Transvenous Liver Biopsy Research Articles

Veno‐occlusive disease after an anti‐CD33 therapy (gemtuzumab ozogamicin)

Veno‐occlusive disease after an anti‐CD33 therapy (gemtuzumab ozogamicin)

Hepatic dysfunction after left ventricular mechanical assist in patients with end-stage heart failure: role of inflammatory response and hepatic microcirculation

Background. In the condition of preexisting vital organ failure induced by heart failure, hepatic failure often progresses despite establishment of adequate hemodynamic support through a left ventricular assist device (LVAD) and results in a high mortality rate. We hypothesized that inflammatory responses, including those induced by infection and their influence on organ perfusion, may contribute to the pathogenesis of this progressive hepatic failure and subsequent multiple organ failure as reported in the current investigation on multiple organ failure after major surgery or trauma. Methods. Hepatic function and its relation to inflammatory response and hepatic microcirculation were evaluated in 16 consecutive patients who received an implantation of LVAD for end-stage cardiomyopathy, between 1992 and 2000. Patients were divided into two groups: 5 patients who died from multiple organ failure after severe hepatic failure (group 1) and 11 patients who did not develop severe hepatic failure (group 2). Serum levels of CRP, interleukin (IL)-6, IL-8, and serum hyaluronan, a known indicator of hepatic sinusoidal function, were measured pre- and postoperatively in both groups. Results. Serum ALT and AST levels during LVAD support were similar in the two groups. Serum total bilirubin (T-Bil), CRP, IL-6, and IL-8 levels before and during the first 20 days of LVAD support were significantly higher in group 1 than those in group 2 ( p < 0.01 to 0.05). Serum hyaluronan levels in both groups were significantly correlated with T-Bil levels ( r = 0.60, p < 0.05 in group 1; r = 0.68, p < 0.0001 in group 2). Histopathological examination by transvenous liver biopsy in a group 1 patient showed hepatic sinusoidal damage as well as cholestasis and fibrosis. Conclusions. Patients with hyperbilirubinemia and inflammatory reactions before LVAD support showed increased hyperbilirubinemia and inflammatory cytokine and hyarulonan levels despite adequate hemodynamics achieved under LVAD support. These results suggest that inflammatory response contributes to subsequent aggravation of hepatic dysfunction, probably with underlying and continuing derangement in hepatic sinusoidal microcirculation even under systemic circulatory support.

Serum laminin and type IV collagen are accurate markers of histologically severe alcoholic hepatitis in patients with cirrhosis

Background/Aims: Severe alcoholic hepatitis occurs mainly in patients with cirrhosis, and has a high death rate. Corticosteroid therapy has been particularly advocated as reducing mortality in patients with severe histologic lesions. However, identification of these patients is difficult, requiring transvenous liver biopsy. Extracellular matrix serum markers have been proposed as non-invasive diagnostic tools in alcoholic liver disease. The aim of this study was to determine the accuracy of 5 extracellular matrix serum markers, i.e. laminin (Lam), N-terminal peptide of type III procollagen (PIIINP), type I (CI), type III (CIII) and type IV (CIV) collagens in identifying patients with severe histologic alcoholic hepatitis from among those with cirrhosis and suspected alcoholic hepatitis.Methods: We studied 80 consecutive patients with alcoholic cirrhosis and clinical suspicion of alcoholic hepatitis referred for transvenous liver biopsy. Clinical severity of alcoholic hepatitis was assessed according to Maddrey's score. Histological severity was scored using the sum of the 3 following items: polynuclear infiltration (0–3); hepatocytes alterations (0–3); Mallory bodies (0–2). According to this score, patients were divided into 3 groups: mild (1–3), moderate (4–6), and severe (7–8) alcoholic hepatitis. Serum levels of the 5 extracellular matrix serum markers were measured at the time of biopsy using radioimmunoassays. Diagnostic value for histologically severe alcoholic hepatitis of the 5 extracellular matrix serum markers was assessed using receiver operating characteristic curves.Results: Histological alcoholic hepatitis was present in 67 patients (mean alcoholic hepatitis score: 3.4±2.3). Maddrey's score was 66% sensitive and 69% specific for the diagnosis of severe histologic alcoholic hepatitis. The serum Lam and CIV concentrations were the most accurate in identifying correctly patients with severe histologic alcoholic hepatitis. At a cut-off of 4.1 UI/ml, Lam was 90% sensitive and 77% specific, whereas at a cut-off of 150 ng/ml, CIV was 89% sensitive and 77% specific. Combination of markers did not result in improved diagnostic value.Conclusion: In patients with cirrhosis, determination of serum Lam or CIV could represent a simple and accurate non-invasive method for identification of patients with histologically severe alcoholic hepatitis eligible for corticosteroid treatment.

THE PATHOLOGY, DIAGNOSIS, AND TREATMENT OF HEPATIC VENO‐OCCLUSIVE DISEASE: CURRENT STATUS AND NOVEL APPROACHES

THE PATHOLOGY, DIAGNOSIS, AND TREATMENT OF HEPATIC VENO‐OCCLUSIVE DISEASE: CURRENT STATUS AND NOVEL APPROACHES

Transvenous liver biopsy

In patients with an indication for histological evaluation of diffuse liver disease a transvenous approach may be advisable if a percutaneous technique is contraindicated by severe coagulopathy or ascites. In general, the procedure may be performed as an aspiration core, or forceps biopsy technique using a transjugular approach. Alternatively, the forceps biopsy technique may be performed via a transfemoral access. Adequate specimens for histologic diagnosis may be obtained in 77-100% with either biopsy technique. Complications after transvenous liver biopsies occur in 0-20% with an overall mortality rate below 0.5%. Although the transvenous liver biopsy techniques take more time and are more expensive than percutaneous biopsy techniques, they represent a safe and effective alternative for obtaining adequate liver samples for histological diagnosis in special clinical settings.

Transvenous Liver and Renal Biopsy in High-Risk Patients

Transvenous Liver and Renal Biopsy in High-Risk Patients

Transvenous liver biopsy (TVLB) in fulminant, subfulminant and severe acute hepatic failure

Transvenous liver biopsy (TVLB) in fulminant, subfulminant and severe acute hepatic failure

Utility of transvenous liver biopsies and wedged hepatic venous pressure measurements in sixty marrow transplant recipients.

Sixty marrow transplant recipients with liver dysfunction underwent transvenous liver biopsy and measurement of the hepatic venous pressure gradient. Biopsies were done on 29 patients using a Cook needle inserted through the jugular vein, on 30 patients through the femoral vein with a Mansfield biopsy forceps, and on 1 patient using both instruments. The average number of evaluable portal spaces was 4.0 for aggregated Cook needle specimens and 5.2 for Mansfield forceps specimens. The average number of central venules was 2.6 for Cook needle specimens and 3.5 for Mansfield specimens. Tissue obtained with the Mansfield forceps had crush artifact, especially along the edges, making assessment of bile ducts more difficult than in Cook needle specimens. Liver histology aided management in 53/60 patients by confirming the clinical diagnosis in 24 (40%) and by providing additional diagnoses in 29 (48%). Hepatic venous pressure gradient > 10 mmHg correlated with a histologic diagnosis of veno-occlusive disease (P = 0.001); this gradient value provided 91% specificity and 86% positive predictive value. Eleven patients had bleeding complications, 9 after Cook needle biopsy and 2 after Mansfield forceps biopsy. There were 3 procedure-related deaths, 2 from intraperitoneal bleeding after Cook needle biopsy and 1 from femoral vein bleeding after Mansfield biopsy. We conclude that transvenous liver biopsy and pressure measurements provide useful diagnostic information in marrow transplant patients with liver disease. In our hands, the Mansfield forceps was associated with a lower risk of intra-abdominal bleeding and capsular perforation of the liver while providing adequate histology for diagnosis. Hepatic venous pressure gradients > 10 mmHg were highly specific for a diagnosis of veno-occlusive disease in this patient population.

Transvenous liver biopsy with the radial jaw forceps in patients with non-correctable coagulopathy

Transvenous liver biopsy with the radial jaw forceps in patients with non-correctable coagulopathy

Transfemoral liver biopsy by forceps: a review of 104 consecutive procedures.

Transvenous liver biopsy is performed on patients with contraindications to percutaneous biopsy. Transfemoral liver biopsy has not been widely reported, and we present our experience of 104 consecutive procedures. During a 30-month period, 88 patients underwent 104 transfemoral liver biopsies. Under fluoroscopic guidance a 9 Fr curved introducer catheter is passed into the right hepatic vein via a standard femoral sheath. A 7 Fr biopsy forceps is then passed into the liver, opened and wedged. Prior to biopsy, the image intensifer is rotated so the relation of the capsular surface to the biopsy site is verified and capsular perforation avoided. Tissue samples obtained in 97 of 104 procedures (93%) were adequate for diagnosis in 83 (80%). Complications occurred in six procedures (6%) including two capsular perforations; the latter two were treated by coil embolization. We found transfemoral liver biopsy using forceps to be a safe, well-tolerated procedure with a high diagnostic yield and it is a technically easy alternative to the transjugular approach using large needles.

Transvenous Liver Biopsy in Patients with Cirrhosis with Use of the Femoral Venous Approach and a Flexible Forceps

Jose I. Bilbao, MD Jesus Sola, MD Alfonso Iglesias, MD Felix Contreras, MD Bruno Sangro, MD Jesus M. Longo, MD Jesus J. Vazquez, MD P m c u T A N E o u s liver biopsy is often essential in the definitive diagnosis of liver diseases. However, parenchymal liver diseases are sometimes associated with coagulation disorders or ascites. In such cases, the conventional percutaneous approach is contraindicated due to the high risk of hemorrhage, which could lead to death (1). When both thrombocytopenia and prolonged prothrombin time are present, different approaches to the classic technique have been suggested, like plugging of the needle tract ( 2 4 ) or transjugular liver biopsy, for which extensive experience (5) and good histologic results have been reported (5-7). These techniques, however, are not without risk of bleeding. For this reason, a new transvenous approach consisting of the introduction of forceps through femoral vein puncture has been reported for patients with and without cirrhosis (8,9). We have used this approach in the performance of biopsies in 30 consecutive patients with known or suspected cirrhosis.

Portal hypertension in lymphoproliferative and myeloproliferative disorders: Hemodynamic and histological correlations

The pathogenesis of portal hypertension in patients with lymphoproliferative and myeloproliferative disorders is not fully understood. We investigated 20 patients with myeloproliferative disease and 47 patients with lymphoproliferative disease. Transvenous liver biopsies and hepatic vein pressure gradient measurements were performed in all patients, and portal vein blood flow was measured by pulsed Doppler sonography in 31 of these patients and in 22 normal volunteers. The hepatic vein pressure gradient was significantly higher in patients with hepatic infiltrates, fibrosis or both than in patients without hepatic lesions (8.3 +/- 5.0 mmHg vs. 4.1 +/- 2.3 mmHg; p < 0.01). Portal vein blood flow was significantly higher in patients with hematological disease than in normal volunteers (31.2 +/- 15.5 ml/min.kg vs. 14.2 +/- 4.6 ml/min.kg;p < 0.01). In 81.8% of patients with hepatic infiltrates, fibrosis or both and increased portal vein blood flow, the hepatic vein pressure gradient was greater than 6 mm Hg. Although we saw a significant correlation between splenic vein blood flow and portal vein blood flow (n = 20; p < 0.01), we found no significant correlation between splenic vein blood flow and hepatic vein pressure gradient or spleen size. Hepatic infiltration and fibrosis appear to be major determinants of increased hepatic vein pressure gradient, probably because they increase intrahepatic vascular resistance. The role of increased splenic blood flow is probably not determinant. However, because portal pressure was not measured directly in this study, the incidence of portal hypertension may have been underestimated.

Identification of the Rochalimaea henselae 16S rRNA Sequence in the Liver of a French Patient with Bacillary Peliosis Hepatis

Colleagues-Rochalimaea henselae, a recently identified pathogen [1, 2], is the causative agent of bacillary angiomatosis [3], bacillary peliosis hepatis [4], and prolonged fever with persistent bacteremia [5], diseases that occur primarily in immunocompromised patients. Because these conditions have been found almost exclusively in patients living in the United States, the existence of R. henselae outside North America has been questioned. A 36-year-old French patient with AIDS, who had never been in North America, was seen in our department for fever, weight loss, abdominal pain, hepatosplenomegaly, pancytopenia, and moderately elevated levels of aminotransferase, -y-glutamyltransferase, and alkaline phosphatase. Transvenous liver biopsy yielded a tissue specimen with multiple peliotic spaces and microabscesses. A liver section stained by the Warthin-Starry technique showed clumps of bacilli, confirming the diagnosis ofbacillary peliosis hepatis. DNA was extracted from a fragment of the liver biopsy specimen and submitted to 30 cycles of polymerase chain reaction amplification, using primers p93E and p13B as described by Reiman et al. [3]. A 480-bp fragment, corresponding to a eubacterial 16S rRNA gene region, was enzymatically amplified and submitted to an additional 30 cycles of amplification with unequal molar amounts of two amplification primers to generate ssDNA for sequence analysis [6]. The sequence obtained was

Transvenous liver biopsy in critically ill patients: adequacy of tissue samples.

In a consecutive series of 33 patients (38 biopsies), the authors analyzed the pathologic specimens obtained with their relatively new transvenous biopsy method. From the point of view of establishing a useful pathologic diagnosis, the method proved worthwhile in the series of predominantly critically ill patients. A specific diagnosis or a later confirmatory tissue diagnosis was achieved in 18 patients, and a strong clinical correlation was achieved in 10 more. There were no complications from this repeatable, technically relatively simple, and safe procedure.

Sinusoidal portal hypertension in hepatic amyloidosis.

Hepatic venous catheterisation and transvenous liver biopsy were performed in five patients with hepatic amyloidosis. In three patients, hepatic venous pressures were normal and histological examination of the liver biopsy specimen showed discrete and sparse perisinusoidal amyloid deposits. In the other two, however, the gradient between wedged and free hepatic venous pressures was increased (12 and 16 mmHg; normal 1-4 mmHg) and amyloid deposits were abundant and diffuse in the Disse's space. This study shows that portal hypertension in patients with hepatic amyloidosis is of the sinusoidal type and is related to the reduction of vascular space of hepatic sinusoids by massive perisinusoidal amyloid deposits. Furthermore, portal hypertension is associated with a poor prognosis in patients with hepatic amyloidosis.

Portal hypertension and ascites in acute hepatitis: clinical, hemodynamic and histological correlations.

We attempted to ascertain the mechanism of portal hypertension and ascites complicating acute hepatitis in 66 patients who underwent transvenous liver biopsy and measurement of hepatic venous pressure gradient. Increase in hepatic venous pressure gradient was related to the severity of acute hepatitis, as indicated by the significant correlation between the values for hepatic venous pressure gradient and serum bilirubin, serum albumin or coagulation factor V, and by its higher value in patients with, than in patients without, encephalopathy. Hepatic venous pressure gradient was higher in patients with, than in patients without, ascites (12.5 +/- 3.4 vs. 8.4 +/- 3.6 mmHg, respectively; p less than 0.001). No ascites was clinically detectable in the patients in whom hepatic venous pressure gradient was below 6 mmHg. We tested the hypothesis that sinusoidal collapse due to liver cell dropout was a major factor in portal hypertension. Semiautomatic determination of the fractional area of sinusoidal collapse on chromotrope-stained sections and automatic measurement of Sirius red-stained collagen fiber density were performed. Hepatic venous pressure gradient significantly correlated with fractional sinusoidal collapse area (r = 0.61, p less than 0.001) and with Sirius red-stained collagen fiber density (r = 0.43, p less than 0.01). We conclude that portal hypertension in the course of acute hepatitis is related to the severity of liver damage and is a major factor in the development of ascites. Portal hypertension is mainly determined by intrahepatic vascular space being reduced by the collapse of sinusoids.

Are clinical criteria adequate for the diagnosis of severe alcoholic hepatitis ? Lessons from transvenous liver biopsy

Are clinical criteria adequate for the diagnosis of severe alcoholic hepatitis ? Lessons from transvenous liver biopsy

Suprahepatic manometry and transvenous hepatic biopsy: personal experience apropos of 100 cases

SummaryAuthor’s personal experience after 100 transvenous liver biopsy is reported.A particular reference to sus-hepatic manometry and venography is given.Cirrhotic patients bleeding from esophageal varices or with ascites presents with a higher portal pressure than other cirrhotics. Moreover, cirrhosis has been diagnosed whenever pressure gradient was superior to 23 mmHg.This exam seems particularly relevant in cases of portal hypertension and is, of course, the only biopsy technique available when a transcapsular ap proach is contraindicated.

The inconvenience of investigations used in hepatology: patients' and hepatologists' opinions.

The purpose of this study was to estimate and compare the inconvenience of six investigations used in hepatology, as experienced by 113 inpatients and imagined by 80 hepatologists. For patients, the investigations, in order of increased inconvenience rate were: (1) venous puncture, (2) BSP clearance, (3) transvenous liver biopsy, (4) percutaneous liver biopsy, (5) laparoscopy and (6) oesogastroscopy. Hepatologists gave a higher inconvenience rate for all investigations than patients and the ranking of the crude inconvenience rate of each investigation was different for hepatologists and patients. For 84% of patients, oesogastroscopy was over 10 times more inconvenient than a venous puncture, whereas only 15% of hepatologists considered oesogastroscopy over 10 times more inconvenient (p less than 0.001). Multidimensional analysis indicated that hepatologists underestimated the role of pain in the rejection of re-investigation for transvenous liver biopsy, percutaneous liver biopsy and oesogastroscopy. These results suggest that hepatologists must improve the psychological and pharmacological premedication of these investigations according to the reaction of their patients, especially before oesogastroscopy.

Transvenous Liver Biopsy

Transvenous liver biopsy was attempted 1033 times in 932 patients in whom percutaneous liver biopsy was contraindicated. A hepatic tissue specimen was obtained in 1000 out of these 1033 attempts. The specimen was unfragmented and/or large enough to allow correct evaluation of liver architecture in 518 of the 807 successful biopsies (64.2%) in patients with liver fibrosis or cirrhosis and in 191 of the 193 successful biopsies (98.9%) in patients with nonfibrotic lesion of the liver. Transvenous liver biopsy was followed by no or minor complication in all our patients except for one who suffered fatal intraperitoneal bleeding due to perforation of the liver capsule. It is concluded that transvenous liver biopsy is a workable, efficient, safe procedure for obtaining hepatic tissue specimens and that this method is essential in a department of hepatology.