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__NOTOC__ | __NOTOC__ | ||
{{Cirrhosis}} | {{Cirrhosis}} | ||
{{CMG}} {{AE}} | {{CMG}} {{AE}} {{Cherry}} | ||
==Overview== | ==Overview== | ||
The gold standard diagnostic test for cirrhosis is liver biopsy, although it is rarely necessary for diagnosis or treatment. NT-proBNP | The gold standard diagnostic test for cirrhosis is [[liver biopsy]], although it is rarely necessary for diagnosis or treatment. [[Brain natriuretic peptide|NT-proBNP]] may be used to evaluate the complications of cirrhosis. | ||
==Other Diagnostic Studies== | ==Other Diagnostic Studies== | ||
===Liver Biopsy=== | ===Liver Biopsy=== | ||
Features of [[liver biopsy]] are as follows:<ref name="pmid9683971">{{cite journal |vauthors=Williams EJ, Iredale JP |title=Liver cirrhosis |journal=Postgrad Med J |volume=74 |issue=870 |pages=193–202 |year=1998 |pmid=9683971 |pmc=2360862 |doi= |url=}}</ref><ref name="pmid12865280">{{cite journal |vauthors=Blomley MJ, Lim AK, Harvey CJ, Patel N, Eckersley RJ, Basilico R, Heckemann R, Urbank A, Cosgrove DO, Taylor-Robinson SD |title=Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study |journal=Gut |volume=52 |issue=8 |pages=1188–93 |year=2003 |pmid=12865280 |pmc=1773750 |doi= |url=}}</ref><ref name="pmid11211142">{{cite journal |vauthors=Kim CK, Lim JH, Lee WJ |title=Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients |journal=J Ultrasound Med |volume=20 |issue=2 |pages=99–104 |year=2001 |pmid=11211142 |doi= |url=}}</ref><ref name="pmid443970">{{cite journal |vauthors=Abdi W, Millan JC, Mezey E |title=Sampling variability on percutaneous liver biopsy |journal=Arch. Intern. Med. |volume=139 |issue=6 |pages=667–9 |year=1979 |pmid=443970 |doi= |url=}}</ref><ref name="pmid14647056">{{cite journal |vauthors=Bedossa P, Dargère D, Paradis V |title=Sampling variability of liver fibrosis in chronic hepatitis C |journal=Hepatology |volume=38 |issue=6 |pages=1449–57 |year=2003 |pmid=14647056 |doi=10.1016/j.hep.2003.09.022 |url=}}</ref><ref name="pmid12385448">{{cite journal |vauthors=Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER |title=Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection |journal=Am. J. Gastroenterol. |volume=97 |issue=10 |pages=2614–8 |year=2002 |pmid=12385448 |doi=10.1111/j.1572-0241.2002.06038.x |url=}}</ref><ref name="pmid11172192">{{cite journal |vauthors=Bravo AA, Sheth SG, Chopra S |title=Liver biopsy |journal=N. Engl. J. Med. |volume=344 |issue=7 |pages=495–500 |year=2001 |pmid=11172192 |doi=10.1056/NEJM200102153440706 |url=}}</ref><ref name="pmid19243014">{{cite journal |vauthors=Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD |title=Liver biopsy |journal=Hepatology |volume=49 |issue=3 |pages=1017–44 |year=2009 |pmid=19243014 |doi=10.1002/hep.22742 |url=}}</ref> | |||
* Cirrhosis is primarily a [[Histology|histological]] diagnosis. The [[Gold standard (test)|gold standard]] for diagnosis of cirrhosis is [[liver biopsy]]. | |||
* Sample of the liver is obtained by:<ref name="pmid16636018">{{cite journal |vauthors=Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK |title=Transjugular liver biopsy: how good is it for accurate histological interpretation? |journal=Gut |volume=55 |issue=12 |pages=1789–94 |year=2006 |pmid=16636018 |pmc=1856467 |doi=10.1136/gut.2005.090415 |url=}}</ref> | |||
**[[Percutaneous]] | |||
*Cirrhosis is primarily a histological diagnosis. | |||
*Sample of the liver is obtained by:<ref name="pmid16636018">{{cite journal |vauthors=Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK |title=Transjugular liver biopsy: how good is it for accurate histological interpretation? |journal=Gut |volume=55 |issue=12 |pages=1789–94 |year=2006 |pmid=16636018 |pmc=1856467 |doi=10.1136/gut.2005.090415 |url=}}</ref> | |||
**Percutaneous | |||
**Transjugular | **Transjugular | ||
**Laparoscopic radiographically-guided fine-needle approach. | **Laparoscopic radiographically- guided fine-needle approach | ||
* Percutaneous [[biopsy]] of focal lesions may be performed in combination with either [[ultrasound]] or [[CT|CT imaging]].<ref name="pmid15278290">{{cite journal |vauthors=Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP |title=[Bioptic diagnosis of chronic hepatitis. Results of an evidence-based consensus conference of the German Society of Pathology, of the German Society for Digestive and Metabolic Diseases and of Compensated Hepatitis (HepNet)] |language=German |journal=Pathologe |volume=25 |issue=5 |pages=337–48 |year=2004 |pmid=15278290 |doi=10.1007/s00292-004-0692-7 |url=}}</ref> | |||
* | * Percutaneous [[liver biopsy]] remains the cornerstone of diagnosis. It is quick and simple to perform [[liver biopsy]] in a patient with normal [[Platelet|platelet count]] and [[Prothrombin time|INR]].<ref name="pmid22833761">{{cite journal |vauthors=Tannapfel A, Dienes HP, Lohse AW |title=The indications for liver biopsy |journal=Dtsch Arztebl Int |volume=109 |issue=27-28 |pages=477–83 |year=2012 |pmid=22833761 |pmc=3402072 |doi=10.3238/arztebl.2012.0477 |url=}}</ref> | ||
* Histologically, cirrhosis may be classified as micronodular, macronodular, or mixed, but this classification is nonspecific to the [[etiology]]. | |||
* Histology of the [[liver]] may change as the disease progresses, and [[Serology|serological]] markers are much more specific. | |||
* A [[biopsy]] is not necessary if the [[clinical]], [[Medical laboratory|laboratory]], and [[Radiologic sign|radiologic]] data suggest cirrhosis. | |||
*Liver biopsy may be suggestive of etiology: | * [[Liver biopsy]] may be suggestive of [[etiology]]: | ||
* | ** [[Alcoholic liver disease]] : [[Liver biopsy]] may show [[hepatocyte]] necrosis, presence of [[Mallory body|mallory bodies]], neutrophilic infiltration and perivenular inflammation. | ||
** | ** [[Primary biliary cirrhosis|Primary biliary cirrhosis]] : Gold standard diagnostic modality is the detection of [[antimitochondrial antibodies]] along with [[liver biopsy]] as confirmation if florid [[bile duct]] lesions. | ||
* | * There is a small but significant risk of [[liver biopsy]], and cirrhosis itself predisposes for complications due to [[liver biopsy]].<ref>{{cite journal |last=Grant |first=A|year=1999 | title=Guidelines on the use of liver biopsy in clinical practice |journal=Gut |volume=45 |issue=Suppl 4 |pages=1-11 |id=PMID 10485854 |url=http://gut.bmj.com/cgi/content/full/45/suppl_4/IV1|quote=The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding. }}</ref> | ||
*Risks of [[liver biopsy]] include: | |||
**[[Bleeding|Hemorrhage]] | |||
**[[Bile duct|Biliary]] [[peritonitis]] | |||
*Risks: | **[[Hematoma]] | ||
** | **[[Perforation]] of other [[Viscus|viscera]] | ||
** | **[[Mortality rate|Mortality rates]] of between 0.01% and 0.1% | ||
** | |||
** | |||
** | |||
* Patients with moderate [[coagulopathy]]: | |||
*Patients with moderate coagulopathy: | **Plugged [[liver biopsy]] : injection of gelatin sponges or metal coils down the tract after [[biopsy]] | ||
** | **[[Laparoscopic surgery|Laparoscopic]] [[liver biopsy]] performed on a sedated patient with moderate [[coagulopathy]] | ||
**Laparoscopic liver | ***Advantage: allows direct visualisation of the [[liver]] | ||
***Advantage: | |||
*Patients with severe clotting disorders: | *Patients with severe clotting disorders: | ||
*Transjugular liver biopsy : | **Transjugular [[liver biopsy]]: | ||
** | ***Risk of [[Peritoneum|intraperitoneal]] [[Bleeding|bleed]] is less | ||
** Disadvantages: | *** Disadvantages: | ||
*** | **** [[Biopsy|Biopsies]] are small: multiple [[Biopsy|biopsies]] required | ||
*** | **** Taken 'blindly' | ||
===NT-proBNP (N Terminal pro Brain Natriuretic Peptide)=== | ===NT-proBNP (N Terminal pro Brain Natriuretic Peptide)=== | ||
* N Terminal pro Brain Natriuretic peptide is an important factor for evaluating the complications of cirrhosis.<ref name="pmid22911531">{{cite journal |author=Ljubicic N, Gomercic M, Zekanovic D, Bodrozic-Dzakic T, Djuzel A |title=New insight into the role of NT-proBNP in alcoholic liver cirrhosis as a noninvasive marker of esophageal varices |journal=[[Croatian Medical Journal]] |volume=53 |issue=4 |pages=374–8 |year=2012 |pmid=22911531 |pmc=3428825 |doi= |url=http://www.cmj.hr/2012/53/4/22911531.htm |accessdate=2012-09-06}}</ref> | * N Terminal pro [[Brain natriuretic peptide|Brain Natriuretic peptide]] is an important factor for evaluating the complications of cirrhosis.<ref name="pmid22911531">{{cite journal |author=Ljubicic N, Gomercic M, Zekanovic D, Bodrozic-Dzakic T, Djuzel A |title=New insight into the role of NT-proBNP in alcoholic liver cirrhosis as a noninvasive marker of esophageal varices |journal=[[Croatian Medical Journal]] |volume=53 |issue=4 |pages=374–8 |year=2012 |pmid=22911531 |pmc=3428825 |doi= |url=http://www.cmj.hr/2012/53/4/22911531.htm |accessdate=2012-09-06}}</ref> | ||
* High levels of NT-proBNP ( >101 pg/ml) | * High levels of NT-[[Brain natriuretic peptide|proBNP]] ( >101 pg/ml) serve as a marker of [[esophageal varices]]. | ||
* | ===Hepatic venous pressure gradient measurement=== | ||
*Hepatic venous pressure gradient (HVPG) measurement is the difference between [[Hepatic vein|hepatic venous]] [[wedge pressure]] (HVWP) and free [[Hepatic vein|hepatic venous]] pressure (FHVP). | |||
*HVPG reflects the intra-[[sinusoidal]] [[pressure]].<ref name="pmid16496346">{{cite journal |vauthors=Boyer TD |title=Wedged hepatic vein pressure (WHVP): ready for prime time |journal=Hepatology |volume=43 |issue=3 |pages=405–6 |year=2006 |pmid=16496346 |doi=10.1002/hep.21118 |url=}}</ref> | |||
*HVPG is measured through insertion of a [[catheter]] in right [[internal jugular vein]].<ref name="pmid22223943">{{cite journal| author=Chelliah ST, Keshava SN, Moses V, Surendrababu NR, Zachariah UG, Eapen C| title=Measurement of hepatic venous pressure gradient revisited: Catheter wedge vs balloon wedge techniques. | journal=Indian J Radiol Imaging | year= 2011 | volume= 21 | issue= 4 | pages= 291-3 | pmid=22223943 | doi=10.4103/0971-3026.90693 | pmc=3249946 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22223943 }}</ref> | |||
{{#ev:youtube|9cEOpr-MRL4|500}} | |||
==References== | ==References== | ||
Latest revision as of 17:36, 14 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
The gold standard diagnostic test for cirrhosis is liver biopsy, although it is rarely necessary for diagnosis or treatment. NT-proBNP may be used to evaluate the complications of cirrhosis.
Other Diagnostic Studies
Liver Biopsy
Features of liver biopsy are as follows:[1][2][3][4][5][6][7][8]
- Cirrhosis is primarily a histological diagnosis. The gold standard for diagnosis of cirrhosis is liver biopsy.
- Sample of the liver is obtained by:[9]
- Percutaneous
- Transjugular
- Laparoscopic radiographically- guided fine-needle approach
- Percutaneous biopsy of focal lesions may be performed in combination with either ultrasound or CT imaging.[10]
- Percutaneous liver biopsy remains the cornerstone of diagnosis. It is quick and simple to perform liver biopsy in a patient with normal platelet count and INR.[11]
- Histologically, cirrhosis may be classified as micronodular, macronodular, or mixed, but this classification is nonspecific to the etiology.
- Histology of the liver may change as the disease progresses, and serological markers are much more specific.
- A biopsy is not necessary if the clinical, laboratory, and radiologic data suggest cirrhosis.
- Liver biopsy may be suggestive of etiology:
- Alcoholic liver disease : Liver biopsy may show hepatocyte necrosis, presence of mallory bodies, neutrophilic infiltration and perivenular inflammation.
- Primary biliary cirrhosis : Gold standard diagnostic modality is the detection of antimitochondrial antibodies along with liver biopsy as confirmation if florid bile duct lesions.
- There is a small but significant risk of liver biopsy, and cirrhosis itself predisposes for complications due to liver biopsy.[12]
- Risks of liver biopsy include:
- Hemorrhage
- Biliary peritonitis
- Hematoma
- Perforation of other viscera
- Mortality rates of between 0.01% and 0.1%
- Patients with moderate coagulopathy:
- Plugged liver biopsy : injection of gelatin sponges or metal coils down the tract after biopsy
- Laparoscopic liver biopsy performed on a sedated patient with moderate coagulopathy
- Advantage: allows direct visualisation of the liver
- Patients with severe clotting disorders:
- Transjugular liver biopsy:
- Risk of intraperitoneal bleed is less
- Disadvantages:
- Transjugular liver biopsy:
NT-proBNP (N Terminal pro Brain Natriuretic Peptide)
- N Terminal pro Brain Natriuretic peptide is an important factor for evaluating the complications of cirrhosis.[13]
- High levels of NT-proBNP ( >101 pg/ml) serve as a marker of esophageal varices.
Hepatic venous pressure gradient measurement
- Hepatic venous pressure gradient (HVPG) measurement is the difference between hepatic venous wedge pressure (HVWP) and free hepatic venous pressure (FHVP).
- HVPG reflects the intra-sinusoidal pressure.[14]
- HVPG is measured through insertion of a catheter in right internal jugular vein.[15]
{{#ev:youtube|9cEOpr-MRL4|500}}
References
- ↑ Williams EJ, Iredale JP (1998). "Liver cirrhosis". Postgrad Med J. 74 (870): 193–202. PMC 2360862. PMID 9683971.
- ↑ Blomley MJ, Lim AK, Harvey CJ, Patel N, Eckersley RJ, Basilico R, Heckemann R, Urbank A, Cosgrove DO, Taylor-Robinson SD (2003). "Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study". Gut. 52 (8): 1188–93. PMC 1773750. PMID 12865280.
- ↑ Kim CK, Lim JH, Lee WJ (2001). "Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients". J Ultrasound Med. 20 (2): 99–104. PMID 11211142.
- ↑ Abdi W, Millan JC, Mezey E (1979). "Sampling variability on percutaneous liver biopsy". Arch. Intern. Med. 139 (6): 667–9. PMID 443970.
- ↑ Bedossa P, Dargère D, Paradis V (2003). "Sampling variability of liver fibrosis in chronic hepatitis C". Hepatology. 38 (6): 1449–57. doi:10.1016/j.hep.2003.09.022. PMID 14647056.
- ↑ Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER (2002). "Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection". Am. J. Gastroenterol. 97 (10): 2614–8. doi:10.1111/j.1572-0241.2002.06038.x. PMID 12385448.
- ↑ Bravo AA, Sheth SG, Chopra S (2001). "Liver biopsy". N. Engl. J. Med. 344 (7): 495–500. doi:10.1056/NEJM200102153440706. PMID 11172192.
- ↑ Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD (2009). "Liver biopsy". Hepatology. 49 (3): 1017–44. doi:10.1002/hep.22742. PMID 19243014.
- ↑ Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK (2006). "Transjugular liver biopsy: how good is it for accurate histological interpretation?". Gut. 55 (12): 1789–94. doi:10.1136/gut.2005.090415. PMC 1856467. PMID 16636018.
- ↑ Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP (2004). "[Bioptic diagnosis of chronic hepatitis. Results of an evidence-based consensus conference of the German Society of Pathology, of the German Society for Digestive and Metabolic Diseases and of Compensated Hepatitis (HepNet)]". Pathologe (in German). 25 (5): 337–48. doi:10.1007/s00292-004-0692-7. PMID 15278290.
- ↑ Tannapfel A, Dienes HP, Lohse AW (2012). "The indications for liver biopsy". Dtsch Arztebl Int. 109 (27–28): 477–83. doi:10.3238/arztebl.2012.0477. PMC 3402072. PMID 22833761.
- ↑ Grant, A (1999). "Guidelines on the use of liver biopsy in clinical practice". Gut. 45 (Suppl 4): 1–11. PMID 10485854.
The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding.
- ↑ Ljubicic N, Gomercic M, Zekanovic D, Bodrozic-Dzakic T, Djuzel A (2012). "New insight into the role of NT-proBNP in alcoholic liver cirrhosis as a noninvasive marker of esophageal varices". Croatian Medical Journal. 53 (4): 374–8. PMC 3428825. PMID 22911531. Retrieved 2012-09-06.
- ↑ Boyer TD (2006). "Wedged hepatic vein pressure (WHVP): ready for prime time". Hepatology. 43 (3): 405–6. doi:10.1002/hep.21118. PMID 16496346.
- ↑ Chelliah ST, Keshava SN, Moses V, Surendrababu NR, Zachariah UG, Eapen C (2011). "Measurement of hepatic venous pressure gradient revisited: Catheter wedge vs balloon wedge techniques". Indian J Radiol Imaging. 21 (4): 291–3. doi:10.4103/0971-3026.90693. PMC 3249946. PMID 22223943.