Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.

There has been little research into the socioeconomic burden associated with non-alcoholic steatohepatitis (NASH). Direct medical, direct non-medical and indirect costs resulting from NASH were captured in a realworld setting. Extrapolating the per-patient cost to a population level demonstrates the rising prevalence of NASH and related comorbidities. Lay summary There has been little research into the socioeconomic burden associated with non-alcoholic steatohepatitis (NASH). The GAIN study provides real-world data on the direct medical, direct non-medical, and indirect costs associated with NASH, including patientreported outcomes in five European countries (UK, France, Germany, Spain, and Italy) and the USA. Mean total annual per patient cost of NASH was estimated at V2,763, V4,917, and V5,509 for the direct medical, direct non-medical, and indirect cost categories, respectively.

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BackgroundLiver disease is an increasing cause of premature mortality in the UK. Its management in primary care is not well understood. It is unclear what role commissioning bodies are playing in liver disease in the UK.AimThe aim of this study was to assess the level of engagement with community chronic liver disease management amongst CCGs and health authorities across the UK.Design & settingA cross-sectional survey to all UK CCGs and health authorities.MethodSurvey questions were developed by the British Liver Trust, in collaboration with topic experts, and evaluated structures in place relating to liver disease management at commissioning/health board level.ResultsThere were 159 responses representing 99% UK coverage of CCGs/health boards. 20% reported an individual responsible for liver disease within their organisation with 40% and 29% reporting having pathways in place to respond to abnormal liver blood tests and liver disease more generally respectively. All those reporting use of pathways reported using national guidelines to guide content. 25% made use of transient elastography (Fibroscan) and 16% of direct serum fibrosis markers (eg, ELF score) which are both part of current NICE guidelines. There was marked regional variation in all areas of engagement surveyed, with Wales having exceptionally high levels of engagement in all areas in contrast to the other nations.ConclusionThe results of this survey should be used as a catalyst to highlight necessary regional improvements to the primary care management of chronic liver disease across the UK.