Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.
Letter to Gut
We are pleased that the publication of the Guidelines (1) has been well received. However, based on a number of comments that we have received, we would like to make two minor modifications to the text of the Guidelines; these do not affect the principal recommendations:
In the discussion on outpatient biopsy we stated that ‘Patients with a strong suspicion of malignancy should not be biopsied as a day case because such patients may have a higher risk of haemorrhage than patients without cancer’. Based on unpublished data from a number of units, we suggest that this should be modified to ‘When considering biopsy of a patient with a strong suspicion of malignancy, the health care practitioner should be aware there may be a greater risk of haemorrhage and a longer period of post-biopsy monitoring should therefore be considered’.
In section 1.7 of the supplementary material we stated that ‘A liver biopsy may be indicated in those with PBC where the response to treatment is poor and other treatable causes may be present and should be done if second line treatment with Obeticholic acid is considered.’ Based on current evidence, we suggest removing the phrase ‘and should be done if second line treatment with Obeticholic acid is considered’.
Judith I Wyatt
Neuberger J, Patel J, Caldwell H, et al. Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology. Gut. 2020;69(8):1382-1403. doi:10.1136/gutjnl-2020-321299