Cirrhosis diagnostic study of choice: Difference between revisions

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=== Gold standard/Study of choice: ===
=== Gold standard/Study of choice: ===
* Liver biopsy is the gold standard test for the diagnosis of cirrhosis.
* Cirrhosis is primarily a [[Histology|histological]] diagnosis. [[Liver biopsy]] is the gold standard test for the diagnosis of cirrhosis.
* The following result of [gold standard test] is confirmatory of [disease name]:
* The following result of [[liver biopsy]] is confirmatory of cirrhosis:
** Result 1
** Presence of bridging fibrous [[Septum (disambiguation)|septa]]
** Result 2
** Parenchymal [[Nodule (medicine)|nodules]] bearing a mixture of replicating and sensecent [[Hepatocyte|hepatocytes]]
* The [name of investigation] should be performed when:
** Involvement of most or all of the [[liver]]
** The patient presented with symptoms/signs 1. 2, 3.
* [[Liver biopsy]] should be performed in order to:
** A positive [test] is detected in the patient.
** Confirm the [[diagnosis]]
* [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
** Determine prognosis
* The diagnostic study of choice for [disease name] is [name of investigation].
** Diagnose the underlying [[etiology]] of cirrhosis
* There is no single diagnostic study of choice for the diagnosis of [disease name].
*** [[Alcoholic liver disease]] : [[Liver biopsy]] may show [[hepatocyte]] necrosis, presence of [[Mallory body|mallory bodies]], neutrophilic infiltration and perivenular inflammation
* There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
*** [[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
* [Disease name] is mainly diagnosed based on clinical presentation.
** Manage and evaluate rejection subsequent to [[liver transplantation]]
* Investigations:
** Evaluate abnormal [[Liver|hepatic]] investigations
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
** Rule out [[Liver|hepatic]] [[Neoplasm|neoplasms]]
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
** Diagnose [[Cholestasis|cholestatic]] [[liver]] disease
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.
** Evaluate infiltrative or [[Granuloma|granulomatous]] disease
** Evaluate unexplained [[jaundice]] 
** Evaluate [[Adverse drug reaction|drug reactions]]
** Monitor progression of diseases such as [[primary biliary cirrhosis]], [[Hepatitis C|chronic hepatitis C]]<sup> </sup>or [[alcoholic liver disease]]
* Cirrhosis is mainly diagnosed based on clinical presentation, [[Medical laboratory|laboratory]], and [[Radiologic sign|radiologic]] data.


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>
==== Features of liver biopsy<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>
* 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]]
**[[Percutaneous]]
**Transjugular 
**Transjugular 
**Laparoscopic radiographically- guided fine-needle approach
**[[Laparoscopic surgery|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 [[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>  
* Percutaneous [[liver biopsy]] is 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]].
*  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.
* 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.
* 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>
* [[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:
*Risks of [[liver biopsy]] include:
**[[Bleeding|Hemorrhage]]
**[[Bleeding|Hemorrhage]]
Line 52: Line 51:
***Advantage: allows direct visualisation of the [[liver]]
***Advantage: allows direct visualisation of the [[liver]]


*Patients with severe clotting disorders:  
*Patients with severe [[Coagulation|clotting]] disorders:  
**Transjugular [[liver biopsy]]:
**Transjugular [[liver biopsy]]:
***Risk of [[Peritoneum|intraperitoneal]] [[Bleeding|bleed]] is less
***Risk of [[Peritoneum|intraperitoneal]] [[Bleeding|bleed]] is less
Line 58: Line 57:
**** [[Biopsy|Biopsies]] are small: multiple [[Biopsy|biopsies]] required 
**** [[Biopsy|Biopsies]] are small: multiple [[Biopsy|biopsies]] required 
**** Taken 'blindly'
**** Taken 'blindly'
****Indications for obtaining a biopsy specimen, divided according to the type of clinical question framed, are as follows:
***** Evaluation of abnormal hepatic laboratory test results
***** Confirmation of diagnosis and prognostication
***** Suspected hepatic neoplasm
***** Diagnosis of cholestatic liver disease
***** Evaluation of infiltrative or granulomatous disease
***** Following a case of liver transplantation to evaluate and manage rejection
***** To evaluate unexplained jaundice or suspected drug reactions The biopsy specimen may be used to identify or exclude possible etiologies for physical or laboratory abnormalities. Although various disease states may present similarly, diagnostic histologic patterns exist when used in the context of clinical presentation. For example, infiltration of the hepatic parenchyma by fat may exist in diseases due to alcohol abuse, hepatitis C, diabetes, obesity, or combinations thereof. For each disease state, histologic clues exist that distinguish one from the other.<sup> [[null 5], [null 6], [null 7]]</sup>  Liver biopsy plays little role in the determination of the organism responsible for systemic infection because blood cultures generally are revealing. The notable exceptions are intrahepatic tuberculosis and ''Mycobacterium avium'' complex (MAC).  Another indication for biopsy is the determination of the extent of histologic change present in a biopsy specimen. This involves scoring systems for the degrees of inflammation and fibrosis noted by the pathologist. Many systems exist for describing the microscopic findings, ranging from simplistic to complex. The majority of scoring systems report the degree of inflammation as the grade of the disease and the amount of fibrosis as the stage. An example here would be the finding of moderate inflammation (grade 3) in a specimen from a cirrhotic (stage 4) liver.  The third set of indications is the monitoring of the progression of disease or of treatment efficacy. For example, liver biopsy specimens frequently are used to evaluate and treat rejection following liver transplantation. Repeated biopsies are used less frequently to monitor progression of diseases such as primary biliary cirrhosis, chronic hepatitis C,<sup> [[null 8]] </sup>or alcoholic liver disease.  Regardless of the indication for the biopsy, identifying which information the procedure is anticipated to yield is important.
===== Sequence of Diagnostic Studies =====
The [name of investigation] should be performed when:
* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
* A positive [test] is detected in the patient, to confirm the diagnosis.


==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 17:06, 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

Diagnostic Study of Choice

Gold standard/Study of choice:

Features of liver biopsy[1][2][3][4][5][6][7][8]

References

  1. Williams EJ, Iredale JP (1998). "Liver cirrhosis". Postgrad Med J. 74 (870): 193–202. PMC 2360862. PMID 9683971.
  2. 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.
  3. 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.
  4. Abdi W, Millan JC, Mezey E (1979). "Sampling variability on percutaneous liver biopsy". Arch. Intern. Med. 139 (6): 667–9. PMID 443970.
  5. 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.
  6. 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.
  7. Bravo AA, Sheth SG, Chopra S (2001). "Liver biopsy". N. Engl. J. Med. 344 (7): 495–500. doi:10.1056/NEJM200102153440706. PMID 11172192.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.