This leaflet tells you about having a transjugularliverbiopsy. It explains what is involved and what the possible risks are. It is not meant to replace informed discussion between you and your doctor, but can act as a starting point for such discussions. If you have any questions about the procedure, please ask the doctor who has referred you or the department that will be performing it.
C. Behrens et al. in his review article ‘TransjugularLiverbiopsy’ has stated that the technical success rate ranges between 87 to 97%. The most common reason for technical failure is difficulty in cannulating the hepatic vein. The other reason is lack of access to jugular vein, however access through alternate venous routes helps us to overcome this problem. The biopsy sample of 15 mm, containing 6-10 portal tracts was sufficient in most cases to achieve histopathological diagnosis of diffuse liver disease. Sample fragmentation rate was seen in 14 to 25% of patients which can interfere in making histopathological evaluation for reaching diagnosis. Complication rates ranged between 1.3-6.5%. Most of the complications encountered are minor complications like neck pain, abdominal pain, bleeding at puncture site, subscapular haematoma. Major complications are observed in 0.6% of patients. Mortality is seen in less than 0.1% of adults and ~ 0.1% of paediatric population and is related to ventricular arrhythmia during access to hepatic veins, perforation of the hepatic artery and haemorrhage from extracapsular liver puncture. Other complications documented are haemobilia, pseudoaneurysm etc (6).
Transjugularliverbiopsy as compared with percutaneous liverbiopsy (PCLB) in an outpatient setting is by far a safer approach in patients with coagulopathies -. Von Willebrand’s disease (vWD) is the most com- mon inherited bleeding disorder, affecting 1 - 3 percent of the global population . There are no data published to date, on the safety of PCLB in patients with vWD.
100%), in F1 and F2 (highly near), and in F3 (almost identical). Real time elastography assessment of liver fibrosis were sensitive and specific with high accuracy rate in different fibrosis stages in comparison to LB. (66.7%/100%,89.7%/66.7%, 45%/93.3% and 80% /94.5%) in F0, F1, F2 and F3 respectively. Shinya Fujiwara et al., (14) reported that measurement of hepatic elastography confirmed to be a very useful and specific noninvasive tool for assessment of the hepatic fibrosis especially in chronic HCV infection where heaptic inflammation and fibrosis markers are correlated very well with the progression of the hepatic fibrosis. In the same direction, Castera et al., (9) also confirmed the previous results and found that combining hepatic elastography and Fibrometer (a blood test that measures hyaluronate, prothrombin time, platelets count, AST, α2 macroglobulin, urea, and age) can provide an 87% accuracy rate. However, Ferraioli et al., (10) reported that hepatic elastography isn’t 100% accurate and has been shown to have a high degree of accuracy for predicting mild fibrosis, severe fibrosis and cirrhosis, but, it is less likely to distinguish the difference between no or minimal fibrosis. At CI = 95 %, AUROC of our elastography readings were (0.75, 0.78 and 0.80) in F1, F2 and F3 respectively when compared to that of LB (METAVIR score). Our results and conclusions are slight near to a similar study conducted by Sporea et al., (15) on 274 patients with HCV infection where AUROC were calculated retrospectively to be (0.89, 0.90 and 0.93) to predict fibrosis stages F1, F2, and F3 respectively. High values more than our readings were reported in a metaanalysis carried by Friedrich-Rust et al., (16) which included 518 patients with chronic HCV disease, AUROC were calculated retrospectively to be (0.87, 0.91 and 0.93) to diagnose fibrosis stages. Elastography can be considered an adequate diagnostic technique for the assessment of hepatic fibrosis, particularly in chronic HCV. Rizzo et al., had shown similar findings and concluded that
lesions, we demonstrated a significant correlation between one of these features and clinical outcome. Accordingly, intrahepatic cholestasis is an independent predictor of 3-month mortality, together with age and the Maddrey ’ s score, a commonly used robust parameter that includes serum bilirubin and prothrombin time. We acknowledge that our study suffers from some limita- tions. First, due to missing date, we were not able to include modern prognostic markers such as the Lille or the Glasgow scores, nor the C-reactive protein. Whether intraparenchymal cholestasis combined with the short-term evolution of serum bilirubin included in the Lille score brings additional information on prognosis remained to be explored. Secondly, our assessment of intrahepatic cholestasis may be suboptimal with regards to the semi-quantitative analysis, and the criticism may be raised that conversion of a subjective observation (i.e. lesion present in more or less than 50% of the biopsy) into a categorical variable is arbitrary and subject to inconsistency. However, we have tested the reproducibil- ity of the scoring system and demonstrated an excellent inter observer agreement between the two histopatholo- gists. Thirdly, the prevalence of histological lesions in alcoholic liver disease may be influenced by the timing of liverbiopsy in relation to clinical deterioration, as fea- tures such as steatosis, hepatocyte ballooning and Mal- loy-Denk bodies tend to be less prominent over time. Therefore, it is questionable whether intralobular choles- tasis would still be relevant if the liverbiopsy had been performed later in the course of the disease.
Background: Liverbiopsy is an established procedure to diagnose disease, to assess prognosis and to follow up of liver diseases. Although liverbiopsy is a confirmatory diagnostic procedure of majority of the hepatological disorders, it carries the risk of complications. Though major complications rarely occur, minor complications are common. To minimize complications, several biopsy techniques have been developed. The present study was intended to correlate the clinical diagnoses with histological diagnoses and to observe the complications encountered by the children with percutaneous liverbiopsy procedure. Patients and Methods: A total of 30 paediatric patients of suspected liver diseases, based on predefined eligibility criteria, were subjected to biopsy for confirmation of diagnosis. An ultrasound of liver was routinely performed before the procedure to mark the site for percutaneous biopsy. The field was prepared with alcohol-based solution (povidone-iodine) and sterile drapes were placed over the patient. Local anaesthetic was administered with 2% lidocain solution 20mg/ml (preferably levobupivacaine 2.5mg/ ml) in both superficial and deep planes. A blind liverbiopsy was done at the point of maximum dullness by percussion over the right trunk. We used cutting needle. The diameter of the needle used in our study was 14-gauge (1.4 mm) which allowed adequate collection of tissue for diagnosis. The biopsy material was taken in a very small amount of sterile normal saline and was immediately sent to the laboratory for evaluation. Results: Half (50%) of the patients was more than 5 years of age with median age being 5.0±3.9 years. Majority (80%) was male. Ninety percent of the patients belonged to poor socioeconomic class. Clinically the cases were diagnosed as having chronic hepatitis (23.3%) followed by CLD (16.7%), isolated hepatomegaly (16.7%), liver cirrhosis (13.3%) and storage disease (13.3%). Hepatosplenomegaly and congenital hepatic fibrosis, each was 6.7%. Histological diagnoses of biopsy material obtained from the liver confirmed that one-sixth (16.7%) of the cases had liver cirrhosis. Storage disease and glycogen storage disease each comprised 13.3% of the cases and congenital biliary atresia 10%. Very few cases had moderate fatty changes with cholestasis, congenital hepatic fibrosis, chronic inflammatory cells, chronic viral hepatitis and secondary biliary cirrhosis. Nearly half (46.7%) patients had mild pain and discomfort at the site of biopsy, most of which spontaneously went away. However, some 3 (10%) patients developed major complications needing management. Conclusion: Liverbiopsy is a well established procedure in the diagnosis and follow up of liver diseases. But it is not without risk of complications. So, before deciding for a liverbiopsy, the indications and risks must be assessed cautiously for each patient.
Transjugular intrahepatic portosystemic shunt (TIPS) surgery inserted metal stent into the liver parenchyma radiologically to establish a shunt between portal vein and hepatic vein/inferior vena cava. It is an efficient method for reducing portal pressure, and has been widely used for treatment of complications of portal hypertension [10, 11]. TIPS has gradually become the first-line therapeutic choice for cirrhotic patients with acute variceal hemorrhage who failed with endoscopic hemostasis [12, 13], with an estimated technical success- ful rate of 93–100% . TIPS is also used in treatment of refractory ascites [14–16] and hepatorenal syndrome  due to the circulatory effects on portal hyperten- sion. However, there have been concerns about TIPS implantation, especially with high rate of hepatic en- cephalopathy (HE) post-TIPS . More recently, the development and usage of covered metal stents signifi- cantly reduce the shunt dysfunction in comparison with bare mental stents insertion , leading to the lower occlusion rate of consecutive bleeding and improvement of overall survival [19, 20]. However, few studies focused on the long-term outcomes of patients receiving TIPS for complications of portal hypertension and liver cir- rhosis, especially with respect to variceal bleeding versus refractory ascites. Thus, in this retrospective study, we evaluated the long-term efficacy and outcomes of TIPS in treatment of variceal bleeding and/or refractory asci- tes. The major objectives of the present study were to observe the occurrence of clinical complications of TIPS, and predictors of survival.
. For all these reasons, early liverbiopsy and therapy rather than follow-up are mandated. The limited recommendations for liverbiopsy in the international guidelines dealing with chronic HBV infection should be reviewed specifically for Egyptian patients. They should be considered as special entity with their own special guidelines. Treatment decision of chronic HBV is a crucial decision affecting not only the patient socioeconomic and health welfare but also the community progression. In the current study, HBeAg was found to be negative in 88%, 92%, 96%, and 100% in the four studied groups respectively. So, most of the studied patients were HBeAg negative (94%) and only (6%) were HBeAg positive. This is in accordance with El- Zayadi et al who reported that 90-95% of Egyptian patients were HBeAg negative , also it is comparable to other studies reported in Middle East and Mediterranean countries . HBeAg disappears early in patients with HBV genotype D, which is the predominant genotype in Egypt, this occurs due to mutations in the pre core and/or basic core promoter regions of the genome that abolish or diminish the production of HBeAg .
The goal of this paper is, in short, to allay the anxiety caused by this situation for the general pathologist by setting forth some basic principles for assessment of liverbiopsy specimens from chronic hepatitis patients. There will be elements of review, of course, but this will not be academically complete; such papers have already been published by a number of wise and skilled hepatopatho- logists. 5–11 Instead, this paper will briefly describe the histopathologic features of note, some pros and cons of the different grading/staging systems, and the extra things that one must look out for to know that one has confidently squeezed every bit of clinically important information out of every biopsy.
As was shown in Case 4, it may be difficult to differentiate clinically between MTX-induced liver damage and autoimmune hepatitis in patients with RA. Also, as in Case 3, if liver tis- sues show steatohepatitis-like findings that do not match a typical MTX-induced damage pat- tern, it is necessary to consider the potential contribution of pathogenic factors other than MTX, e.g., the effects of metabolic disorders, steroid administration, etc. On the other hand, for minimizing the burdens of medical examina- tions, it is necessary to replace liverbiopsy by non-invasive tests [7-9, 11-14]. Without doubt, non-invasive methods of assessment of liver fibrosis are valuable to monitor the liver condi- tion and detect liver fibrosis early in patients treated with MTX because many aspects of MTX-induced liver damage progress as subclin- ical disorders. However, since these non-inva- sive tests can only evaluate the severity of liver fibrosis and cannot provide information about the etiology [11-14], liverbiopsy cannot be excluded from the management protocols of patients with RA treated with MTX.
The almost universal finding of HCV RNA elevation in patients with liver disease and its absence in individuals with normal biopsy specimens have led some to question whether the level of HCV RNA might be predictive of the degree of liver injury. Most studies that have used branched DNA testing have not been able to detect any relationship between the level of HCV RNA and the grade or stage of hepatitis. In contrast, several studies using reverse-transcription polymerase chain reaction have found a correlation with liver histopathology. Thus, testing of the level of HCV RNA in serum is not clinically useful to distinguish between various grades of histological injury or to monitor disease progression. Although the reasons for the lack of correlation between liver histopathology and these blood test parameters remain unclear (further studies are needed to explain), one explanation may be that the former is shaped by dynamic events such as immunologic activity, frequency and intensity of exacerbations and the total duration of disease, as well as more static factors such as the route of transmission and viral genotype. Evaluation of histological activity by alternative test methods such as ALT and HCV RNA, which are often performed on a limited number of samples, is likely to give misleading information about overall disease intensity in a chronic and dynamically changing condition like chronic hepatitis C .
While data collection was ongoing, a first draft of the TA for the liverbiopsy procedure was produced. Observable actions were identified from video data and included in task descriptions. Further information was taken from the interviews including detailed descriptions of the procedure; potential errors/complications, includ- ing their identification and prevention; cues that indicate procedure success, safety and completion; decisions made; and the information that guided these decisions. Areas needing clarification were identified and explored in subsequent interviews. Throughout this process, the TA was redrafted and refined. Drafting the document in this manner provided a fully developed tool.
The key pathological change of the AIH is inter- face hepatitis, namely piecemeal necrosis. The portal area and portal area inflammation is the main pathological manifestation of AIH, charac- terized by inflammation in the portal area, and liver damage caused by circle plate, tube around single or small clusters of chronic pro- gressive liver cell necrosis the change from the angle of necrosis of liver cells called piecemeal necrosis and piecemeal necrosis due to associ- ated with inflammatory cell infiltration in the liver lobular parenchyma and interstitial area at the junction, from another angle of inflamma- tion also known as pathological interface hepa- titis AIH . Special point infiltration around the
infected persons, so that advanced morphological changes are found during a routine, control analysis of blood. On the other hand, serious morphological changes can be followed by relatively normal biochemi- cal parameters of the liver function. The facts about the individual differences among the infected in the devel- oping cirrhosis are of great importance, what make some of them rest stable for 5 to 10 years from the be- ginning of the infection (3). In large prospective studies we find that those patients can be divided according to the stage of fibrosis into the groups of fast, intermediary and slow fibroses, developing the fibrosis in a few dec- ades (4). The investigation of individual differences in fibrosis point to the influence of age, male gender, and alcohol consumption. On the contrary, the serum levels of HCV RNA and viral genotype do not influence the progression to a fibrosis in HHC (5, 6). The role of HFE gene is controversial, but it was recently shown that obesity has a negative influence on the degree and the progression of fibrosis (7).The investigations in the ex- periment and in human material have shown that rever- sion of fibrosis is possible (8).
A 41-year-old Chinese woman was admitted to cardiac ward with exertional chest discomfort and dyspnea for 2 months. Vital signs were nor- mal. Physical examination revealed jugular vein distention, cardiac dullness enlargement and distant heart sounds. Normal cardiac enzymes and N-terminal pro-B-type natriuretic peptide. Normal blood gas analysis, liver function, renal function and thyroid function. Negative serolo- gy for viral hepatitis, cytomegalovirus, herpes, Epstein-Barr virus and human immunodeficien- cy virus. Normal values of immunoglobulin (Ig) G, IgA, IgM, IgE, and CD 3 , CD 4 , CD 8 cell subsets. Serum tumor markers were normal including alpha fetal protein (AFP), carcinoembryonic antigen (CEA), carcinoma antigen (CA) 19-9 and CA-125. Negative tuberculosis skin test and serum antibody of tuberculosis. However, eryth- rocyte sedimentation rate was slightly elevated at 37 mm/hour and D-Dimer was obviously high of >38 mg/l FEU.
Surgery can be considered for patients with recurrent variceal bleed- ing despite use of the abovemen- tioned treatments. Non-shunt opera- tions include urgent liver transplanta- tion, devascularisation procedures and splenectomy. Portosystemic shunt procedures are aimed at either diverting portal blood flow, e.g. porto- caval or mesocaval shunts, or decom- pressing the portal system but pre-
pethidine i.v. or an equal volume (1 ml) of 0.9% normal saline as premedication. All patients received 10 mg of metoclopramide i.v. The premedications were prepared by an independent nurse who was not involved with the care of patient before and after the procedure. The pre- pared medications were identical in volume and appear- ance and labeled with randomization number and patient details. The patients, assisting nurse and the op- erator were unaware of what premedication the patient received. The metoclopramide was given to mask the side effect of pethidine that patients may experience. Following disinfection of the skin with iodine, the pa- tients were given the assigned premedication. The skin and subcutaneous layers of the thoracic wall were locally anaesthetized with 10 ml of 1% xylocaine containing 1:100,000 adrenaline. A small incision into the skin was made using a disposable scalpel. The liverbiopsy was performed using a modified Menghini  biopsy set (17G X 70 mm Surecut, TSK Laboratory, Japan) using standard technique. Immediately following the biopsy the patients were placed on their right-side to rest on a sand bag for 1 hour, followed by an hour of lying flat. Blood pressure, pulse and wound site were checked regularly in the first hour. Lying and standing blood pressure were measured immediately prior to the pro- cedure and two hours post procedure. All patients were observed for 4 hours after the procedure before dis- charge. Patients were asked to self-evaluate pain experi- enced using a visual analogue score (VAS, 0–10) at the end of procedure, and an hour after the procedure. Pa- tients were then followed up with a telephone call 24 hours after the procedure to assess their pain scores, retrospective pain scores and willingness to have a re- peat procedure if it was required in the future.
presented in the ER again three months later with severe respiratory distress and expired due to a massive pulmonary embolism.
Another patient with a major complication was an inpatient who developed severe hypotension after the biopsy. The INR and platelet counts were within normal limits. A CT scan revealed a small perihepatic hematoma and mild ascites. This patient was also managed conservatively and was later discharged in stable condition.
When considering the population of 41 patients with liverbiopsy, the distribution of the rheumatic diseases was as follows: 25 RA cases, eight SpA cases (including four ankylosing spondylitis and four psoriatic arthritis), six pSS cases and two CTD cases (including one sys- temic lupus erythematosus and one mixed CTD). These groups of patients significantly differed only by their mean age (P = 0.01) but not by either disease duration, MTX exposure duration, or cumulative or weekly dose mean values (data not shown). There was an expected link between the rheumatic disease and the expression of autoimmune markers. The presence of rheumatoid factor, anti-CCP antibodies and the HLA-DR shared epi- tope was mostly reported with RA patients. No signifi- cant association was observed between the rheumatic disease and the other autoimmune markers such as anti- nuclear antibodies, anti-DNA antibodies, and presence of HLA-B27 or HLA-DRB1*03.
In HCC, Chan et al 16 showed that shotgun sequencing of plasma samples from HCC patients would allow cancer- associated copy number aberrations and mutations to be analyzed noninvasively and in a genomewide fashion. How- ever, ctDNA of HCC has not been well characterized so far. In this study, we detected cancer-speciﬁc genomic rearrange- ments on 46 HCCs by whole-genome sequencing and vali- dated some of them by polymerase chain reaction (PCR) using ctDNA detection in patient sera. We investigated whether ctDNA levels re ﬂect HCC tumor dynamics and could be used as a predictor of poor prognosis by quantifying each of the cancer-speciﬁc genomic rearrangements. We have also investigated whether exome sequencing of cell-free DNA (which is deﬁned in this paper as whole extracellular DNA circulating in blood containing ctDNA) in a patient with liver cancer could identify somatic mutations in cancer tissue.