Transjugular liver biopsy – Indications, adequacy, quality of specimens, and complications – A systematic review

Transjugular liver biopsy (TJLB) is considered an inferior biopsy, used when percutaneous liver biopsy (PLB) is contraindicated. According to recent literature, specimens with ⩾6 complete portal tracts (CPTs) are needed for histological diagnosis of chronic liver disease but ⩾11 CPTs to reliably stage and grade. Mean CPT number in PLB series is 7.5; more passes increase complications. Sixty-four series reporting 7649 TJLBs were evaluated for quality of specimen and safety. Major indications were coagulation disorders and/or ascites. Success rate was 96.8%. Fragmentation rate was 34.3%, not correlating with length or diagnostic adequacy. With a mean of 2.7 passes, mean CPT number was 6.8. Histological diagnosis was achieved in 96.1% of TJLBs, correlating with length (p = 0.007) and CPT number (p = 0.04). Tru-Cut specimens had a mean CPT number of 7.5 and, compared to Menghini specimens, were longer (p < 0.008), less fragmented (p < 0.001) and more diagnostic (p < 0.001). Thinner needles (>16-G) provided significantly longer and less fragmented specimens. Minor and major complication rates were 6.5% and 0.56%, respectively, and increased in children, but not with additional passes. In adults, mortality was 0.09% (haemorrhage 0.06%; ventricular arrhythmia 0.03%). TJLB is safe, providing specimens qualitatively comparable to PLB, and may improve further using ⩾18-G Tru-Cut needle and >3 passes.

Introduction

Liver biopsy (LB), mainly performed either percutaneously, without or with radiological/ultrasound guidance, or transjugularly, is the most specific test to assess the nature and severity of liver diseases [1], [2].

Transjugular liver biopsy (TJLB) was first described experimentally in 1964 [3]. In 1967, transjugular hepatic vein catheterization was used for biliary tract cholangiography [4], and 3 years later the same authors reported the first TJLBs [5].

TJLB is usually indicated when PLB is contraindicated due to coagulopathy and/or ascites [2], [6], in liver transplant recipients [7], [8], [9], [10], [11], and patients with acute liver failure (ALF) [12], [13] or congenital clotting disorders [14], [15], [16], [17], [18].

However, the quality of TJLB specimens has been questioned, because of smaller and more fragmented specimens compared to PLB. Thus, TJLB has been considered a second-class biopsy [2], [3], [19], [20]. Moreover, the role of LB has changed from solely a diagnostic to a prognostic tool, particularly in patients with chronic viral hepatitis, with grade and stage of liver damage guiding therapy [19], prompting a re-evaluation of the adequacy of biopsy samples. Currently, a LB specimen of ⩾15 mm long and/or containing ⩾6 complete portal tracts (CPTs) suffices for the histological diagnosis of diffuse liver disease [2], whereas at least 20 mm and/or 11 CPTs are considered optimal for reliable staging and grading [19], [21]. In particular, CPT number has been considered the most appropriate parameter for evaluating adequacy of a liver specimen and comparison between different kinds of LBs or type and size of needle [2], [22]. In this regard, the quality of PLB may not be superior to TJLB [23].

We reviewed the published literature about the technique, indications, success and safety of TJLB, and the quality characteristics of TJLB specimens, in relation to the recently proposed minimum requirements for the assessment of chronic viral hepatitis.