Liver biopsy - when and how?

RE: Liver biopsy - when and how?

Andrew Kent — Fri, 12 Feb 2016 13:45:53 GMT

This was one I did a few weeks ago:

RE: Liver biopsy - when and how?

Thomas Johnson — Fri, 12 Feb 2016 11:24:03 GMT

[quote user="Francisco Gomez"]

[quote user="Thomas Johnson"]

I've not had any problems afterwards.

[/quote]

Have you found the results helpful? I suspect C+S mainly? Would you consider it with a cat with high liver enzimes even if it doesn't abnormal in ultrasound?

[/quote]

The last one I did cultured an E. coli, so was helpful in picking an antibiotic. If the bloods indicated cholestasis but the liver looked normal I would probably still take a bile aspirate.

RE: Liver biopsy - when and how?

Andrew Kent — Fri, 12 Feb 2016 11:18:55 GMT

[quote user="Francisco Gomez"]Never done this - what sort of medical restrain/gauge needle would you use?[/quote]

So needs pretty heavy sedation or GA.

There is a description in the BSAVA procedures guide if you have it - usually use 21-23G needles.

[quote user="Francisco Gomez"]Have you found the results helpful? I suspect C+S mainly? Would you consider it with a cat with high liver enzimes even if it doesn't abnormal in ultrasound?[/quote]

Both cytology and C+S are useful - particularly in cats as they have a high incidence of infectious biliary tract disease. I would do it routinely on any cat I suspect may have cholangitis/cholangiohepatitis.

Andy

RE: Liver biopsy - when and how?

Andrew Kent — Fri, 12 Feb 2016 11:13:45 GMT

[quote user="John Flynn"]1) Is the "cup" on the laparoscopic biopsies mcuh different from the tru-cut in terms of reliability (I've obviously no experience of this)? I'd skimmed a paper in JVIM last year I think it was that talked about "cup" samples (I didn't know what these were at time) and didn't find them more reliable than tru-cut ones when compared to surgically-cut sections at necrospy - although I think these were all single samples rather than multiple sampling.[/quote]

Good question! So I think the reality is that any liver sample is a balance between invasiveness and reliability. The study you mention compared a single needle and cup biopsies to a biopsy that is incompatible with life (i.e. it was a PM study) and we could never take that much liver safely from a live dog so I'm not sure it was that useful. It wasn't compared to a standard surgical biopsy (which is a shame).

And I think its true that any sampling method has limits if you only take one and that some of the other studies more recently have demonstrated that there is often a difference between liver lobes and therefore the number of biopsies is probably most important and that they are from a number of places.

I think it is easier (and safer) to systematically biopsy multiple liver lobes at laparoscopy or open surgery and would be worried about trying to do that with a trucut needle.

[quote user="John Flynn"]2) What is the current recommended treatment for a Mini Schnauz with idiopathic hypertriglyceridemia as cause of cholestasis? I'm guessing given the high fasting cholesterol that the triglycerides will be high in this case also and have already checked that ACTH stim was normal and T4/TSH was OK-ish (there were some skin changes also). Are we just talking dietary management with ultra-low fat diet?[/quote]

So I would start with an ultra low dat diet (RC GI low fat or Hills I/D low fat) plus ursodeoxycholic acid plus omega 3 supplementation (this supposedly reduces lipoprotein synthesis). If thats not working in a month (i.e. fasting trigs still v high) then people will often try gemfibrozil. There are a few other options if that then doesn't work.

[quote user="John Flynn"]3) What is the best resource you know of to read to get up-to-date on current thoughts on liver disease diagnosis and treatment in dogs?[/quote]

Difficult one - I'm not sure there is an single resource that covers everything. Kirk's current veterinary therapy (most recent edition) has some good chapters on aspects of liver disease and there are some good review articles around as well (on things like portal hypertension, chronic hepatitis etc). But I don't think there is any single book that covers everything!

Andy

RE: Liver biopsy - when and how?

Francisco Gomez — Fri, 12 Feb 2016 11:12:39 GMT

[quote user="Thomas Johnson"]

I've not had any problems afterwards.

[/quote]

Have you found the results helpful? I suspect C+S mainly? Would you consider it with a cat with high liver enzimes even if it doesn't abnormal in ultrasound?

RE: Liver biopsy - when and how?

Thomas Johnson — Fri, 12 Feb 2016 11:06:03 GMT

[quote user="Francisco Gomez"]

[quote user="Andrew Kent"]

And yes bile aspirate very safe with ultrasound, gets harder as the dog gets bigger and I would still go through liver as you do at surgery. I don't do it if there are significant GB wall changes as I worry it might not seal well but otherwise find it useful.

[/quote]

Never done this - what sort of medical restrain/gauge needle would you use?

[/quote]

I've done this a few times in cats with a 22 gauge 1 inch needle, I've not had any problems afterwards.

RE: Liver biopsy - when and how?

Francisco Gomez — Fri, 12 Feb 2016 10:45:09 GMT

[quote user="Andrew Kent"]

[/quote]

Never done this - what sort of medical restrain/gauge needle would you use?

RE: Liver biopsy - when and how?

John Flynn — Fri, 12 Feb 2016 10:28:13 GMT

Fantastic, Andy - helpful as always!

Two further Q's:

1) Is the "cup" on the laparoscopic biopsies mcuh different from the tru-cut in terms of reliability (I've obviously no experience of this)? I'd skimmed a paper in JVIM last year I think it was that talked about "cup" samples (I didn't know what these were at time) and didn't find them more reliable than tru-cut ones when compared to surgically-cut sections at necrospy - although I think these were all single samples rather than multiple sampling.

2) What is the current recommended treatment for a Mini Schnauz with idiopathic hypertriglyceridemia as cause of cholestasis? I'm guessing given the high fasting cholesterol that the triglycerides will be high in this case also and have already checked that ACTH stim was normal and T4/TSH was OK-ish (there were some skin changes also). Are we just talking dietary management with ultra-low fat diet?

3) What is the best resource you know of to read to get up-to-date on current thoughts on liver disease diagnosis and treatment in dogs?

Many thanks!

RE: Liver biopsy - when and how?

Andrew Kent — Fri, 12 Feb 2016 09:09:27 GMT

Hi John,

The how is the easy (ish) bit. I pretty much never do trucut biopsies for the reasons you describe, I have seen a number of cases where trucuts were subsequently repeated with another method and the initial diagnosis proved wrong. So the only time I might do it is with a focal lesion on ultrasound that I want a sample of.

Most of my liver biopsies are done laparoscopically and its one of the procedures where I really think this is superior as access around the liver is so much better. It uses large cupped forceps to take chunks from the edge of a number of lobes and can also guide bile aspiration.

But I think you can get good samples at surgery and, as you describe, take the tips of multiple lobes plus focal sampling of any lesions. But the evidence does suggest that lobes can differ so we should sample as many as possible.

I submit most of my samples in formalin and then keep one frozen myself to submit for copper quantification of the histo suggests this will be useful.

In terms of pathologist - this is not an exhaustive list so I am sure there are many good options - my logic is that I use pathologists that are actively involved in liver pathology research as they are likely to be most up to date with the area, so I use either Bridge pathology or Cambridge Vet School Pathology Service. But, I am sure there are other good places!

The when is harder and more a matter of opinion - for me the changes need to be persistent (so usually continuing for weeks-months - with the exception that we occasionally biopsy acute cases if things are not going well) and I tend to only do it if I can't explain the changes through imaging, with an extra-hepatic cause.

So in your example it sounds like the bloods and imaging fit with chronic cholestasis so I would be unlikely to biopsy initially - if its a Mini Schnauz I would check triglycerides if you haven't done so - idiopathic hypertriglyceridaemia is the number one cause of cholestasis in the Mini Schnauzers I see.

Hope that helps - would be interested to hear if other people are doing it differently or would like to recommend other pathologists!

Andy