Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology
Introduction
The gold standard for the establishment of diagnosis and stage of liver disease is histological inspection of a liver biopsy. This is an invasive procedure with well-described risks [1]. On finding symptoms or signs of liver disease most clinicians will attempt to arrive at an aetiological diagnosis prior to liver biopsy by checking viral serology, autoantibodies and indicators of iron or copper storage. The benefits of proceeding to liver biopsy when physical examination or blood tests indicate likely treatable diseases such as haemochromatosis (HCT) or autoimmune liver disease are usually obvious. The possible benefits of doing a liver biopsy in an individual found to have elevated liver enzymes but no diagnostic blood tests are less obvious.
The histological causes of abnormal liver biochemistry have been reported previously in patients with overt signs of advanced liver disease or sizeable alcohol consumption [2], [3] and in small numbers of patients with slightly elevated transaminases [4]. Liver biochemistry has also been studied in blood donors but these findings must be applied to a general or patient population with caution [5]. The purpose of this study was to address a relatively common clinical scenario, i.e. to assess the findings on liver biopsy in a large unselected group of patients found to have persistently elevated liver biochemistry in the absence of a history of drug or alcohol use or diagnostic blood tests. The histological findings were then applied as either a definite pathological diagnosis or as an avenue for further exploration.
Section snippets
Patients and methods
Data were collected prospectively on 397 consecutive patients who had sustained abnormal liver function tests (LFTs), defined as an alanine transaminase (ALT), gamma glutamyl transferase (γGT) or alkaline phosphatase (alk. phos.) more than twice the upper limit of normal for at least 6 months. These patients were identified by referral from their general practitioner or consultant on the unexplained finding of abnormal liver function tests. Those patients identified as having known liver
Results
All patients were offered percutaneous liver biopsy and 43 patients (11%) declined, therefore 354 liver biopsies were performed with informed consent. The histological diagnoses suggested by these biopsies are detailed in Table 1 and the final clinical diagnoses that were reached are outlined in Table 2. Twenty-one patients (6%) had a histologically normal liver biopsy while 93 patients (26%) were found to have some degree of fibrosis on liver biopsy ranging from periportal fibrosis in 42
Discussion
This was a prospective analysis of a large group of patients with sustained abnormalities of their liver biochemistry in the absence of diagnostic blood tests. Ninety four percent of the liver biopsies obtained were histologically abnormal with a large range of aetiologies uncovered. Disorders of fat metabolism and/or deposition such as NASH or fatty liver comprised by far the most common diagnosis and other potentially sinister diseases were also discovered. The finding that fatty liver/NASH
References (16)
- et al.
Prospective evaluation of unexplained chronic liver transaminase abnormalities in asymptomatic and symptomatic patients
Am J Gastroenterol
(1999) - et al.
The pattern of fibrosis in the acinar zone 3 areas in early alcoholic liver disease
J Hepatol
(1991) - et al.
A randomized, controlled trial of maintenance interferon therapy for patients with chronic hepatits C virus and persistent viremia
Gastroenterology
(1999) - et al.
Guidelines on the use of liver biopsy in clinical practice. British Society of Gastroenterology
Gut
(1999) - et al.
Is liver biopsy useful in the evaluation of patients with elevated liver enzymes?
Ann Intern Med
(1989) - et al.
The nature of unexplained chronic aminotransferase elevation of a mild to moderate degree in asymptomatic patients
Hepatology
(1989) - et al.
The clinical significance of slightly to moderately increased liver transaminase values in asymptomatic patients
Scand J Gastroenterol
(1999) - et al.
Elevated serum alanine aminotransferase in blood donors; the contribution of hepatitis C virus
Ann Intern Med
(1991)