Percutaneous Liver Biopsy Research Articles

The application of artificial intelligence to support biliary atresia screening by ultrasound images: A study based on deep learning models.

Early confirmation or ruling out biliary atresia (BA) is essential for infants with delayed onset of jaundice. In the current practice, percutaneous liver biopsy and intraoperative cholangiography (IOC) remain the golden standards for diagnosis. In Taiwan, the diagnostic methods are invasive and can only be performed in selective medical centers. However, referrals from primary physicians and local pediatricians are often delayed because of lacking clinical suspicions. Ultrasounds (US) are common screening tools in local hospitals and clinics, but the pediatric hepatobiliary US particularly requires well-trained imaging personnel. The meaningful comprehension of US is highly dependent on individual experience. For screening BA through human observation on US images, the reported sensitivity and specificity were achieved by pediatric radiologists, pediatric hepatobiliary experts, or pediatric surgeons. Therefore, this research developed a tool based on deep learning models for screening BA to assist pediatric US image reading by general physicians and pediatricians. De-identified hepatobiliary US images of 180 patients from Taichung Veterans General Hospital were retrospectively collected under the approval of the Institutional Review Board. Herein, the top network models of ImageNet Large Scale Visual Recognition Competition and other network models commonly used for US image recognition were included for further study to classify US images as BA or non-BA. The performance of different network models was expressed by the confusion matrix and receiver operating characteristic curve. There were two methods proposed to solve disagreement by US image classification of a single patient. The first and second methods were the positive-dominance law and threshold law. During the study, the US images of three successive patients suspected to have BA were classified by the trained models. Among all included patients contributing US images, 41 patients were diagnosed with BA by surgical intervention and 139 patients were either healthy controls or had non-BA diagnoses. In this study, a total of 1,976 original US images were enrolled. Among them, 417 and 1,559 raw images were from patients with BA and without BA, respectively. Meanwhile, ShuffleNet achieved the highest accuracy of 90.56% using the same training parameters as compared with other network models. The sensitivity and specificity were 67.83% and 96.76%, respectively. In addition, the undesired false-negative prediction was prevented by applying positive-dominance law to interpret different images of a single patient with an acceptable false-positive rate, which was 13.64%. For the three consecutive patients with delayed obstructive jaundice with IOC confirmed diagnoses, ShuffleNet achieved accurate diagnoses in two patients. The current study provides a screening tool for identifying possible BA by hepatobiliary US images. The method was not designed to replace liver biopsy or IOC, but to decrease human error for interpretations of US. By applying the positive-dominance law to ShuffleNet, the false-negative rate and the specificities were 0 and 86.36%, respectively. The trained deep learning models could aid physicians other than pediatric surgeons, pediatric gastroenterologists, or pediatric radiologists, to prevent misreading pediatric hepatobiliary US images. The current artificial intelligence (AI) tool is helpful for screening BA in the real world.

EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes.

EUS-guided liver biopsy (EUS-LB) has gained momentum in recent years, especially with availability of newer needle designs. Given the emerging comparative data on EUS-LB with second-generation needles and percutaneous LB (PC-LB), we conducted a systematic review and meta-analysis to compare the safety and efficacy of the two techniques. We searched multiple databases from inception through November 2021 to identify studies comparing outcomes of EUS-LB and PC-LB. Pooled estimates were calculated using a random-effects model, and the results were expressed in terms of pooled proportions and odds ratio (OR) along with relevant 95% confidence intervals (CIs). Five studies with 748 patients were included in the final analysis. EUS-LB was performed in 276 patients and PC-LB in 472 patients. Across all studies, PC-LB had an overall higher diagnostic accuracy than EUS-LB, 98.6% confidence interval (CI: 94.7-99.7) versus 88.3% (49.6-98.3), OR: 1.65, P = 0.04. On assessing data from randomized controlled trials, there was no difference between the two. While pooled diagnostic adequacy and overall adverse events were not significantly different between PC-LB and EUS-LB, the former was superior in terms of the mean number of complete portal tracts (CPT) and total specimen length. PC-LB and EUS-LB produce similar results. PC-LB allows obtaining longer samples and more CPT. Further studies are needed to see if these trends hold up as more providers begin to perform EUS-LB.

S1701 Bile Leak: A Rare Complication of Percutaneous Liver Biopsy

Introduction: Percutaneous liver biopsy is a cornerstone in diagnosing various hepatobiliary disorders. It is generally a safe procedure. Bile leak is a very rare complication, with rates less than 0.001%. Case Description/Methods: A 79-year-old woman presented to the emergency department with severe right upper quadrant abdominal pain along with nausea and vomiting after undergoing an ultrasound-guided percutaneous liver biopsy for elevated liver enzymes. On examination, right upper quadrant tenderness was appreciated. Computed tomography (CT) and Magnetic resonance imaging (MRI) of the abdomen were suggestive of blood products within the gallbladder. She underwent Endoscopic retrograde cholangiopancreatography (ERCP) for increased bilirubin (Table). On Fluoroscopy, she was found to have a bile leak at the level of the common hepatic duct (Figure). A temporary plastic biliary stent was placed into the common bile duct (CBD). Discussion: There are guidelines by the American Association for the Study of Liver and the Society of Interventional Radiology to prevent complications after percutaneous needle biopsies and liver biopsies. Utilizing ultrasound can help avoid injury to the gall bladder and large bile ducts. A biopsy of at least 2-3 cm length and 16-gauge caliber is considered sufficient. Patients should be closely observed for at least 2-4 hours after the procedure. Keeping a low threshold for prompt evaluation with appropriate imaging modalities and timely intervention can help overcome this challenge and reduce morbidity and mortality.Figure 1.: Fluoroscopy demonstrates extravasation of contrast at the level of the common hepatic duct, suggestive of bile leak Table 1. - Trend of total bilirubin through the hospital course. Notice the 50% decrease after biliary stent placement Total Bilirubin (mg/dL) 0.8 3.6 6.2 6.7 7.4 3.1 2.7 2.2 0.9

S1932 Acute Pancreatitis After Liver Biopsy: Clots or Stones?

Introduction: Percutaneous liver biopsy is a frequently utilized tool in the diagnosis of many liver diseases including metastatic liver lesions. Bleeding complications occur in 1% of cases and hemobilia is rare. Hemobilia causing acute pancreatitis after percutaneous liver biopsy is extremely rare with approximately 20 reported cases in literature. Symptoms include right upper quadrant pain, nausea, jaundice, hematemesis, hematochezia or melena. We present an interesting case of a woman who developed acute pancreatitis secondary to hemobilia after liver biopsy. Case Description/Methods: A 60-year-old female with recurrent high-grade serious peritoneal cancer and recent metastases to liver was admitted for acute pancreatitis. Patient presented with nausea and right upper quadrant pain that started after percutaneous liver biopsy one day prior. Labs notable for Hgb 10.4, lipase > 3000, amylase 3349, total bilirubin 3.6, direct 3.3, AST 631, ALT 482, alkaline phosphatase 240. CT A/P showed diffuse swelling of pancreas with fluid and mesenteric fat stranding suspicious for acute pancreatitis. Given liver enzyme elevation with mixed hepatocellular and cholestasis pattern, abdominal MRI was obtained to evaluate any biliary obstruction. MRI showed mildly prominent CBD at 0.8 cm with debris in distal CBD, cystic duct, and gallbladder indicative of hemorrhagic products. No hematoma noted in the liver parenchyma. Patient underwent ERCP with sphincterotomy and clots were cleared from the duct with balloon sweep (Figure). Discussion: Hemobilia, described as upper GI bleeding within the biliary tree has a reported incidence of less than 0.059% after percutaneous liver biopsy. It can occur within a few hours or several days later, with an average interval of five days. Although rare, hemobilia can lead to acute pancreatitis in a mechanism similar to gallstone pancreatitis. Excessive bleeding and increased clot formation cause obstruction in the biliary tree and impedes drainage from the ampulla which in turn triggers pancreatitis. Diagnosis can be made by ultrasound, angiography, ERCP, or MRCP. Treatment depends on the extent of bleeding and includes conservative management to advanced interventions-hepatic angiography with arterial embolization, ERCP with sphincterotomy or stent placement. Thus, our case highlights importance of recognizing hemobilia as an etiology for acute pancreatitis after percutaneous liver biopsy.Figure 1.: Removal of blood clots from bile duct by balloon sweep via ERCP

Plugged percutaneous liver biopsy using Tru-cut needle and coils: A retrospective study.

Plugged percutaneousliver biopsy, though has been in use for many years, is being used more frequently in patients in whom percutaneous liver biopsy is contraindicated due to proven or probable bleeding tendencies. We report our experience with this procedure, its indications, efficacy, and complications in Indian population over 2 years. A retrospective study of 127 consecutive patients who had undergone plug liver biopsy from April 2017 to May 2019 was done from the database maintained in our department. The indications, technical success, complications, and impact of histological diagnosis on the management of those patients were evaluated. A total of 127 biopsies were performed of which 68 were males and 59 were females, aged between 7 and 73 years. No procedures were abandoned; however, 13 cases needed ultrasonography (USG)guidance because of small size of the liver or presence of right perihepatic fluid. Out of 127 biopsies, none of the samples was inadequate and yielded adequate tissue for histopathological diagnosis. Seven patients required repeat study only because underlying liver disease was suspected clinically and the previous biopsy report had turned out to be normal. Histopathological examination in our study showed autoimmune hepatitis in 61, cirrhotic changes either hepatitis B virus (HBV)or hepatitis C virus (HCV) related in 40, veno-occlusive disease in 3, cholestatic disease in 2, and Wilson's disease in 2 patients. The remaining 19 were normal. Complications occurred in 3 patients - arterioportal fistula, pneumothorax, and inadequate coiling causing mild hemoperitoneum. Percutaneous liver biopsy followed by plugging of the tract with coils is a safe, easy, and effective method in patients with underlying bleeding tendencies, minimal ascites, and small liver.

S3026 Hepatic Sarcoidosis Hiding Beneath Mesenteric Panniculitis

Introduction: Mesenteric panniculitis is a rare inflammatory disease that affects the adipose tissue of intestinal mesentery. The incidence of mesenteric panniculitis ranges from 0.16%-3.4%. Though its etiology is unknown, it has been linked to a range of conditions including vasculitides, malignancies, abdominal trauma, and autoimmune diseases. We present a case of a 32-year-old male with a history of chronic abdominal pain and unintentional weight loss who presented with worsening transaminitis eventually found to have mesenteric panniculitis and hepatic sarcoidosis. Case Description/Methods: A 32-year-old male with a history of sarcoidosis and pulmonary embolism, not compliant with medication, presented to the emergency department with a six-month history of sharp, intermittent, and diffuse abdominal pain. He denied any fevers, nausea, vomiting, diarrhea, changes in medications or diet, recent travel, or sick contacts. He also endorsed a 20-pound weight loss. On presentation, he was tachycardic to 121 and febrile to 100F. Labs were significant for a hemoglobin of 8.2, AST 105 U/L, ALT: 81U/L, and ALP 51 U/L. On physical exam, the abdomen was diffusely tender to palpation in the epigastric region and right upper quadrant. He was started on IV Ceftriaxone. Computed Tomography (CT) of the abdomen and pelvis revealed a hazy appearance of mesentery with numerous mesenteric lymph nodes suspicious of mesenteric panniculitis, hepatomegaly, multistational upper abdominal lymphadenopathy, and a 2.0 cm ill-defined hepatic lesion (Figure 1). Percutaneous liver biopsy revealed hepatic sarcoidosis and mesenteric panniculitis. He was initiated on a two-week tapered course of prednisone. Azathioprine was later added with marked improvement in his symptoms. Discussion: Mesenteric panniculitis is a rare fibroinflammatory condition of unknown etiology. There is limited understanding of the pathogenic mechanism, but it has been linked to autoimmune processes. Presenting symptoms are vague and highly variable, but abdominal pain is reported to be the most common. CT scan is the imaging modality preferred, however, diagnosis is established by histological confirmation. No specific treatment exists, but steroids have demonstrated promising results. Our case illustrates the need for maintaining a high index of suspicion for mesenteric panniculitis when evaluating patients with a history of autoimmune disease presenting with vague abdominal pain in addition to transaminitis.Figure 1.: CT scan (axial view) showing focal lesion in the liver and mesenteric lymphadenopathy.

S3125 Overlapping Hepatotoxicity and Colitis Associated With Immune Checkpoint Inhibitors

Introduction: Immunotherapy with immune checkpoint inhibitors (ICIs) has become the standard of care for many solid-organ and hematologic malignancies. Gastrointestinal toxicities are common side effects that typically occur 6 weeks after starting ICI therapy. Overlapping hepatotoxicity and colitis associated with ICIs is rare and may be overlooked, resulting in high mortality. Case Description/Methods: A 73-year-old man with metastatic squamous cell carcinoma (SCC) of the head and neck presented with intermittent, diffuse abdominal discomfort, bloating and painless non-bloody diarrhea (up to 6 episodes daily) triggered by meals. Symptom onset was 6 weeks after starting pembrolizumab for head and neck SCC. Pembrolizumab therapy was held, and supportive therapy with proton pump inhibitors, antacids and antidiarrheals provided partial symptom relief. Laboratory work up showed elevated AST 132 U/L, ALT 220 U/L, ALP 851 U/L and normal total bilirubin. ANA was elevated with titer 1:80, with normal total IgG (699.5 mg/dL) and negative serologies for anti-smooth muscle antibody, CMV, EBV, and HSV. Abdominal CT with contrast showed a dilated common bile duct (CBD) of 11 mm and a new curvilinear filling defect in the distal CBD, without choledocholithiasis. MRCP revealed mildly dilated intrahepatic biliary ducts, CBD dilation (13 mm), and an ovoid 8mm soft tissue nodule in the periampullary duodenum. Upper endoscopy was nondiagnostic. At this time, the patient’s symptoms improved, but there was high suspicion of grade-2 ICI-associated hepatitis (ICIH). Percutaneous liver biopsy showed interlobular bile duct injury with intraepithelial lymphocytes and neutrophils and a neutrophilic ductular reaction consistent with ICIH. Serial lab work demonstrated improvement of liver enzymes, with AST 77 U/L, ALT 69 U/L and ALP 667 U/L at 60 days after initial labs. Diarrhea resumed, up to 6 episodes per day, consistent with the Common Terminology Criteria for Adverse Events diagnosis of ICI-related colitis (ICIC). Initial supportive therapy failed to improve diarrhea; thus, a prednisone taper was started, resolving the colitis. He declined the option to resume immunotherapy and transitioned to comfort care (Figure 1). Discussion: Overlapping ICIH and ICIC is rare and may have discordance between symptomatology and lab findings. Early recognition of overlapping ICIH and ICIC, supportive treatment, permanent cessation of the inciting ICI and switching it with alternative immunosuppressive therapy may improve patient outcomes and quality of life.Figure 1.: Panel A - CT chest/abdomen with contrast (coronal view) showing common bile duct dilation of 1.2 cm (yellow calipers) status post cholecystectomy. Panel B. Upper endoscopy showing prominent ampulla with free-flowing bile. Panel C. Histology of percutaneous, ultrasound-guided liver biopsy with H&E staining (10×) shows preserved lobular hepatic architecture with mixed inflammatory infiltrate including lymphocytes, histiocytes, and scattered eosinophils expanding the portal tracts. Table 1. - Immune Checkpoint Inhibitor Associated Hepatitis Grades, adapted from the American Society of Clinical Oncology, 2021 Grade Criteria 1 Asymptomatic (AST or ALT > ULN to 3.0 X ULN and/or total bilirubin > ULN to 1.5 X ULN) 2 Asymptomatic (AST or ALT > 3.0 to ≤ 5 X ULN and/or total bilirubin > 1.5 to ≤ 3 X ULN) 3 AST or ALT 5-20 X ULN and/or total bilirubin 3-10 X ULN, OR symptomatic liver dysfunction; fibrosis by biopsy; compensated cirrhosis; and reactivation of chronic hepatitis 4 AST or ALT > 20 X ULN and/or total bilirubin > 10 X ULN OR decompensated liver function (e.g., ascites, coagulopathy, encephalopathy, and coma) Abbreviations: AST, aspartate transferase; ALT, alanine transaminase; ULN, upper limit of normal.

Changes in indications for outpatient percutaneous liver biopsy over 5 years: from hepatitis C to fatty liver disease

Although the use of non-invasive methods for assessment of liver fibrosis has reduced the need for biopsy, the diagnosis of liver damage still requires histological evaluation in many patients. We aim to describe the indications for percutaneous liver biopsy (PLB) and the rate of complications in an outpatient setting over 5 years. This observational, single-center, and retrospective study included patients submitted to real-time ultrasound (US)-guided biopsies from 2015 to 2019. We collected age, gender, coagulation tests, comorbidities, and the number of needle passes. The association between the variables and complications was evaluated using the generalized estimating equations method. We analyzed 532 biopsies in 524 patients (55.3% male) with a median age of 49 years (range 13–74y). An average of 130.3 biopsies per year were performed in the first 3 years of the study versus 70.5 in the other 2y. The main indications were hepatitis C virus (HCV) infection (47.0%), autoimmune and cholestatic liver diseases (12.6%), and metabolic dysfunction-associated fatty liver disease (MAFLD) (12.1%). The number of HCV-related biopsies had a remarkable reduction, while MAFLD-related procedures have progressively raised over time. Around 54% of the patients reported pain, which was significantly associated with females ( p = 0.0143). Serious complications occurred in 11 patients (2.1%) and hospital admission was necessary in 10 cases (1.9%). No patient required surgical approach and there were no deaths. No significant association was found between the studied variables and biopsy-related complications. The indications for PLB in an outpatient setting have changed from HCV to MAFLD over the years. This procedure is safe and has a low rate of serious complications, but new strategies to prevent the pain are still needed, especially for females. Aunque el uso de métodos no invasivos para evaluar la fibrosis hepática ha reducido la necesidad de una biopsia, el diagnóstico de daño hepático aún requiere una evaluación histológica en muchos pacientes. Nuestro objetivo es describir las indicaciones de la biopsia hepática percutánea ambulatoria y la tasa de complicaciones durante cinco años. Este estudio observacional, retrospectivo y unicéntrico incluyó pacientes sometidos a biopsias guiadas por ecografía en tiempo real desde 2015 hasta 2019. Recogimos información sobre edad, sexo, pruebas de coagulación, comorbilidades y número de pasadas de aguja. La asociación entre variables y complicaciones se evaluó mediante el método de ecuaciones de estimación generalizada. Analizamos 532 biopsias en 524 pacientes (55,3% hombres) con una edad media de 49 años (rango de 13 a 74 años). Se realizó una media de 130,3 biopsias por año en los primeros tres años del estudio frente a 70,5 en los otros dos años. Las principales indicaciones fueron la infección por el virus de la hepatitis C (HCV) (47,0%), las enfermedades hepáticas autoinmunes y colestásicas (12,6%) y la enfermedad del hígado graso asociada a disfunción metabólica (MAFLD) (12,1%). El número de biopsias relacionadas con la HCV tuvo una reducción notable, mientras que los procedimientos relacionados con MAFLD han aumentado progresivamente con el tiempo. Alrededor del 54% de los pacientes informaron dolor, que se asoció significativamente con las mujeres (p = 0,0143). Se produjeron complicaciones graves en 11 pacientes (2,1%) y el ingreso hospitalario fue necesario en 10 casos (1,9%). Ningún paciente requirió abordaje quirúrgico y no hubo muertes. No se encontró asociación significativa entre las variables estudiadas y las complicaciones relacionadas con la biopsia. Las indicaciones para la biopsia hepática percutánea ambulatoria han cambiado de HCV a MAFLD con el pasar de los años. Este procedimiento es seguro y tiene una baja tasa de complicaciones graves, pero aún se necesitan nuevas estrategias para prevenir el dolor especialmente en mujeres.

S3315 Acute Cholestatic Hepatitis Following m-RNABNT162b2 SARS-CoV-2 Vaccination: Could It Be Genetic?

Introduction: Given the morbidity and mortality of COVID-19, development of vaccines targeting SARs-CoV-2 was essential. Despite their overall safety and efficacy, atypical complications have been reported. We report a case of post-vaccination acute cholestatic hepatitis, consistent with drug-induced liver injury (DILI). Case Description/Methods: A 61-year-old man with no past medical history presented with 2 weeks of jaundice and pruritus, 1 month after his second dose of the m-RNABNT162b2 SARS-CoV-2 vaccine. He denied use of any medications, supplements, tobacco, alcohol, drugs, or family history of liver disease. Vital signs and physical exam were unremarkable. Admission labs included ALP 265 U/L, AST 50 U/L, ALT 68 U/L, total bilirubin 14.9 mg/dL, and direct bilirubin 12 mg/dL. Ultrasound revealed normal liver surface without ductal dilatation, confirmed by MRCP. Serologies (HIV, HAV IgM, HBV core IgM, HBV surface antigen, HCV antibody), autoimmune markers (ANA, anti-mitochondrial, anti-actin, anti-liver-kidney-microsomal), and respiratory viral panel (SARS-CoV-2, influenza A/B, RSV) were negative. Hemoglobin, platelets, INR, albumin, gamma-glutamyl transpeptidase (GGT), and immunoglobulins were normal. Percutaneous liver biopsy revealed cholestasis with mild portal lymphocytic infiltrates and lobular inflammation (Figure 1), without portal fibrosis, PAS+ globules, or iron deposition. Molecular genetic testing (Next Generation Sequencing, Prevention Genetics® 77 Gene Cholestasis Panel) was performed. No genetic variants were identified in 77 genes associated with cholestasis, though single copy variants of several autosomal recessive genes were detected. Symptoms resolved with supportive care. Labs one month later were notable for ALP 175 U/L, (AST hemolyzed), ALT 68 U/L, and total bilirubin 3.2 mg/dL. Discussion: Prior reports have described cholestasis due to immune-mediated hepatitis after COVID mRNA vaccination1, but these features were absent in this case. Given the patient’s normal GGT, we hypothesized that increased cytokine release led to cholestatic injury in an individual genetically predisposed to cholestasis by genetic variation in ATP8B1 or ABCB11. Future studies comparing genetic variants in patients with liver injury may provide insight into mechanisms of idiosyncratic DILI following mRNA vaccination against SARS-CoV-2.Figure 1.: Liver biopsy showing cholestasis in a patient who developed jaundice after COVID mRNA vaccination.

Differences in HDL-Bound Apolipoproteins in Patients With Advanced Liver Fibrosis Due to Nonalcoholic Fatty Liver Disease.

The mechanisms leading to increased cardiovascular disease in patients with nonalcoholic fatty liver disease (NAFLD) and advanced liver fibrosis remain incompletely understood. This study assessed HDL-bound proteins in patients with NAFLD with or without advanced fibrosis. This cross-sectional study at a university hospital included 185 patients with or without type 2 diabetes (T2D). Patients underwent liver proton magnetic resonance spectroscopy to measure intrahepatic triglyceride accumulation and those with NAFLD underwent a percutaneous liver biopsy. Advanced lipid testing with lipoprotein subfraction measurements and targeted proteomics of HDL-bound proteins was performed. Patients with and without advanced fibrosis had similar clinical characteristics, except for lower HDL-C (34 ± 8 vs 38 ± 9 mg/dL, P = 0.024) and higher prevalence of T2D in advanced fibrosis. Patients with advanced fibrosis had lower HDL particle number. A panel of 28 HDL-bound proteins were targeted and quantified by multiple reaction monitoring liquid chromatography-tandem mass spectrometry. Five proteins were found to be decreased in patients with advanced fibrosis (ApoC-I [P < 0.001], ApoC-IV [P = 0.012], ApoM [P = 0.008], LCAT [P = 0.014], and SAA4 [P = 0.016]). No differences were observed in these proteins in patients with vs without NAFLD or steatohepatitis. The pCAD index, associated with coronary artery disease and cardiovascular mortality, was significantly higher in patients with advanced fibrosis (97 ± 5 vs 86 ± 25, P = 0.04). Patients with NAFLD with advanced fibrosis showed significant differences in HDL-bound protein levels; this translated into increased cardiovascular risk based on pCAD index. Different lipoprotein composition and function may explain the link between liver disease and increased cardiovascular mortality in these patients.

A Rare Cause of Liver Fibrosis in an Adolescent Woman

A Rare Cause of Liver Fibrosis in an Adolescent Woman

Noninvasive Diagnosis of Hepatic Fibrosis in Hemodialysis Patients with Hepatitis C Virus Infection.

Hepatitis C virus (HCV) is a major health problem in hemodialysis patients, which leads to significant morbidity and mortality through progressive hepatic fibrosis or cirrhosis. Percutaneous liver biopsy is the gold standard to stage hepatic fibrosis. However, it is an invasive procedure with postbiopsy complications. Because uremia may significantly increase the risk of fatal and nonfatal bleeding events, the use of noninvasive means to assess the severity of hepatic fibrosis is particularly appealing to hemodialysis patients. To date, researchers have evaluated the performance of various biochemical, serological, and radiological indices for hepatic fibrosis in hemodialysis patients with HCV infection. In this review, we will summarize the progress of noninvasive indices for assessing hepatic fibrosis and propose a pragmatic recommendation to diagnose the stage of hepatic fibrosis with a noninvasive index, in hemodialysis patients with HCV infection.

Endoscopic Ultrasound-Guided Fine-Needle Biopsy versus Fine-Needle Aspiration in the Diagnosis of Focal Liver Lesions: Prospective Head-to-Head Comparison.

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA) from focal liver lesions are indicated in selected cases, but there has been no previous comparison of needle types of the same size. The aim of our study was to compare the histologic diagnostic accuracy and adequacy of cores obtained with EUS-FNB needles in contrast to those obtained with FNA needles in focal liver lesions. This prospective one-center study included patients with left lobe hepatic focal lesions with contraindications for percutaneous liver biopsy or need for EUS for concomitant lesions. Each patient had one pass of 22G EUS-FNB (Franseen) needle and one pass of 22G EUS-FNA in a crossover manner, without macroscopic on-site evaluation. Each sample was analyzed separately for histologic adequacy and diagnosis. The final diagnosis was based on histology results or on imaging follow-up in the case of negative biopsies. The EUS-FNB samples (n = 30) were found to be more adequate for histologic analysis, with more cellularity and longer tissue aggregates than the EUS-FNA samples (n = 30). The accuracy of EUS-FNB was 100%, whereas that of EUS-FNA was 86.7% (p = 0.039). No post-procedure complications were noted. The 22G EUS-FNB needle proved superior to 22G EUS-FNA in terms of tissue acquisition diagnostic accuracy and histologic adequacy in focal liver lesions.

Major complications after percutaneous biopsy of native or transplanted liver in pediatric patients: a nationwide inpatient database study in Japan

AimAlthough major complication rates following percutaneous liver biopsy (PLB) have been reported to be higher in children than in adults, scarce data are available regarding pediatric patients stratified by native and transplanted liver. We aimed to assess the factors associated with major complications after percutaneous biopsy of native or transplanted liver using a nationwide inpatient database.MethodsUsing the Japanese Diagnosis Procedure Combination database, we retrospectively identified pediatric patients who underwent PLB between 2010 and 2018. We described major complication rates and analyzed factors associated with major complications following PLB, stratified by native and transplanted liver.ResultsWe identified 3584 pediatric PLBs among 1732 patients from 239 hospitals throughout Japan during the study period, including 1310 in the native liver and 2274 in the transplanted liver. Major complications following PLB were observed in 0.5% (n = 18) of the total cases; PLB in the transplanted liver had major complications less frequently than those in the native liver (0.2% vs. 1.0%, p = 0.002). The occurrence of major complications was associated with younger age, liver cancers, unscheduled admission, anemia or coagulation disorders in cases with native liver, while it was associated with younger age alone in cases with transplanted liver.ConclusionsThe present study, using a nationwide database, found that major complications occurred more frequently in pediatric cases with native liver and identified several factors associated with its major complications.

Acute hepatitis following mRNA BNT162b2 COVID-19 vaccination.

BACKGROUND: Widespread administration of COVID-19 vaccinations have led to reports of rare but potentially serious side effects. METHODS: We present two cases of acute hepatitis following mRNA BNT162b2 (Comirnaty, Pfizer-BioNTech) vaccination. RESULTS: A 25-year-old male presented to hospital with progressive jaundice 5 days following his second dose of Comirnaty. Initial bloodwork revealed severe hepatocellular enzyme elevation and conjugated hyperbilirubinemia with preserved INR. Extensive serologic workup was negative, with normal imaging. Percutaneous liver biopsy was performed and revealed acute cholestatic hepatitis possibly related to drug-induced liver injury. He was started on prednisone 40 mg daily with good initial response but had a second flare; a biopsy was repeated which showed near-identical findings. Steroids were discontinued given non-response and the patient had gradual near complete resolution of liver enzymes and hyperbilirubinemia. A 32-year-old male presented with a 4-week history of nausea followed by progressive choluria, jaundice, and pruritis. He received his second dose of Comirnaty vaccination two weeks prior to presentation. Initial bloodwork showed mixed enzyme elevation with hyperbilirubinemia. Serological workup and imaging were unrevealing. He underwent liver biopsy which showed severe intrahepatic cholestasis, with drug-induced liver injury being suggested as most likely cause. His course was self-limited with resolution of serological abnormalities and symptoms. CONCLUSIONS: While overwhelmingly safe on a population level, our case series illustrate two cases of acute icteric hepatitis following mRNA BNT162b2 vaccination. Clinicians should be aware of this association with hepatic inflammation and consider vaccine history an important component of evaluating patients with acute liver injury.

Update on endoscopic ultrasound-guided liver biopsy.

Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a minimally-invasive alternative to the traditional (percutaneous or transjugular) liver biopsy techniques for the diagnosis of liver parenchymal diseases. Po-tentially, EUS-LB combines the advantages of percutaneous and transjugular liver biopsy in addressing focused sampling in addition to measuring portal pressure. Additionally, EUS-LB facilitates access to both the lobes of the liver which is not considered with the traditional percutaneous liver biopsy. Multiple studies have compared EUS-LB with conventional liver biopsy and reported comparable diagnostic yield, increased acquisition of complete portal tracts, and longer specimen length as compared to the traditional approaches. EUS-LB is associated with lesser post-procedural pain and shorter recovery time, while providing lower risk of complications when compared to traditional liver biopsy. Innovations in needle types, needle sizes and suction techniques have aimed at further optimizing the EUS-LB technique. This review article updates current literature with focus on the variations in the technique and equipment used for EUS-LB, and compares EUS-LB with traditional methods of liver biopsy.

The benefit of contrast-enhanced ultrasound in biopsies for focal liver lesions: a retrospective study of 820 cases.

This study compared the performance between ultrasound (US)- and contrast-enhanced US (CEUS)-guided liver biopsies and evaluated the benefit of CEUS in percutaneous biopsy for focal liver lesions (FLLs). We performed a retrospective study of 820 patients with FLLs, who underwent percutaneous liver biopsy in our center between 2017 and 2019. The patients were divided into two groups based on whether US (n = 362) or CEUS (n = 458) used before a biopsy. The two groups were compared based on specimen adequacy for pathological diagnosis and diagnostic accuracy of liver biopsy. Stratification analysis was performed based on lesion and protocol characteristics to provide detailed information for selecting the imaging guidance for biopsy. Compared with the US group, the CEUS group yielded more acceptable samples (97.6% vs. 99.4%, p < 0.05) and improved diagnostic accuracy (92.6% vs. 96.4%, p < 0.05), and achieved better sensitivity (92.5% vs. 96.2%, p < 0.05) for liver biopsies, especially in FLLs ≥ 5 cm, heterogeneous hypoechoic FLLs, or FLLs with an obscure boundary. The CEUS group showed significantly higher accuracy compared with the US group pertaining to single-puncture biopsies (100% vs. 92.7%, p < 0.05) or biopsies with punctures ≤ 2 (97.6% vs. 94.3%, p < 0.05). CEUS achieved an enhanced success rate for sampling and diagnostic accuracy of liver biopsies, especially in FLLs ≥ 5 cm, heterogeneous hypoechoic FLLs, or FLLs with an obscure boundary. CEUS can be used to decrease the number of punctures needed, which might increase the safety of liver biopsy. • CEUS can help confirm an adequate biopsy site, increasing the sampling success rate and diagnostic accuracy of the liver biopsy. • CEUS can be used to decrease the number of punctures needed to improve the safety of liver biopsy. • It is recommended to use CEUS guidance for liver biopsies, especially with FLLs ≥ 5 cm, heterogeneous hypoechoic FLLs, or FLLs with an obscure boundary.

Use of preprocurement biopsy in donation after circulatory death liver transplantation.

We perform routine preprocurement image-guided percutaneous liver biopsies on potential donation after circulatory death (DCD) liver donors. The purpose of this study was to examine the impact of preprocurement liver biopsy on the use of livers from DCD donors. We retrospectively reviewed demographics, liver histology, and disposition of DCD liver donors within a single organ procurement organization (OPO) who underwent preprocurement liver biopsy from January 2000 through December 2019. A total of 212 potential donors underwent prerecovery biopsy. No donors were lost as a result of complications of biopsy. Of these, 183 (86.3%) had acceptable biopsies: 146 (79.8%) were successfully transplanted and 37 (20.2%) were deemed not suitable for transplant. In contrast, of 120 DCD livers recovered with the intent to transplant that were not biopsied prior to recovery, 59 (49.2%) were successfully transplanted, and 61 (50.8%) were deemed not suitable for transplant. A total of 14 donors were ruled out for transplant based on prerecovery histology. Successfully transplanted livers that underwent preprocurement biopsy were more likely to come from donors aged older than 50 years or with body mass index more than 30 kg/m2 compared with successfully transplanted livers without a prerecovery biopsy. Biopsy excluded 6.6% of DCD donor livers for transplant prior to recovery and facilitated the successful recovery and transplant of two-thirds of potential DCD donor livers. Livers intended for transplant at the time of recovery that did not undergo preprocurement biopsy were more likely to not be recovered or to be discarded. Preprocurement biopsy provides additional histologic information prior to deploying resources and helps to identify usable livers that might otherwise be declined for transplant. Consideration of liver biopsy in this group benefits OPOs and transplant centers by maximizing organ use and optimizing resource deployment.

Elective percutaneous liver biopsy and use of aspirin

ObjectivesPercutaneous liver biopsy is an essential diagnostic investigation in hepatology. Among complications, which are rare, bleeding is the most feared. Many patients scheduled for a liver biopsy are taking aspirin. Surprisingly no information is available in the literature on this frequent clinical situation. The American Association for the Study of Liver Diseases (AASLD) position paper on percutaneous liver biopsy does not specifically recommend stopping low dose aspirin prior to an elective percutaneous liver biopsy. The European Association for the Study of the Liver also remains unspecific without giving clear recommendation on stopping or not low dose aspirin before the procedure. The aim of this study is to document current practice concerning the management of patients scheduled for an elective percutaneous biopsy and taking low dose aspirin.DesignAn online questionnaire was designed to gather data on current practice on the perioperative management of percutaneous liver biopsy and use of aspirin.SettingsThe questionnaire was emailed to AASLD members in September 2018.ParticipantsFour hundred sixty six responses were collected.ResultsSeventy eight percent postpone elective percutaneous liver biopsy if International Normalised Ratio is ≥1.5 or Quick ≤50%. Ninety five percent postpone biopsy if platelet count is ≤50,000 × 106/L. Seventy five percent stop low dose aspirin, on average, 6 days prior to the percutaneous liver biopsy. This choice of management does not seem to be related to previous complications since 86% report not having experienced any bleeding in patients taking low dose aspirin. Nevertheless, this practice has logistic consequences since 61% of the respondents postponed a liver biopsy due to intake of low dose aspirin.ConclusionsDespite the lack of clear statement in guidelines and evidence supporting this practice, three quarters of physicians practicing in hepatology stop low dose aspirin before elective percutaneous liver biopsy.

Impact of risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy of space-occupying lesions

IntroductionUltrasound-guided percutaneous liver biopsy is considered the technique of choice for the histological diagnosis of space-occupying lesions, given its high level of safety and diagnostic performance. However, since it is an invasive diagnostic procedure, complications can occur. Various clinical and radiological parameters have been analysed as factors related with the efficacy of the technique or with its complications; however, the results have been contradictory. Thus, we aimed to evaluate the impact of various risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy in the diagnosis of space-occupying lesions in ordinary clinical practice. Material and methodsThis retrospective observational study included all patients who underwent real-time ultrasound-guided percutaneous biopsies of space-occupying liver lesions with the free-hand technique between December 2012 and February 2018 in the diagnostic imaging department at the Hospital Clínico Universitario de Santiago de Compostela.We analysed the following risk factors: location of the lesion in upper liver segments (II, IVa, VII, or VIII); proximity to the liver capsule, distance from the skin >100mm, interposition of osseus or vascular structures, inability to go through healthy parenchyma, and lack of patient cooperation during the procedure.Efficacy was analysed in terms of the number of cylinders obtained and the percentage of adequate biopsies; safety was analysed in terms of the percentage of complications, which were classified as major or minor. ResultsWe included 295 biopsies in 278 patients (median age, 69 years; 64.1% male; 44.7% had prior neoplasms). In 61.4%, the biopsy was indicated for the initial diagnosis; 82.4% of biopsies were done in hospitalised patients, and 65% of the lesions were located in the right liver lobe.The median number of cylinders obtained was 3 (range 1–6); 91.2% of the biopsies were adequate and 92.2% were considered clinically useful. These percentages did not differ significantly according to the presence of risk factors. Complications occurred in 10 (3.4%) patients. Complications were considered major in 3 (0.9%) patients (2 (0.6%) bleeding complications and 1 (0.3%) infectious complication) and minor in 7 (2.4%). The percentage of complications was significantly higher in patients who did not cooperate during the procedure (P=.04). ConclusionsUltrasound-guided percutaneous liver biopsy is an efficacious and safe technique for the histological diagnosis of space-occupying liver lesions. Our results confirm the increased rate of complications when patients fail to cooperate during the procedure.