Case Presentation
GI Grand Rounds
April 7, 2008
L.R.
• 50yo BF presents from the ER after
leaving OSH for evaluation of increase
LFTs
• CC: Jaundice
HPI
• Noted dark urine 2 weeks prior to
presentation
– Tx w/ levaquin at OSH
• Became jaundiced w/ RUQ pain
• OSH - monitored, Vit K PO
– INR 1.5 --> 1.2
• No travel, tattoos, IVDA, sick contacts,
unusual foods
• No confusion
• No bleeding/bruising/petechiae
Past Medical History
• Hypothyroidism
– Dx 2 months ago
• Asthma as a child
• HgS trait
• Rheumatic fever without residual
disease
Social History
• Lives in Gadsden with her son
• First grade teacher
• No ETOH/Drugs/tobacco
• Allergies: Ampicillin
• Meds:
– Synthroid
– Multivitiamin
PE
• 98.9, 95, 111/75, 20, 96% RA
• AO x3, pleasant, NAD
• Icteric, PERRL, MMM
• No JVD, RRR, no MRG
• CTA B
• ND NABS, mild tender hepatomegaly, no
splenomegaly
• No flap, neurologically intact
Initial Labs at UAB (3/19)
• ALT: 2386, AST: 2042, BT: 24.0, BD:
14.1, INR: 1.48, GGT: 82, ALP: 123
• WBC: 6.2, Hg: 13.3, PCV: 38, Plt: 177
– Diff: 57S, 25L, 18M
• Ammonia: 47
• Na: 140, K: 3.9, Cl: 110, HCO3: 25,
BUN: 5, Cr: 0.8
• MELD: 21
Imaging
• U/S 3/19
– Hepatomegaly, chronic cholecystitis, renal cysts
• CT 3/20
– Hepatomegaly (16.8cm)
– Numerous low attenuation hepatic lesions too
small to accurately characterize
– Thickened edematous GB w/ calculi
– Patent vasculature
• U/S 3/20 - Marked for liver biopsy
Representative CT Images
CT images #2
CT images #3
Hepatitis w/u
• OSH Tylenol negative
• Negative studies:
– ASMA, AMA, HBs Ag, HCV PCR, HBc IgM, HCV
Ab
• AAT 223 (88-174)
• Ceruloplasmin 35
• HBs Ab positive
• OSH ANA negative
– ANA 1:320 speckled (returned after biopsy)
Course
• LFT remained elevated at
approximately 2000
• Bilirubin remains elevated
• Patient transfused FFP in preparation
for liver biopsy to clarify diagnosis
• INR 1.33 w/ PT 16.7
• 2 more units of FFP given and liver bx
performed
Course #2
• After the biopsy patient felt hot and had L
shoulder pain
• Approximately 1 hour following liver biopsy
patient became unresponsive
• Code called, patient w/ spontaeous
respirations and palpable pulse
– BP not obtained w/ manual cuff
• Peripheral vein resuscitation until central
access by MET team
• Patient transferred to MICU team
Course #3
• Volume resusitation continued from the floor
• RBCs ordered from floor transfused,
additional units given
• PCV to 20 from 30 the am of the procedure
• Abdomen became tense w/ intra-abdominal
pressure measured over 50cm H20
• Emergent surgery by Glystein
Surgical course
• Prior to surgery
– 12L crystaloid
– 8 units PRBCs
– 4 units FFP
• Coded in transport to surgery
– Rapidly recovery w/ epi and fluids
Surgical course #2
• Immediately after entry through the
peritoneum, air expelled and large amount of
blood was present
• Short liver laceration was palpated
• Bleeding was originating from this laceration
• Figure 8 suture not tied to get hemostasis
• Second suture tied w/ pledgets, w/ better
control, but bleeding at the edges
Surgical Course #3
• Surgery stopped at this point due to
coagulapathy interfering w/ their
interventions
• Packed locally and closed w/ Bogota
bag
• EBL 4L
• PCV 24-->16 despite rapid infusions
Liver biopsy appearance
•
Bravo 2001
Liver biopsy results
• Hepatitis, moderately to severely active
disease
– Compatible with AIH
– Not specific
• No significant fibrosis on Trichrome
• Case: S-08-0007867
Course
• Patient continued to decompensate with
DIC and developed TRALI
• Ventilator settings maximized and
patient remained hypoxic
• She died from complications from her
liver biopsy at 18:10, 3/21
Discussion
Liver Biopsy
• Percutaneous approach first by Ehrlich
in 1883 with aspiration
– Biopsy first percutaneous done in 1923
• Popularized by Menghini in 1958 with
“one-second needle biopsy of the liver”
– Intrahepatic phase was 6-15 min before
• Transjugular Liver biopsy
– Described in 1964
Bravo 2001
Liver Biopsy
• Represents a specimen typically 1.2-
2mm in diameter and 1-3cm long
• 1/50,000 of the total liver mass
– Sampling issues
• Need 6-8 portal triads for adequate
specimen
• Need to be looking for a diffuse process
– Or use guided technique
Different methods
• Suction needles
– Our standard-Jamshidi 1.9 (Klatskin/Menghini 1.6)
– Smaller diameter
• Cutting needles
– Associated w/ increased intrahepatic time
– Increased risk of bleeding
– Larger diameter
– Preferred in cirrhosis 2/2 fragmentation
Ultrasound
• Delineate structures outside the liver
prior to procedure
– Chilaiditi syndrome (bowel between
abdominal wall and the liver)
• Ensure no mass lesions requiring
guided biopsy
• Not clear if it decreases complication
rate
Indications for liver biopsy
Bravo 2001
Indications continued
• Provides diagnosis in 90% of patients
with unknown LFT abnormalities
• Staging of disease in HCV, ETOH
• Monitor side effects of tx.
• Diagnose systemic dz
– Amyloid, sarcoid, lymphoma, HIV, Tb, FUO
Bravo 2001
Liver Biopsy as Outpatient
• Need for hospitalization in 1-3% of cases
• Should not have medical problems increasing
the risk of the biopsy
• Monitor for 6 hours after the biopsy
• Patient should be able to return to the
hospital where the biopsy was performed
within 30 min
• Need a reliable person to stay with the
person for a the first night after the biopsy
Bravo 2001
Contraindications
Bravo 2001
More contraindications
• Extrahepatic biliary obstruction and
cholangitis
– Can be complicated by pain, bile
peritonitis, sepsis and death
• Possibly amyloid
– 1 in 18 had a bleed in a small series.
Grant 1999
Known complications
• Bleeding
• Biliary injury or bile peritonitis or pleuritis
• Pneumothroax or hemothorax
• Pneumoperitoneum, bowel perforation
• Anaphalaxis from echinococcal cyst
• Breakage of the biopsy needle
• Death ~0.01% (reported up to 0.17%)
– 3 month mortality of 17% due to selection bias
Grant 1999
Timing
• 61% of complications realized within 2
hours
• 82% of complications within 10 hours
• 96% of complications present within 24
hours
Bravo 2001
Preventing Bleeding
• Biopsy of a tumor
– Go through normal liver tissue first.
• Platelets >100K (56K at Mayo)
– If less than 60K platelets, more risk
• Correct coagulopathies
– 90% of bleeds in percutaneous approach
have INR 20
completed
Grant 1999
Bleeding
• Typically caused by inspiration during the
procedure
• Can be caused by injury to a branch of the
hepatic artery
• Risk factors
– Increased age, more than 3 passes, cirrhosis, liver
cancer, ESRD/uremia, encephalopathy, ascites
• Major Bleeding occurs in 0.35-0.5% of cases
• Ultrasound detected bleeding in 23% of
patients at 24h.
Grant 1999
Intraperitoneal Bleeding
• If suspected diagnose w/ U/S or CT for
free fluid
• Alert surgeon and angiographer
• Provisions for PRBCs, coagulation
factors (plasma) and platelets
• If fail aggressive resuscitation within 2
hours
– surgery v. angiography
Bravo 2001
Other Bleeding
• Subcapsular
– Typically self limited
– Conservative management is sufficient
– Can cause hypotension, tachycardia
• Hemobilia
– Least common type of hemorrhage
• 0.05% of cases
– GI bleeding, biliary pain, jaundice
– Associated w/ transient bacteremia
Grant 1999
Puncture of Viscera
• Incidence of 0.01-0.1%
• Puncture of lung, colon, kidney, GB
have been described
Grant 1999
Indications for IJ approach
Bravo 2001
IJ approach is not perfect
• Typically requires multiple passes
• Specimen is 0.3cm to 2cm long
– Smaller
• Complication rate 1.3-20.2%
– Neck hematoma, horner’s syndrome, cardiac
arrhythmias, pneumothorax, fistula between
hepatic artery and vein or biliary tree, capsule
rupture.
• Mortality rate 0.1-0.5%
Questions?
References
• Bravo AA, Sheth SG, Chopra S. Liver Biopsy.
NEJM 2001 344: 495-500.
• Feldman M, Friedman LS, Brandt LJ.
Sleisenger and Fordtran’s Gastrointestinal
and Liver Disease. 8th edition. Saunders-
Elsevier. 2006
• Grant A, Neuberger J. Guidelines on the use
of liver biopsy in clinical practice. Gut 1999.
45(supp IV) IV1-IV11.