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Role of Liver
Biopsy Examination in Chronic Hepatitis C
Whether
a liver biopsy examination is necessary
in all HCV-infected patients is controversial. The 2002 National
Institutes of Health Consensus Statement considers the liver
biopsy examination to be a “useful part of informed consent,”
and in most patients with chronic hepatitis C, “the value
of pretreatment liver biopsy outweighs its risks.”
Patient groups in which
the role of biopsy examination is more debatable are patients
with persistently
normal alanine transaminase (ALT) levels
and those with genotypes
2 and 3.
In those with clinical
evidence of cirrhosis or portal hypertension, a liver biopsy
examination may add little further information unless an additional
diagnosis is suspected, and may be associated with more complications.
The biopsy examination
remains the most reliable method to assess the extent of necroinflammatory
activity (grade) and fibrosis
(stage). The degree of fibrosis
has prognostic value in predicting treatment response, although
this effect has diminished as therapies have improved, and
may influence the timing of antiviral therapy.
Individuals with more severe
histologic disease are at greater risk for liver-related complications,
in the short term, than those with early disease. A person
with early histologic disease may choose to defer treatment,
awaiting more effective or easier-to-tolerate therapies.
It
is recommended that a biopsy examination be considered in
those who are over the age of 40, those who wish to defer
treatment, or those in whom the risk-benefit of antiviral
therapy is unclear.
Recently, fibrosis indices
calculated by using a combination of biomarkers such as the
Fibrotest
(Fibrosure; Biopredictive, Paris, France), Forns’ index, or
the AST/platelet
ratio index have been proposed as
an alternative to liver biopsy examination.
These indices appear most
accurate at the extremes of the fibrosis spectrum (minimal
fibrosis and bridging fibrosis/cirrhosis).
The authors conclude, “With
the increased understanding of hepatic fibrogenesis, new biomarkers
of matrix metabolism that predict accurately fibrosis and
risk for fibrosis progression are likely to be identified,
and the future role of the liver biopsy examination in managing
patients with chronic HCV infection is likely to change.”
Recommended
Reading
Bravo
A, Sheth S, Chopra S. Liver biopsy. N Engl J Med 2001;344:
495-500.
Fontana R, Lok A. Noninvasive monitoring of patients with chronic hepatitis
C. Hepatology 2002;36: S57-S64.
Poynard
T, Imbert-Bismut F, Munteanu M. Overview of the diagnostic
value of biochemical markers of liver fibrosis (FibroTest,
HCV FibroSure) and necrosis (ActiTest) in patients with chronic
hepatitis C. Comp Hepatol 2004; 3:8.
Rossi
E, Adams L, Prins A. Validation of the FibroTest biochemical
markers score in assessing liver fibrosis in hepatitis C patients.
Clin Chem 2003;49: 450-454.
07/08/05
Source
W Wong and N Terrault.
Update on Chronic Hepatitis C: Role of Liver Biopsy Examination.
Clinical Gastroenterology and Hepatology 3(6):
507-520. June 2005.
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