Liver Biopsy Sampling in Chronic Viral Hepatitis

 

 Buy Article Permissions and Reprints

In chronic viral hepatitis, liver biopsy is performed to grade and stage liver damage. Liver biopsy samples are usually taken with a needle using a percutaneous procedure. This method produces a core of tissue representing approximately 1/50,000th of the liver mass, which raises concern about how representative a needle biopsy can be. A critical review of the literature reveals methodological limits unacceptable in this era of evidence-based medicine. Integrating earlier experience with more recently produced data indicates that a biopsy sample 2 cm or more in length containing at least 11 complete portal tracts should be reliable for grading and staging chronic viral hepatitis.

REFERENCES

• 1 von Frerichs F T. Uber den Diabetes. Berlin; Hirschwald 1884
  Google Scholar
• 2 Menghini G. One-second needle biopsy of the liver.  Gastroenterology. 1958;  35 190-195
  PubMedGoogle Scholar
• 3 Sherlock S, Dooley J. Diseases of the Liver and Biliary System, 4th ed. London; Blackwell Scientific 1997
  Google Scholar
• 4 Van Leeuwen D J, Wilson L, Crowe D R. Liver biopsy in the mid-1990s: questions and answers.  Semin Liver Dis. 1995;  15 340-358
  PubMedGoogle Scholar
• 5 Lebrec D. Various approaches to obtaining liver tissue: choosing the biopsy technique.  J Hepatol. 1996;  25 (Suppl 1) 20-24
  CrossrefPubMedGoogle Scholar
• 6 Scheuer P J. Classification of chronic viral hepatitis: a need for a reassessment.  J Hepatol. 1991;  13 372-374
  CrossrefPubMedGoogle Scholar
• 7 Schmid M, Flury R, Buhler H et al.. Chronic viral hepatitis B and C: an argument against the conventional classification of chronic hepatitis.  Virchows Arch. 1994;  425 221-226
  PubMedGoogle Scholar
• 8 Ludwig J. The nomenclature of chronic active hepatitis: an obituary.  Gastroenterology. 1993;  105 274-278
  PubMedGoogle Scholar
• 9 Batts K B, Ludwig J. Chronic hepatitis. An update on terminology and reporting.  Am J Surg Pathol. 1995;  19 1409-1417
  CrossrefPubMedGoogle Scholar
• 10 Gerber M A. Chronic hepatitis C: the beginning of the end of a time honored nomenclature?.  Hepatology. 1992;  15 733-734
  PubMedGoogle Scholar
• 11 Desmet V J, Gerber M, Hoofnagle J H et al.. Classification of chronic hepatitis: diagnosis, grading and staging.  Hepatology. 1994;  19 1513-1520
  CrossrefPubMedGoogle Scholar
• 12 Brunt E M. Grading and staging the histopathological lesions of chronic hepatitis: the Knodell histology activity index and beyond.  Hepatology. 2000;  31 241-246
  CrossrefPubMedGoogle Scholar
• 13 Bravo A A, Sheth S G, Chopra S. Liver biopsy.  N Engl J Med. 2001;  344 495-500
  CrossrefPubMedGoogle Scholar
• 14 Saadeh S, Cammell G, Carey W D et al.. The role of liver biopsy in chronic hepatitis C.  Hepatology. 2001;  33 196-200
  CrossrefPubMedGoogle Scholar
• 15 Lok A S. Hepatitis B infection: Pathogenesis and management.  J Hepatol. 2000;  32 (Suppl 1) 89-97
  PubMedGoogle Scholar
• 16 Booth J C, O'Grady J, Neuberger J. Clinical guidelines on the management of hepatitis C.  Gut. 2001;  49 (Suppl 1) 1-21
  CrossrefPubMedGoogle Scholar
• 17 Dienstang J L. The role of liver biopsy in chronic hepatitis C.  Hepatology. 2002;  36 S152-S160
  CrossrefPubMedGoogle Scholar
• 18 Knodell R G, Ishak K G, Black W C et al.. Formulation and application of a numerical scoring system for assessing histological activity in asymptomatic chronic active hepatitis.  Hepatology. 1981;  1 431-435
  CrossrefPubMedGoogle Scholar
• 19 The French METAVIR Cooperative Study Group . Intraobserver and interobserver variations in liver biopsy interpretation in patients with chronic hepatitis C.  Hepatology. 1994;  20 15-20
  CrossrefPubMedGoogle Scholar
• 20 Ishak K, Baptista A, Bianchi L et al.. Histological grading and staging of chronic hepatitis.  J Hepatol. 1995;  22 696-699
  CrossrefPubMedGoogle Scholar
• 21 Guido M, Faa G. Morphological diagnosis of chronic hepatitis. Minimal requirements for histopathological referral [in Italian].  Pathologica. 1998;  90 176-182
  PubMedGoogle Scholar
• 22 Goldin R D, Goldin G J, Burt A D et al.. Intra-observer and inter-observer variation in the histopathological assessment of chronic viral hepatitis.  J Hepatol. 1996;  25 649-654
  CrossrefPubMedGoogle Scholar
• 23 Westin J, Lagging L M, Weistal R et al.. Interobserver study of liver histopathology using the Ishak score in patients with chronic hepatitis C virus infection.  Liver. 1999;  19 183-187
  CrossrefPubMedGoogle Scholar
• 24 Gronbaek K, Christensen P B, Hamilton-Dutoit S et al.. Interobserver variation in interpretation of serial liver biopsies from patients with chronic hepatits C.  J Viral Hepat. 2002;  9 443-449
  CrossrefPubMedGoogle Scholar
• 25 Yano M, Kumada H, Kage M et al.. The long-term pathological evolution of chronic hepatitis C.  Hepatology. 1996;  23 1334-1340
  CrossrefPubMedGoogle Scholar
• 26 Gebo K A, Herlong H F, Torbenson M S et al.. Role of liver biopsy in management of chronic hepatitis C: a systematic review.  Hepatology. 2002;  36 S161-S172
  CrossrefPubMedGoogle Scholar
• 27 Zeuzem S, Feinman S V, Rasenack J et al.. Peg-interferon alpha-2a in patients with chronic hepatits C.  N Engl J Med. 2000;  343 1666-1672
  CrossrefPubMedGoogle Scholar
• 28 Manns M P, Mc Hutchinson J G, Gordon S C et al.. Peg-interferon alpha 2b plus ribavirin compared with interferon alpha 2b plus ribavirin for initial treatment of chronic hepatitis C: a randomized trial.  Lancet. 2001;  358 958-965
  CrossrefPubMedGoogle Scholar
• 29 Saracco G, Ciancio A, Olivero A et al.. A randomized 4-arm multicenter study of interferon alpha -2b plus ribavirin in the treatment of patients with chronic hepatits C not responding to interferon alone.  Hepatology. 2001;  34 133-138
  CrossrefPubMedGoogle Scholar
• 30 Shiratori I, Imazeki F, Moriyama M et al.. Histologic improvement of fibrosis in patients with hepatits C who have sustained response to interferon therapy.  Ann Intern Med. 2000;  132 517-524
  PubMedGoogle Scholar
• 31 Oberti F, Valsesia E, Pilette C et al.. Non-invasive diagnosis of hepatic fibrosis and cirrhosis.  Gastroenterology. 1997;  113 1609-1616
  CrossrefPubMedGoogle Scholar
• 32 Imbert-Bismut F, Ratziu V, Pieroni L et al.. Biochemical markers of liver fibrosis in patients with hepatits C virus infection: a prospective study.  Lancet. 2001;  357 1069-1075
  CrossrefPubMedGoogle Scholar
• 33 Fontana R J, Lok A SF. Noninvasive monitoring of patients with chronic hepatitis C.  Hepatology. 2002;  36 S57-S64
  CrossrefPubMedGoogle Scholar
• 34 Forns X, Ampurdanes S, Llovet J M et al.. Identification of chronic hepatitis C patients without hepatic fibrosis by a simple predictive model.  Hepatology. 2002;  36 986-992
  CrossrefPubMedGoogle Scholar
• 35 Oh S, Afdhal N H. Hepatic fibrosis: are any of the serum markers really useful?.  Curr Gastroenterol Rep. 2001;  3 12-18
  PubMedGoogle Scholar
• 36 Friedman S L. Liver fibrosis-from bench to bedside.  J Hepatol. 2003;  38 S38-S53
  PubMedGoogle Scholar
• 37 Afdhal N H. Diagnosing fibrosis in hepatitis C: is the pendulum swinging from biopsy to blood tests?.  Hepatology. 2003;  37 972-974
  CrossrefPubMedGoogle Scholar
• 38 Geller S A, Pitman M B. Morphological diagnostic procedures (liver biopsy). In: McSween RNM, Burt AD, Portmann BC, et al. Pathology of the Liver. London; Churchill Livingston 2002: 943-960
  Google Scholar
• 39 Farrel R J, Smiddy P F, Pilkington R M et al.. Guided versus blind liver biopsy for chronic hepatis C: clinical benefits and costs.  J Hepatol. 1999;  30 580-587
  CrossrefPubMedGoogle Scholar
• 40 Grant A, Neuberger J. Guidelines of the use of liver biopsy in clinical practice.  Gut. 1999;  45 (Suppl 1) 1-11
  PubMedGoogle Scholar
• 41 Ahmad M, Riley T R. Can one predict when ultrasound will be useful with percutaneous liver biopsy?.  Am J Gastroenterol. 2001;  96 547-549
  CrossrefPubMedGoogle Scholar
• 42 Lindor K D, Bru C, Jorgensen R A et al.. The role of ultrasonography and automatic-needle biopsy in outpatients percutaneous liver biopsy.  Hepatology. 1996;  23 1079-1083
  CrossrefPubMedGoogle Scholar
• 43 Farrel R J, Smiddy P F, Pilkington R M et al.. Guided versus blind liver biopsy for chronic hepatis C: clinical benefits and costs.  J Hepatol. 1999;  30 580-587
  CrossrefPubMedGoogle Scholar
• 44 Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies.  J Hepatol. 1986;  2 165-173
  CrossrefPubMedGoogle Scholar
• 45 Demetris A J, Ruppert K. Pathologist's perspective on liver needle biopsy size?.  J Hepatol. 2003;  39 275-277
  CrossrefPubMedGoogle Scholar
• 46 McGill D B, Rakela J, Zinsmeister A R, Ott B J. A 21-year experience with major hemorrhage after percutaneous liver biopsy.  Gastroenterology. 1990;  99 1396-1400
  PubMedGoogle Scholar
• 47 Tobkes A I, Nord H J. Liver biopsy: review of methodology and complications.  Dig Dis. 1995;  13 267-274
  CrossrefPubMedGoogle Scholar
• 48 Terjung B, Lemnitzer I, Ludwig-Dumoulin F et al.. Bleeding complications after percutaneous liver biopsy. An analysis of risk factors.  Digestion. 2003;  67 138-145
  CrossrefPubMedGoogle Scholar
• 49 Froehlich F, Lamy O, Fried M, Gonvers J J. Practice and complication of liver biopsy: result of a national survey in Switzerland.  Dig Dis Sci. 1993;  38 1480-1484
  CrossrefPubMedGoogle Scholar
• 50 McGill D B, Rakela J, Zinsmeister A R, Ott B J. A 21-year experience with major haemorrhage after percutaneous liver biopsy.  Gastroenterology. 1990;  99 1396-1400
  PubMedGoogle Scholar
• 51 Jacobs W H, Goldberg S B. Statement on outpatient percutaneous liver biopsy.  Dig Dis Sci. 1989;  34 322-323
  CrossrefPubMedGoogle Scholar
• 52 Nousbaum J B, Cadranel J F, Bonnemaison G et al.. Clinical practice guidelines on the use of liver biopsy.  Gastroenterol Clin Biol. 2002;  26 848-878
  PubMedGoogle Scholar
• 53 Buckley A, Petrunia D. Practice guidelines for liver biopsy. Canadian Association of Gastroenterology.  Can J Gastroenterol. 2000;  14 481-482
  PubMedGoogle Scholar
• 54 Shalm S W. The diagnosis of cirrhosis: clinical relevance and methodology.  J Hepatol. 1997;  27 1118-1119
  CrossrefPubMedGoogle Scholar
• 55 Waldstein S, Szanto P B. Accuracy of sampling by needle biopsy in diffuse liver disease.  Arch Pathol. 1950;  50 326-329
  PubMedGoogle Scholar
• 56 Soloway R D, Baggenstoss A H, Schoenfield L J, Summerskill W HJ. Observer error and sampling variability tested in evaluation of hepatitis and cirrhosis by liver biopsy.  Dig Dis Sci. 1971;  16 1082-1086
  PubMedGoogle Scholar
• 57 Abdi W, Milln J C, Mezey E. Sampling variability on percutaneous liver biopsy.  Arch Intern Med. 1979;  139 667-669
  CrossrefPubMedGoogle Scholar
• 58 Baunsgaard P, Sanchez G C, Lundborg C J. The variation of pathological changes in the liver evaluated by double biopsies.  Acta Pathol Microbiol Scand [A]. 1979;  87 51-57
  PubMedGoogle Scholar
• 59 Maharaj B, Maharaj R J, Leary W P et al.. Sampling variability and its influence on the diagnostic yield of percutaneous needle biopsy of the liver.  Lancet. 1986;  1 523-525
  PubMedGoogle Scholar
• 60 Pagliaro L, Rinaldi F, Craxi A et al.. Percutaneous blind biopsy versus laparoscopy with guided biopsy in diagnosis of cirrhosis. A prospective, randomized trial.  Dig Dis Sci. 1983;  28 39-43
  CrossrefPubMedGoogle Scholar
• 61 Poniachik J, Bernstein D E, Reddy K R et al.. The role of laparoscopy in the diagnosis of cirrhosis.  Gastrointest Endosc. 1996;  43 568-571
  CrossrefPubMedGoogle Scholar
• 62 Scheuer P J, Lefkowitch J H. Liver Biopsy Interpretation 6th ed. Philadelphia; WB Saunders 2000
  Google Scholar
• 63 Picciotto A, Ciravegna G, Lapertosa G, Celle G. Percutaneous or laparoscopic needle biopsy in the evaluation of chronic liver disease?.  Am J Gastroenterol. 1984;  79 567-568
  PubMedGoogle Scholar
• 64 Gaiani S, Gramantieri L, Venturoli N et al.. What is the criterion for differentiating chronic hepatitis from compensated cirrhosis? A prospective study comparing ultrasonography and percutaneous liver biopsy.  J Hepatol. 1997;  27 979-985
  CrossrefPubMedGoogle Scholar
• 65 Fanning L, Loane J, Kenny-Walsh E et al.. Tissue viral load variability in chronic hepatitis C.  Am J Gastroenterol. 2001;  96 3384-3389
  CrossrefPubMedGoogle Scholar
• 66 Regev A, Berho M, Jeffers L J et al.. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection.  Am J Gastroenterol. 2002;  97 2614-2618
  CrossrefPubMedGoogle Scholar
• 67 Persico M, Palmentieri B, Vecchione R et al.. Diagnosis of chronic liver disease: reproducibility and validation of liver biopsy.  Am J Gastroenterol. 2002;  97 491-492
  CrossrefPubMedGoogle Scholar
• 68 Siddique I, El-Naga H A, Madda J P, Memon A, Hasan F. Sampling variability on percutaneous liver biopsy in patients with chronic hepatitis C virus infection.  Scand J Gastroenterol. 2003;  38 427-432
  CrossrefPubMedGoogle Scholar
• 69 Holund B, Poulsen H, Schlichting P. Reproducibility of liver biopsy diagnosis in relation to the size of the specimen.  Scand J Gastroenterol. 1980;  15 329-335
  PubMedGoogle Scholar
• 70 Schlichting P, Holund B, Poulsen H. Liver biopsy in chronic aggressive hepatitis. Diagnostic reproducibility in relation to size of specimen.  Scand J Gastroenterol. 1983;  18 27-32
  CrossrefPubMedGoogle Scholar
• 71 Vargas-Tank L, Martinez V, Jiron M I et al.. Tru-Cut and Menghini needles: different yield in histological diagnosis of liver diseases.  Liver. 1985;  5 178-181
  PubMedGoogle Scholar
• 72 Colombo M, Del Ninno E, De Franchis R et al.. Ultrasound-assisted percutaneous liver biopsy: superiority of the Tru-cut over the Menghini needle for diagnosis of cirrhosis.  Gastroenterology. 1988;  95 487-489
  CrossrefPubMedGoogle Scholar
• 73 Rocken C, Meier H, Klauck S et al.. Large-needle biopsy versus thin-needle biopsy in diagnostic pathology of liver diseases.  Liver. 2001;  21 391-397
  CrossrefPubMedGoogle Scholar
• 74 Petz D, Klauck S, Rohl F W et al.. Feasibility of histological grading and staging of chronic viral hepatitis using specimens obtained by thin-needle biopsy.  Virchows Arch. 2003;  442 238-244
  PubMedGoogle Scholar
• 75 Colloredo G, Guido M, Sonzogni A, Leandro G. Impact of liver biopsy size on histological evaluation of chronic viral hepatitis: the smaller the sample, the milder the disease.  J Hepatol. 2003;  39 239-244
  CrossrefPubMedGoogle Scholar
• 76 Andriulli A, Annese V, Facciorusso D, Giacobbe A. First do no harm: power, oppression, and violence of liver biopsy.  Gastroenterology. 2003;  125 272-273
  PubMedGoogle Scholar
• 77 Green R M, Flamm S L. First do no harm: power, oppression, and violence of liver biopsy.  Gastroenterology. 2003;  125 273-274
  PubMedGoogle Scholar

Maria GuidoM.D. 

Istituto di Anatomia Patologica

Via Gabelli, 61, 35100 Padova, Italy

Email: mguido@unipd.it