy is usually not performed.

Infectious complications that generally occur after transplantation, cytomegalovirus(CMV) for example, remains common and is frequently associated with parenchymal microabscess‐ es which are found in the liver biopsy of CMV patients.

#### *7.10.2. Bone marrow transplantation*

*7.9.2. Non-malignant lesions*

56 Liver Biopsy – Indications, Procedures, Results

recommended [102].

*7.10.1. Liver transplantation*

radiology, biopsy is usually not necessary.

*7.9.3. Most prevalent mass lesions [102, 103]*

neoplasms, rare primary bile duct neoplasms.

**transplantation, Living donors and Morbid obesity**

dothelial cells of intrahepatic arteries and veins.

ly all patients transplanted for that disease.

hyperplasia, fatty infiltration, rare primary liver neoplasms.

In cases of Hemangioma or Focal Nodular Hyperplasia (FNH), diagnosed and confirmed by

FNH and hepatic adenoma are benign tumors and are less frequently observed than HCC. Their diagnosis is done using imaging techniques (ultrasound or helicoidal scanner). How‐ ever, differential diagnosis is necessary because, although FNH only requires radiological follow-up, in some cases, higher risk circumstances have been recognized and surgery is

**•** Benign: cysts, hemangioma, adenoma, liver abscess (amebic or pyogenic), focal nodular

**•** Malignant: hepatocellular carcinoma, cholangiocarcinoma, metastatic, rare primary liver

With regards to liver transplantation, liver biopsy remains very useful in the management of transplanted patients. In this clinical situation, if a rejection is suspected and other complica‐ tions have been ruled out, a guided biopsy will be performed. This procedure can be of

In the first few weeks and months after transplantation, the major causes of abnormal liver tests include preservation injury, acute rejection, opportunistic infections (e.g., cytomegalo‐ virus, hepatitis), vascular compromise, and/or biliary stricture. Of these, acute allograft re‐ jection is the most common and results from direct alloantigenic stimulation of recipient T cells by donor dendritic cells (antigen-presenting cells). The effector T cells can then prefer‐ entially injure biliary epithelial cells of both interlobular and septal bile ducts as well as en‐

*The main histological features of acute rejection* Acute rejection is characterized by an infiltration of mixed, predominantly mononuclear cells within portal tracts. The inflammatory infil‐ trates include lymphocytes, macrophages, plasma cells, polymorphonuclear neutrophils and eosinophils. The inflammatory cells typically infiltrate the bile duct epithelium and are asso‐ ciated with bile duct damage. Subendothelial inflammation (endothelialitis), which may in‐ volve both portal and central veins, is also a typical feature. The most common grading system is the Banff schema, a consensus document proposed by an international panel of pathologists and liver transplant physicians [105]. Criteria helping to distinguish recurrent hepatitis C after transplantation from allograft rejection; Hepatitis C (HCV) recurs in virtual‐

great value in order to confirm the specific diagnosis and to indicate treatment [104].

**7.10. New evolving fields for liver biopsy: Liver transplantation, Bone marrow**

A liver biopsy is effective in the evaluation of a bone marrow transplant recipient with ele‐ vated liver tests [106]. Known complications of bone marrow transplantation include venoocclusive disease (VOD) and graft-versus-host disease (GVHD). A biopsy is necessary to diagnose VOD. It develops within 1 to 4 weeks after transplantation and is characterized by occlusion of central veins, sinusoidal fibrosis, and pericentral hepatocyte necrosis. Acute GVHD develops within 6 weeks after transplantation and affects the skin, gastrointestinal tract, and liver. It is characterized by degenerative bile duct lesions with some degree of mononuclear inflammation. Cholestasis may be present. Chronic GVHD is a multiorgan process that develops 80 to 400 days after transplantation and is often preceded by acute GVHD. The changes in the liver are similar to those in acute disease, but the ducts show more prominent changes and are likely to be reduced in number or destroyed. A prominent periportal mononuclear infiltrate, or even piecemeal necrosis, may be seen.

**8. Non-invasive tests for liver disease and assessment of fibrosis and**

Limitations of biopsy have led clinical investigators to study alternative methods to in‐ vestigate liver disease especially for the assessment of liver fibrosis. Since fibrosis is of sufficient importance in chronic liver disease and because it progresses to cirrhosis it is frequently used as the outcome and prognostic variable in clinical studies. Hepatic fib‐ rosis is currently viewed as a dynamic process that may regress after successful treat‐ ment of chronic liver diseases. Serum markers, such as non-invasive markers, offer an attractive alternative. They are objective, allowing a dynamic calibration of fibrosis, can be performed repeatedly, are more cost effective and many of them are performed as a

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

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

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**Indirect markers of liver fibrosis:** among them, the AST to Platelet Ratio Index (APRI), combines aspartate amiotransferase (AST) with platelet count. It was used in several studies conducted in cohorts of patients with hepatitis C and showed a rather good di‐ agnostic performance and reproducibility, [110] particularly for cirrhosis. Forns and col‐ leagues reported a fibrosis index (Forns' index) based on platelet count, γ-glutamyl transferase (GGT), and cholesterol levels [111]. It is rather good for excluding significant fibrosis, but only average for diagnosing significant fibrosis. However, one important limit of both APRI and Forns' indexes are that they leave almost half of the patients

Another widely investigated combination set of noninvasive markers of liver fibrosis is the Fibrotest; a combination of five blood tests based on a mathematical formula: GGT, biliru‐ bin, haptoglobin, apolipoprotein A1, alfa2 macroglobulin adjusted for gender and age. Ac‐ cording to the investigators, it could exclude cases with significant fibrosis (METAVIR > F2), having 100% of negative predictive value, and more than 90% positive predictive value, us‐

Another noninvasive method for the assessment of liver fibrosis is elastography (Fibro‐

FibroScan device (EchoSens, Paris, France) uses a mild-amplitude, low frequency vibration transmitted through the liver. It induces an elastic shear wave that is detected by pulse-echo ultrasonography as the wave propagates through the organ. The velocity of the wave corre‐

This device is in widespread use in many parts of the world, but is not yet approved in the

Most of the studies have been conducted on patients with chronic hepatitis C but a few

lates with tissue stiffness which correlates well with the degree of fibrosis.

studies have also covered fibrosis and cirrhosis due to other etiologies.

**cirrhosis**

routine analysis [109].

unclassified.

Scan) [113].

United States.

ing liver biopsy as a reference [112].

**8.1. Elastography (FibroScan)**

#### *7.10.3. Liver transplant living donor*

Liver biopsies detect silent donor disease in potential living liver donors, especially patients suffering subclinical non-alcoholic fatty liver disease (NAFLD). The contribution of liver bi‐ opsy or even the need to perform this, when a potential donor is being evaluated is a contro‐ versial issue [107]. In the University of Pittsburgh Medical Center a retrospective study of the histopathologic examination and diagnoses of 284 patients, who were evaluated as living do‐ nors from 2001 to 2005 was carried out. Hepatic histology was correlated with liver injury tests and with demographic characteristics in an otherwise normal healthy population. A mi‐ nority (n=119; 42%) of biopsies from this population of 143 males/141 females (average age=36.8years; mean BMI=26.6) were completely normal. The remainder showed steatosis (n=107; 37%), steatohepatitis (n=44; 15%), or unexplained low-grade/early stage chronic hepa‐ titis, primary biliary cirrhosis, or nodular regenerative hyperplasia (n=16; 6%). Biopsy find‐ ings disqualified 29/56 donors, negative factors were: obesity, age and liver iron content, contributing to NAFLD pathogenesis. The conclusion was that liver biopsy provides valuable information about otherwise undetectable liver disease in potential liver donors.

#### *7.10.4. Morbid obesity*

About 90 per cent of morbidly obese patients show histological abnormalities of the liver. Morbid obesity may lead to severe disease showing steatosis, ballooning degeneration, lobular inflammation and fibrosis in the study of liver biopsy. These features are similar to the lesions observed in alcoholic hepatitis and may end in cirrhosis and liver failure. Many factors such as, alcohol, drugs, diabetes, viruses, can contribute to progressive liver damage. The development of severe fatty liver disease may be asymptomatic showing a poor correlation with liver function tests. It has been reported that after bypass surgery, weight loss is accompanied by improvement in fatty change and the liver function tests are normal.

Histopathologic findings in the liver of 160 patients who were undergoing laparoscopic gas‐ tric bypass or gastric banding for morbid obesity, were recorded, also clinical data (gender, age, BMI and associated diseases) and laboratory evaluation were obtained [108].The diag‐ nosis obtained were : 63 non-nonalcoholic steatohepatitis (non-NASH), 54 NASH, 26 chronic hepatitis B (CHB), 15 alcoholic steatohepatitis and NASH, and 2 chronic hepatitis C (CHC).The coexistence of clinical and histological features of steatohepatitis with another chronic liver disease may reflect the biological significance of the chronic inflammatory con‐ dition in the obese population, which requires further investigation.
