The Utility of Liver Biopsy in the Evaluation of Liver Disease and Abnormal Liver Function Tests

Abstract

Objectives: We aimed to assess the value of liver biopsy in the evaluation of abnormal liver tests.

Methods: We analyzed consecutive liver biopsy specimens performed for evaluation of unexplained abnormal liver tests from 2014 to 2018. Diagnoses were categorized histologically and clinically. We determined whether histologic examination led to a specific diagnosis and whether prebiopsy laboratory variables predicted the underlying etiology.

Results: Among the 383 liver biopsy specimens included, chronic hepatitis was the most common histologic (25%) and clinical (17%) diagnosis. Liver biopsy led to a clinical diagnosis in 87% of patients. The most likely clinical diagnoses were autoimmune hepatitis, nonalcoholic fatty liver disease, and drug-induced liver injury (38, 33, and 32 patients, respectively). Using sensitivity, specificity, and positive and negative predictive values, we found that liver tests were not predictive of a specific diagnosis. In patients with no history of liver disease or clinical features of portal hypertension, biopsy specimens revealed histologic cirrhosis in 5% of patients.

Conclusions: Histopathologic diagnoses were made in 85% of patients undergoing liver biopsy for investigation of unexplained liver tests, leading to a clinical diagnosis in 87% of patients. However, neither liver tests themselves nor their patterns were useful in predicting histologic or clinical diagnoses.

Keywords: Cirrhosis; Enzymes; Hepatic; Hepatitis; Histology; Panel.

Figure 1

CONSORT diagram of patients included. The diagram depicts selection of patients from all patients undergoing liver biopsy over the study time period.

Figure 2

Liver tests in patients with different clinical and histologic disease categories. Alanine transaminase (ALT) levels (A), aspartate transaminase (AST) levels (B), total bilirubin (TB) (C), alkaline phosphatase (AP) levels (D), and ALT levels (E) among acute hepatitis, chronic hepatitis, and cirrhosis. Each point represents one patient, and the bar represents the mean of all values. AIH, autoimmune hepatitis; DILI, drug-induced liver injury; HCV, hepatitis C virus; NASH, nonalcoholic steatohepatitis.

Image 1

Histologic examples of liver injury patterns. A, Alcoholic hepatitis: steatohepatitis with extensive ballooning degeneration and Mallory-Denk bodies (arrow). B, Steatohepatitis with moderate fat (black arrow), approximately 20% of image. Collections of lymphocytes (white arrow) and ballooned hepatocytes (arrowhead). C, Autoimmune hepatitis: severe portal and lobular hepatitis with numerous plasma cells (arrow), eosinophils, and apoptotic hepatocytes (arrowhead). D, Transplant rejection: expansion of the portal tract by a mixed inflammatory infiltrate. Venulitis (arrow) is present, as is bile duct damage (arrowhead). E, Congestive hepatopathy: markedly dilated sinusoids (arrow) with no significant inflammation, normal portal tract (arrowhead), and iron deposition. F, Drug-induced liver injury: cholestatic hepatitis with cholate stasis and cannilicular bile (arrow). Mild portal inflammation with bile duct damage (arrowhead) and eosinophils. G, Primary biliary cholangitis: two portal tracts with bile duct damage and infiltration by lymphocytes. Florid duct lesion is present (arrow). Relatively normal hepatocytes present. All images H&E-stained slides with ×20 objective. Representative images are shown.

Image 1

Histologic examples of liver injury patterns. A, Alcoholic hepatitis: steatohepatitis with extensive ballooning degeneration and Mallory-Denk bodies (arrow). B, Steatohepatitis with moderate fat (black arrow), approximately 20% of image. Collections of lymphocytes (white arrow) and ballooned hepatocytes (arrowhead). C, Autoimmune hepatitis: severe portal and lobular hepatitis with numerous plasma cells (arrow), eosinophils, and apoptotic hepatocytes (arrowhead). D, Transplant rejection: expansion of the portal tract by a mixed inflammatory infiltrate. Venulitis (arrow) is present, as is bile duct damage (arrowhead). E, Congestive hepatopathy: markedly dilated sinusoids (arrow) with no significant inflammation, normal portal tract (arrowhead), and iron deposition. F, Drug-induced liver injury: cholestatic hepatitis with cholate stasis and cannilicular bile (arrow). Mild portal inflammation with bile duct damage (arrowhead) and eosinophils. G, Primary biliary cholangitis: two portal tracts with bile duct damage and infiltration by lymphocytes. Florid duct lesion is present (arrow). Relatively normal hepatocytes present. All images H&E-stained slides with ×20 objective. Representative images are shown.