Jaundice other diagnostic studies
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. 
The gold standard diagnostic test for jaundice caused by cirrhosis is liver biopsy, although it is rarely necessary for diagnosis or treatment. Sample of the liver is obtained bypercutaneous approach, transjugular approach, and laparoscopic radiographically- guided fine-needle approach. A biopsy is not necessary if the clinical, laboratory, and radiologic data suggest cirrhosis. There is a small but significant risk associated with liver biopsy, and cirrhosis itself predisposes to the complications of liver biopsy.
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Features of liver biopsy are as follows:
- Cirrhosis is primarily a histological diagnosis. The gold standard for diagnosis of cirrhosis is liver biopsy.
- Sample of the liver is obtained by:
- Percutaneous approach
- Transjugular approach
- Laparoscopic radiographically- guided fine-needle approach
- Percutaneous biopsy of focal lesions may be performed in combination with either ultrasound or CT imaging.
- Percutaneous liver biopsy remains the cornerstone of diagnosis. It is quick and simple to perform liver biopsy in a patient with normal platelet count and INR.
- Histologically, cirrhosis may be classified as micronodular, macronodular, or mixed, but this classification is nonspecific to the etiology.
- Histology of the liver may change as the disease progresses, and serological markers are much more specific.
- A biopsy is not necessary if the clinical, laboratory, and radiologic data suggest cirrhosis.
- Liver biopsy may be suggestive of etiology:
- Alcoholic liver disease: Liver biopsy may show hepatocyte necrosis, presence of mallory bodies, neutrophilic infiltration and perivenular inflammation.
- Primary biliary cirrhosis: Gold standard diagnostic modality is the detection of antimitochondrial antibodies along with liver biopsy to confirm presence of florid bile duct lesions.
- There is a small but significant risk associated with liver biopsy, and cirrhosis itself predisposes to the complications of liver biopsy.
- Risks of liver biopsy include:
- Biliary peritonitis
- Perforation of other viscera
- Mortality rate between 0.01% and 0.1%
- Patients with moderate coagulopathy:
- Plugged liver biopsy: injection of gelatin sponges or metal coils down the tract after biopsy
- Laparoscopic liver biopsy is performed on a sedated patient with moderate coagulopathy
- Advantage: allows direct visualisation of the liver
- Patients with severe clotting disorders:
- Transjugular liver biopsy:
- Risk of intraperitoneal bleed is less
- Transjugular liver biopsy:
- ↑ Williams EJ, Iredale JP (1998). "Liver cirrhosis". Postgrad Med J. 74 (870): 193–202. PMC 2360862. PMID 9683971.
- ↑ Blomley MJ, Lim AK, Harvey CJ, Patel N, Eckersley RJ, Basilico R, Heckemann R, Urbank A, Cosgrove DO, Taylor-Robinson SD (2003). "Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study". Gut. 52 (8): 1188–93. PMC 1773750. PMID 12865280.
- ↑ Kim CK, Lim JH, Lee WJ (2001). "Detection of hepatocellular carcinomas and dysplastic nodules in cirrhotic liver: accuracy of ultrasonography in transplant patients". J Ultrasound Med. 20 (2): 99–104. PMID 11211142.
- ↑ Abdi W, Millan JC, Mezey E (1979). "Sampling variability on percutaneous liver biopsy". Arch. Intern. Med. 139 (6): 667–9. PMID 443970.
- ↑ Bedossa P, Dargère D, Paradis V (2003). "Sampling variability of liver fibrosis in chronic hepatitis C". Hepatology. 38 (6): 1449–57. doi:10.1016/j.hep.2003.09.022. PMID 14647056.
- ↑ Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER (2002). "Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection". Am. J. Gastroenterol. 97 (10): 2614–8. doi:10.1111/j.1572-0241.2002.06038.x. PMID 12385448.
- ↑ Bravo AA, Sheth SG, Chopra S (2001). "Liver biopsy". N. Engl. J. Med. 344 (7): 495–500. doi:10.1056/NEJM200102153440706. PMID 11172192.
- ↑ Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD (2009). "Liver biopsy". Hepatology. 49 (3): 1017–44. doi:10.1002/hep.22742. PMID 19243014.
- ↑ Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK (2006). "Transjugular liver biopsy: how good is it for accurate histological interpretation?". Gut. 55 (12): 1789–94. doi:10.1136/gut.2005.090415. PMC 1856467. PMID 16636018.
- ↑ Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP (2004). "[Bioptic diagnosis of chronic hepatitis. Results of an evidence-based consensus conference of the German Society of Pathology, of the German Society for Digestive and Metabolic Diseases and of Compensated Hepatitis (HepNet)]". Pathologe (in German). 25 (5): 337–48. doi:10.1007/s00292-004-0692-7. PMID 15278290.
- ↑ Tannapfel A, Dienes HP, Lohse AW (2012). "The indications for liver biopsy". Dtsch Arztebl Int. 109 (27–28): 477–83. doi:10.3238/arztebl.2012.0477. PMC 3402072. PMID 22833761.
- ↑ Grant, A (1999). "Guidelines on the use of liver biopsy in clinical practice". Gut. 45 (Suppl 4): 1–11. PMID 10485854.
The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding.