Patient Education and Consent

Obtain written consent, using the appropriate patient consent form. Explain the benefits and risks of the procedure to the patient, and make sure that he or she understands them well.

Equipment

Sterile gloves are required.

A liver biopsy tray should be available that contains the following items (see the image below):

Core biopsy needle, preferably 16 gauge, 11.5 cm
Povidone-iodine solution
Formalin bottle (specimen container)
Injection needle, 21 gauge, 3.75 cm
Injection needle, 25 gauge, 2.5 cm
Sterile drape(s)
Saline solution (0.9%), 10-mL ampule
Surgical scalpel blade
Gauze pads, 7.5 × 7.5 cm

Percutaneous liver biopsy. Liver biopsy tray.

View Media Gallery

Appropriate vials should be available for cultures and special stains, if indicated.

A study comparing the adequacy rates of the BioPince (Argon Medical, Frisco, TX; n = 53) 16-gauge and Achieve (Becton Dickinson, Franklin Lakes, NJ; n = 141) 18-gauge biopsy needles for percutaneous liver biopsy in patients with parenchymal liver disease found that the BioPince needle acquired a significantly greater total core length and a great number of portal tracts, with significantly improved adequacy rates and no major complications.^[12]

Anesthesia

Local anesthesia with 1% or 2% lidocaine is used. Some anxious patients may require a small oral or intravenous dose of a benzodiazepine (eg, lorazepam). In rare cases, consideration may be given for the use of procedural sedation (eg, midazolam and fentanyl). Overnight fasting by the patient is usually required prior to the procedure.

Positioning

The patient should be supine, with his or her right side near the edge of the bed. The patient’s right arm should be above the head. The feet should be angled across the bed to expand the intercostal space as much as possible. Adjust the height of the bed for comfort; the optimal position is usually at or slightly below the level of the operator's elbows.

Technique

Karamshi M. Performing a percutaneous liver biopsy in parenchymal liver diseases. Br J Nurs. 2008 Jun 26-Jul 9. 17 (12):746-52. [QxMD MEDLINE Link].
Myers RP, Fong A, Shaheen AA. Utilization rates, complications and costs of percutaneous liver biopsy: a population-based study including 4275 biopsies. Liver Int. 2008 May. 28 (5):705-12. [QxMD MEDLINE Link].
Almeida P, Schreiber RA, Liang J, Mujawar Q, Guttman OR. Clinical Characteristics and Complications of Pediatric Liver Biopsy: A Single Centre Experience. Ann Hepatol. 2017 Sep-Oct. 16 (5):797-801. [QxMD MEDLINE Link].
Bolia R, Matta J, Malik R, Hardikar W. Outpatient Liver Biopsy in Children: Safety, Feasibility, and Economic Impact. J Pediatr Gastroenterol Nutr. 2017 Jul. 65 (1):86-88. [QxMD MEDLINE Link].
Weldon CB, Madenci AL, Tiao GM, Dunn SP, Langham MR, McGahren ED, et al. Evaluation of the diagnostic biopsy approach for children with hepatoblastoma: A report from the children's oncology group AHEP 0731 liver tumor committee. J Pediatr Surg. 2020 Apr. 55 (4):655-659. [QxMD MEDLINE Link].
Gilmore IT, Burroughs A, Murray-Lyon IM, Williams R, Jenkins D, Hopkins A. Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London. Gut. 1995 Mar. 36 (3):437-41. [QxMD MEDLINE Link].
Sporea I, Popescu A, Sirli R. Why, who and how should perform liver biopsy in chronic liver diseases. World J Gastroenterol. 2008 Jun 7. 14 (21):3396-402. [QxMD MEDLINE Link].
Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med. 2001 Feb 15. 344 (7):495-500. [QxMD MEDLINE Link].
Grant A, Neuberger J. Guidelines on the use of liver biopsy in clinical practice. British Society of Gastroenterology. Gut. 1999 Oct. 45 Suppl 4:IV1-IV11. [QxMD MEDLINE Link].
Jacobs WH, Goldberg SB. Statement on outpatient percutaneous liver biopsy. Dig Dis Sci. 1989 Mar. 34 (3):322-3. [QxMD MEDLINE Link].
Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD, American Association for the Study of Liver Diseases. Liver biopsy. Hepatology. 2009 Mar. 49 (3):1017-44. [QxMD MEDLINE Link].
Hall TC, Deakin C, Atwal GS, Singh RK. Adequacy of percutaneous non-targeted liver biopsy under real-time ultrasound guidance when comparing the Biopince™ and Achieve™ biopsy needle. Br J Radiol. 2017 Dec. 90 (1080):20170397. [QxMD MEDLINE Link].
Varela-Ponte R, Martínez-Lago N, Vieito-Villar M, Martin Carreira-Villamor J. Impact of risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy of space-occupying lesions. Radiologia (Engl Ed). 2022 Nov-Dec. 64 (6):497-505. [QxMD MEDLINE Link].
Caturelli E, Giacobbe A, Facciorusso D, Bisceglia M, Villani MR, Siena DA, et al. Percutaneous biopsy in diffuse liver disease: increasing diagnostic yield and decreasing complication rate by routine ultrasound assessment of puncture site. Am J Gastroenterol. 1996 Jul. 91 (7):1318-21. [QxMD MEDLINE Link].
Hakime A, Barah A, Deschamps F, Farouil G, Joskin J, Tselikas L, et al. Prospective comparison of freehand and electromagnetic needle tracking for US-guided percutaneous liver biopsy. J Vasc Interv Radiol. 2013 Nov. 24 (11):1682-9. [QxMD MEDLINE Link].
Govender P, Jonas MM, Alomari AI, Padua HM, Dillon BJ, Landrigan-Ossar MF, et al. Sonography-guided percutaneous liver biopsies in children. AJR Am J Roentgenol. 2013 Sep. 201 (3):645-50. [QxMD MEDLINE Link].
Howard R, Karageorge G, van Harselaar K, Bell M, Basford P, Schultz M, et al. Post-procedure surveillance in liver biopsy: how long is long enough?. N Z Med J. 2008 Aug 22. 121 (1280):8-14. [QxMD MEDLINE Link].
Firpi RJ, Soldevila-Pico C, Abdelmalek MF, Morelli G, Judah J, Nelson DR. Short recovery time after percutaneous liver biopsy: should we change our current practices?. Clin Gastroenterol Hepatol. 2005 Sep. 3 (9):926-9. [QxMD MEDLINE Link].
Filingeri V, Sforza D, Tisone G. Complications and risk factors of a large series of percutaneous liver biopsies in patients with liver transplantation or liver disease. Eur Rev Med Pharmacol Sci. 2015 May. 19 (9):1621-9. [QxMD MEDLINE Link].
McGill DB, Rakela J, Zinsmeister AR, Ott BJ. A 21-year experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology. 1990 Nov. 99 (5):1396-400. [QxMD MEDLINE Link].
Froehlich F, Lamy O, Fried M, Gonvers JJ. Practice and complications of liver biopsy. Results of a nationwide survey in Switzerland. Dig Dis Sci. 1993 Aug. 38 (8):1480-4. [QxMD MEDLINE Link].
Midia M, Odedra D, Shuster A, Midia R, Muir J. Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review. Diagn Interv Radiol. 2019 Jan. 25 (1):71-80. [QxMD MEDLINE Link]. [Full Text].
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Bissonnette J, Riescher-Tuczkiewicz A, Gigante E, Bourdin C, Boudaoud L, Soliman H, et al. Predicting bleeding after liver biopsy using comprehensive clinical and laboratory investigations: A prospective analysis of 302 procedures. J Thromb Haemost. 2022 Dec. 20 (12):2786-2796. [QxMD MEDLINE Link]. [Full Text].
Ioannidis O, Malliora A, Christidis P, Pramateftakis MG, Kotidis E, Mantzoros I, et al. Hemobilia Caused by Arterioportal Fistula Following Percutaneous Liver Biopsy Complicated by Acute Cholecystitis and Review of the Literature. Curr Health Sci J. 2022 Apr-Jun. 48 (2):235-241. [QxMD MEDLINE Link]. [Full Text].
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Media Gallery

Percutaneous liver biopsy. Deeper injection of local anesthetic.
Percutaneous liver biopsy. Infiltrating skin at biopsy site.
Percutaneous liver biopsy. Aspirating saline.
Percutaneous liver biopsy. Switching to biopsy needle.
Percutaneous liver biopsy. Making skin nick.
Percutaneous liver biopsy. Penetrating tissue planes.
Percutaneous liver biopsy. Biopsy needle inside liver.
Percutaneous liver biopsy. Taking plunger out.
Percutaneous liver biopsy. Transferring liver biopsy specimen to formalin bottle.
Percutaneous liver biopsy. Aspirating lidocaine.
Percutaneous liver biopsy. Patient lying on right side.
Percutaneous liver biopsy. Ultrasonography of liver.
Percutaneous liver biopsy. Hepatic parenchyma and blood vessels as seen on ultrasonography.
Percutaneous liver biopsy. Marking biopsy site.
Percutaneous liver biopsy. Liver biopsy tray.
Percutaneous liver biopsy. Sterile drape application.
Percutaneous liver biopsy. Percussion over liver.
Percutaneous liver biopsy. Preparing field.
Ultrasound-assisted percutaneous liver biopsy. Video courtesy of George Y Wu, MD, PhD.

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Author

Gaurav Arora, MD, MS Assistant Professor of Internal Medicine, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Gaurav Arora, MD, MS is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Coauthor(s)

Walid S Ayoub, MD Clinical Assistant Professor of Medicine, Division of Gastroenterology and Hepatology and Liver Transplant Program, Stanford University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Joseph K Lim, MD Associate Professor of Medicine, Director, Yale Viral Hepatitis Program, Section of Digestive Diseases, Yale University School of Medicine

Joseph K Lim, MD 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

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The authors gratefully acknowledge the unnamed patient who graciously agreed to be photographed during the procedure for this article.

The authors and editors of also gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Medscape Drugs & Diseases 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.