title: Indications of Liver Biopsy in the Era of Noninvasive Assessment of Liver Fibrosis.
abstract: BACKGROUND
  Liver biopsy (LB) has been used as diagnostic modality in liver diseases (LD). Over last two decades, there has been remarkable improvement in understanding of natural history, molecular diagnostics of viral hepatitis, genetic of LD, and also limitations of LB. There is current trend in avoiding LB in the management of various LDs.
  
  
  OBJECTIVE
  To determine utility of LB in clinical practice.
  
  
  METHODS
  In a prospective study, 2413 patients of LD were followed up, 219 (9%) were acute, and remaining 2194 (90.9%) were chronic LD. Patients were evaluated by biochemical parameters, virological studies, and imaging endoscopy as and when required. LB was performed in 176 (7.2%) patients when no conclusion could be drawn from the noninvasive workup. Patients with platelet count <50,000/cm(2), ascites, and overt bleeding were excluded. Patients with international normalization ratio (INR) more than 1.5 were not excluded. No prophylactic use of fresh frozen plasma and platelet transfusion was done. There was no major complication related to the procedure. Indications for LB were as follows: cryptogenic LD 38 cases, hepatitis B infection 35, suspected autoimmune hepatitis 30, mass lesion in the liver and lymphoma 29, evaluation of portal hypertension 15, elevated liver enzymes 11, hepatitis C infection 9, and drug-induced LD 4, and miscellaneous 5 cases which were primary biliary cholangitis, primary sclerosing cholangitis, cholestatic LD, sarcoidosis, and amyloidosis.
  
  
  RESULTS
  LB changed the diagnosis in 55 (31.2%). These were cryptogenic LD in 24 cases, portal hypertension 15, elevated liver enzymes 11, and 5 others. In remaining, LB confirmed clinical diagnosis and helped in making management decisions.
  
  
  CONCLUSIONS
  LB was required in 7.2% of patients with chronic LD. In 31.2% cases, LB changed the diagnosis. LB was a safe procedure even in presence of low platelet count and abnormal INR.
authors.affiliation: Bombay Hospital and Medical Research Centre, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Amarapurkar
authors.affiliation: SRL Dr Avinash Phadke Laboratory, Mumbai, India.
authors.forename: Anjali
authors.initials: A
authors.lastname: Amarapurkar
keywords: AIH, autoimmune hepatitis; APRI, aspartate transaminases to platelet ratio index; CMV, cytomegalovirus; EBV, Epstein bar virus; HCC, hepatocellular carcinoma; HEV, hepatitis E virus; INCPH, idiopathic noncirrhotic portal hypertension; LB, liver biopsy; LD, liver disease; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; NRH, nodular regenerative hyperplasia; autoimmune hepatitis; cryptogenic cirrhosis; noncirrhotic portal hypertension; steatohepatitis