Cirrhosis diagnostic study of choice: Difference between revisions
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**** Taken 'blindly' | **** Taken 'blindly' | ||
=== Gold standard/Study of choice in developed countries: === | === Gold standard/Study of choice in developed countries: === | ||
*Transient elastography and the Acoustic Radiation Force Impulse (ARFI) technique are well-established methods for the staging of [[fibrosis]] in various [[liver]] diseases: <ref name="pmid20581229">{{cite journal |vauthors=Castera L, Pinzani M |title=Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango? |journal=Gut |volume=59 |issue=7 |pages=861–6 |year=2010 |pmid=20581229 |doi=10.1136/gut.2010.214650 |url=}}</ref><ref name="pmid22239521">{{cite journal |vauthors=Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D, Takahashi H, Yoneda M, Suda T, Zeuzem S, Herrmann E |title=Performance of Acoustic Radiation Force Impulse imaging for the staging of liver fibrosis: a pooled meta-analysis |journal=J. Viral Hepat. |volume=19 |issue=2 |pages=e212–9 |year=2012 |pmid=22239521 |doi=10.1111/j.1365-2893.2011.01537.x |url=}}</ref><ref name="pmid18395077">{{cite journal |vauthors=Friedrich-Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, Herrmann E |title=Performance of transient elastography for the staging of liver fibrosis: a meta-analysis |journal=Gastroenterology |volume=134 |issue=4 |pages=960–74 |year=2008 |pmid=18395077 |doi=10.1053/j.gastro.2008.01.034 |url=}}</ref><ref name="pmid15690481">{{cite journal |vauthors=Ziol M, Handra-Luca A, Kettaneh A, Christidis C, Mal F, Kazemi F, de Lédinghen V, Marcellin P, Dhumeaux D, Trinchet JC, Beaugrand M |title=Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C |journal=Hepatology |volume=41 |issue=1 |pages=48–54 |year=2005 |pmid=15690481 |doi=10.1002/hep.20506 |url=}}</ref><ref name="pmid14698338">{{cite journal |vauthors=Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, Christidis C, Ziol M, Poulet B, Kazemi F, Beaugrand M, Palau R |title=Transient elastography: a new noninvasive method for assessment of hepatic fibrosis |journal=Ultrasound Med Biol |volume=29 |issue=12 |pages=1705–13 |year=2003 |pmid=14698338 |doi= |url=}}</ref><ref name="pmid23558397">{{cite journal |vauthors=Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, Cantisani V, Correas JM, D'Onofrio M, Drakonaki EE, Fink M, Friedrich-Rust M, Gilja OH, Havre RF, Jenssen C, Klauser AS, Ohlinger R, Saftoiu A, Schaefer F, Sporea I, Piscaglia F |title=EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology |journal=Ultraschall Med |volume=34 |issue=2 |pages=169–84 |year=2013 |pmid=23558397 |doi=10.1055/s-0033-1335205 |url=}}</ref><ref name="pmid25911335">{{cite journal |vauthors= |title=EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis |journal=J. Hepatol. |volume=63 |issue=1 |pages=237–64 |year=2015 |pmid=25911335 |doi=10.1016/j.jhep.2015.04.006 |url=}}</ref><ref name="pmid21205132">{{cite journal |vauthors=Castera L, Bedossa P |title=How to assess liver fibrosis in chronic hepatitis C: serum markers or transient elastography vs. liver biopsy? |journal=Liver Int. |volume=31 Suppl 1 |issue= |pages=13–7 |year=2011 |pmid=21205132 |doi=10.1111/j.1478-3231.2010.02380.x |url=}}</ref><ref name="pmid23732714">{{cite journal |vauthors=Chou R, Wasson N |title=Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review |journal=Ann. Intern. Med. |volume=158 |issue=11 |pages=807–20 |year=2013 |pmid=23732714 |doi=10.7326/0003-4819-158-11-201306040-00005 |url=}}</ref><ref name="pmid26779260">{{cite journal |vauthors=Khallafi H, Qureshi K |title=Imaging Based Methods of Liver Fibrosis Assessment in Viral Hepatitis: A Practical Approach |journal=Interdiscip Perspect Infect Dis |volume=2015 |issue= |pages=809289 |year=2015 |pmid=26779260 |pmc=4686715 |doi=10.1155/2015/809289 |url=}}</ref><ref name="pmid23954643">{{cite journal |vauthors=Singh S, Fujii LL, Murad MH, Wang Z, Asrani SK, Ehman RL, Kamath PS, Talwalkar JA |title=Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis |journal=Clin. Gastroenterol. Hepatol. |volume=11 |issue=12 |pages=1573–84.e1–2; quiz e88–9 |year=2013 |pmid=23954643 |pmc=3900882 |doi=10.1016/j.cgh.2013.07.034 |url=}}</ref> | |||
* The '''FibroScan (transient elastography)''' uses elastic waves to determine [[liver]] stiffness which theoretically may be converted into a liver score. | |||
* The FibroScan produces an ultrasound image of the [[liver]] (from 20-80mm) along with a pressure reading (in kPa). | |||
* Transient elastography is much faster than a [[biopsy]] (usually lasts 2.5-5 minutes) and is completely painless. | |||
* Findings on transient elastography may show reasonable correlation with the severity of cirrhosis:<ref>{{cite journal |author=Foucher J, Chanteloup E, Vergniol J, ''et al'' |title=Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study |journal=Gut |volume=55|issue=3 |pages=403-8 |year=2006 |pmid=16020491 |doi=10.1136/gut.2005.069153}}</ref><ref name="pmid22733854">{{cite journal |author=Xie L, Chen X, Guo Q, Dong Y, Guang Y, Zhang X |title=Real-time elastography for diagnosis of liver fibrosis in chronic hepatitis B |journal=[[Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine]] |volume=31 |issue=7 |pages=1053–60 |year=2012|pmid=22733854 |doi= |url=}}</ref> | |||
** Increasing [[Scar|scarring]] of the [[liver]] is associated with increasing "stiffness" of the [[Tissue (biology)|tissue]]. | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
Revision as of 15:02, 21 December 2017
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Cirrhosis diagnostic study of choice On the Web |
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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
In developing countries, liver biopsy is the gold standard test for the diagnosis of cirrhosis. The presence of bridging fibrous septa, parenchymal nodules bearing a mixture of replicating and sensecent hepatocytes and involvement of most or all of the liver are confirmatory of cirrhosis. Liver biopsy helps in confirmation of the diagnosis, determination of prognosis, underlying etiology, management of rejection subsequent to liver transplantation and evaluation of abnormal hepatic investigations. Sample of the liver may be obtained by Percutaneous, transjugular and laparoscopic radiographically- guided fine-needle approach. However, percutaneous liver biopsy is considered as the cornerstone of diagnosis. In developed countries, Fibroscan (transient elastography) is replacing liver biopsy as the gold standard diagnostic modality.
Diagnostic Study of Choice
Gold standard/Study of choice in developing countries:
- Cirrhosis is primarily a histological diagnosis. Liver biopsy is the gold standard test for the diagnosis of cirrhosis.
- The following result of liver biopsy is confirmatory of cirrhosis:
- Presence of bridging fibrous septa
- Parenchymal nodules bearing a mixture of replicating and sensecent hepatocytes
- Involvement of most or all of the liver
- Liver biopsy should be performed in order to:
- Confirm the diagnosis
- Determine prognosis
- Diagnose the underlying etiology of cirrhosis
- 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
- Manage and evaluate rejection subsequent to liver transplantation
- Evaluate abnormal hepatic investigations
- Rule out hepatic neoplasms
- Diagnose cholestatic liver disease
- Evaluate infiltrative or granulomatous disease
- Evaluate unexplained jaundice
- Evaluate drug reactions
- Monitor progression of diseases such as primary biliary cirrhosis, chronic hepatitis C or alcoholic liver disease
- Cirrhosis is mainly diagnosed based on clinical presentation, laboratory, and radiologic data.
Features of liver biopsy[1][2][3][4][5][6][7][8]
- 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 is 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.
- 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:
Gold standard/Study of choice in developed countries:
- Transient elastography and the Acoustic Radiation Force Impulse (ARFI) technique are well-established methods for the staging of fibrosis in various liver diseases: [13][14][15][16][17][18][19][20][21][22][23]
- The FibroScan (transient elastography) uses elastic waves to determine liver stiffness which theoretically may be converted into a liver score.
- The FibroScan produces an ultrasound image of the liver (from 20-80mm) along with a pressure reading (in kPa).
- Transient elastography is much faster than a biopsy (usually lasts 2.5-5 minutes) and is completely painless.
- Findings on transient elastography may show reasonable correlation with the severity of cirrhosis:[24][25]
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.
- ↑ Castera L, Pinzani M (2010). "Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango?". Gut. 59 (7): 861–6. doi:10.1136/gut.2010.214650. PMID 20581229.
- ↑ Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D, Takahashi H, Yoneda M, Suda T, Zeuzem S, Herrmann E (2012). "Performance of Acoustic Radiation Force Impulse imaging for the staging of liver fibrosis: a pooled meta-analysis". J. Viral Hepat. 19 (2): e212–9. doi:10.1111/j.1365-2893.2011.01537.x. PMID 22239521.
- ↑ Friedrich-Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, Herrmann E (2008). "Performance of transient elastography for the staging of liver fibrosis: a meta-analysis". Gastroenterology. 134 (4): 960–74. doi:10.1053/j.gastro.2008.01.034. PMID 18395077.
- ↑ Ziol M, Handra-Luca A, Kettaneh A, Christidis C, Mal F, Kazemi F, de Lédinghen V, Marcellin P, Dhumeaux D, Trinchet JC, Beaugrand M (2005). "Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C". Hepatology. 41 (1): 48–54. doi:10.1002/hep.20506. PMID 15690481.
- ↑ Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, Christidis C, Ziol M, Poulet B, Kazemi F, Beaugrand M, Palau R (2003). "Transient elastography: a new noninvasive method for assessment of hepatic fibrosis". Ultrasound Med Biol. 29 (12): 1705–13. PMID 14698338.
- ↑ Bamber J, Cosgrove D, Dietrich CF, Fromageau J, Bojunga J, Calliada F, Cantisani V, Correas JM, D'Onofrio M, Drakonaki EE, Fink M, Friedrich-Rust M, Gilja OH, Havre RF, Jenssen C, Klauser AS, Ohlinger R, Saftoiu A, Schaefer F, Sporea I, Piscaglia F (2013). "EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology". Ultraschall Med. 34 (2): 169–84. doi:10.1055/s-0033-1335205. PMID 23558397.
- ↑ "EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis". J. Hepatol. 63 (1): 237–64. 2015. doi:10.1016/j.jhep.2015.04.006. PMID 25911335.
- ↑ Castera L, Bedossa P (2011). "How to assess liver fibrosis in chronic hepatitis C: serum markers or transient elastography vs. liver biopsy?". Liver Int. 31 Suppl 1: 13–7. doi:10.1111/j.1478-3231.2010.02380.x. PMID 21205132.
- ↑ Chou R, Wasson N (2013). "Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review". Ann. Intern. Med. 158 (11): 807–20. doi:10.7326/0003-4819-158-11-201306040-00005. PMID 23732714.
- ↑ Khallafi H, Qureshi K (2015). "Imaging Based Methods of Liver Fibrosis Assessment in Viral Hepatitis: A Practical Approach". Interdiscip Perspect Infect Dis. 2015: 809289. doi:10.1155/2015/809289. PMC 4686715. PMID 26779260.
- ↑ Singh S, Fujii LL, Murad MH, Wang Z, Asrani SK, Ehman RL, Kamath PS, Talwalkar JA (2013). "Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis". Clin. Gastroenterol. Hepatol. 11 (12): 1573–84.e1–2, quiz e88–9. doi:10.1016/j.cgh.2013.07.034. PMC 3900882. PMID 23954643.
- ↑ Foucher J, Chanteloup E, Vergniol J; et al. (2006). "Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study". Gut. 55 (3): 403–8. doi:10.1136/gut.2005.069153. PMID 16020491.
- ↑ Xie L, Chen X, Guo Q, Dong Y, Guang Y, Zhang X (2012). "Real-time elastography for diagnosis of liver fibrosis in chronic hepatitis B". Journal of Ultrasound in Medicine : Official Journal of the American Institute of Ultrasound in Medicine. 31 (7): 1053–60. PMID 22733854.