1. Approach to medical liver biopsies Dr Behrang Mozayani Consultant Histopathologist Southmead hospital Bristol

2. Indications for biopsy  Abnormal unexplained liver function tests  Evaluation of diagnosis, grade and stage of disease  Unexplained cholestatic liver disease  FUO  Suspected hepatic tumour  Post transplantation

3. Size of biopsy  …biopsy of at least 2-3 cm in length and 16-gauge in calibre is recommended (AASLD position paper)  Current UK standard: minimum 15mm and 6 portal tracts. Often 18 gauge

4. Cases  Most common diagnosis  Should be straight forward  Not always one answer without clinical information

5. Case 1  68 year old female  Abnormal lfts  Episodes of pruritus  AMA positive  Raised alk phos and IgM

6. diagnosis  Primary biliary cirrhosis

7. Case 2  57 year old male  Episodes of Jaundice and pruritus  High alk phos, low GGT  ALTs 200s  Abnormal hepatic duct on MRCP

8. diagnosis  Chronic large duct obstruction  Wider differential

9. Case 3  61 year old male  Generally unwell  ALTs 300s  On hormone therapy for prostate cancer

10. diagnosis  Central perivenulitis/acute hepatitis

11. Case 4  80 year old male  Sudden onset of jaundice  Acutely unwell  Autoantibodies negative

12. diagnosis  Acute hepatitis

13. Case 5  25 year old male  Known UC  Abnormal LFTs

14. diagnosis  Primary sclerosing cholangitis

15. Case 6  54 year old male  Ultrasound suggests cirrhosis  ?cause

16. diagnosis  Steatohepatitis and incomplete cirrhosis

17. Case 7  61 year old female  Feeling tired, poor appetite  ALT 500s  IgG raised  ANA+  Viral serology negative  No drug history

18. diagnosis  Autoimmune hepatitis

19. Case 8  60 year old male  High ferritin in work up  C282Y homocygote  Normal lft’s

20. diagnosis  Genetic haemochromatosis

21. Case 9  64 year old female  Cirrhosis  Heart failure  Abnormal lft’s

22. diagnosis  Cirrhosis ? Aetiology  A1AT deficiency

23. Case 10  22 year old female  Abnormal lfts and fibroscan  Low caeruloplasmin, high serum copper  Chromosome 13 mutation

24. diagnosis  Wilson’s disease