Patient Education and Consent
Patient preparation prior to undertaking a liver biopsy is essential. Ideally, education should begin during an office visit prior to the biopsy. The procedure must be explained to the patient in sufficient detail, with careful attention paid to anxiety and pain management issues.
On the day of the biopsy, review recent laboratory evaluation of prothrombin time (PT) and complete blood count (CBC), including platelets. Explain the procedure to the patient, and obtain informed consent.
Preprocedural Planning
Aspirin should be discontinued 1 week before the biopsy procedure. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be stopped 3 days prior to the procedure. The patient may, or may not, be asked to complete an overnight fast. Eating before the procedure allows for gallbladder contraction, reducing the risk of gallbladder puncture. An empty stomach, however, may decrease the likelihood of postprocedure nausea and vomiting. This is an important consideration because many biopsies are performed with the patient under light sedation.
In most instances, the biopsy procedure is undertaken on an outpatient basis, [1] in accordance with the following recommendations derived from a statement by the American Gastroenterological Association (AGA) [16] :
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The patient must remain within 30 minutes of the facility at which the biopsy was performed
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The patient must be accompanied by a reliable person the first night after the procedure
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The patient should have no contraindications or conditions that increase the risk associated with the procedure
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The facility where the biopsy is performed should have an approved blood bank, laboratory, inpatient bed, and personnel available to the patient for at least 6 hours after the procedure; however, the American Association for the Study of Liver Diseases (AASLD) has recommended a routine observation period of 2-4 hours [17]
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Hospitalization should accompany evidence of bleeding, bile leak, pneumothorax, or pain requiring more than one analgesic dose
Equipment
Various needles are available for obtaining a liver biopsy specimen. They may be divided into three broad categories as follows:
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Suction needles (Jamshidi, Klatskin, and Menghini)
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Cutting needles (Tru-cut and Vim-Silverman)
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Spring-loaded cutting needles
Each needle type has proposed advantages and disadvantages. Suction needles are thought to yield desirable sample size but may fragment cirrhotic livers. Conversely, cutting needles do not fragment liver tissue but may deliver inadequate tissue samples. Spring-loaded needles are thought to decrease the amount of time that the needle is in the liver but may increase patient discomfort due to the clicking noise of the triggering mechanism. Needle selection is largely a result of physician preference and experience.
Patient Preparation
After the patient is positioned and draped, administer local anesthesia with 1% lidocaine in both superficial and deep planes.
Place the patient supine, remove pillows, and elevate the right arm behind the head. The legs and feet may be angled to the left to further open the right intercostal spaces.
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Biopsy needle inside the liver.
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Patient lying on right side.
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Ultrasonography of the liver.
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Marking the biopsy site.
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Sterile drape application.
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Percussion over the liver.
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Preparing the field.
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Ultrasound-assisted percutaneous liver biopsy. Video courtesy of George Y Wu, MD, PhD.
