Liver tissue - Medium Biopsy 1-3 cm

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Histology of liver tissue.

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Liver Tissue - Medium Biopsy (1-3 cm)

Why is it done?
- Diagnosis of liver disease: To obtain tissue samples for histopathological examination when liver pathology is suspected but not yet confirmed
- Assessment of cirrhosis: To stage the degree of liver fibrosis and cirrhosis in patients with chronic liver disease (hepatitis B, C, alcohol-related liver disease)
- Evaluation of unexplained liver dysfunction: When laboratory findings are abnormal but etiology remains unclear despite non-invasive testing
- Detection of liver tumors: To differentiate between benign lesions and hepatocellular carcinoma or metastatic disease
- Identification of infections: To diagnose granulomatous infections, fungal infections, or parasitic diseases affecting the liver
- Evaluation of fatty liver disease: To assess degree of steatosis and inflammation in NAFLD or alcoholic fatty liver disease
- Assessment of autoimmune hepatitis: To confirm diagnosis and evaluate degree of inflammation and fibrosis
- Monitoring drug-induced liver injury: To evaluate extent of liver damage from medications or toxins
Normal Range
- Specimen size: 1-3 cm (medium biopsy sample)
- Normal histology: Intact hepatic architecture with no inflammation, fibrosis, or steatosis
- Fibrosis staging (Metavir/Ishak scale): F0 = no fibrosis (normal)
- Inflammatory activity (HAI/Metavir): A0 = no inflammation (normal)
- Steatosis: <5% of hepatocytes involved (normal)
- Portal tracts: Normal architecture without expansion or inflammation
- No necrosis, cirrhosis, or malignant cells present
Interpretation
- Fibrosis Staging (Metavir Scale):
  - F0: No fibrosis (normal) - No portal fibrosis or septa
  - F1: Mild fibrosis - Portal fibrosis without septa
  - F2: Moderate fibrosis - Occasional portal-portal or portal-central septa
  - F3: Advanced fibrosis - Numerous portal-portal and/or portal-central septa
  - F4: Cirrhosis - Complete bridging septa with architectural distortion
- Inflammatory Activity (HAI Score):
  - A0: Absent - No inflammation
  - A1: Mild - Minimal inflammation in portal areas and/or hepatocyte necrosis
  - A2: Moderate - Moderate inflammation in portal areas and/or hepatocyte necrosis
  - A3: Severe - Marked inflammation and/or hepatocyte necrosis
- Steatosis Grading:
  - S0: <5% hepatocytes involved (normal)
  - S1: 5-33% hepatocytes involved (mild)
  - S2: 33-66% hepatocytes involved (moderate)
  - S3: >66% hepatocytes involved (severe)
- Other Findings:
  - Granulomas: Suggestive of sarcoidosis, TB, fungal infections, or primary biliary cholangitis
  - Iron overload: Indicates hemochromatosis or secondary iron deposition
  - Malignant cells: Confirms hepatocellular carcinoma or metastatic disease
  - Infiltrations: May indicate amyloidosis or other systemic diseases
Associated Organs
- Primary Organ: Liver (hepatic system)
- Related Organ Systems:
  - Biliary system - impaired bile flow and cholestasis
  - Gastrointestinal tract - portal hypertension and varices
  - Spleen - splenomegaly and portal hypertension sequelae
  - Kidney and pancreas - involvement in systemic diseases
- Diseases Diagnosed or Monitored:
  - Chronic Hepatitis B and C - determines fibrosis stage and inflammation
  - Alcoholic liver disease - assess steatosis, inflammation, and cirrhosis
  - Non-alcoholic fatty liver disease (NAFLD) - grades severity and fibrosis
  - Autoimmune hepatitis - confirms diagnosis and stages disease
  - Primary biliary cholangitis (PBC) - identifies portal inflammation and damage
  - Primary sclerosing cholangitis (PSC) - assesses biliary inflammation
  - Hemochromatosis - demonstrates iron deposition in hepatocytes
  - Hepatocellular carcinoma (HCC) - confirms malignancy
  - Wilson disease - identifies copper deposition
  - Alpha-1 antitrypsin deficiency - demonstrates PAS+ globules
- Potential Complications/Risks:
  - Hepatic encephalopathy - from advanced cirrhosis and portal hypertension
  - Variceal bleeding - esophageal or gastric varices with cirrhosis
  - Hepatic decompensation - ascites, jaundice, and liver failure
  - Hepatorenal syndrome - acute kidney dysfunction from liver failure
  - Hepatic malignancy progression - advanced carcinoma and metastasis
Follow-up Tests
- Liver Function Tests:
  - ALT, AST, alkaline phosphatase, bilirubin - periodic monitoring
  - INR/PT - assess synthetic function in cirrhosis
- Non-invasive Fibrosis Assessment:
  - Transient elastography (FibroScan) - assess liver stiffness
  - FIB-4 index calculation - estimate fibrosis stage
  - APRI score - assess fibrosis and cirrhosis risk
- Viral and Immunologic Testing:
  - HBV DNA/RNA PCR - viral load quantification if indicated
  - HCV genotype and viral load - assess treatment response
  - Autoimmune markers - ANA, anti-smooth muscle antibody for autoimmune hepatitis
- Imaging Studies:
  - Ultrasound - assess liver architecture, portal hypertension, HCC surveillance
  - CT or MRI - evaluate liver lesions, staging malignancy
  - Doppler ultrasound - assess portal vein patency and flow
- HCC Screening (if cirrhosis present):
  - Alpha-fetoprotein (AFP) - every 6 months
  - Ultrasound with contrast - every 3-4 months
- Metabolic Testing:
  - Iron studies - ferritin, transferrin saturation if hemochromatosis suspected
  - Ceruloplasmin - if Wilson disease suspected
  - Alpha-1 antitrypsin level - if deficiency suspected
- Monitoring Frequency:
  - Mild fibrosis (F1): LFTs every 12 months; consider repeat biopsy in 5-10 years if no treatment
  - Moderate fibrosis (F2-F3): LFTs every 6-12 months; imaging annually
  - Cirrhosis (F4): Ultrasound and AFP every 3-6 months; endoscopy for varices if indicated
Fasting Required?
- Fasting Status: NO fasting required
- Pre-procedure Preparation:
  - NPO (nothing by mouth) 2-4 hours before biopsy if conscious sedation planned
  - Complete fasting 6-8 hours if general anesthesia is being used
  - Bathroom visit and bowel prep may be recommended depending on approach
- Medications to Avoid/Adjust:
  - Anticoagulants (warfarin, DOACs) - discontinue 3-7 days before; INR must be <1.5
  - Antiplatelet agents (aspirin, NSAIDs, clopidogrel) - discontinue 5-7 days before
  - Heparin - hold 4-6 hours before procedure
  - Verify medication adjustments with ordering physician - critical for bleeding risk
- Essential Lab Work Before Biopsy:
  - Prothrombin time (PT/INR) - ensure adequate clotting function
  - Complete blood count (CBC) - assess platelet count (should be >50,000)
  - Type and crossmatch - if high bleeding risk
  - Hepatitis serology - HBsAg, anti-HCV status
- Other Patient Preparation:
  - Informed consent - discuss risks (bleeding, infection, perforation)
  - Abdominal exam and imaging (ultrasound) - to identify biopsy site
  - Remove all jewelry and valuables from abdomen
  - Arrange for responsible adult driver (if sedation used)
  - Arrive 30 minutes early for IV placement and vital sign monitoring
  - Wear comfortable, loose clothing that is easy to remove
  - Post-procedure rest period: Observation for 4-6 hours; avoid strenuous activity for 1-2 weeks

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