SHORT REPORT Liver biopsy for parenchymal liver disease—Is routine real time image guidance unnecessary? Anil John & Saad Al Kaabi & Madiha Emran Soofi & Muneera Mohannadi & Salva Manam Kandath & Moataz Derbala & Rafie Yakoub & Esra Mohammed Al-Ahdal & Manik Sharma & Hamid Wani & Nazeeh Dweik & Anjum John & Mohammed Tariq Butt Received: 18 May 2013 /Accepted: 20 August 2013 /Published online: 19 September 2013 # Indian Society of Gastroenterology 2013 Abstract Liver biopsy even today remains the standard of care for grading and staging chronic hepatitis despite advances in noninvasive markers of liver fibrosis. Literature suggests an expanding role for real-time image guided liver biopsy and declining trend for blind liver biopsies. In our center, where we perform around 400 liver biopsies per year, we performed a prospective clinical audit of our practice of blind outpatient percutaneous liver biopsies. Patients requiring histological grading and staging of chronic hepatitis routinely undergo blind outpatient percutaneous liver biopsies in our endoscopy unit unless there is a definite indication for real-time image guidance. All procedures were assessed for safety, and all specimens were evaluated by a specimen quality grading score for adequacy for grading and staging of chronic hepati- tis. Of the 446 patients referred for histological grading and staging of chronic hepatitis C by liver biopsy, only 42 patients (9.5 %) required real-time ultrasound for liver biopsy. The remaining 404 patients underwent blind outpatient percutane- ous liver biopsies which were found to be extremely safe with no major complications, yielding adequate liver tissue with high specimen quality score allowing optimal grading and staging of chronic hepatitis. Keywords Complications . Percutaneous biopsy . Quality assurance Introduction Despite advances in assessing liver fibrosis by noninvasive markers and techniques, liver biopsy even today remains the standard of care for obtaining hepatic tissue for histopathological grading and staging of chronic hepatitis. The role of liver biopsy assumes more relevance in the current era of newer treatments for chronic hepatitis B and C and in this age of liver transplantation. Our unit has been performing on an average around 400 liver biopsies per year since the late 1990s as part of the diagnostic evaluation of patients with mostly chronic hepatitis C, who receive subsidized state funded antiviral treatment with pegylated interferon and ribavirin [1]. In view of the large volumes of patients for liver biopsy, we have been following the practice of blind biopsies by gastroenterologists as an outpatient bedside procedure reserving real time image guid- ance for specific indications and situations like morbid obesity, presence of incidental focal liver lesions, post-liver transplant state, anatomical variations, or in the event of failure to aspirate liver tissue by blind technique or in any clinical situation where the point of maximum liver dullness cannot be percussed out and marked. Image guided liver biopsy is performed by inter- ventional radiologists in our institution and has a long waiting time in our overburdened radiology suite and incurs the extra cost of real time imaging by ultrasonography. We prospectively audited the safety and histological ade- quacy of our practice of blind non-image-guided biopsies for chronic parenchymal liver disease as an outpatient bedside procedure with discharge after an observation period of 4 h. Methods Division of Gastroenterology and Hepatology had received 446 patients referred for liver biopsy for grading and staging of chronic hepatitis during the 1-year period from June 2010 to A. John (*) : S. Al Kaabi : M. Mohannadi : M. Derbala : R. Yakoub : M. Sharma : H. Wani : N. Dweik : M. T. Butt Department of Gastroenterology, Hamad Medical Corporation, Doha, Qatar e-mail: aniljohn44@gmail.com M. E. Soofi : S. M. Kandath : E. M. Al-Ahdal Department of Pathology, Hamad Medical Corporation, Doha, Qatar A. John Medical Research Center, Hamad Medical Corporation, Doha, Qatar Indian J Gastroenterol (January–February 2014) 33(1):50–54 DOI 10.1007/s12664-013-0393-3