the age old question-Biopsy or imaging

[48weeks]

I'm not sure how a biopsy is considered the gold standard by so many on here. It is just a small sample of your liver taken from just one spot. Seems to me that for it to be considered a gold standard, several biopsy's would have to be taken from several areas around the liver and that would be painful and expensive.  Isn't there some kind of advanced imaging that would provide a more representative diagnosis. Does anyone know what the most advanced imaging currently being offered is?  Is it the MRE that is offered only at the 3 or 4 Mayo clinics?

[48weeks]

Thanks everybody

[Advocate1955]

Since you have already completed triple tx and are currently UND and awaiting or have already obtained SVR, it's not an issue for you.  However, for others who either may not know the specific cause of their liver inflammation and/or need to know the specific stage of their fibrosis in order to guide decisions about treatment, it is my understanding that AASLD and hepatologists continue to feel that a liver biopsy is the best tool not only for staging fibrosis, but also for ruling out and or diagnosing certain liver diseases.
Advocate1955

[Dee1956]

Hi I can understand your anxiety.  I was afraid to get my biopsy because my platelets were so low.
From everything I have read the imaging is not the best way to find out the status of your liver.  I have read it can show no damage to a lot of damage but the middle ground is difficult to gauge.

I would want to know precisely how damaged my liver was, via biopsy. so I could make an educated decision.

Saying that...it is possible that since my biopsy in 2009 there are new and improved ways of finding out the status however in my case...my blood work did not indicate how much damage I had.

I wish you the best
Dee

[HectorSF]

"I'm not sure how a biopsy is considered the gold standard by so many on here..."

A biopsy is considered the gold standard not by us, but by the leading experts in the field of liver disease such as the AASLD (American Association for the Study of Liver Diseases) and EASL (European...). These are the organizations that represent the liver disease experts in the US and Europe.

Some other responses to your questions...
To prevent as much as possible sampling errors as possible a certain amount of the liver much be biopsied. How the procedure is performed and the needle used make sure enough tissue is sampled. An ideal size is 3 cm long after formalin fixation obtained with a 16 gauge needle according to the AASLD practice guidelines. If you want to know how a biopsy is performed read the guideline below.

The reason traditional imaging (ultrasound, CT , MRI) can not be used to stage liver disease is because the architecture of the liver doesn't change dramatically until a person has cirrhosis. When cirrhosis is complete nordular growths can be seen on the liver indicating regenerative tissue. Portal hypertension will develop and the blood system around the liver also changes. An enlarge spleen will be seen and varices. But for stages 0-3 the liver doesn't change in its function of its general anatomy.  
Another point is that only a biopsy can detect the cause of the liver disease. Particular distortions of the hepatocytes occur due the the various causes of liver disease. Imaging, MRE or TE can't do that.

AASLD POSITION PAPER
Liver Biopsy

http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/Liver%20Biopsy.pdf

This position paper has been approved by the AASLD and represents the position of the association.

Indications for Liver Biopsy—Overview

Historically, liver biopsy was used almost exclusively as a diagnostic tool., However, as the result not only of new natural history data and the introduction of many new therapies for patients with liver disease, liver biopsy and histological assessment of the liver has now taken on an important role in clinical management. Therefore, as of 2009, liver biopsy currently has three major roles: (1) for diagnosis, (2) for assessment of prognosis (disease staging), and/or (3) to assist in making therapeutic management decisions.

Recommendations

1. Liver biopsy should be considered in patients in whom diagnosis is in question, and when knowledge of a specific diagnosis is likely to alter the management plan (Class I, Level B).
2. Liver histology is an important adjunct in the management of patients with known liver disease, particularly in situations where (prognostic) information about fibrosis stage may guide subsequent treatment; the decision to perform liver biopsy in these situations should be closely tied to consideration of the risks and benefits of the procedure (Class I, Level B).
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EASL Clinical Practice Guidelines: Management of hepatitis C virus infection
European Association for the Study of the Liver

4.4.4. Assessment of liver disease severity

Assessment of liver disease severity is recommended prior to therapy. Identifying patients with cirrhosis is of particular importance, as their likelihood of responding to therapy and post-treatment prognosis are altered, and surveillance for HCC is required. Assessment of the stage of fibrosis by biopsy is not required in patients with clinical evidence of cirrhosis. Since significant fibrosis may be present in patients with repeatedly normal ALT, evaluation of disease severity should be performed regardless of ALT patterns. Endoscopy to rule out esophageal varices and portal hypertension should be performed in patients with known cirrhosis.

Liver biopsy remains the reference method. The risk of severe complications is very low (1/4000–10,000), but biopsy remains an invasive procedure. Histological features (necroinflammation = grading; fibrosis = staging) should be reported using a structured, semi-quantitative method. Various scoring systems have been validated for use in chronic hepatitis C. The most widely used in Europe are METAVIR, Scheuer, Ishak, and Knodell’s HAI. Metavir and Scheuer’s scores are more reproducible and less prone to observer variation, but less discriminant both for fibrosis and for necroinflammation than Ishak and Knodell.

Will covered the rest relating to Transient Elastography and MRE to assess liver fibrosis in patients with chronic hepatitis C.

Hope this helps.
Hector

[willbb]

There are certain degrees of error on any markers done to diagnose liver damage(fibrosis)  regardless of the method.

The last research I read ( I will try to find it later) was approx. 25 % degree of error on biopsy

My own personal feelings and also those of my hepatologist in the transplant centre I attend agree that  in the future.... biopsy will be used less and less.

Not necessary ,because of the error factor but because  the fact in the future the therapy for HCV in all likelihood be even more efficient with less side effects and shorter treatment times(possibly >90%)  there will even be less need for biopsy  

Also the  sophistication of the" fibrosure along with fibroscan" (often used in conjuction) is greatly improving   giving clinicians very good indications of liver damage(fibrosis) making the invasive procedure of biopsy even less prevalent.

All   JMO

Best...
Will