AASLD expert opinion: where liver biopsy still matters

An AASLD Expert Practice Opinion, written by a panel appointed by its guidelines committee after a targeted literature review, restates the place of liver biopsy now that non-invasive tests handle most fibrosis staging.

Biopsy serves three purposes: making a diagnosis when the cause is unclear, staging inflammation or fibrosis when non-invasive results are discordant or indeterminate, and guiding management. Percutaneous biopsy suits most patients. Transjugular biopsy is preferred with ascites or coagulopathy, or when hepatic venous pressure gradient is wanted. EUS-guided biopsy is attractive when endoscopy is already needed for varices or portal pressure measurement. Done by experienced operators, the three approaches appear similar in safety and tissue yield.

The panel is candid about limits: sampling variability, disagreement between pathologists, and procedural risk. This is expert opinion rather than graded guidance, but it is a useful check on when to stop relying on elastography alone.

• Consider biopsy when the cause of liver disease remains unclear after serology and imaging
• Use biopsy when non-invasive fibrosis tests are discordant or indeterminate and the result would change management
• Choose the transjugular route in patients with ascites or significant coagulopathy
• Consider EUS-guided biopsy when endoscopy is already planned for varices
• Ask for an adequate core length and an experienced liver pathologist to limit sampling error

Why it matters

It sets out when tissue still changes management in an era that increasingly relies on elastography.

Don't overread it

This is an expert practice opinion based on a targeted review, not a graded guideline.

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