Parenchymal Liver Disease Research Articles

Liver and Biliary Disease in Infancy

Liver disease in infancy is a relatively rare but serious cause of morbidity and mortality. Since jaundice is a common finding in the neonatal period, the immediate priority is to differentiate between unconjugated hyperbilirubinaemia, which is generally a benign developmental phenomenon, and conjugated hyperbilirubinaemia (conjugated fraction >20%), which is always pathological. Conjugated hyperbilirubinaemia, suggested by yellow urine and stools that are not yellow or green in an infant of any age, is pathognomonic of liver parenchymal or bile duct disease and warrants prompt investigation because some of its causes require urgent treatment; genetic counselling may also be required.

Anaesthesia for elective liver resection: some points should be revisited.

Improvement in surgical techniques, technology and perioperative assessment has dramatically simplified the anaesthetic care for elective liver resection. Patients with a non-tumorous healthy liver should only need the usual preoperative assessment. Patients with pre-existing parenchymal liver disease should be specifically assessed for gas exchange impairment, alcoholic or nutritional-associated cardiomyopathy, infection, cirrhosis decompensation, acute alcoholic hepatitis, and kidney impairment. The type of anaesthetic management does not influence the intra- and postoperative courses. Intermittent clamping of the portal vascular triad is better tolerated than prolonged continuous periods of ischaemia--especially in patients with abnormal liver parenchyma. Intraoperative antibiotic prophylaxis must be administered to prevent translocation of intestinal enterobacteria to the systemic circulation in patients with both healthy and diseased livers. Blood-salvage techniques have limited indications in liver resection. Systematic invasive haemodynamic monitoring is no longer warranted. An arterial cannula should only be considered in procedures of long duration and in selected situations likely to cause anticipated circulatory impairment: total liver vascular occlusion, repeat surgery, combined organ resection, and surgery conducted on tumours >10 cm in size or in connection with the vena cava. In a recent large series of liver resections, 60% of patients did not need a blood transfusion, only 2% of transfused patients received >10 units of blood and cirrhosis was not predictive of increased intraoperative bleeding. Postoperative ascites, which always develops at the expense of circulating fluid, is a frequent occurrence in patients with healthy or diseased livers. Intra- and postoperative fluid limitation does not prevent postoperative ascites. Volume expansion, diuretics and vasopressor therapy should be initiated early to prevent kidney failure.

Anaesthesia for elective liver resection: some points should be revisited

Improvement in surgical techniques, technology and perioperative assessment has dramatically simplified the anaesthetic care for elective liver resection. Patients with a non-tumorous healthy liver should only need the usual preoperative assessment. Patients with pre-existing parenchymal liver disease should be specifically assessed for gas exchange impairment, alcoholic or nutritional-associated cardiomyopathy, infection, cirrhosis decompensation, acute alcoholic hepatitis, and kidney impairment. The type of anaesthetic management does not influence the intra- and postoperative courses. Intermittent clamping of the portal vascular triad is better tolerated than prolonged continuous periods of ischaemia - especially in patients with abnormal liver parenchyma. Intraoperative antibiotic prophylaxis must be administered to prevent translocation of intestinal enterobacteria to the systemic circulation in patients with both healthy and diseased livers. Blood-salvage techniques have limited indications in liver resection. Systematic invasive haemodynamic monitoring is no longer warranted. An arterial cannula should only be considered in procedures of long duration and in selected situations likely to cause anticipated circulatory impairment: total liver vascular occlusion, repeat surgery, combined organ resection, and surgery conducted on tumours >10 cm in size or in connection with the vena cava. In a recent large series of liver resections, 60% of patients did not need a blood transfusion, only 2% of transfused patients received >10 units of blood and cirrhosis was not predictive of increased intraoperative bleeding. Postoperative ascites, which always develops at the expense of circulating fluid, is a frequent occurrence in patients with healthy or diseased livers. Intra- and postoperative fluid limitation does not prevent postoperative ascites. Volume expansion, diuretics and vasopressor therapy should be initiated early to prevent kidney failure.

Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection.

Needle liver biopsy has been shown to have a high rate of sampling error in patients with diffuse parenchymal liver diseases. In these cases, the sample of liver tissue does not reflect the true degree of inflammation, fibrosis, or cirrhosis, despite an adequate sample size. The aim of this study was to determine the rate and extent of sampling error in patients with chronic hepatitis C virus infection, and to assess the intraobserver variation with the commonly used scoring system proposed by Scheuer and modified by Batts and Ludwig. A total of 124 patients with chronic hepatitis C virus infection underwent simultaneous laparoscopy-guided biopsies of the right and left hepatic lobes. Formalin-fixed paraffin-embedded sections were stained with hematoxylin and eosin and with trichrome. The slides were blindly coded and randomly divided among two hepatopathologists. Inflammation and fibrosis were scored according to the standard grading (inflammation) and staging (fibrosis) method based on the modified Scheuer system. Following the interpretation, the slides were uncoded to compare the results of the right and left lobes. Fifty of the samples were blindly resubmitted to each of the pathologists to determine the intraobserver variation. Thirty of 124 patients (24.2%) had a difference of at least one grade, and 41 of 124 patients (33.1%) had a difference of at least one stage between the right and left lobes. In 18 patients (14.5%), interpretation of cirrhosis was given in one lobe, whereas stage 3 fibrosis was given in the other. A difference of two stages or two grades was found in only three (2.4%) and two (1.6%) patients, respectively. Of the 50 samples that were examined twice, the grading by each pathologist on the second examination differed from the first examination in 0% and 4%, and the staging differed in 6% and 10%, respectively. All observed variations were of one grade or one stage. Liver biopsy samples taken from the right and left hepatic lobes differed in histological grading and staging in a large proportion of chronic hepatitis C virus patients; however, differences of more than one stage or grade were uncommon. A sampling error may have led to underdiagnosis of cirrhosis in 14.5% of the patients. These differences could not be attributed to intraobserver variation, which appeared to be low.

Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection

OBJECTIVES: Needle liver biopsy has been shown to have a high rate of sampling error in patients with diffuse parenchymal liver diseases. In these cases, the sample of liver tissue does not reflect the true degree of inflammation, fibrosis, or cirrhosis, despite an adequate sample size. The aim of this study was to determine the rate and extent of sampling error in patients with chronic hepatitis C virus infection, and to assess the intraobserver variation with the commonly used scoring system proposed by Scheuer and modified by Batts and Ludwig. METHODS: A total of 124 patients with chronic hepatitis C virus infection underwent simultaneous laparoscopy-guided biopsies of the right and left hepatic lobes. Formalin-fixed paraffin-embedded sections were stained with hematoxylin and eosin and with trichrome. The slides were blindly coded and randomly divided among two hepatopathologists. Inflammation and fibrosis were scored according to the standard grading (inflammation) and staging (fibrosis) method based on the modified Scheuer system. Following the interpretation, the slides were uncoded to compare the results of the right and left lobes. Fifty of the samples were blindly resubmitted to each of the pathologists to determine the intraobserver variation. RESULTS: Thirty of 124 patients (24.2%) had a difference of at least one grade, and 41 of 124 patients (33.1%) had a difference of at least one stage between the right and left lobes. In 18 patients (14.5%), interpretation of cirrhosis was given in one lobe, whereas stage 3 fibrosis was given in the other. A difference of two stages or two grades was found in only three (2.4%) and two (1.6%) patients, respectively. Of the 50 samples that were examined twice, the grading by each pathologist on the second examination differed from the first examination in 0% and 4%, and the staging differed in 6% and 10%, respectively. All observed variations were of one grade or one stage. CONCLUSIONS: Liver biopsy samples taken from the right and left hepatic lobes differed in histological grading and staging in a large proportion of chronic hepatitis C virus patients; however, differences of more than one stage or grade were uncommon. A sampling error may have led to underdiagnosis of cirrhosis in 14.5% of the patients. These differences could not be attributed to intraobserver variation, which appeared to be low.

Sonography of diffuse liver disease.

Sonography is often the first imaging procedure performed in the evaluation of individuals with suspected liver disease. Evaluation for biliary dilatation is always performed, because bile duct obstruction can cause abnormal liver test results, raising the suspicion of liver disease. Ultrasound is a useful but imperfect tool in evaluating diffuse liver disease. We discuss the uses and limitations of sonography in evaluating parenchymal liver disease. Sonography can show hepatomegaly, fatty infiltration of the liver, and cirrhosis, all with good but imperfect sensitivity and specificity. Sonography is of limited usefulness in acute hepatitis. Increased parenchymal echogenicity is a reliable criterion for diagnosing fatty liver. Cirrhosis can be diagnosed in the correct clinical setting when the following are present: a nodular liver surface, decreased right lobe-caudate lobe ratio, and indirect evidence of portal hypertension (collateral vessels and splenomegaly). Ultrasound plays an important role in the imaging of conditions and procedures common in patients with diffuse liver disease.

A prospective comparison of the diagnostic accuracy of ERCP, MRCP, CT, and EUS in biliary strictures

Background: The differential diagnosis of biliary strictures remains a challenge. This study evaluated magnetic resonance cholangiopancreatography (MRCP) as a new procedure in comparison with the established methods of diagnosis including ERCP or percutaneous transhepatic cholangiography (PTC), CT, and EUS. Methods: Fifty patients (21 men, 29 women, mean age 65.7 years) with jaundice but no pain suspected to have biliary strictures were enrolled in this prospective study. MRCP, ERCP/PTC, CT, and EUS were performed prospectively; images and videotapes (EUS) of these tests were reviewed blindly under standardized conditions. Reference standards for comparison were surgery, a biopsy confirming malignancy, or the clinical course during follow-up (at least 12 months) in cases without histopathologic proof of malignancy. Results: Seven patients ultimately proved to have jaundice caused by parenchymal liver disease and 43 had a biliary stricture (17 benign, 26 malignant). Forty patients underwent all 4 imaging tests. There were 10 patients in whom patient-specific problems precluded some procedures but who were included in an intention-to-diagnose analysis. The sensitivity and specificity for diagnosis of malignancy in the 50 patients were as follows: 85% / 75% for ERCP/PTC, 85% / 71% for MRCP, 77% / 63% for CT, and 79% / 62% for EUS, with similar values in the 40 patients who underwent all 4 imaging methods. The combination of MRCP and EUS improved specificity. Conclusions: Although MRCP provides the same imaging information as direct cholangiography, it has limited specificity for the diagnosis of malignant strictures. In the differential diagnosis of biliary strictures, several tests including ERCP-guided tissue diagnosis are still required, and MRCP has only a limited clinical role. (Gastrointest Endosc 2002;55:870-6.)

Current liver biopsy practices for suspected parenchymal liver diseases in the United States: the evolving role of radiologists

OBJECTIVE: The aim of this study was to determine current liver biopsy practices in the United States. METHODS: We mailed a questionnaire to 260 randomly selected members of the American Association for the Study of Liver Diseases. Statistical analysis was conducted using the χ 2 test. RESULTS: A total of 128 members (49%) responded, with 106 responses suitable for inclusion. Of the respondents, 25% had a radiologist perform >50% of their patients’ liver biopsies, whereas 38% personally performed all their patients’ biopsies. During training, 87% of respondents were taught to perform liver biopsy using the “blind” technique, 2% with ultrasound (US) guidance, and 11% both. A total of 76% used US guidance during liver biopsy. More private practitioners than those practicing in academic centers used the “blind” technique (35% vs 18%; p = 0.02) and referred >50% of their patients for liver biopsy to Radiology (36% vs 17%; p = 0.01); desire for real-time US guidance was the main reason in 43% of cases. Of the respondents, 75% used US for safety reasons; 77% of those who did not use US believed that it was unnecessary. Overall, 87% of respondents indicated that patient safety was the most important issue during liver biopsy; only 2% thought that personal convenience and cost-effectiveness were most important. CONCLUSIONS: Respondents’ chief concern was patient safety, and most used US for this reason. Private practitioners were less likely than those practicing in academic centers to use US guidance and were more likely to refer patients to Radiology.

Current liver biopsy practices for suspected parenchymal liver diseases in the United States: the evolving role of radiologists.

The aim of this study was to determine current liver biopsy practices in the United States. We mailed a questionnaire to 260 randomly selected members of the American Association for the Study of Liver Diseases. Statistical analysis was conducted using the chi2 test. A total of 128 members (49%) responded, with 106 responses suitable for inclusion. Of the respondents, 25% had a radiologist perform >50% of their patients' liver biopsies, whereas 38% personally performed all their patients' biopsies. During training, 87% of respondents were taught to perform liver biopsy using the "blind" technique, 2% with ultrasound (US) guidance, and 11% both. A total of 76% used US guidance during liver biopsy. More private practitioners than those practicing in academic centers used the "blind" technique (35% vs 18%; p = 0.02) and referred >50% of their patients for liver biopsy to Radiology (36% vs 17%; p = 0.01); desire for real-time US guidance was the main reason in 43% of cases. Of the respondents, 75% used US for safety reasons; 77% of those who did not use US believed that it was unnecessary. Overall, 87% of respondents indicated that patient safety was the most important issue during liver biopsy; only 2% thought that personal convenience and cost-effectiveness were most important. Respondents' chief concern was patient safety, and most used US for this reason. Private practitioners were less likely than those practicing in academic centers to use US guidance and were more likely to refer patients to Radiology.

Prevalence and Risk Factors of Chronic Liver Disease among Oil Refinery Workers

Prevalence and Risk Factors of Chronic Liver Disease among Oil Refinery Workers: Hon‐Ke SIA, et ale Department of Internal Medicine, Chang‐Hua Christian Hospital—Objectives: The objective of this study was to determine the prevalence and major risk factors of chronic liver diseases among workers in an oil refinery and research factory with ultrasonography as an assessment tool. Methods: After a walk‐through survey in the factory, workers were classified into exposed and non‐exposed groups. Regular health screening data for the past four years were collected and all 700 workers were asked to fill out a questionnaire about their life style. A total of 345 workers voluntarily participated in the study, and 326 of them had abdominal ultrasonography. Results: Fatty liver disease (FLD) was found to be the most common problem (27.9%), followed by hepatitis virus infection (HBsAg positive rate: 18.0%, anti‐HCV positive rate: 2.6%). The major causes of persistent alanine aminotransferase (ALT) increase were FLD and hepatitis virus infection. Obesity was the most important determinant of FLD and hepatitis virus infection was that of parenchymal liver disease (PLD). Modeling by multiple logistic regression model demonstrated that exposure to petroleum distillates or other chemicals in this factory was not associated with FLD, PLD or persistent ALT increase even in workers employed for more than twenty years. Obesity and virus infection did not show a synergistic hepatotoxic effect on solvent exposure probably due to a low level of exposure. Conclusions: Fatty liver and chronic hepatitis B infection were the major chronic liver diseases in oil‐refinery workers in Taiwan, where exposure to hepatotoxic solvents was low.

Contrast-Enhanced Hepatic Sonography

Hepatic applications of sonography include evaluation of the gallbladder and bile ducts, assessment of patients with suspected portal hypertension, and evaluation of focal and diffuse parenchymal liver disease. Ultrasound imaging (US) is generally a reliable and accurate method to diagnose a variety of hepatic abnormalities; however, in some cases there is a need to improve sonography's sensitivity and specificity, particularly for the detection and characterization of hepatic masses. Recent clinical experience has shown that the addition of a US contrast agent can enhance sonography's diagnostic capabilities including improving assessments of hepatic blood flow and the detection and characterization of hepatic neoplasms. One intravenously administered US contrast agent is now available in the United States, but its approved indication is limited to echocardiographic applications. Additional agents that have more diagnostic applications are likely to become available. Contrast-enhanced sonography may play a significant role in the diagnosis and management of patients with suspected hepatic abnormalities. This article describes two generic types of US contrast agents—vascular agents and tissue-specific agents—and includes a review of recent published reports on clinical applications of contrast-enhanced hepatic sonography.

Detrimental effects of nitric oxide inhibition on hepatic encephalopathy in rats with thioacetamide-induced fulminant hepatic failure.

Hepatic encephalopathy is a complex neuropsychiatric syndrome seen secondary to acute liver failure, chronic parenchymal liver disease, or portal-systemic anastomosis. Vasodilatation induced by nitric oxide (NO) may be involved in the development of hepatic coma. However, there are no comprehensive data concerning the effects of NO inhibition on the severity of hepatic encephalopathy. Male Sprague-Dawley rats weighing 300-350 g were used. Fulminant hepatic failure was induced by intraperitoneal injection of thioacetamide (TAA, 350 mg kg-1 day-1) for 3 days. Rats were divided into two groups to receive either NG-nitro-L-arginine methyl ester (L-NAME, 20 mg kg-1 day-1 via intragastric gavage) or normal saline (N/S) from 2 days prior to TAA administration for 5 days. Severity of encephalopathy was assessed by counts of motor activity and neurobehaviour test scores. Plasma levels of endotoxin, tumour necrosis factor-alpha and nitrate/nitrite were determined by the chromogenic Limulus assay, enzyme-linked immunosorbent assay and colorimetric assay, respectively. Compared with N/S-treated rats, the mortality rate was significantly higher in rats receiving L-NAME (59% vs. 18%, P < 0.01). Inhibition of NO had detrimental effects on the counts of motor activities (P < 0.05) and neurobehaviour score (P < 0.01). Rats treated with L-NAME had significantly higher plasma levels of endotoxin (26.7 +/- 3.8 pg mL-1) and tumour necrosis factor-alpha (29.4 +/- 6.5 pg mL-1) compared with rats treated with N/S (13.2 +/- 2.7 pg mL-1 and 11.2 +/- 2.6 pg mL-1, respectively, P < 0.01). Plasma levels of endotoxin and tumour necrosis factor-alpha, but not of nitrate/nitrite, were significantly correlated with the severity of hepatic encephalopathy (P < 0.05). Chronic L-NAME administration had detrimental effects on the severity of encephalopathy in TAA-treated rats, suggesting a protective role of NO in the development of fulminant hepatic failure.

Intrahepatic portal-hepatic venous anastomosis: a portal-systemic shunt with neurological repercussions

Intrahepatic shunts are rarely diagnosed as a cause of neurocognitive abnormality. A complaint of fatigue led to the diagnosis of a right portal vein–hepatic vein aneurysmal communication in a 23-yr-old, otherwise healthy woman. Neuropsychological testing, imaging, and MR spectroscopy revealed changes similar to those described in patients with cirrhosis and subclinical hepatic encephalopathy. T1-weighted MRI showed a hyperintense globus pallidus, a feature seen in subjects with and without portal-encephalopathy. Portal-systemic shunting in the absence of parenchymal liver disease reproduces neurological features described in cirrhosis.

TIPS Reduces Hepatic Asialoglycoprotein Receptor Concentration in Healthy Pigs

Technetium-99m-labeled diethylenetriamine pentaacetic acid galactosyl human serum albumin (TcGSA), a new agent for liver scintigraphy, is selectively attached to asialoglycoprotein receptors on liver cell membranes. A direct correlation exists between asialoglycoprotein receptor concentration, [R]o and hepatic functional reserve. The purpose of this study was to determine the effects of transjugular intrahepatic portosystemic shunting (TIPS) on hepatic asialoglycoprotein receptor concentration in pigs without liver parenchymal disease. TIPS was performed in eight pigs with use of a single 10-mm-wide x 68-mm-long Wallstent dilated to 10 mm. TcGSA dynamic imaging studies were performed before and twice after (7 and 14 days) TIPS. To be included in the study, pigs had to have a patent TIPS at 1 week of follow-up. Liver function tests were drawn parallel to the TcGSA studies. Liver biopsies were performed at 2 weeks when the animals were killed. Five of the eight pigs had open shunts at 1 week and were included in the study. There was a significant (P < .0001, Student t test) difference between the mean [R]o of the pre-TIPS studies ([R]o = 1.12+/-0.04 microM) and the mean of the post-TIPS studies at 7 days ([R]o = 0.40+/-0.04 microM) and 14 days ([R]o = 0.51+/-0.06 microM, P < .01). The only blood test that was abnormal after TIPS was ammonia (mean, 129.0+/-42.7). Liver biopsies were normal. TIPS reduces asialoglycoprotein receptor concentration in normal pigs.

ANALYSIS OF DIFFUSE PARENCHYMAL LIVER DISEASE BY LIVER SCINTIGRAMS: DIFFERENTIAL DIAGNOSIS USING FUZZY INFERENCE AND GENETIC ALGORITHM IN NUCLEAR MEDICINE

In nuclear medicine, diagnosis of diffuse parenchymal liver disease such as chronic hepatitis (CH) or liver cirrhosis (LC) is evaluated by size and distortion of the liver, distribution of radioactive tracer in the liver, size and activities of the tracer in the spleen, the degree of visualization of the bone marrow, etc. using colloid liver scintigraphy, It is not difficult to read a scintigram for a typical pattern; however in some cases it is difficult to distinguish between normal and CH or CH and LC visually. Therefore, we tried to use fuzzy inferences to perform differential diagnosis. Using fuzzy inference, differential diagnosis of LC could be performed up to 100%, but those of CH and Severe fibrosis (SF) could not be performed sufficiently. Therefore genetic algorithm was tried to determine the fuzzy rules. By combining genetic algorithm and fuzzy inference, CH, SF, and LC could be differentiated to the degree 70%, 60%, and 100%, respectively.

Liver transplantation in the adult: who and when to transplant?

The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected, or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue. Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease; and secondly, in an acceptable risk taking manner. Major criteria for indication in the most common liver diseases can be summarized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred, is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 mumol/L is generally required; c) apart from "small" hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications; d) acute liver failure requires early referral to a liver transplant center for potential emergency indication. In an organ shortage situation which is likely to perdure, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure.

PREDICTIVE MODELS OF NATURAL HISTORY IN PRIMARY BILIARY CIRRHOSIS

Primary biliary cirrhosis is a slow, progressive disease. Although many years may elapse before asymptomatic primary biliary cirrhosis patients begin experiencing symptoms of liver disease, their overall survival is significantly lower than the normal population. The Mayo natural history model has been developed to depict patient survival in the absence of effective therapeutic intervention. Although there are a number of caveats in applying this model, it has been validated using external data sets and established as an accepted tool for clinical or research purposes. Furthermore, recent data suggest that the Mayo natural history model continues to provide useful, predictive information in the presence of ursodeoxycholic acid therapy, which has been shown to lower the serum bilirubin to the natural history model for patient survival. In addition to the natural history model for patient survival, mathematical models have been developed to describe histologic progression and development of esophageal varices.

Ultrasound-guided liver biopsy for parenchymal liver disease. An economic analysis

Ultrasound-guided liver biopsy for parenchymal liver disease. An economic analysis

HEPATIC PORPHYRIAS

The porphyrias are metabolic disorders characterized by abnormal heme biosynthesis with excessive accumulation and excretion of porphyrias or porphyrin precursors. Defects in the enzymes of the heme biosynthetic pathway result in porphyria. Several of the disorders have been classified as hepatic because the major site of the biochemical defect has been localized to the liver. This article describes the enzymes of the heme biosynthetic pathway, the clinical features of the hepatic porphyrias and management of the disorders.

Ultrasound-guided liver biopsy for parenchymal liver disease: an economic analysis.

The use of ultrasound (US) to assist in liver biopsy for nonfocal liver disease has been shown to significantly decrease the incidence of minor complications (defined as pain requiring treatment, hypotension, or bleeding). In this study, decision analysis was used to estimate the average additional net charge for US guidance. The risks for minor and major complications were extracted from the literature. The incidence of minor complications such as pain and bleeding not requiring hospitalization has been reported as 49% for blind liver biopsy and 39% for US-guided liver biopsy. Major complications requiring hospital admission occur in 4% of blind liver biopsies and 2% of US-guided liver biopsies. A decision tree was used to calculate the total charges of liver biopsy and its associated complications. The charge for treating an episode of minor complications was estimated at $605. The charge related to an episode of major complications was estimated at $1533. The total charge for an ultrasound-guided liver biopsy (except the added charge for the use of ultrasound) was $1770, or $102 less than the same charge for blind liver biopsy. The addition of ultrasound in performing liver biopsies for diffuse parenchymal liver disease is cost-saving if the additional charge of US is less than $102.