Liver cirrhosisDetlef Schuppan, Nezam H Afdhal

Prepared by:Prepared by:Dr.Mohammad Shaikhani.Dr.Mohammad Shaikhani.

Assistant professor.Assistant professor.

Sulaimani UniversitySulaimani UniversityCollege of Medicine.College of Medicine.

Liver BiopsyLiver BiopsyThe Reference The Reference Standard for Standard for

FibrosisFibrosis

Why measure fibrosis?Why measure fibrosis?

• Assessment of disease– Diagnosis– Prognosis– Treatment decisions

• Monitoring disease– Natural history– Treatment effects– Drug development

Cross-sectional

Dynamic change over time

Disadvantages of Liver BiopsyDisadvantages of Liver Biopsy• Hazard to the patient• Resource usage

– Bed– Imaging– Staff– Processing

• Interpretation

• Sampling error– 1/50,000 of the liver– Fibrosis not evenly distributed

• 20% error in scoring

Time

Liver biopsy: advantagesLiver biopsy: advantages

• Provides information about numerous variables:

• Tissue architectural changes

• Necroinflammatory injury

• Fibrotic stage

• Alterations of parenchyma/ bile duct epithelium

• Accumulation of fat, copper, iron;molecular / genetic changes.

• Liver biopsy may identify multiple disease etiologies.

Ideal markers of fibrosisIdeal markers of fibrosis

• Performed on a serum or urine sample• Test cheap and relatively easy• A continuous variable

– Allows distinction of small changes• Correlates with fibrosis over full range

– Accurate for all comparisons• Provides clinically meaningful data

– Prognostic information and treatment response

Serum markers of LF:Serum markers of LF:

• Serum markers of liver fibrosis accurately predict liver related death over 5-8 years follow-up

• Performance is at least as good as histology

Other Tests for FibrosisOther Tests for Fibrosis

• Fibroelastogram– Ultrasound – Caution in obesity

• Micro bubbles– Performed with imaging– Invasive

• MRI– Additional information– Costly

Composite TestsComposite Tests

• Biopsy

+

• Non-invasive markers– Selective thresholds

+• Imaging

Non-invasive evaluation of liver fibrosis: Non-invasive evaluation of liver fibrosis: advantagesadvantages

• Liver biopsy– Hazardous, inaccurate

• Serum Markers– Safe, non-invasive, Accurate

• Are serum markers sufficient?– Correlate with histology– Predictive of long term outcome– Repeatable– Fibrosis may be targeted early before

advanced cirrhosis occurs.

Non or minimally invasive alternatives for liver biopsy include: Clinical indices Cross-sectional imaging Serum biomarkers Liver stiffness measurement Portal pressure measurement.

Most alternatives assess one aspect of liver disease&translate it into a numeric score. Overlap between categories may limit applications. A single numeric score cannot be a substitute for complete histologic assessment. Within defined clinical contexts, noninvasive assessment is an attractive alternative & a validated contributer to clin management. Serum biomarkers& liver stiffness assessment may become indispensable in longitudinal studies& to document trt outcomes. The accuracy of the more reliable techniques is around 80%.