Liver Biopsy or Non-Invasive Evaluation of Liver Disease?

The reason we want to recognize ongoing liver damage as soon as possible is so that, hopefully, we can prescribe treatment to prevent damage from preceding from mild liver damage –> liver fibrosis –> cirrhosis –> portal hypertension –> the complications of liver failure +/or hepatocellular carcinoma.

For the above reason we want to vigorously evaluate mildly elevated liver function tests when they come to our attention. See Reference (1)

The following Abstract is from Reference (1):


Liver biopsy (LB) has been used as diagnostic modality in liver diseases (LD). Over last two decades, there has been remarkable improvement in understanding of natural history, molecular diagnostics of viral hepatitis, genetic of LD, and also limitations of LB. There is current trend in avoiding LB in the management of various LDs.


To determine utility of LB in clinical practice.


In a prospective study, 2413 patients of LD were followed up, 219 (9%) were acute, and remaining 2194 (90.9%) were chronic LD. Patients were evaluated by biochemical parameters, virological studies, and imaging endoscopy as and when required. LB was performed in 176 (7.2%) patients when no conclusion could be drawn from the noninvasive workup. Patients with platelet count <50,000/cm(2), ascites, and overt bleeding were excluded. Patients with international normalization ratio (INR) more than 1.5 were not excluded. No prophylactic use of fresh frozen plasma and platelet transfusion was done. There was no major complication related to the procedure. Indications for LB were as follows: cryptogenic LD 38 cases, hepatitis B infection 35, suspected autoimmune hepatitis 30, mass lesion in the liver and lymphoma 29,evaluation of portal hypertension 15, elevated liver enzymes 11, hepatitis C infection 9, and drug-induced LD 4, and miscellaneous 5 cases which were primary biliary cholangitis, primary sclerosing cholangitis, cholestatic LD, sarcoidosis, and amyloidosis.


LB changed the diagnosis in 55 (31.2%). These were cryptogenic LD in 24 cases, portal hypertension 15, elevated liver enzymes 11, and 5 others. In remaining, LB confirmed clinical diagnosis and helped in making management decisions.


LB was required in 7.2% of patients with chronic LD. In 31.2% cases, LB changed the diagnosis. LB was a safe procedure even in presence of low platelet count and abnormal INR.


An Outstanding Approach To The Evaluation of Incidentally Discovered Liver Function Test Abnormalities From American Family Physician
Posted on July 4, 2016 — The two charts at the beginning of the post from the AFP article nicely summarizes a reasonable approach.
Posted on July 4, 2016 by Tom Wade MD

(1) Indications of Liver Biopsy in the Era of Noninvasive Assessment of Liver Fibrosis. [PubMed Abstract] J Clin Exp Hepatol. 2015 Dec;5(4):314-9. doi: 10.1016/j.jceh.2015.08.005. Epub 2015 Oct 23.

(2) Cirrhosis Imaging from

(3) Special Report: Noninvasive Liver Assessment from

(4) Portal Hypertension Imaging from

(5) Shear wave elastography for evaluation of liver fibrosis. [PubMed Abstract] [Full Text HTML] [Full Text PDF]. J Ultrasound Med. 2014 Feb;33(2):197-203. doi: 10.7863/ultra.33.2.197.

(6) is the online Journal of Ultrasound In Medicine.


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