October 2004BSG Guidelines in Gastroenterology - PDF document

October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical Practice1.Introduction2.Formulation of guidelines2.1Validity and Grading of Recommendations2.1.1Categories of Evidence2.1.2Grading of Recommendations2.2Scheduled Review of Guidelines3.Types of Liver Biopsy3.1.Percutaneous Liver Biopsy3.1.1Transthoracic (Transparietal) and3.1.2Blind and Guided Liver Biopsies3.1.3Plugged Liver Biopsy3.2Transvenous (Transjugular) Liver Biopsy3.3Laparoscopic Liver Biopsy4.Background4.1.Mortality and Morbidity4.1.1.Mortality4.1.2.Causes of Mortality4.2.Morbidity5.Indications for Liver Biopsy6.Contraindications6.1.The Uncooperative Patient6.2.Extrahepatic Biliary Obstruction6.3.Bacterial Cholangitis6.4.Abnormal Coagulation Indices6.4.1Prothrombin Time6.4.2Thrombocytopaenia6.4.3Platelet Function / Bleeding Time (BT)6.5.Ascites6.6.Cystic lesions6.7.Amyloidosis7.The Biopsy Procedure7.1.Informed Consent7.2.Experience of the Operator7.3.Sedation7.4.Haematological Investigations7.4.1Vitamin K, Fresh Frozen Plasma (FFP) andPlatelet Transfusion7.6Ultrasound Percutaneous Liver Biopsy7.7Prophylactic Antibiotics7.8Type of Biopsy Needle7.9Number of Passes7.10Post Biopsy Observation8.Transjugular liver biopsy9.Outpatient Percutaneous Liver Biopsy10.Recommendations (9.1-9.11)11.ReferencesJames Neuberger, Dr Allister Grant, Professor ChrisDay and Dr Sushma Saxseena. Within the boundariesto make the guidelines Òevidence basedÓ.Advances in medical technology and especially ingreatly influenced the diagnosis and management ofGastroenterology, together with the Royal College ofaudit and from reviewing the literature that thereguidelines examine the evidence regarding the use of2. FORMULATION OF GUIDELINESValidity and Grading of Recommendations(Grimshaw, Eccles et al. 1995).Ia:Evidence obtained from meta-analysis ofIb:Evidence obtained from at least one randomised- BSG Guideline

s in GastroenterologyOctober 2004 Guidelines on the use of Liver Biopsy in Clinical PracticeIIa:Evidence obtained from at least one well designedIIb:Evidence obtained from at least one other type ofIV:Evidence obtained from expert committee reports orGrading of RecommendationsA:Requires at least one randomised-controlled trial asB:Requires the availability of clinical studies withoutC:Requires evidence from expert committee reports orScheduled Review of Guidelines3. METHODS OF LIVER BIOPSYPercutaneous Liver BiopsyPercutaneous liver biopsy may be classified according to manner, or whether the after the procedure.Transthoracic (Transparietal) and SubcostalFor both these approaches the patient lies supine. Thesubcostal route (2.7%) (Perrault, McGill et al. 1978).After the biopsy procedure the patient then lies supineA blind liver biopsy is one, which is taken as, describedprior to taking the biopsy.undertaken during real time imaging of the liver byadvantage that the biopsy will be taken where there isthicker hepatic parenchyma, and is more likely to avoid the or 3.1.3.Plugged Liver Biopsy(Riley, Irving et al.1984) (Tobin and Gilmore.1989). It hasIn this technique a biopsy is taken with a Tru-cut needlewhile the breath is still held in expiration, gelatin issafe and well tolerated (Fandrich 1996).Transvenous (Transjugular) Liver BiopsyDisorders of coagulation occur commonly in patients6mm in length) but was associated with an increased3.2.1.Transjugular liver biopsy was first described in 1964 October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical Practiceposition checked by injection of contrast medium. Thethe liver. Specimens taken by the transjugular route tendto be shorter than those taken by the percutaneous routeal, 2002, Corr 1992).3.2.2. Transfemoral: sometimes a transjugular approachis not possible and a transfemoral route may be usedw

idely between centres. In the U.K. it is often used forlaparoscopic surgery. It has also been used in centresessential in the management of that patient. Some U.S.those of the laparoscopy itself.4. COMPLICATIONSThe indications for, and methods of liver biopsy haveThe reported mortality from percutaneous liver biopsyvaries considerably. This is partly due to the fact thatThe overall mortality rate in the 3 months after liverfew are due solely to the liver biopsy. The overall mortalitypercutaneous biopsy was 0.11% (McGill, Rakela et al.in a retrospective Italian study of 68000 percutaneousal. 1986). Three of these patients had a laparotomy, andwhich are risk factors for bleeding (McGill, Rakela et al.biopsy is haemorrhage, it is reasonable to assume thatthe patient. Patients with suspected biliary peritonitisshould have an early laparotomy. It has also beenhaemodynamically unstable) should be considered forBurroughs et al. 1995) although angiography is likely toPercutaneous liver biopsy The overall morbidity from percutaneous liver biopsy ishas been reported (Perrault, Mcgill et al. 1978).Pain is probably the commonest complication of liver1995, Forssell, Bronkowsky et al.1981) with moderate(Perrault, McGill et al. 1978). Hypotension and vasovagal BSG Guidelines in GastroenterologyOctober 2004 Guidelines on the use of Liver Biopsy in Clinical Practicein approximately 3% of liver biopsies (Perrault, McGill et�haemoglobin of 2g/dL) occurs in 0.35% -0.5% of allprocedures (McGill, Rakela et al. 1990), Knauer 1978).intrahepatic or subcapsular haematomas detectable byPuncture of other viscera occur infrequently with anto the anaesthetic, breakage of the biopsy needle (Lazar1978), and intrahepatic arteriovenous fistulae (Okuda,Transjugular liver biopsy5. INDICATIONS FOR LIVER BIOPSYPercutaneous liver biopsy has a small but inherent risk(in terms of altering treatment or disease outcom

e).Prospective studies have shown that the histologicalestablishing the diagnosis (Sorbi 2000, Skelly 2001).Acute hepatitisAcute hepatitis of unknown aetiology including possiblepercutaneous liver biopsy, but liver biopsy in typical acuteviral hepatitis is usually not necessary. The usefulness of(as shown by HCV-RNA in peripheral blood) isuncertain. The recent guidelines from the Nationalparticular, the consensus statement suggests that thenormal liver tests, the need for and timing of follow-those with non-genotype 1 virus, require definition.assessing the degree of fibrosis and exclusion of othera percutaneous biopsy before beginning therapy, in orderNational Institute for Clinical Excellence have publishedHCV.The decision to treat patients with chronic HBV infectionpatients with HBV infection. Whilst, as with otheruseful mainly for clinical trials.(The EASL Jury, 2003).of patients with genetic hemochromatosis is unclear. Thewhen iron markers are equivocal, or to investigate other October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical Practiceiron measurement (Tavill 2001). In contrast, theguidelines from the European Association for the Studyof the Liver (EASL) 2000) recognised that liver biopsyWe therefore recommend that liver biopsy is indicatedto define or exclude the presence of cirrhosis, in thoseneed to be excluded.WilsonÕs DiseaseThe diagnosis of Wilsonhistory, estimation of serum copper and caeruloplasminand the urinary excretion of copper before and after aof Wilsonestimation of liver copper may help contribute to theInfections and Pyrexia of unknown originOccasionally, histological examination and culture ofdiagnosis of PBC (even if patients have no other signsor symptoms of PBC) (Metcalfe, Mitchison et al. 1996).to do a liver biopsy to make the diagnosis of PBC. Thebe needed to make the diagnosis of small duct PSC.uncertain.

The histological diagnoses of fatty liver,without histology. Furthermore, in those with a historyof alcohol excess, other factors may be the cause ora history of alcohol excess and evidence of liver damage,Liver histology is needed to confirm alcoholic hepatitisAutoimmune hepatitis (AIH)Liver biopsy is indicated both in the diagnosis and follow-should be undertaken as part of the workup for thestable, is uncertain: on-going histological inflammatoryactivity is likely to lead to progressive cirrhosis and thisactivity can be reliably excluded only on liver histology soNAFLD is found increasingly commonly. The role of liverCurrently, it is not possible to differentiate fatty liverhistology. Liver tests do not reliably confirm or refute thein all cases of fatty liver.. Those with NASH wouldrequire follow-up and treatment. However, this wouldstrict guidelines for the use of liverabnormal liver enzymes but this must be taken ininvestigations, and take into account the patientdetails. For example, the investigation of an isolatedraised alkaline phosphatase will be very different in an80 year old compared to a 25 year old. Elevations in g-glutamyl transferase (g-GT) have been shown to be asensitive marker of alcohol misuse.However, liver histology in those with persistentlytest abnormalities and, in a small proportion, indicatethe need for specific treatment (Skelly 2001, Sorbi 2000).Of those with an isolated rise in the gamma-GT, 11% hadevidence of hepatic fibrosis (Skelly 2001). BSG Guidelines in GastroenterologyOctober 2004 Guidelines on the use of Liver Biopsy in Clinical PracticeFocal liver lesionsserum a-foetoprotein will allow a diagnosis to be made.antigen, may not require a biopsy of the lesion to makeand focal nodular hyperplasia. Liver histology will beFollowing liver transplantationliver transplant units. Some units perform routinebiopsies (Nakhleh, Schwartzenberg et al.1990)

. Liverbiopsy is also useful in the diagnosis of invasive CMVinfection and in assessing recurrent disease (Hubscher,tests, rejection, preservation or reperfusion injury, viralinfection, drug toxicity, recurrent disease and other causesResearchderive no potential benefit from the procedure, and willThe procedure will also need approval from theappropriate Research Ethics Committee (or equivalent).6. CONTRAINDICATIONSthan it is now. These studies were done before the adventappear to be common sense, many of them have beenThe Uncooperative PatientBuhac et al. 1977). However in one study, seriousal. 1975). With current imaging techniques (specificallypreferable (Rosch, Lakin et al. 1973).when a biliary system is infected then culture of a pieceespecially in the context of investigation of TB or a PUO.is a well-recognised phenomenon (McClosky, Gold et al.al, 1975). These findings confirm the risks ofdisseminating infection at the time of liver biopsy.contraindication to percutaneous liver biopsy. A numberof investigators have demonstrated that the degree ofbleeding from the liver puncture site (observed atof the biopsy track collapsing down after the core hasbeen taken together with the high local levels of clottingpercutaneous liver biopsy, the liver is not the onlybleed, peripheral indices of clotting must still be taken October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical PracticeSeveral large studies have failed to show an increasedprothrombin time of 4 seconds above control values(Ewe 1981)(McGill, Rakela et al. 1990)(Dillon, Simpsonwas commoner if the INR was raised, with 3.3% of the�1.5, and 7.1% occurring when the INR was 1.5that approximately 90% of the bleeds occurred inreassurance that the patient will not bleed after thefrom published data. One authority proposes a plateletgroups such as the Mayo Clinic regard counts as low a

s to be safe (McGill, Rakela et al. 1990). Most (Sherlock 1997) whilst a survey of were significantlymore likely to bleed after percutaneous liver biopsy thanremains scanty and takes no account of the function ofU.S. (73% VU.K. centres prior to liver biopsy even though the ingestionPatients with renal impairment usually haveabnormalities of platelet function. According to one smallstudy, patients with end stage renal failure onbiopsy, independent of the BT (Wolf, Weber et al.1995).Several other factors are likely to affect platelet functionwith or without affecting the BT. This fact, togetherbetween different operators, makes the use of thedifficult to interpret. The Royal Free Hospital were ables (42%) were more likely to havetimes and higher blood urea and serum bilirubin thanthe elevated serum bilirubin may well be just asurrogate marker for the severity of liver disease)(Blake,Percutaneous biopsy of the liver in the presence of tenseThe reasons for this vary from, the high likelihood of notuncontrollable bleeding into the ascites. Whilst theserandomised controlled clinical trials. There is evidencecomplication rate (Little, Ferris et al. 1996) (Murphy,obvious being to perform a total paracentesis prior toperforming the percutaneous biopsy. Other optionsinclude image-guided biopsy, transjugular liver biopsy, orlaparoscopic biopsy. BSG Guidelines in GastroenterologyOctober 2004 Guidelines on the use of Liver Biopsy in Clinical Practicethe biliary tree and therefore run the risk of biliaryperitonitis after biopsy.Recent advances in the treatment of hydatid disease of theliver mean that this may no longer be so (Kumar andChattopadhyay. 1992). Aspiration of hydatid cysts with 19-(Bret, Fond et al. 1988) and therapeutically (Felice, Pirolaethanol under albendazole cover.disease was first used in 1928 (Waldenstrm, 1928).Volwiler and Jones reported the first death fromhaemorrhage after

amyloid liver biopsy. This episodecontraindications to percutaneous liver biopsy (Volwiler &such as a rectal biopsy. native language wherever possible, and whenand the commands given to them during the biopsy.affect upon the complication rate after the biopsy. Thegastroenterologists and general physicians was seenperforms Transjugular biopsies.We recommend that pre-registration house officersshould not perform percutaneous liver biopsies except indone frequently, and only then under close supervision.midazolam sedation for the biopsy procedure if there isendoscopy. Midazolam should be given with caution inhave blood grouped and serum saved, and in hospitalsand platelet count should be checked prior to the biopsy(preferably within 24 hrs). With the current data it can a percutaneous. Vitamin K,Platelet TransfusionVitamin K, fresh frozen plasma and platelet supportabnormalities prior to liver biopsy. There are howeverof plugged or transjugular biopsy. Vitamin K is useful October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical Practiceprior to the biopsy, and is most effective where theor malabsorbtion. The prothrombin time should bechecked before doing the biopsy to ensure that clottingcorrect the prothrombin time (Spector, Corn et al.1966)(Contreras, Ala et al.1992). One study however,its efficacy, especially in the context of patients withConference-1987). However, post-transfusion plateletUltrasound is a safe and readily available investigation.Practice amongst gastroenterologists varies greatly, with2002, Mayoral 2001, Rossi 2001). There is, both in EuropeHowever this is not current practice in the U.K.shrunken liver and the abdominal wall, thereby avoidinginadvertent puncture of an adjacent viscus (Dixon,Percussing for the superior and inferior borders of theUltrasound Guided Percutaneous Liver Biopsyextensively in the investigation of foc

al liver lesions,should reduce complications. One prospective studyReasons for these alterations included interposition oflung or gall bladder. In contrast, the rate of haematomaguidance (Vautier, Scott et al. 1994). Pre-biopsy imagingRakela et al. 1990).Papini et al 1991, Lindor et al, 1996, Farrell et al,associated with fewer major and minor complicationsWe believe that the use of guided liver biopsy or fine obesity. There are training implications if UKgastroenterologists were to undertake ultrasound-guideddocumented (LeFrock, Ellis, et al. 1975)(McClosky, Goldcomplications for patients with choledocho-patients (Bubak, Parayko,et al.1991) whereas theRoyal Free group could show no increased risk BSG Guidelines in GastroenterologyOctober 2004 Guidelines on the use of Liver Biopsy in Clinical Practicepatients to be able to make strong recommendations, Type of Biopsy NeedleUK are the Tru-cut and the Menghini needles (Gilmore,former, as its name describes is a cutting needle, whilefor the Tru-cut needle and 1/1000 for the Menghinifrequently with the Tru-cut needle when compared toTru-cut/ Vim Silverman cutting needles and found nodifference in complication rates (Perrault, McGill et al.1978)(McGill, Rakela et al.1990). The theoreticalpatient to move, thereby minimising the potential fordiameter on complications are rare, however Forssell ethaving a smaller biopsy specimen (Rocken 2001).Specimens from the Tru-cut needles are larger and giveNumber of Passesthis may have an effect on morbidity. It has been clearlyof complications when the percutaneous biopsy is takenmore than three biopsies were taken (Perrault, McGill etbiopsy is undertaken, taking two specimens improvesdiagnostic yield with an increased number of minorbiopsies are taken (Maharaj & Bhoora. 1992).number of passes made, but is also significantly linked(McGill, Rakela, et al. 1990). Therefore we conclude thatunder circumst

ances where the likelihood of a samplingerror is high such as in some cases of macronodularcirrhosis, two biopsies could be taken. However thePost Biopsy Observationconsideration in practical terms however is the likelytime period in which complications are going to occur.who develop a coagulopathy post biopsy (Reichert,Weisenthal, et al.1983). The occurrence of delayedbiopsy. Clearly patients can not be kept in hospital for 2The first large studies addressing the issue of post-biopsythe first three hours after liver biopsy (Knauer. 1978)(Perrault, McGill et al. 1978), and recommended thatpatients should be kept in hospital for 6 hours after the October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical Practice(Perrault,indicated (such as coagulopathy, significant ascites,suspected vascular tumour, a failed percutaneous liver9. OUTPATIENT PERCUTANEOUS LIVER BIOPSYin many U.S. centres since the early 1970s (Perrault,widely taken up in this country with only 4% of(Gilmore, Burroughs et al. 1995). In centres which doperform day case biopsies in this country a 91% patiental. 1995)(Janes & Lindor. 1993).to U.K. patients (Jacobs, Goldberg et al. 1989). Theyof the biopsy including: encephalopathy, ascites, hepaticWe would add that patients with a strong suspicion ofmalignancy should not be biopsied as an outpatient(McGill, Rakela et al. 1990).access to a laboratory, blood bank and inpatient facilitiesin the 4 hours post liver biopsy. The patient should alsowas undertaken within 30 minutes, and should have areliable individual to stay with on the first post-biopsynight. If the above criteria can not be met, then thePerforming percutaneous liver biopsies as an outpatientreallocation of resources (Perrault, McGill et al 1978).10. RECOMMENDATIONSmust be a clearly defined indication for the biopsy, and10.2. We recommend that all patients who are about toso

me form of imaging of the liver. The interval betweenhave been any changes in the anatomy or pathology. Thisbiopsied under image guidance. We recommend that,Recommendation Grade B.should be checked in the week before the percutaneous liver then the then platelet transfusion may then alternative biopsy methods as describedpossible) at least two days before biopsy.Recommendation Grade B.then percutaneous biopsy can be safely undertaken. If themethods should be tried.Recommendation Grade B. BSG Guidelines in GastroenterologyOctober 2004 Guidelines on the use of Liver Biopsy in Clinical Practiceable to understand and co-operate with instructions10.5. Sedation with midazolam may be given forguidelines on sedation during endoscopy. Sedationshould be given with caution in liver disease (section6.1.). Recommendation Grade B.Recommendation Grade A.10.7. The grade of the operator has not been shownpercutaneous liver biopsy. We feel however that doctorsbiopsies except in the context of a busy specialisedRecommendation Grade B.bacteraemia (section 7.7). Recommendation Grade B.7.9.). Recommendation Grade B.10.10. Post liver biopsy observation should continueresponsible person to stay with on the first post-biopsyRecommendation Grade B.procedure (section 8.). Recommendation Grade B.Alberti,A.,Morsica,G,et al.(1992). Hepatitis C viraemiaHCV. Lancet 340(8821): 697Alexander, JA. & Smith, BJ. (1993). Midazolam sedationfor percutaneous liver biopsy. Digestive Diseases andAngtuaco TL, Lal SK, Banaad-Omiotek GD, Zaidi SS,Howden CW. Current liver biopsiy practices for suspectedevolving role of radiologists. Am J GastroenterolBerenguer M, Rayon JM, Prieto M, Aguilera V, NicolasD, Ortiz D, Lopez-Andujar R, Mir J, Berenguer J. Are post-term? Liver Transpl 2001;7:790Ben-Ari, Z., Neville, L., et al. (1996). Liver biopsy in liverpatients with choledochojejunostomy. Journal of327.Grade: IIaBingel, A. (1923).

Ueber die parenchympunktion derleber. Verh Dtsch Ges Inn Med 35: 210Blake, JC., Sprengers, D., et al. (1990). Bleeding time inBret, PM., Fond, A., et al. (1988). Percutaneousaspiration and drainage of hydatid cysts in the liver.Bubak, ME., Porayko, MK.,et al. (1991). Complicationssepsis associated with choledochojejunostomy.Caturelli, E., Giacobbe, A., et al. (1996). PercutaneousChau TN, Tong SW, Li TM, To HT, Lee KC, Lai JY, Lai ST,Yuen H. Transjugular liver biopsy with an automatedtrucut-type needle: comparative study withpercutanouys liver biopsy. Eur J Gastroenterol Hepatoltherapy. JAMA 257:1777Contreras, M., Ala, FA., et al. (1992). Guidelines for theuse of fresh frozen plasma. Transfusion Medicine 2: 57Corr P, Beningfield SJ, Davey N. Transjugular liverbiopsy: a review of 200 biopsies. Clin Radiol October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical PracticeDillon, JF., Simpson, KJ., et al. (1994). Liver biopsyDixon, AK., Nunez, DJ., et al. (1987). Failure ofDotter, CT. (1964). Catheter biopsy. Experimentaltechnique for transvenous liver biopsy. Radiology 82:Douds, AC., Joseph, AEA.,et al. (1995). Is day case liverEuropean Association for the Study of the Liver. EASLEASL Jury. EASL International Consensus Conference onHepatitis B. J Hepatol 2003;38:533C. Consensus Statement. J Hepatol 1999;30:956Fandrich CA, Davies RP, Hall PM. Small guage gelfoamdiagnostic value. Australas Radiol 1996; 40: 230Farrell RJ, Smiddy PF, Pilkington RM et al. Guided versusFilice, C., Pirola, F., et al. (1990). New therapeuticForssell, PL., Bronkowsky, HL., et al. (1981). IntrahepaticGalati, JS., Monsour, HP., et al. (1994). The nature ofpatients with Roux-en-Y choledochojejunostomy.Gazelle, GS., Haaga, JR., et al. (1992). Effect of needlebleeding associated with aspiration biopsy. RadiologyGazzard, BG., Henderson, JM.,et al (1975). The use of freshtherapy

before liver biopsy. Gut 16: 621Gilmore, I.T., Burroughs, A. et al. (1995). Indications,England and Wales: an audit by the British Society ofGastroenterology and the Royal College of Physicians ofHamazaki, K., Matsubara, N., et al. (1995). Needle tractultrasonically guided needle liver biopsy. Journal ofHarrison, RF., Davies, M., et al. (1993). Recurrenthepatitis B. A distinct form of rapidly developingcirrhosis. Histopathology. Grade: IIIbscher, S.G., Clements, D.,et al. (1985). BiopsyClinical Pathology 38: 1366bscher, S.G., Elias, E., et al. (1993). Primary biliaryJacobs, WH., Goldberg, SB.,et al. (1989). DigestiveJanes, CH. & Lindor, KD. (1993). Outcome of patientshospitalised for complications after outpatient liver biopsy.Knauer, MC. (1978). Percutaneous biopsy of the liver asKristensen, J., Eriksson, L., et al (1993). Functional155. Grade: IIbKumar, A. & Chattopadhyay, TK. (1992). Management ofhydatid disease of the liver. Postgraduate MedicalLazar, H. (1978). Fractured liver biopsy needles.Lebrec, D. (1996). Various approaches to obtaining livertissue- choosing the biopsy technique. Journal ofLebrec, D., Goldfarb, G., et al. (1982). Transvenous liverbiopsy. Gastroenterology 83: 338Le Frock, JL., Ellis, CA., et al. (1975). Transientbacteraemia associated with percutaneous liver biopsy.Lightdale, CJ. & Das L. (1997). Difficult liver biopsies:Lindor KD, Bru C, Jorgensen RA et al. The role ofultrasonography and automatic-needle biopsy in out- BSG Guidelines in GastroenterologyOctober 2004 Guidelines on the use of Liver Biopsy in Clinical Practicepatient percutaneous liver biopsy. HepatologyLittle, AF., Ferris, JV., et al. (1996). Image guidedLoIudice, T., Buhac, I., et al. (1977). Septicaemia as acomplication of percutaneous liver biopsy.Mahal, AS., Knauer, CM., et al. (1979). Bleeding afterMaharaj, B. & Bhoora, IG. (1992). Complicationswhen one, two, or three specimens are ta

ken.Postgraduate Medical Journal 68: 964967. Grade: IIIMayoral W, Lewis JH. Percutaneous liver biopsy: what isthe current approach? Results of a questionnaire survey.127. Grade IV.McCloskey, RV., Gold, M., et al. (1973). Bacteraemia afterliver biopsy. Archives of Internal Medicine 132: 213McGill, D.B., Rakela, J. et al.(1990). A 21-year experiencewith major haemorrhage after percutaneous liver biopsy.Metcalfe, JV., Mitchison, HC., et al. (1996). NaturalMinuk, GY., Sutherland, LR., et al. (1987). Prospective6 or 24 hours of bed rest after percutaneous liver biopsy.Morris, JS., Gallo, GA., et al. (1975). Percutaneous liverMuir AJ, trotter JF. A survey of current liver biopsy practice88. Grade IV.Munk PL, Morris DC, Connell DG, Mayo JR, Lee MJ,Sallomi DF. Transfemoral venous liver biopsy: commonproblems and complications. Australias RadiologyMurphy, FB., Barefield, KP., et al. (1988). CT- orsonography-guided biopsy of the liver in the presence ofRoentgenology 151: 485Nakhleh, RE., Schwartzenberg, SJ.,et al. (1990). Theyear. Hepatology 11: 465Neuberger J, Wilson P, Adams D. Protocol liver biopsies:the case in favour. Transplant Proc 1998;30:1497NEUSCHWANDER-Tetri BA, Caldwell SH. Nonalcoholicsteatohepatitis: summary of an AASLD Single Topic1219. Grade IV.Okuda, K., Musha, H., et al. (1978). Frequency ofpercutaneous needle puncture of the liver. Gastroenterology1207. Grade: IVShaughnessy DF, Atterbury C, Bolton Maggs P, MurphyM, thomas Yates S, Williamson LM; the BritishTransfusion Workforce. British Journal of HaematologyPapini E, Pacella CM, Rossi Z et al. A randomised trial ofPerrault, J.,McGill, DB. et al. (1978). Liver biopsy:Piccininio, F., Sagnelli, E. et al. (1986). Complicationsfollowing percutaneous liver biopsy. Journal of173.Grade: IIIQureshi, WA., DuBose, TJ., et al. (1997). Effect ofReichert, CM., Wiesenthal, LM., et al. (1983). Delayedhaemorrhage after percutaneous liver

biopsy. Journal ofRocken C, Meier H, Klauck S, Wolff S, Malfertheiner P,Roessner A. Large-needle biopsy versus thin-needlebiopsy in diagnostic pathology of liver disease. LiverRossi P, Sileri P, Gentileschi P, Sica GS, Forlini A, StolfiVM, De Majo A, Coscarel G, Canale S, Gaspari AL.Percutaneous liver biopsy using an ultrasound-guidedSawyerr AM, McCormick PA, Tennyson GS, Chin J, DickR, Scheuer PJ, Burroughs AK, McIntyre N. A comparison October 2004BSG Guidelines in Gastroenterology Guidelines on the use of Liver Biopsy in Clinical PracticeSebagh M, Rifai K, Feray C, Yilmaz F, Falissard B, RocheB, Bismuth H, Samuel D, Reynes M. All liver recipientsbenefit from the protocol 10-year liver biopsy. HepatologySharma, P., McDonald, GB., et al. (1982). The risk ofSherlock, S. & Dooley, J. (1997). Diseases of the liver and Ed. London Blackwell Scientific.Shah S, Mayberry JF, Wicks ACB, Rees Y, Playford RJ.Skelly MM, James PD, Ryder SD. Findings on liver biopsyabsence of diagnostic serology. J Hepatol 2001;35:195Spector, MD., Corn, M., et al. (1966). Effect of plasmaStotland, BR. & Lichtenstein, GR. (1996). Liver biopsyStauffer, MH., et al. (1961). Amyloidosis: Diagnosis withSue, M., Caldwell, SH., et al. (1996). Variation betweencentres in technique and guidelines for liver biopsy. Liver270.Grade: IIISorbi D, McGill DB, Thistle JL, Therneau TM, Henry J,Tavill AS. Diagnosis and Management ofTobin, MV. & Gilmore, IT. (1989). Plugged liver biopsy inpatients with impaired coagulation. Digestive DiseasesVautier, G., Scott, B., et al. (1994). Liver biopsy: blind orVolwiler, W. & Jones, CM. (1947). The diagnostic andto trocar biopsy. New England Journal of Medicine 237:Wolf, DC., Weber, F., et al. (1995). Role of the templatepercutaneous liver biopsy. Hepatology 22: 509A.These guidelines have been prepared by the British Society of Gastroenterology.of specific clinical situations and resource ava