Percutaneous Liver Biopsy: Reflections and Refinements

Abstract

Department of Medicine, University of Western Ontario, London, Ontario Correspondence: Dr Cameron N Ghent, University of Western Ontario, London, Ontario N6A 5A5. Telephone 519-642-3232, fax 519-642-2545, e-mail drghent@on.aibn.com Received for publication August 7, 2005. Accepted August 12, 2005 Almost 50 years ago, Menghini (1) described the one-second percutaneous suction liver biopsy and the needle that bears his name and revolutionized the practice of hepatology. He described some refinements a few years later (2) but the technique has changed little since then. It is, therefore, timely to re-evaluate the place of this timehonoured diagnostic test, given the tremendous changes that have revolutionized hepatology since then. Better diagnostic tests for many diseases have led to a decreased need for biopsy to make a diagnosis in many patients. The increasing resolution and sophistication of imaging modalities, such as ultrasound, computed tomography and magnetic resonance imaging, have decreased the need for obtaining liver tissue for histological examination in some patients, particularly those with focal liver lesions. However, three developments in hepatology have increased the need for biopsy. Among the reasons for increasing use of biopsy is the large population of newly diagnosed hepatitis C patients, many of whom require pretreatment biopsy, not for diagnosis but for staging, according to current practice guidelines (3). In addition, the increased use of liver transplantation as standard treatment of end-stage liver disease of diverse etiologies has led to more biopsies being performed to differentiate the cause of graft dysfunction, and to assess the suitability of potential donor livers for transplantation. The third major impact on the practice of hepatology is the dramatic increase in obesity, diabetes, hyperlipidemia and hypertension (the metabolic syndrome) in Western societies and its accompanying fatty liver problems requiring assessment by histology. This is another case of liver biopsy serving a role as largely a staging rather than a diagnostic procedure (4), although some selectivity is needed in choosing to biopsy big people with big livers. Excellent reviews of the indications, contraindications and technical aspects of this procedure have been recently published (5-8). The British Society of Gastroenterology has developed clinical practice guidelines for percutaneous liver biopsy (9), and the American College of Gastroenterology guidelines are specific to the use of liver biopsy as an outpatient procedure (10). The Canadian Association of Gastroenterology guidelines (11) are the most recent and do not differ substantially from earlier recommendations, but also do not meet the published arbitrary criteria for developing and using guidelines (12,13). This biased and personal review is based on over 30 years of performing and teaching the technique of percutaneous liver biopsy within academic health care centres and reviewing a large number of biopsy specimens with expert hepatopathologists. I will focus on some technical and some general aspects that are either neglected in other reviews or are commonly misunderstood by the neophyte gastroenterologists and hepatologists we attempt to teach. Alternative approaches to obtaining tissue such as transvenous biopsy, fine needle aspiration and operative or laparoscopic biopsy will only be mentioned when they are appropriate alternatives to routine transthoracic biopsy.