Will liver biopsy become obsolete in the near future?

Introduction: Liver biopsy forms the core of hepatopathology by providing tissue suitable for light microscopic, histochemical, immunochemical, ultrastructural and molecular biological studies. The possibility of the liver biopsy being obsolete will be discussed in this oration with evidence for and against this proposition being presented including our own experience and research.
The case for liver biopsy becoming obsolete: The case for the liver biopsy becoming obsolete includes, complications of liver biopsy, the inadequacy of liver tissue for assessment, the variability in the histopathological diagnoses and the availability of non-invasive markers for the assessment of liver disease. In considering the latter, a part of study 1, “The value of Brunt scoring in predicting the short-term outcome of non-alcoholic steatohepatitis”, will be used to illustrate that there is moderate concordance between transaminase levels and the histological grade assessed by BRUNT scoring used in monitoring the underlying disease activity in non-alcoholic steatohepatitis (NASH). Study 2, “The histomorphological patterns of liver disease in a cohort of Sri Lankan children”, assessed the diagnostic approach to paediatric liver disease based on histomorphological patterns adopted in the local context in the absence of electron microscopic facilities, sophisticated enzyme assays, biochemical investigations and genetic testing that aid in the diagnosis of paediatric liver disease especially the metabolic hepatopathies. Study 3, “Evaluating the usefulness of liver biopsy in the paediatric population”, investigated the implications of the above approach on diagnosis and management of children with liver disease. In this study, 92% (56/61) of biopsy reports were shown to have a significant impact on the diagnosis and management of paediatric liver diseases. In assessing the adequacy of liver tissue obtained for histological examination, study 4 revealed that only 29 biopsies (33.7%) fulfilled both criteria of being more than 1 cm in length and having more than 6 complete portal tracts which was the recommendation given by Royal College of Pathologists of the United Kingdom. It was also revealed that the correlation between the length of the biopsy and the number of complete portal tracts present, was weak.
The case against liver biopsy becoming obsolete: The contribution of the liver biopsy in routine clinical practice as well as in research, such as in raising the awareness and describing emerging entities are described to support the case against the obsolescence of liver biopsy. Study 5 evaluates the usefulness of liver biopsies in adults and the findings reveal that 84.7% (98% CI-79.8%- 89.6%) of the biopsy reports made a significant contribution to the management of patients with liver disease. In study 6, the clinical, biochemical and histological profile of 100 NASH patients and the short term follow up and outcome of patients following lifestyle modification are described. This is the first reported series of NASH patients in a Sri Lanka. Despite cirrhosis in children due to non-alcoholic fatty liver disease (NAFLD) being considered extremely rare in the Asia Pacific region in 2008, study 7 describes five children with advanced fibrosis and cirrhosis due to NAFLD in a preliminary report. A case report titled “Worsening cholestasis and possible cefuroxime-induced liver injury following successful therapeutic endoscopic retrograde cholangiopancreaticography for distal common bile duct stone” is presented to illustrate the value of liver biopsy in establishing the diagnosis in situations where multiple causes could account for the clinical picture. Finally, in Study 8, two audits of liver biopsies conducted in our institution during the periods 2012 - 2015 and 2019 - 2022 are presented as evidence that the number of liver biopsies performed and reported have not decreased.
In conclusion, despite the many draw backs of liver biopsy and the availability of several non-invasive markers of liver disease, there still appears to be a definite role for liver biopsy in clinical practice as well as in providing insights into and enhancing the awareness of liver diseases. It, therefore, appears unlikely that liver biopsy will become obsolete in the near future.