Liver biopsy and acute hepatology in intensive care unit patients

Besides hepatic impairment in critical illness and sepsis, patients with specific liver diseases such as acute liver failure (ALF), alcohol-associated hepatitis (AAH), liver cirrhosis with acute decompensation or acute-on-chronic liver failure (ACLF) regularly requires management in intensive care. Uncertainties exist, if and when liver biopsy is needed for diagnosis and treatment at the intensive care unit (ICU).

We review the role of liver biopsy in the diagnostic workup of liver dysfunction and organ failure at the ICU. We summarize the recommended indications by international guidelines, preferred biopsy techniques and add clinical experience from our tertiary liver center.

The diagnostic workup of liver failure should be performed at specialized hepatology centers. Several conditions of suspected liver disease, particularly ALF, AAH, autoimmune hepatitis, and ACLF, may benefit for prognosis assessment and treatment decisions from liver histology. However, biopsy results need to consider the clinical context and require center expertise. In comparison to percutaneous approaches, transjugular liver biopsy is generally preferred due to lower procedure-related risks and acceptable tissue yield. Mini-laparoscopy or endoscopic ultrasound (EUS)-guided biopsy might be alternatives. Scientific evidence for liver biopsy in intensive care medicine is quite scarce, necessitating further research on clinical algorithms.