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Decreasing Liver Biopsy Complications
- Guadalupe Garcia-Tsao, MD;
- James L. Boyer, MD; and
- Peter McPhedren, MD
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IN RESPONSE:
Kovacs and colleagues object to prebiopsy hemostasis screening using prothrombin time increment-over-control and Ivy bleeding time as safety measures. They emphasize the importance of bleeding history and suggest that the prothrombin time INR be substituted for the prothrombin time increment.
We agree that a history taken from an alert, responsive patient, including medication history (especially regarding aspirin and nonsteroidal anti-inflammatory drugs [NSAIDs]) is probably more important than any laboratory test for preoperative or pre-procedure hemostasis. All our patients are specifically instructed not to take aspirin or NSAIDs for at least 10 days before prebiopsy blood tests and the liver biopsy itself. We also agree that INR comparisons should be more useful than our prothrombin time data. For the record, the current ISI in our coagulation laboratory is 2.23; the INR, at 3 seconds over control, would be 1.63.
However, as Kovacs and colleagues indicate, the INR has not yet been established as an effective predictor of surgical bleeding in any predictive test, any more than the prothrombin time, partial thromboplastin time, or bleeding time have been [1, 2]. The laboratory tests all work better in differential diagnosis of the cause of a reported bleeding tendency than they do in predicting bleeding.
It is also true that the bleeding time may not be prolonged in approximately one third of patients taking aspirin; it is not known whether biopsy or surgery is any safer in the patient taking aspirin who has a normal bleeding time than in one who has a prolonged bleeding time. Although Rodgers and Levin's meta-analysis [2] failed to show any predictive value for bleeding times done preoperatively or before procedures such as biopsies, a study of bleeding times using the current technique at this hospital did show a higher frequency of excessive bleeding at surgery in patients with prolonged bleeding times (12%) as compared with controls (4%) [3]. For this reason we continue to use the bleeding time before liver biopsies have been done.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
Include no more than 300 words of text, three authors, and five references
Type with double-spacing
Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright 2004 by the American College of Physicians
