Juerg Reichen

The diagnostic value of liver biopsy

BackgroundSince the introduction of molecular diagnostic tools such as markers for hepatitis C and different autoimmune diseases, liver biopsy is thought to be useful mainly for staging but not for diagnostic purposes. The aim was to review the liver biopsies for 5 years after introduction of testing for hepatitis C, in order to evaluate what diagnostic insights – if any – remain after serologic testing.MethodsRetrospective review of all liver biopsies performed between 1.1.1995 and 31.12.1999 at an academic outpatient hepatology department. The diagnoses suspected in the biopsy note were compared with the final diagnosis arrived at during a joint meeting with the responsible clinicians and a hepatopathologist.ResultsIn 365 patients, 411 diagnoses were carried out before biopsy. 84.4 % were confirmed by biopsy but in 8.8 %, 6.8 % and 10.5 % the diagnosis was specified, changed or a diagnosis added, respectively. Additional diagnoses of clinical relevance were unrecognized biliary obstruction and additional alcoholic liver disease in patients with chronic hepatitis C. Liver biopsy led to change in management for 12.1 % of patients.ConclusionEven in the era of advanced virological, immunological and molecular genetic testing, liver biopsy remains a useful diagnostic tool. The yield is particularly high in marker negative patients but also in patients with a clear-cut prebiopsy diagnosis, liver biopsy can lead to changes in patient management.

Severe autoimmune hepatitis in patients with previous spontaneous recovery of a flare

BACKGROUND/AIMS Autoimmune hepatitis can present acutely and pursues a variable, usually progressive course. Spontaneous remissions have been described, but their influence on the course of subsequent attacks has not yet been studied. METHODS Charts from 1980 to 2000 were reviewed. Cases of autoimmune hepatitis were further examined to identify those with prior episodes of transient elevation of the serum aminotransferase activities of unknown etiology. RESULTS Fifty-one patients with autoimmune hepatitis were identified, nine of whom (18%) had experienced a transient episode of elevated aminotransferase activities which had resolved spontaneously. The median period of time separating the two flares was 10 months (range: 4 months-23 years). The median age at diagnosis was 41 years in both groups. More than 75% of the patients in either group suffered from a type 1 autoimmune hepatitis. Importantly, patients with spontaneous recovery of a previous episode had a higher serum alanine transaminase activity (P<0.02), were less likely to respond to immunosuppressive therapy (78 versus 98%, P=0.077) and required transplantation more frequently (22 versus 0%, P=0.028). Histologically, these patients did not have more fibrosis than patients without previous flare. CONCLUSIONS More than 10% of autoimmune hepatitis may begin with a spontaneously resolving episode. However, the spontaneous recovery of a previous attack should not falsely reassure: a subsequent flare of autoimmune hepatitis can still be severe.

The Bridge – August 2001

Biliary lipid secretion and canalicular membranes (see pages 164±169) The origin of biliary phospholipid species remains unclear; one theory held that they derive from detergent (bile acid) accessible microdomains in the canalicular membrane. Nibbering and colleagues demonstrate quite convincingly that this is not the case: while they were able to markedly alter biliary cholesterol output (diosgenin feeding) canalicular membrane composition remained constant and phospholipid composition ± whether in detergent susceptible or resistant fraction ± differed from that of bile. It appears that composition of the canalicular membrane is mainly designed to withstand the detergent actions of bile acids.