Liver biopsy in a district general hospital: Changes over two decades

Table 1 Patient demographics and clinical features

	Median values (range)	Normal values
Age (yr)	57 (25-86)
Sex (F/M)	51:37
Liver biochemistry
ALT (U/L)	66.5 (11-1103)	10-31
Bilirubin (μmol/L)	13 (5-430)	1-17
GGT (U/L)	221 (20-1394)	0-50
ALP (U/L)	145 (44-994)	45-145
Platelets (× 109/L)	239 (93-813)	150-500
Indications for biopsy:
Acute hepatitis	5
Chronic hepatitis/Chronic elevated liver tests/Staging of disease	75
Abnormal imaging	8
Disease follow-up	3
Routes of biopsy:
Blind	32 (31)
USS guided	60 (11)
TJB	2
Laparoscopic	1

ALT: Alanine aminotransferase; GGT: Gamma glutamyltransferase; ALP: Alkaline phosphatase; USS: Ultrasonography; TJB: Transjugular liver biopsy.

¹Failed.

Table 2 Liver biopsies between 1986 and 1995

Number of successful liver biopsies	Diagnosis pre-biopsy	History	Abnormal liver tests	Viral serology	Autoimmune /Immunoglobulins	Imaging	Others	Final Diagnosis
6	PBC	Y	Y	N	Y	Normal	n/a	PBC
3	AIH	N	Y	N	Y	Normal	n/a	AIH: 3 (staging)
1	LKM hepatitis	N	Y	N	Y LKM + AMA	Spleen +	n/a	Possible overlap AIH/PBC
3	ALD	Y	Y	N	N	Normal/Spleen +	n/a	ALD: 3 (cirrhosis in 1)
3	Abnormal Liver tests	N	Y	N	N	Echogenic liver	Elevated ferritin	NAFLD (simple steatosis): 3
1	ALD/Iron overload	Y	Y	N	N	Normal	Elevated ferritin	Porphyria cutanea tarda (plasma porphyrin 618, faecal porphyrin +)
1	Iron overload	N	Y	N	N	Normal	Elevated ferritin and homozygous C282Y	Primary haemochromatosis

Total number of biopsies performed: 19; Failed biopsies: 1; Successful biopsies: 18. Y: Present; N: Negative or not present; n/a: Not applicable; PBC: Primary biliary cirrhosis; AIH: Autoimmune hepatitis; ALD: Alcoholic liver disease; NAFLD: Non-alcoholic fatty liver disease; LKM: Liver, kidney, microsomal antibody; AMA: Anti-mitochondrial antibody.

Table 3 Liver biopsies between 1996 and 2006

Number of successful liver biopsies	Diagnosis pre-biopsy	History	Abnormal liver tests	Viral serology	Autoimmune/Immunoglobulins	Imaging	Others	Final Diagnosis
24	Abnormal liver tests	Non-specific Abdominal pains in 2	Y	N	SMA in 1 IgG in 1	Normal/Echogenic	n/a	Simple steatosis: 12 NASH: 4 Autoimmune(including overlap): 2 Drug-related: 2 Microhamartomas: 1(laparoscopy) Non-specific: 2 Venous congestion: 1
6	NAFLD	Metabolic features present	Y	N	IgA elevated in 2	Echogenic 3	n/a	NASH: 1 Simple steatosis: 4 Normal: 1
3	Alcohol	Strong alcohol history	Y	N	Elevated IgG in 1 Autoimmune normal	Normal 2 Ascites 1	n/a	ALD: 1 (staging) ALD: 1 (diagnosis; transjugular) AIH: 1
6	Iron overload	N	Y in 2	N	N	Echogenic 3	Elevated Ferritin in all	C282Y/C282Y: 4 C282Y/H63D: 1 NAFLD (simple steatosis): 1
2	Alcohol/Iron overload?	Strong alcohol history	Y	N	Elevated IgA	Echogenic 2	Elevated Ferritin in 2	C282Y/H63D + alcohol features: 2
8	Liver lesions on imaging	N	Y in 2	N	N	Multiple lesions noted on US/CT	n/a	Lung primary: 3 GIST: 1 GI tract: 2 Pancreas: 1 NASH: 1
9	Hepatitis C	Y	Y	PCR positive	N	Normal	n/a	Hepatitis C (staging) Genotype 1:6 Genotype 3:3
1	Hepatitis B	Y	Normal	Y	N	Normal	n/a	Hepatitis B (staging)
1	PBC	N	Y	N	Elevated IgM AMA: 1: 640	Normal	n/a	PBC
8	AIH	N	Y	N	AIH: ANA + SMA in 3 Isolated SMA in 1 LKM + AMA in 1 Non-specific: Isolated SMA in 2 ANA only in 1	Normal (7); Splenomegaly in 1	n/a	AIH: 3 (staging)(transjugular in 1) AIH: 1 (diagnosis) Possible AIH/PBC overlap: 1 Non-specific: 3
2	Drug induced	Y	Y	N	Polyclonal increase in Ig	Normal	n/a	Drug-cholestasis: 1 NAFLD(simple steatosis): 1
3	Miscellaneous	Y	Y in PUO	N	N	Normal	n/a	PUO: 1 Methotrexate: 2(staging)

Total number of biopsies: 76; Failed biopsies: 3; Number of successful biopsies: 73. Y: Present; N: negative or not present; n/a: Not applicable. PBC: Primary biliary cirrhosis; PUO: Pyrexia of unknown origin; AIH: Autoimmune hepatitis; ALD: Alcoholic liver disease; NAFLD: Non-alcoholic fatty liver disease. NASH: Non-alcoholic steatohepatitis; LKM: Liver, kidney, microsomal antibody; SMA: Smooth muscle antibody. ANA: Anti-nuclear antibody; AMA: Anti-mitochondrial antibody; IgG: Immunoglobulin G; IgA: Immunoglobulin A; IgM: Immunoglobulin M; US: Ultrasound; CT: Computed tomography.

Table 4 Liver biopsies for acute hepatitis

Acute hepatitis	Pre-biopsy diagnosis	Final diagnosis
1	Cause unknown	Likely drug-induced; prednisolone started
2	Cause unknown	Mild steatohepatitis
3	Pyrexia of unknown origin	Tuberculosis excluded
4	Cause unknown	No specific features
5	Cause unknown	Microhamartomas with cholestatic hepatitis