Cholecystectomy is a Predictor of Taking Liver Biopsy in Patients with Steatohepatitis-Related Liver Disease

Abstract

Purpose: Steatohepatitis (SH)-related liver disease due to either alcohol use (ASH) or non-alcoholic steatohepatitis (NASH) is a common cause of cirrhosis and liver transplantation in the US. Although imperfect, liver biopsy is a definitive method of diagnosing SH and assessing its severity. However, liver biopsy is not always performed in clinical practice, and often, a diagnosis of SH is made clinically by exclusion of other causes of liver disease and history of alcohol use. We performed retrospective analysis to determine factors predictive of taking a liver biopsy among SH-related liver disease patients. Methods: Patients with SH-related liver disease, including ASH and NASH, managed at a single tertiary care center (2007-2011) were stratified based on receipt of liver biopsy for confirming diagnosis. Chisquare and t-tests were used for comparing categorical and continuous variables, respectively. Logistic regression model was built to assess factors associated with taking liver biopsy for diagnosing SH, its etiology, and assess its severity. Data were reported as odds ratio (OR) with 95% confidence interval (CI). Results: ASH patients (N=226) presented more often to clinician with symptoms of cirrhosis or its complications compared to NASH (69 vs. 27%; P<0.0001). Comparing 110 (22%) patients receiving liver biopsy to 391 non-biopsied cases, those undergoing liver biopsy differed for: female gender (53 vs. 42%; P=0.03), history of cholecystectomy (49 vs. 29%; P=0.0001), NASH diagnosis (73 vs. 50%; P<0.0001), asymptomatic presentation (71 vs. 49%; P<0.0001), median ALT (61 vs. 48; P=0.03), and MELD score (8 vs. 11; P=0.005). Age, race, and proportion of metabolic syndrome components, steatosis on imaging, cirrhosis, and HCC were similar. After controlling for significantly different and clinically relevant variables, patients undergoing liver biopsy were over two-fold more likely to have had cholecystectomy: OR [95% CI] of 2.1 [1.3-3.5]. Histology details available on 95 (70 NASH) biopsies showed NASH patients to differ from ASH for: steatosis >33% of hepatocytes (62 vs. 41%; P=0.03), lobular inflammation (94 vs. 72%; P=0.03), trend for higher NASH activity score (3.7±1.5 vs. 2.8±1.9; P=0.058), and lower stage 3 or 4 fibrosis (54 vs. 72%; P=0.15). Conclusion: About 2/3 of biopsies in SH-related liver disease is taken at the time of cholecystectomy. Most of these biopsies are taken for NASH patients. Studies are needed to examine whether taking routine liver biopsy at laparotomy for alcoholics is helpful in improving patient adherence to alcohol abstinence and in early diagnosis of liver disease related to ASH.