Professor El-Omar has chosen Professor James Neuberger, Honorary Consultant Hepatologist at the Liver Unit, Queen Elizabeth Hospital, Birmingham and Professor of Medicine at the University of Birmingham to do the next #GUTBlog. The blog focusses on the “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” published in Gut in August 2020. Professor Neuberger was the first author on this guideline and Dr Mathis Heydtmann was the senior author working with a multidisciplinary team of healthcare professionals.
“‘When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much he had learned in seven years’ – Mark Twain
‘You’re finally 21… and legally able to do everything you’ve been doing since you were 16’ – Unknown
‘At twenty-one, so many things appear solid, permanent, untenable’ – Orson Wells
It is 21 years since Dr Allister Grant and I published the BSG Guidelines on the use of liver biopsy in clinical practice [1] and this month, the revised Guidelines have been published. We started from scratch and now, comparing the old and current guidelines has led me to reflect both how much some things have changed and how little other things have changed. Most of the changes have been good. When we first wrote the guidelines, Allister, then a Registrar on the Liver Unit in Birmingham, did the hard work and I did the editing, accepting any plaudits and passing any criticisms on to Allister. Allister is now Medical Director at the Royal Cornwell Hospitals NHS Trust and remains active in Hepatology and Gastroenterology. At that time, we were in transition from prejudice-based medicine to evidence-based medicine. Now the process for producing guidelines is much more formalised, evidence is reviewed, assessed and graded, the guidelines group has to have a better-defined and broader based membership and follow a defined path. The process does allow for clinical judgement to play a role in formulating recommendations but moves away from what a previous editor of the BMJ called ‘GOBSATs’ (Good Old Boys Sat Around a Table!) where the clinician with the greatest eminence or greatest bombast would make ex cathedra statements that had to be adopted.
Now fewer biopsies are done as newer non-invasive ways of diagnosing and staging disease have evolved, and most biopsies are done under imaging by radiologists. The importance of collaboration between the clinician, operator, histopathologist, other health care professionals and lay members is being increasingly acknowledged and this is reflected in the membership of the Guidelines group.
The biggest uncertainty that remains lies with the haemostasis. 21 years ago, life was simple and all one needed before doing a liver biopsy was a recent platelet count, prothrombin time and group and save. Now it is appreciated that the balance between thrombosis and thrombolysis is far more subtle in liver disease and the simple measures of clotting are not just of limited value but may be misleading. Use and abuse of FFP and platelets remains. Gaining consent too used to be so much simpler 21 years ago; all you had to do was wave a form in front of the patient and get them to sign. Nowadays, consent is quite rightly taken a lot more seriously and, following the Supreme Court judgement in Lanarkshire and Montgomery, consent has to be taken much more rigorously and clinicians need to be aware that a signed consent form does not mean fully informed consent has been given (see Trefaut vs. Johnston).
What has not changed is that those who worked so hard to develop and review the guidelines did so in their own time, unpaid (apart from travel expenses) and with enthusiasm. I am so grateful to them. The BSG was extremely supportive with administration and it is to the credit and that of the Royal Colleges of Radiologists and of Pathologists that they devote so much time, effort and resource to supporting guidelines. Of all the members, I would like to thank Dr Mathis Heydtmann especially who coordinated the supplementary section on specific indications and managed reference manager so well! Despite everyone seeing and approving the final document, two errors slipped through – it is the Royal College of Pathologists and Mathis’ name was spelled incorrectly. Apologies to both.
What is new in the guidelines?
Percutaneous liver biopsy is not free of complications (such as bleeding, organ perforation, sepsis and death) with risk factors including older age, comorbidities, indication and disordered coagulation. There is no conclusive evidence that the number of passes or experience of the operator is related to complications. Development of complications does not necessarily imply any wrongdoing.
It is recommended that for non-lesional biopsies, in patients with liver disease, a transvenous route should be used if the INR is >1.4. For percutaneous lesional biopsies, the INR should be <2.0.
There is no evidence that fresh frozen plasma is effective in reducing bleeding and is not recommended.
While radiologists now obtain most liver biopsies, there is little clear evidence that this is associated with reduced complications or increase in adequate samples.
Although there is little convincing evidence that obtaining percutaneous liver biopsy under imaging guidance reduces complications, we recommend that where possible, liver biopsy should be obtained under ultrasound guidance
We recommend the use of automated cutting-type needles and that full core biopsy needles are used, provided that the operator is sufficiently experienced in the use of these needles. We recommend that a 16 G needle should be used for the percutaneous approach, although an 18G needle should be used for percutaneous biopsy of a solid lesion; the length of the sample should be at least 20 mm.
There should be clear communication between the clinician requesting the biopsy, the person obtaining the biopsy and the histopathologist generating the report. The request form should include the indication(s) and all relevant clinical and other information to ensure that the procedure is done as safely as possible and that the histopathologist has all the necessary information.
The biopsy report should clearly deal with the clinical indication(s) for the biopsy and conclude with a concise diagnostic summary. The report should be given in a timely fashion. For biopsies obtained outside a specialist liver centre, the reporting pathologist should have access to a second opinion from a liver centre.
Research and audit questions
In many aspects of liver biopsy, the evidence is weak; studies are largely retrospective with few prospective studies do
We recommend that there should be local and national audits for the major complications of liver biopsy
We recommend that there should be national standards, evidence-based where possible, about the training and competencies of those obtaining liver biopsies.
We recommend that there is further research into the haematological parameters that preclude safe percutaneous biopsies and into interventions to reduce the risk of bleeding after liver biopsy”
Reference:
- Grant A, Neuberger J. Guidelines on the use of liver biopsy in clinical practice. British Society of Gastroenterology. Gut1999;45(Suppl 4):IV1–11.doi:10.1136/gut.45.2008.iv1 PMID:10485854