Ultrasound

I just switched doctors and now have a specialist who is super-involved with latest meds and trends and trials.  I'm 39yo, geno 1a, viral load in Sep2009 was 860, viral load Mar2010 was 50k.  No biopsy yet.  New doc wants to test load again this or next week.  Just had an ultrasound of liver, spleen, lower torso today.  Radiologist hasn't given their opinion yet, but the tech said everything looked "good".  My question is, Does the biopsy actually help and will it give any information that may mean I can skip the biopsy?  Just curious.  Next steps are to reassess and possibly treat with SOC or do a study or wait until new PIs released next year.  Thanks for any comments.

[IAmTheWalrus]

It is great that you have a specialist that is very involved. Having a good hepatologist is probably the first best thing to have for someone with HCV.

You have a very low viral load. However, viral load does not indicate much about disease progression. Even the previous 50K test is very low. Most viral loads are in the 100,000+ range up to several million. There are many factors that can affect disease progression.

Radiology and ultrasound imaging really can't give an accurate picture of liver disease or the extent of damage to the liver. Imaging is good for detecting abnormalities, anatomical structure, size, and the presence of tumors, but they do not indicate how far liver damage has progressed.

There are some imaging techniques used by some for staging liver disease, but the accepted standard for this is the large needle biopsy of the liver tissue. This allows microscopic inspection of the cellular structures of the liver and the extent to which fibrosis or scarring and necrosis of the liver tissue has occurred.

The result of the biopsy is usually given as a Metavir score between 0 and 4 which indicates the extent of damage, and a Knodell score between 0 and 18 which indicates the level of inflammation of the liver tissue. The Metavir score is probably the more important one, or at least gets the most discussion here.

Here's some additional information about this you may find useful:
http://www.hcvadvocate.org/hepatitis/factsheets_pdf/grade_stage.pdf

Good luck to you!

[22hamilton]

Hi there, did you mean to say will the ultrasound help provide info so you can skip the biopsy ? All the various procedures are about building up a picture of your liver health. An ulrasound scan will only give an image that reflects the size of your liver and spleen,the surface-smooth or mottled,presence or absence of tumours,elasticity of portal vein,rough level of fattiness etc.
Biopsies are still the gold standard for looking into liver pathology at a cellelar level and if performed well will give you an accurate staging/grading figure for your liver.Biopsies are no big deal really so dont worry about it.
Whether you doctor decides to treat you without a biopsy is up to him really, you have a lowish viral load so that bodes well for future treatment whether it be SOC or the new treatments coming along in the next few years.

Good look

[frijole]

THere is no correlation with viral load and the  extent of liver damage.  That is, even though your VL is low (and 50,000 is very low) you could have extensive damage - damage that will not show up on an ultrasound.  THe ultrasound is a good tool to detect cancer but you really do need the biopsy to detect the inflammation and subsequent damage that HCV does.  I hope you will get that biopsy.
frijole

[Trinity4]

As info:

While liver biopsy is considered the “gold standard” for assessing the severity of liver disease, it is not always accurate and has several shortcomings. Liver biopsy can under- or over-estimate the severity of hepatitis C, particularly if the biopsy is small and if it is not read by a knowledgeable expert. In addition, liver biopsy is an invasive procedure that is expensive and not without complications. At least 20 percent of patients have pain requiring medications after liver biopsy. Rare complications include puncture of another organ, infection, and bleeding. Significant bleeding after liver biopsy occurs in one out of 100 to one out of 1,000 cases, and deaths are reported in one out of 5,000 to one out of 10,000 cases. Obviously, noninvasive means of grading and staging liver disease would be very helpful but do not provide the complete health of the liver as does biopsy.

Trinity

[Diane12855]

You say you are a 1a. That pretty much means you NEED a biopsy to see if you should treat now or wait for the new PIs. The xray tech had no business telling you anything about your ultrasound... they are not qualified, so just forget what that person said. You need to know how much inflammation and fibrosis your liver has and there is only one way that I know of that genotype 1s can get that info. I'm a 1a too, I was stage 2 grade 2, but I'm 55 and they say that after 50 things get worse much faster, so I'm doing the 48 weeks... only 7 shots in so far, and believe me, if I could have waited and only had to go 24 weeks with the new meds, that would have been the way I would have wanted to go. BTW, I had ultrasounds and a MRI of my liver done 6 months before they discovered the hep C and all my results came back "Normal".

[neptune235]

A biopsy is part of a long-term complete workup for anyone with HCV.

Needle biopsies are done without anesthesia, and the idea that I'm laying there impaled by a steel needle, awake, and subject to the yips creeps me out to no end.  Consider me a big baby.

So...my hepatologist did a transjugular liver biopsy.  It was done in the cath lab, and involved a large dose of fentanyl, and an xray guided catheter inserted into the jugular, through the heart and to the liver via the portal vein where a sample is retrieved.  I know, I know, this procedure is not without a risk either, but at least I was out cold for it.

The reason for the biopsy was a change in my ultrasound that was suggestive of early cirrhosis.

10 years ago, when I was first diagnosed, I declined the biopsy that the hepatologists offered.  My decision was to treat irrespective of the results. so the information gained from the biopsy would not affect my decision.  To me, that made the risk unacceptable and unnecessary.

Just pointing out that there are many sides to the issue of timing and necessity of a liver biopsy.

[spectda]

It sounds to me like the procedure you had was a lot riskier then a needle biopsy. I have had three of them, and they are not painful. I am not mr stoic, they just are not painful. The worst part is impatiently lying on your side for three hours afterward.

By the way, my last biopsy earlier this year was the a ct guided needle biopsy and they give you anesthesia, they do not put you out (which by the way is not as safe as staying awake), but but it puts you in a twilight state and relaxes you. The biopsy itself is over in a minute.

I just say this so people who have not had one should understand that there is nothing to be afraid of, and when they are done with it they will realize how not a big deal it was.

There are risks to the procedure, as there are to even the most minor medical procedures. If this is done by an experienced dr, especially if it is ct guided (my first two were not) it is especially low risk.

[Trinity4]

I agree spectda.  I had the same type of biopsy done in '07 and it was easy breezy and waiting for hours afterwards was the only PITA.

Will have another done in October or November of this year.  No worries there either.

Trinity

[neptune235]

Both procedures are carry a distinct risk, and there are many issues to consider before deciding on a course of treatment.

The larger point is that if one is motivated to treat regardless of the biopsy results, then, IMO, the biopsy is unnecessary for making the treatment decision, and the risk, then, becomes unacceptable.

[mikesimon]

I had one on my birthday in 2006. Then I drove myself to a fancy restaurant for a late lunch.
Image guided is the preferred approach - mine was ultrasound guided. My birthday biopsy was performed with a "spring-loaded biopsy mechanism'. It was like a nail gun - I heard a clunk sound and that was it. I have had a lot of liver biopsies and the was by far the easiest and quickest. I have never gotten any drugs beforehand and I have undergone them in my hospital room. A doctor would just pop in holding a tray with needles and a tissue tube on it.
I agree that it's no big thing.

[22hamilton]

Yes I agree with the above posts, dont want to scare people unnecessarily,have had 4 biopsies and they are no big deal as far as I'm concerned.

[adamben101]

Thank everyone for the comments.  As for the biopsy, I'm not scared of it (although we'd all rather be doing something else and skipping it if we could).  My new Dr is going to have all my latest info next week and we'll schedule the biopsy and discus treatment options.  It appears so far that my infection is less than 2 years old, but I want to take care of it asap.  Thanks again for the help!  Good luck to all!

[spectda]

I forgot that you have only had the infection for a short time. It's highly unlikely that you have sustained any liver damage in two years. Good luck with the treatment. - Dave

[Diane12855]

I didn't notice you had only been infected for 2 years either. If that is so, you could most likely wait for the new PI drugs that will be out next year (hopefully). Then you wouldn't have to treat as long and would have a much better chance at SVR.