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

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

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

Fatty change Ethanol, fatty liver disease, obesity, diabetes, drugs Councilman bodies Viral hepatitis, drugs, toxins, ischemia (acidophilic bodies)

Hydropic change (ballooning degeneration) Viral hepatitis, drugs, cholestasis, fatty liver disease Cholestasis Duct obstruction or injury, drugs, viral hepatitis Interlobular duct injury Primary biliary cirrhosis, primary sclerosing cholangitis,

Piecemeal necrosis Viral hepatitis, primary biliary cirrhosis, drugs, Wilson

**3. The generally accepted indications of liver biopsy are the following**

**•** Diagnosis for a better scoring of grading and staging of chronic viral hepatitis C or hepati‐ tis B, alcoholic liver disease, non-alcoholic steato-hepatitis, or autoimmune hepatitis.

**•** If there are suspected disorders of cupper metabolism for the diagnosis of Wilson's dis‐

Increased iron stores Hemochromatosis, transfusions, hemolysis

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

**•** In patients with raised ferritine for the diagnosis of hemochromatosis

ease, with quantitative estimation of copper in liver tissue.

**•** Evaluation of possible autoimmune hepatitis

hepatitis C

disease

Ethanol, obesity, diabetes, drugs, Wilson disease, biliary

tract disease, hepatocellular carcinoma

Sarcoid, infections (tuberculosis, fungi), drugs

nostic or therapeutic relevance.

36 Liver Biopsy – Indications, Procedures, Results

**2.2. Who should be biopsied?**

sive confirmation is needed [8,9].

Mallory bodies \* (hyaline) (see pages: 13, 15, 17 and 18)

Granulomas\*\*

(see pages: 19, 20 and 21)

**Type of Injury Causes**

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

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

Special stains for special circumstances are ordered if indicated by the clinical situation. For instance, the Ziehl-Nielsen is ordered for mycobacteria, and Grocott's silver methanamine stain is used when granulomas are observed or when fungi infection is suspected. The Con‐ go Red stain is requested when amyloid is suspected to be present Rhodamine stain, Victo‐ ria blue or orcein stain is used to detect copper deposition when there is clinical suspicion of Wilson's disease. Immunohistochemistry is used to confirm the presence of Hepatitis B sur‐ face antigen and Hepatitis B core antigen [10].

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