Interventional Procedures in Hepatobiliary Diseases, An Issue of Clinics in Liver Disease (eBook)

Andres Cardenas (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
476 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-32659-9 (ISBN)

Infos

The field of hepatobiliary diseases has advanced enormously in the past 3 decades. The incorporation of new diagnostic and therapeutic interventions in clinical hepatology as well as liver transplantation has exponentially grown and specialty fields have emerged within the liver disease arena. Interventional procedures play a critical role in the management of patients with hepatobiliary diseases as they offer diagnostic and definite treatment options for an array of conditions. Interventions include those that directly measure portal pressure, perform transjugular liver biopsy and place transjugular intrahepatic portsosystemic shunts as therapy for complications of portal hypertension. Other commonly performed intervention is digestive and hepatobiliary endoscopy which offers not only diagnostic but also therapeutic choices in various areas such as portal hypertension and hepatobiliary disease. Endoscopy plays a fundamental role in the management of patients with almost all types of liver disease. Additionally, both the fields of hepatology and endoscopy have become very specialized and thus a thorough knowledge of the indications, findings, therapeutic possibilities and complications that arise from endoscopic interventions is a must for the practicing clinician. The rising incidence of liver cancer has also placed radiofrequency ablation and chemoembolization of liver lesions at the forefront of interventional therapies for hepatocellular carcinoma. Finally the management of acute liver failure has certainly evolved with new therapeutic options such as liver assist devices that can help manage these patients in the intensive care unit. This issue of Clinics in Liver Disease devoted to Interventional Hepatology is a timely and unique one. The Guest Editors have assembled an outstanding group of experts in several fields that can provide practitioners with state of the art and evidence based articles that help manage patients with hepatobiliary disease.

Textauszug

Transjugular Liver Biopsy

Michel Ble, MDa, Bogdan Procopet, MDabc, Rosa Miquel, MDde, Virginia Hernandez-Gea, MDaef and Juan Carlos García-Pagán, MDaef∗[e-mail],     aHepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS (Institut d’Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona), C/ Villarroel 173, Barcelona 08036, Spain; bGastroenterology Department, 3rd Medical Clinic, University of Medicine and Pharmacy “Iuliu Hatieganu”, Str. Victor Babes 8, Cluj-Napoca 400012, Romania; cGastroenterology Department, Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Strada Constanţa 5, Cluj-Napoca 400158, Romania; dPathology Department, Hospital Clinic, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), C/ Villarroel 173, Barcelona 08036, Spain; eUniversity in Barcelona, Gran Via de les Corts Catalanes, 585, Barcelona 08007, Spain; fCIBERehd (Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, Pabellón 11, Planta 0, Madrid 28029, Spain

∗Corresponding author. Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Villarroel 170, Barcelona 08036, Spain.

Liver biopsy is still the gold standard for evaluation of acute and chronic liver diseases, despite achievements regarding noninvasive diagnosis and staging in liver diseases. Transjugular liver biopsy (TJLB) has proved a good option when ascites and/or significant coagulopathy precludes a percutaneous approach. Because diagnostic hemodynamic procedures can be performed during the same session, it is useful in many clinical settings, regardless of the absence of percuteaneous contraindications. TJLB is a safe technique able to provide good-quality specimens with a low rate of complications. This article presents an overview of TJLB that discusses the technique, applicability, indications, contraindications, complications, and diagnostic accuracy.

Keywords

Transjugular liver biopsy

Tru-Cut needle

Menghini needle

Tissue sample quality

Liver specimen

Ultrasound guidance

HVPG

Cirrhosis stage

Key points

• Transjugular liver biopsy (TJLB) is a safe procedure able to obtain diagnostic liver specimens from patients with diffuse liver disease. Concomitant measurement of the hepatic venous pressure gradient (HVPG) provides relevant information to assess the risk of decompensation, esophageal varices formation and efficacy of portal hypertension treatment.

• Usually, under local anesthesia, the right-sided transjugular approach is used but the femoral veins, left internal jugular vein (LIJV) or external jugular veins could be alternatives routes. Ultrasound guidance makes the jugular puncture easier and safer.

• A 20 mm length specimen containing 11 complete portal tracts is the minimum requirement for a good quality sample. In comparison with percutaneous liver biopsy (PLB), TJLB is definitely not an inferior technique because this goal may be achieved with multiple passes without increasing the risk of bleeding.

• In chronic fibrotic disorders, the use of Tru-cut needle provides longer and and more compact samples than with Menghini technique.

• Major complications (hepatic hematoma or intraperitoneal hemorrhage) due to the procedure are exceptional. However, minor complications (neck hematoma at the site of jugular puncture, accidental carotid puncture) may appear in up to 7%. Despite being a longer procedure than PLB, TJLB is well tolerated. Moreover, conscious sedation and systemic analgesics may increase acceptance.

Introduction: nature of the problem

Despite new advances in the noninvasive diagnosis of chronic liver disease (CLD), liver biopsy is still the gold standard for evaluation of acute and chronic liver injury.1,2 Recently, liver biopsy has been questioned because of drawbacks, such as sampling error3,4 and intra- and interobserver variability5; however, the role of liver biopsy in diagnosis of liver disease remains highly valuable. Liver biopsy remains essential for the diagnosis of some liver diseases, such as nonalcoholic steatohepatitis, abnormal liver tests from unknown origin, or autoimmune hepatitis. Moreover, TJLB is indicated particularly in patients with fulminant hepatitis or acute liver failure of unknown cause; in the setting of bone marrow transplantation, where it helps to differentiate between sinusoidal obstruction syndrome, graft-versus-host disease, recurrent malignancy, and drug toxicity6,7; and in patients with alcoholic hepatitis where histologic alterations have prognostic relevance.8

TJLB was first described in 1964 in dogs,9 and in 1967 a transjugular catheterization of the hepatic veins was first performed in humans as an approach to the biliary tract for cholangiography.10 TJLB is usually performed when ascites and/or a significant coagulopathy preclude a percutaneous approach due to the risk of severe hemorrhage. Given that it is possible to measure hepatic hemodynamics during the same procedure, however, TJLB is used even in the absence of contraindications for PLB. TJLB may increase the probability of obtaining a good biopsy sample by performing several passes without increasing the risk of complications. This article presents an overview of TJLB. The technique, applicability, indications, contraindications, complications, and diagnostic profitability and outcomes of the different sampling approaches are discussed.

Indications/Contraindications

TJLB is an effective and safe technique for obtaining liver tissue in patients with end-stage liver disease and entails lower incidence of hemorrhagic complications than PLB.11 As a consequence, TJLB has traditionally been indicated for conditions where there is a high risk of bleeding.12 Other common indications of TJLB are morbid obesity, small livers, or suspicion of hepatic peliosis.13 Patients with heart failure and cirrhosis14 often need a careful assessment of liver function that may include HVPG assessment and TJLB15 to evaluate the need of combined heart and liver transplantation. Box 1 summarizes the indications of TJLB.

Box 1   Indications of transjugular liver biopsy

Absolute

Ascites

Severe coagulopathy

Need for additional intervention (HVPG)

Relative

Morbid obesity

Small cirrhotic liver

Right pleural effusion/infection

Suspicion of hepatic peliosis

Hepatic hemangioma

Failure of PLB

Condition where TJLB could be the first choice for histologic assessment

Alcoholic hepatitis

Fulminant hepatitis

Acute liver failure from unknown etiology

Abnormal liver tests in bone marrow transplant recipients

Suspicion of cirrhosis with associated portal hypertension

Suspicion of idiopathic portal hypertension/patients with HIV

Concomitant kidney biopsy

There is no specific contraindication for TJLB and the risk-benefit ratio should be evaluated on a case-by-case basis. TJLB should be avoided when central venous access is absent (inferior vena cava obstruction) or in cases of polycystic liver disease, suspicion of cholangitis, and uncontrolled sepsis. Box 2 summarizes some of the relative contraindications.

Box 2   Contraindications to transjugular liver biopsy

Lack of central venous access (inferior vena cava obstruction; occlusion of hepatic veins)

Glenn shunt; Fontan procedure

Polycystic liver disease

Hepatic hydatid disease

Acute cholangitis

Uncontrolled sepsis

Allergy to contrast agent

Uncooperative patient

TJLB is not indicated in patients with focal hepatic lesions. In special circumstances, however, when PLB is contraindicated and there is strong indication of biopsy, TJLB could be performed under external US guidance.

Technique/Procedure

Preparation

1. Patient should be informed about the technique and its risks.

2. Written informed consent should be...

Produkt-Details

• Erscheint lt. Verlag: 3.6.2015
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Gastroenterologie
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Hepatologie
• ISBN-10: 0-323-32659-5 / 0323326595
• ISBN-13: 978-0-323-32659-9 / 9780323326599