Correspondence

Liver Biopsy

N Engl J Med 2001; 344:2030June 28, 2001

Article

To the Editor:

Bravo et al. (Feb. 15 issue)1 list hemostatic contraindications to percutaneous liver biopsy. A prolonged bleeding time (≥10 minutes), in our opinion, has not been proved to predict a risk of biopsy-related bleeding. The evidence that supports the use of this test is based on clinical experience and expert opinion, not the results of controlled studies. The bleeding time is a poorly reproducible test, used for decades primarily because of the lack of a better substitute. Prospective studies in the literature have not convincingly shown that bleeding from a standardized cut in the skin reflects the risk of bleeding elsewhere in the body.2 For these reasons, many reputable hospitals in the United States have eliminated or are in the process of phasing out the use of bleeding time as a standard test.

In addition, an increase in the prothrombin time to three to five seconds more than the control value is well within the range of variability of laboratory instruments and the international sensitivity index of prothrombin-time reagents. Therefore, use of the prothrombin time, expressed in seconds, cannot be generalized among institutions. The validity of the international normalized ratio in patients not taking warfarin is controversial.3

Leslie K. Diaz, M.D.
Jun Teruya, M.D., D.Sc.
Northwestern University Medical School, Chicago, IL 60611

3 References

1. 1

   Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001;344:495-500
   Full Text | Web of Science | Medline

2. 2

   Rodgers RPC, Levin J. A critical reappraisal of the bleeding time. Semin Thromb Hemost 1990;16:1-20.
   

3. 3

   Fairweather RB, Ansell J, van den Besselaar AM, et al. College of American Pathologists Conference XXXI on laboratory monitoring of anticoagulant therapy: laboratory monitoring of oral anticoagulant therapy. Arch Pathol Lab Med 1998;122:768-781
   Web of Science | Medline

To the Editor:

We do not agree on the use of liver biopsy to diagnose hemochromatosis or to assess primary biliary cirrhosis or primary sclerosing cholangitis. If there is a suspicion of hemochromatosis, a genetic test should be performed. If the result of this test is positive, no confirmatory biopsy is necessary. The serum ferritin should be measured, with or without magnetic resonance imaging to check for iron overload. Biopsy is no longer recommended for diagnosing hemochromatosis and is proposed only for use in detecting cirrhosis. Biopsy is indicated if the genetic test is negative and the patient has iron overload.1

Antimitochondrial E2 antibodies can confirm the diagnosis of biliary cirrhosis even in patients without symptoms, so biopsy may no longer be necessary in the early stages of disease but only in more advanced cases.2 Primary sclerosing cholangitis is usually diagnosed by endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiography, since liver biopsy often gives no useful information for diagnosis.3

Giancarlo Spinzi, M.D.
Vittorio Terruzzi, M.D.
Giorgio Minoli, M.D.
Hospital Valduce, 22100 Como, Italy

3 References

1. 1

   Adams P, Brissot P, Powell LW. EASL International Consensus Conference on Haemochromatosis. J Hepatol 2000;33:485-504
   CrossRef | Web of Science | Medline

2. 2

   Metcalf JV, Mitchison HC, Palmer JM, Jones DE, Bassendine MF, James OF. Natural history of early primary biliary cirrhosis. Lancet 1996;348:1399-1402
   CrossRef | Web of Science | Medline

3. 3

   Grant A, Neuberger J. Guidelines on the use of liver biopsy in clinical practice. Gut 1999;45:Suppl IV:IV-1
   CrossRef

To the Editor:

Bravo et al. mention the transjugular route for liver biopsy. Whereas the traditional method involving a suction technique does indeed result in troublesome fragmentation of liver samples — producing tissue inadequate for histologic analysis in up to 18 percent of patients1 — the new, semiautomated cutting devices have had far more success. The Cook Quick-Core biopsy needle, evaluated in several studies and used routinely at our institution, is triggered by hand and obtains cores of tissue up to 20 mm in length. In published reports, almost all the samples obtained by this technique were satisfactory for histologic diagnosis, with complication rates of only 2.8 percent to 5.2 percent.2-4

Coagulopathy and ascites are relative contraindications to percutaneous biopsy, but the procedure is still often performed after the administration of donor platelets or fresh-frozen plasma, with or without plugging of the biopsy tract with gelatin foam. One of the advantages of transvenous liver biopsy is that it circumvents the need to correct coagulopathies before the procedure.

John F. Bruzzi, M.R.C.P.I.
Martin O'Connell, M.R.C.P.I.
John G. Murray, M.R.C.P.I.
Mater Misericordiae Hospital, Dublin, Ireland

4 References

1. 1

   Jackson JE, Adam A, Allison DJ. Transjugular and plugged liver biopsies. Baillieres Clin Gastroenterol 1992;6:245-258
   CrossRef | Web of Science | Medline

2. 2

   Kardache M, Soyer P, Boudiaf M, Cochand-Priollet B, Pelage J-P, Rymer R. Transjugular liver biopsy with an automated device. Radiology 1997;204:369-372
   Web of Science | Medline

3. 3

   Choh J, Dolmatch B, Safadi R, et al. Transjugular core liver biopsy with a 19-gauge spring-loaded cutting needle. Cardiovasc Intervent Radiol 1998;21:88-90
   CrossRef | Web of Science | Medline

4. 4

   De Hoyos A, Loredo ML, Martinez-Rios MA, Gil MR, Kuri J, Cardenas M. Transjugular liver biopsy in 52 patients with an automated Trucut-type needle. Dig Dis Sci 1999;44:177-180
   CrossRef | Web of Science | Medline

Citing Articles (8)

Citing Articles

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   Beom Kyung Kim, Kwang-Hyub Han, Jun Yong Park, Sang Hoon Ahn, Chae Yoon Chon, Ja Kyung Kim, Yong Han Paik, Kwan Sik Lee, Young Nyun Park, Do Young Kim. (2010) A novel liver stiffness measurement-based prediction model for cirrhosis in hepatitis B patients. Liver International 30:7, 1073-1081
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   Daryl J. Kor, James R. Stubbs, Ognjen Gajic. (2010) Perioperative coagulation management – fresh frozen plasma. Best Practice & Research Clinical Anaesthesiology 24:1, 51-64
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   Beom Kyung Kim, Kwang Hyub Han, Jun Yong Park, Sang Hoon Ahn, Chae Yoon Chon, Ja Kyung Kim, Yong Han Paik, Kwan Sik Lee, Young Nyun Park, Do Young Kim. (2009) External Validation of P2/MS and Comparison with Other Simple Non-invasive Indices for Predicting Liver Fibrosis in HBV-Infected Patients. Digestive Diseases and Sciences
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   Armando Tripodi, Veena Chantarangkul, Pier M. Mannucci. (2009) Acquired coagulation disorders: revisited using global coagulation/anticoagulation testing. British Journal of Haematology 147:1, 77-82
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   Armando Tripodi. (2009) Tests of Coagulation in Liver Disease. Clinics in Liver Disease 13:1, 55-61
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6. 6

   A. TRIPODI, S. H. CALDWELL, M. HOFFMAN, J. F. TROTTER, A. J. SANYAL. (2007) Review article: the prothrombin time test as a measure of bleeding risk and prognosis in liver disease. Alimentary Pharmacology & Therapeutics 26:2, 141-148
   CrossRef

7. 7

   Armando Tripodi, Pier Mannuccio Mannucci. (2007) Abnormalities of hemostasis in chronic liver disease: Reappraisal of their clinical significance and need for clinical and laboratory research. Journal of Hepatology 46:4, 727-733
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8. 8

   Paul J Pockros. (2002) Developments in the treatment of chronic hepatitis C. Expert Opinion on Investigational Drugs 11:4, 515-528
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