EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis | 2015 EASL

Estadiamento Doença Hepática 2015

Introduction
Liver fibrosis is part of the structural and functional alterations in
most chronic liver diseases. It is one of the main prognostic factors as the amount of fibrosis is correlated with the risk of developing cirrhosis and liver-related complications in viral and nonviral chronic liver diseases [1,2]. Liver biopsy has traditionally
been considered the reference method for evaluation of tissue
damage such as hepatic fibrosis in patients with chronic liver disease. Pathologists have proposed robust scoring system for staging liver fibrosis such as the semi-quantitative METAVIR score
[3,4]. In addition computer-aided morphometric measurement
of collagen proportional area, a partly automated technique, provides an accurate and linear evaluation of the amount of fibrosis
[5]. Liver biopsy gives a snapshot and not an insight into the
dynamic changes during the process of fibrogenesis (progression,
static or regression). However, immunohistochemical evaluation
of cellular markers such as smooth muscle actin expression for
hepatic stellate cell activation, cytokeratin 7 for labeling ductular
proliferation or CD34 for visualization of sinusoidal endothelial
capillarization or the use of two-photon and second harmonic
generation fluorescence microscopy techniques for spatial assessment of fibrillar collagen, can provide additional ‘‘functional’’
information [6,7]. All these approaches are valid provided that
the biopsy is of sufficient size to represent the whole liver [4,8].
Indeed, liver biopsy provides only a very small part of the whole
organ and there is a risk that this part might not be representative for the amount of hepatic fibrosis in the whole liver due to
heterogeneity in its distribution [9]. Extensive literature has
shown that increasing the length of liver biopsy decreases the
risk of sampling error. Except for cirrhosis, for which micro-fragments may be sufficient, a 25 mm long biopsy is considered an
optimal specimen for accurate evaluation, though 15 mm is considered sufficient in most studies [10]. Not only the length but
also the caliber of the biopsy needle is important in order to
obtain a piece of liver of adequate size for histological evaluation,
with a 16 gauge needle being considered as the most appropriate
[11] to use for percutaneous liver biopsy. Interobserver variation

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