Melvin Lau, MD Series Editor: Richard W. Goodgame, MD


April 09, 2008

Further Diagnostic Work-Up

The CT scan shows ascites, but no evidence of biliary obstruction. Therefore, neither ERCP nor MRCP is a priority in the diagnostic evaluation. To pursue the likely diagnosis of infiltrative liver disease, a liver biopsy is crucial. The option of whether to perform a renal biopsy instead rests on the possibility that a systemic disease, such as amyloidosis, is causing both the hepatic and renal diseases. However, hemostatic abnormalities are common in amyloidosis.[11] In their recent review, Sucker and colleagues[11] report that both acquired hemostatic abnormalities (coagulation factor deficiencies, fibrinolysis, and platelet dysfunction) and amyloid angiopathy (fragility of blood vessels and impaired vasoconstriction) may lead to increased risk of bleeding. Spontaneous bleeding into the brain, gastrointestinal tract, or skin occurs in patients with amyloidosis.[12]

Needle biopsy of solid organs for diagnosis of amyloidosis has been associated with an increased risk of hemorrhagic complications.[12] If amyloidosis is a strong possibility, then it may be preferable to make the diagnosis through safer means, such as through abdominal fat biopsy or rectal biopsy.[13] Biopsy of these sites has an 80% sensitivity for confirming the presence of amyloidosis.[13] The most systematic study on the problem of biopsy-related bleeding was published by Eiro and colleagues.[14] In a prospective study of 394 consecutive needle biopsies of the kidney, they found that bleeding complications were rare, but were positively correlated with a diagnosis of amyloidosis. Sucker and colleagues[11] maintain that if an effort is made to identify and treat all specific hemostatic defects, the risk associated with biopsy can be reduced. This is consistent with the earlier observation that all patients with bleeding after biopsy had abnormal coagulation tests or clinically obvious bleeding before the biopsy was performed.[12] In the absence of such hemorrhagic features, liver biopsy is associated with a low (4%) bleeding rate and no fatalities.[7]

The risk/benefit assessment of diagnostic liver biopsy would involve something along the lines of the following: If amyloidosis seems to be the likely cause of the liver disease and a fat or rectal biopsy showing amyloid deposition could be taken as evidence of hepatic amyloidosis, then this would be the preferred strategy. But if the differential diagnosis remains broad and there is no clinical or laboratory evidence of bleeding or coagulopathy, then liver biopsy should be performed.


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