Transjugular Liver Biopsy

Updated: Jan 25, 2016
  • Author: Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR; Chief Editor: Justin A Siegal, MD  more...
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Overview

Background

Transjugular liver biopsy was first described in 1967 and is now an accepted method of liver biopsy when the percutaneous technique is contraindicated. [1] Some clinicians have considered this technique to be inferior to the percutaneous technique on the grounds that it yields an inadequate sample. [2, 3, 4] This disadvantage has been overcome over the years by using 18-gauge or larger Tru-Cut biopsy needles and by obtaining more than one core. [5, 6]

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Indications

Transjugular liver biopsy is indicated for patients with diffuse liver disease who need a biopsy and have one or more of the following [7, 8] :

  • Deranged coagulation [9]
  • Massive ascites
  • Liver abnormalities such as peliosis hepatitis
  • In combination with transjugular intrahepatic portosystemic shunt (TIPSS) or venography
  • Any other contraindication for percutaneous biopsy
  • Failed percutaneous biopsy
  • Morbid obesity
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Contraindications

No specific contraindications exist for transjugular liver biopsy, but attempts should be made to correct coagulation derangements before proceeding. Lack of venous access is a limitation for this procedure. This technique should not be used in assessing focal liver lesions.

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Technical Considerations

Anatomic considerations

Puncture of the right internal jugular vein is preferred because the right-side approach offers a straighter route for the 7-French sheath and metal guide. Alternate sites, such as the left internal jugular vein and the inferior vena cava, have also been used. [10]  The internal jugular vein lies anterior and lateral to the carotid artery. A low puncture increases the risk of pneumothorax, and a high puncture increases the risk of arterial puncture, as the artery now lies posterior to the vein; thus, a puncture in the middle portion of the internal jugular vein is ideal. [11]

Entry into the right hepatic vein is recommended because sufficient liver tissue is available anteriorly, and the metal guide can easily be directed anteriorly. If the middle hepatic vein is entered, it is important to ensure that the guide is turned posteriorly.

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