Cirrhosis diagnostic study of choice
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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 for diagnosing cirrhosis is:
- Examination of an explanted liver, either at autopsy or following liver transplantation, because the architecture of the entire liver can be appreciated.
- The page name should be "[Disease name] diagnostic study of choice", with only the first letter of the title capitalized. Note that the page is called "Diagnostic study of choice."
- Goal:
- To describe the most efficient/sensitive/specific test that is utilized for diagnosis of [disease name].
- To describe the gold standard test for the diagnosis of [disease name].
- To describe the diagnostic criteria, which may be based on clinical findings, physical exam signs, pathological findings, lab findings, findings on imaging, or even findings that exclude other diseases.
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- Remember to follow the same format and capitalization of letters as outlined in the template below.
- You should include the name of the disease in the first sentence of every subsection.
Diagnostic Study of Choice
Gold standard/Study of choice:
- Liver biopsy is the gold standard test for the diagnosis of cirrhosis.
- The following result of [gold standard test] is confirmatory of [disease name]:
- Result 1
- Result 2
- The [name of investigation] should be performed when:
- The patient presented with symptoms/signs 1. 2, 3.
- A positive [test] is detected in the patient.
- [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
- The diagnostic study of choice for [disease name] is [name of investigation].
- There is no single diagnostic study of choice for the diagnosis of [disease name].
- 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].
- [Disease name] is mainly diagnosed based on clinical presentation.
- Investigations:
- Among patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
- Among patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
- Among patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.
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:
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
- ↑ 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.