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Liver tissue - Large Biopsy 3-6 cm

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Histology of liver tissue.

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Liver Tissue - Large Biopsy 3-6 cm

  • Why is it done?
    • Diagnostic Purpose: A liver tissue biopsy involves obtaining a sample of liver tissue (3-6 cm) for microscopic examination to diagnose various liver diseases, determine disease severity, and assess the degree of fibrosis or cirrhosis present.
    • Primary Indications: Evaluation of chronic hepatitis (B and C), assessment of alcoholic liver disease, investigation of autoimmune hepatitis, diagnosis of non-alcoholic fatty liver disease (NAFLD), evaluation of cirrhosis, assessment of drug-induced liver injury, investigation of cholestasis, and diagnosis of liver tumors or malignancy.
    • Timing and Circumstances: Performed when imaging studies and laboratory tests are inconclusive, when precise staging of liver disease is needed for treatment planning, before initiating antiviral therapy for hepatitis, when unexplained liver dysfunction is present, or when monitoring disease progression over time.
    • Sample Size Advantage: The 3-6 cm tissue sample is considered a large biopsy that provides superior diagnostic material compared to smaller samples, allowing for more accurate histological assessment and reduced sampling error.
  • Normal Range
    • Histological Findings: Normal liver tissue shows intact hepatic architecture with regular hepatocyte arrangement, minimal inflammation, no fibrosis (Ishak score 0 or Metavir score F0), and absence of steatosis.
    • Fibrosis Staging (Metavir Scale): F0 = No fibrosis (Normal), F1 = Portal fibrosis without septa, F2 = Few septa, F3 = Numerous septa without cirrhosis, F4 = Cirrhosis.
    • Inflammation Grading (Activity Score): A0 = No activity, A1 = Minimal activity, A2 = Moderate activity, A3 = Severe activity.
    • Steatosis Assessment: <5% lipid content is considered normal; >5-33% mild steatosis, >33-66% moderate steatosis, >66% severe steatosis.
    • Interpretation of Normal Results: Absence of significant pathology suggests no clinically significant liver disease; normal architecture preserved; hepatocytes normal in appearance; bile ducts intact; minimal to no inflammatory infiltrate.
  • Interpretation
    • Chronic Hepatitis B/C: Findings show portal inflammation with lymphocytic infiltration, interface hepatitis (piecemeal necrosis), varying degrees of fibrosis; Metavir F0-F1 indicates mild disease, F2-F3 moderate disease, F4 indicates cirrhosis.
    • Fatty Liver Disease: NAFLD shows hepatic steatosis without significant inflammation; NASH (non-alcoholic steatohepatitis) demonstrates steatosis with inflammation and hepatocyte ballooning, may progress to fibrosis and cirrhosis.
    • Alcoholic Liver Disease: Characterized by macro and microvesicular steatosis, acute inflammation, hepatocyte necrosis, Mallory-Denk bodies, and potential progression to fibrosis and cirrhosis.
    • Autoimmune Hepatitis: Shows interface hepatitis, plasma cell infiltration, elevated transaminases; may progress to cirrhosis if untreated.
    • Cirrhosis (F4): Distortion of normal hepatic architecture with bridging fibrosis connecting portal areas, formation of regenerative nodules, loss of normal lobular structure, and evidence of portal hypertension.
    • Drug-Induced Liver Injury: Patterns vary depending on offending agent; may show hepatocellular necrosis, cholestasis, steatosis, or granulomatous inflammation.
    • Malignancy/Tumors: Identification of hepatocellular carcinoma, cholangiocarcinoma, or metastatic disease with characteristic cellular atypia and architectural distortion.
    • Factors Affecting Interpretation: Sample quality, adequate number of portal tracts (minimum 10-11), presence of inflammatory activity at time of biopsy, timing of biopsy relative to acute hepatitis exacerbations.
  • Associated Organs
    • Primary Organ: Liver - the largest internal organ responsible for metabolism, detoxification, protein synthesis, and production of biochemicals necessary for digestion.
    • Associated Conditions - Chronic Hepatitis: Hepatitis B virus (HBV), Hepatitis C virus (HCV), with risk of progression to cirrhosis and hepatocellular carcinoma.
    • Metabolic Disorders: Non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency.
    • Autoimmune Diseases: Autoimmune hepatitis, primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC).
    • Alcohol-Related Disease: Alcoholic fatty liver disease, alcoholic hepatitis, alcoholic cirrhosis.
    • Malignancies: Hepatocellular carcinoma, cholangiocarcinoma, hepatic lymphoma, metastatic cancers.
    • Potential Complications of Abnormal Results: Portal hypertension, variceal bleeding, ascites, hepatic encephalopathy, renal failure, liver failure requiring transplantation.
    • Biopsy-Related Risks: Bleeding (major hemorrhage 1:1000, minor bleeding more common), infection, bile peritonitis, pneumothorax if intercostal approach, abdominal pain, and rare death.
  • Follow-up Tests
    • Laboratory Tests: Liver function tests (ALT, AST, ALP, bilirubin), prothrombin time (PT/INR), albumin, platelet count, viral serologies (anti-HCV, HBsAg, HBsAb), autoimmune markers (ANA, anti-smooth muscle antibody).
    • Imaging Studies: Ultrasound to assess for cirrhosis features, computed tomography (CT) or magnetic resonance imaging (MRI) for hepatocellular carcinoma surveillance, elastography for fibrosis assessment.
    • Non-Invasive Fibrosis Markers: FIB-4 score, APRI score, transient elastography (FibroScan), enhanced liver fibrosis (ELF) score for monitoring progression.
    • Viral Evaluation: HCV RNA quantification if positive serology, HBV viral load and genotyping if hepatitis B confirmed.
    • Metabolic Assessment: Iron studies (serum iron, ferritin, transferrin saturation), ceruloplasmin levels, alpha-1 antitrypsin levels if indicated.
    • Surveillance: Repeat biopsy may be considered in 3-5 years for monitoring chronic hepatitis progression; annual AFP and ultrasound if cirrhosis confirmed.
    • Treatment Monitoring: After antiviral therapy initiation, follow up with viral load testing at 12 weeks (for HCV direct-acting antivirals), sustained virological response (SVR) testing, and repeat imaging at 6-12 months.
    • Endoscopy: Upper endoscopy to assess for esophageal varices if cirrhosis (F4) is confirmed.
  • Fasting Required?
    • Fasting Status: No - Fasting is not required for liver tissue biopsy procedure itself; however, if biopsy is performed under sedation, fasting of 6-8 hours may be recommended.
    • Pre-Procedure Preparations: NPO (nothing by mouth) for 6-8 hours before biopsy if conscious sedation is planned; patient should discontinue anticoagulants (warfarin, apixaban, dabigatran) 3-5 days before procedure or follow specific institutional protocols.
    • Medication Management: Hold aspirin and NSAIDs for 3-7 days before procedure; continue essential medications with small sip of water unless instructed otherwise; notify physician of all medications including supplements and herbal preparations.
    • Pre-Biopsy Laboratory Testing: Complete blood count (CBC), prothrombin time (PT/INR), platelet count, and other coagulation studies must be normal or corrected before procedure to minimize bleeding risk.
    • Patient Instructions: Void bladder before procedure; wear loose clothing; remove jewelry and dentures; arrange for responsible adult to provide transportation home; inform physician of allergies, especially to local anesthetics.
    • Post-Procedure Care: Bed rest for 4-6 hours; observe for signs of bleeding or infection; avoid strenuous activity for 3-5 days; pain management as needed; patient should remain hospitalized if complications occur.

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