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Diagnostic Liver Biopsy

  • Author: Kenneth Ingram, PA-C; Chief Editor: Julian Katz, MD  more...
Updated: Oct 12, 2015


Practiced since the late 19th century, liver biopsy remains the criterion standard in the evaluation of the etiology and extent of disease of the liver. Paul Ehrlich performed a percutaneous liver biopsy in Germany in 1883. In the late 1950s, Menghini developed a 1-second aspiration technique, which led to wider use of the procedure and broadened its applications.

Since Menghini, the evolution of liver biopsy has been extensive. At present, percutaneous biopsies are performed primarily by specialists in gastroenterology/hepatology or by radiologists.

A variety of approaches may be utilized for obtaining a liver tissue specimen. These include a blind percutaneous approach after percussion of the chest wall, biopsy under the guidance of ultrasonography or computed tomography (CT), intravascular tissue sampling via the hepatic vein, and intra-abdominal biopsy at laparoscopy or laparotomy.[1]  An endoscopic ultrasound-guided approach has been described.[2]

The choice of one technique over another is based on availability, personal preference, and the clinical situation. Likewise, various needles are available for use, depending on the approach and on physician experience.

Some controversy remains as to what constitutes an adequate liver biopsy sample for accurate evaluation. In general, a sample that is 1.5 cm long and 1.2-2 mm in diameter and contains at least six to eight portal triads is considered adequate. This represents approximately 0.002% of the adult liver. Some hepatologists have advocated the use of 4-cm tissue samples to minimize sampling error, whereas others have found samples of 1 cm to produce minimal interobserver variability.[3]

Although liver biopsy is generally safe and is currently considered the criterion standard for the evaluation of hepatic inflammation and fibrosis, sampling error, rare complications, and, occasionally, significant patient anxiety do occur. These factors have led to keen interest in the development of noninvasive tests for hepatic fibrosis,[4, 5] some of which are now commercially available in the United States.

Although these tests hold promise for reducing the need for liver biopsy, most hepatologists feel that their clinical usefulness is limited at this time. The available tests appear to perform well at the extreme ends of the spectrum of chronic liver disease, but results vary considerably in the intermediate stages of disease frequently seen in clinical practice. Lack of validation of these tests in the community settings where they would most likely be used is also a potential shortcoming of the current testing methods.



Liver biopsy, in combination with history and physical examination data, is a powerful clinical tool for diagnosing and treating liver disease. Indications for obtaining a biopsy specimen, divided according to the type of clinical question framed, are as follows:

  • Evaluation of abnormal hepatic laboratory test results
  • Confirmation of diagnosis and prognostication
  • Suspected hepatic neoplasm
  • Evaluation of infiltrative or granulomatous disease
  • Following a case of liver transplantation to evaluate and manage rejection
  • To evaluate unexplained jaundice or suspected drug reactions

The biopsy specimen may be used to identify or exclude possible etiologies for physical or laboratory abnormalities. Although various disease states may present similarly, diagnostic histologic patterns exist when used in the context of clinical presentation. For example, infiltration of the hepatic parenchyma by fat may exist in diseases due to alcohol abuse, hepatitis C, diabetes, obesity, or combinations thereof. For each disease state, histologic clues exist that distinguish one from the other.[6, 7, 8]

Liver biopsy plays little role in the determination of the organism responsible for systemic infection because blood cultures generally are revealing. The notable exceptions are intrahepatic tuberculosis and Mycobacterium avium complex (MAC).

Another indication for biopsy is the determination of the extent of histologic change present in a biopsy specimen. This involves scoring systems for the degrees of inflammation and fibrosis noted by the pathologist. Many systems exist for describing the microscopic findings, ranging from simplistic to complex. The majority of scoring systems report the degree of inflammation as the grade of the disease and the amount of fibrosis as the stage. An example here would be the finding of moderate inflammation (grade 3) in a specimen from a cirrhotic (stage 4) liver.

The third set of indications is the monitoring of the progression of disease or of treatment efficacy. For example, liver biopsy specimens frequently are used to evaluate and treat rejection following liver transplantation. Repeated biopsies are used less frequently to monitor progression of diseases such as primary biliary cirrhosis, chronic hepatitis C,[9] or alcoholic liver disease.

Regardless of the indication for the biopsy, identifying which information the procedure is anticipated to yield is important.



Contraindications to percutaneous liver biopsy are relatively few, but identifying contraindications is important to avoid the major complications associated with the procedure. Contraindications to liver biopsy include the following:

  • Increased prothrombin time (PT), international normalized ratio (INR) greater than 1.6
  • Thrombocytopenia, platelet count lower than 60,000/μL
  • Ascites ( transjugular route preferred) [10]
  • Difficult body habitus (transjugular route preferred)
  • Suspected hemangioma
  • Suspected echinococcal infection
  • Uncooperative patient
Contributor Information and Disclosures

Kenneth Ingram, PA-C Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health and Science University School of Medicine

Disclosure: Nothing to disclose.


Kenneth D Flora, MD Adjunct Associate Professor of Medicine, Division of Gastroenterology and Hepatology, Oregon Health Sciences University School of Medicine; Consulting Staff, Department of Gastroenterology, The Oregon Clinic

Kenneth D Flora, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association

Disclosure: Nothing to disclose.

Atif Zaman, MD, MPH Associate Professor, Department of Gastroenterology and Hepatology, Department of Public Health and Preventive Medicine, Oregon Health and Science University

Atif Zaman, MD, MPH is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Oregon Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Robert J Fingerote, MD, MSc, FRCPC Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Ontario

Robert J Fingerote, MD, MSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Association

Disclosure: Nothing to disclose.


Medscape Reference thanks George Y Wu, MD, PhD, Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine, for assistance with the video contribution to this article.

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Biopsy needle inside the liver.
Patient lying on right side.
Ultrasonography of the liver.
Marking the biopsy site.
Sterile drape application.
Percussion over the liver.
Preparing the field.
Ultrasound-assisted percutaneous liver biopsy. Video courtesy of George Y Wu, MD, PhD.
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