Percutaneous Liver Biopsy

Updated: Oct 12, 2015
  • Author: Gaurav Arora, MD, MS; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

Percutaneous liver biopsy is a procedure in which a long needle is introduced through the skin, subcutaneous tissues, intercostal muscles, and peritoneum into the liver to obtain a specimen of liver tissue. [1, 2] This procedure is usually performed on an outpatient basis. The patient is then observed for a few hours in the hospital or the ambulatory unit.

The liver biopsy needle used can be one of the following three types:

  • Cutting needle
  • Suction needle (discussed in this article)
  • Spring-loaded needle

This topic focuses on the technical aspects of performing a percutaneous liver biopsy. For a more detailed discussion of the theoretical aspects, see Diagnostic Liver Biopsy.

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Indications

Indications related to initial diagnosis include the following:

  • Evaluation of abnormal liver test results, if all other workup is unrevealing [3]
  • Determination of stage of fibrosis and grade of inflammation for chronic hepatitis B and hepatitis C [4]
  • Evaluation of autoimmune hepatitis
  • Evaluation of a liver mass that does not exhibit typical imaging features of hepatocellular carcinoma (HCC)
  • Quantitative estimation of iron in hemochromatosis
  • Quantitative estimation of copper in Wilson disease
  • Estimation of the severity of alcoholic liver disease
  • Evaluation of drug toxicity
  • Evaluation of the suitability of a donor liver for transplantation
  • Diagnosis and staging of nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH)
  • Evaluation of unexplained jaundice
  • Diagnosis of cholestatic liver disease
  • Evaluation of infiltrative or granulomatous disorders
  • Evaluation of liver injury from immunosuppressive agents (methotrexate)

Indications related to surveiilance during treatment include the following:

  • Follow-up evaluation while on antiviral treatment for chronic hepatitis C (rare)
  • Monitoring of disease activity of autoimmune hepatitis during treatment (may assist in determining if therapy can be discontinued)

Indications relevant to the patient who has undergone a liver transplant include the following:

  • Diagnosis of acute cellular rejection
  • Diagnosis of chronic rejection
  • Diagnosis of recurrent hepatitis C
  • Diagnosis of cytomegalovirus (CMV) hepatitis
  • Protocol biopsies to monitor for fibrosis or inflammation (particularly in patients who received liver transplants to treat liver failure in chronic hepatitis C)
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Contraindications

Contraindications include the following:

  • Uncooperative patient [5]
  • Inability to identify a suitable biopsy site by either percussion or ultrasonographic guidance
  • Prolonged (>1.5) international normalized ratio (INR) [6]
  • Decreased platelet count (<60,000/μL)
  • Bleeding diathesis (eg, hemophilia)
  • Recent use (within the last 7 days) of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) or antiplatelet class of medications
  • Unavailability of blood products for transfusion
  • Morbid obesity of patient
  • Ascites
  • No backup support available from surgery or interventional radiology in case of a complication
  • Suspected hemangioma or hepatic echinococcal cysts
  • Abdominal wall infection over the identified biopsy site
  • Infection in the right pleural cavity or below the right hemidiaphragm
  • Bowel overlying biopsy site (on ultrasonography or other abdominal imaging)
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Technical Considerations

Best practices

Generally, performance of percutaneous liver biopsy should adhere to the following guidelines, which are modified from the American Gastroenterological Association’s 1989 position statement [7] :

  • The patient must be able to easily return to the hospital where the procedure was performed within 30 minutes of developing any adverse symptoms
  • A reliable individual must be available to stay with the patient during the first night after the liver biopsy and provide care and transportation to the hospital, if necessary
  • The patient should not have any preexisting serious medical problems that might increase the risk of complications from the biopsy (eg, encephalopathy, ascites, liver failure with severe jaundice, significant extrahepatic obstruction, significant coagulopathies, or serious comorbidities such as severe congestive heart failure); also, patients should not be very old, very young, or so anxious that they require sedation
  • The facility where the biopsy is to be performed should have an approved laboratory, blood banking unit, easy access to an inpatient bed, and personnel to monitor the patient for 6 hours after the biopsy (however, according to recommendations from the American Association for the Study of Liver Diseases [AASLD], a period of 2-4 hours may suffice [8] )
  • The patient should be hospitalized after biopsy if any evidence exists of bleeding, bile leak, pneumothorax, or other organ puncture; hospitalization is suggested if the patient’s pain requires more than one dose of an analgesic in the first 4 hours after the biopsy
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