Diagnostic Liver Biopsy Technique

Updated: Nov 16, 2020
  • Author: Kenneth Ingram, PA-C; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Approach Considerations

Various approaches may be utilized for obtaining a liver tissue specimen, including a blind percutaneous approach after percussion of the chest wall, biopsy under the guidance of ultrasonography (US) or computed tomography (CT), intravascular tissue sampling via the hepatic vein, and intra-abdominal biopsy at laparoscopy or laparotomy. [1]  An endoscopic US (EUS)-guided approach has been described. [2, 3, 4, 5]

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.


Percutaneous Suction-Needle Biopsy

Determination of biopsy site

With the patient appropriately positioned (see Periprocedural Care), percuss the right trunk to the point of maximum dullness during both inspiration and expiration. This frequently corresponds to a point along the midaxillary line at the second or third intercostal space above the costal margin. Mark this location with a surgical pen or other method. (See the images below.)

Percussion over the liver. Percussion over the liver.
Marking the biopsy site. Marking the biopsy site.

US or CT may be useful for guidance (see the image below), particularly if obtaining a biopsy of a particular region or mass within the liver is desired. Some have advocated that all biopsies be performed under US guidance; however, whether this reduces procedure-related morbidity or is cost-effective has been controversial. [15, 16, 17, 18]

Ultrasonography of the liver. Ultrasonography of the liver.

In a retrospective study of 100 patients with chronic hepatitis C infection, Flemming et al investigated whether higher-quality biopsy specimens for the grading and staging of hepatitis C could be obtained with the help of US guidance (50 patients) or without it (50 patients). [11] The primary biopsy quality determination was made by assessing the number of complete portal tracts that were identifiable in the slides. The specimen's total length and degree of fragmentation provided secondary outcome measures.

The authors found that US-guided biopsies yielded higher-quality specimens than did the other biopsies, having a larger number of complete portal tracks (11.8 vs 7.4), a greater length (24.4 mm vs 19.7 mm), and less fragmentation, as well as a higher overall histopathologic quality assessment. [11] However, there was no significant difference between biopsies performed under US guidance and those that were not with regard to how effectively the specimens could be used to grade and stage chronic hepatitis C virus infections.

Contrast-enhanced US (CEUS) has been suggested as a potentially helpful tool for biopsy of a focal liver lesion, especially when the lesion is inconspicuous or invisible on standard US or when the initial biopsy was insufficient because of necrotic material. [19, 20] CEUS can also improve the characterization of focal liver lesions significantly and may thereby make many biopsies of such lesions superfluous. The World Federation for Ultrasound in Medicine and Biology (WFUMB) has issued guidelines for the use of CEUS in the liver. [21]

Insertion of biopsy needle

Once a suitable biopsy site has been identified, sterile technique is employed. Prepare the field with povidone-iodine solution, and place sterile drapes (see the images below). Administer a local anesthetic (1% lidocaine) in both superficial and deep planes. Patients occasionally describe experiencing a burning or shooting pain that radiates either transversely or to the right shoulder region. This pain is thought to represent contact of the anesthetic with the capsule of the liver.

Preparing the field. Preparing the field.
Sterile drape application. Sterile drape application.

Once adequate anesthesia has been obtained, make a small nick in the skin with a surgical blade to allow introduction of the biopsy needle. Introduce the biopsy needle within close proximity to the upper aspect of the lower rib to avoid the intercostal nerve and vasculature.

As the needle is introduced, a series of several successive "pops" may be felt. Flush small amounts of saline contained in the syringe until resistance is encountered. The resistance is the liver edge; at this point, withdraw the needle slightly and flush it again to remove debris. Apply suction to the syringe, and ask the patient to expire and to hold his/her breath. This shrinks the lung field and minimizes the risk of perforating the gallbladder, while bringing the liver against the thorax wall. The biopsy sample is obtained. (See the image below.)

Biopsy needle inside the liver. Biopsy needle inside the liver.

Apply pressure to the site, followed by an adhesive bandage. Roll the patient onto the right side (see the image below), and instruct him or her to remain in this position for 1 hour to help prevent bleeding or bile leakage. Obtain vital signs every 15 minutes for the first hour, every 30 minutes during the second hour, and then hourly until discharge.

Patient lying on right side. Patient lying on right side.

The video below depicts US-assisted liver biopsy.

Ultrasound-assisted percutaneous liver biopsy. Video courtesy of George Y Wu, MD, PhD.

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. [22]



Complications of liver biopsy occur rarely but are potentially lethal. Those listed below are the ones most commonly observed in clinical practice.

The majority (60%) of complications occur within the first 2 hours, and 96% occur during the first 24 hours following the procedure. Approximately 2% of patients undergoing biopsy require hospitalization for the management of an adverse event. Vasovagal episode and pain are the most common reasons for admission.

Pain occurs in approximately 30% of patients undergoing a liver biopsy. It often is described as a dull ache in the right upper quadrant or shoulder and typically is relatively short in duration, lasting less than 2 hours. This pain often responds to analgesics. Unrelenting, severe abdominal pain is alarming, possibly indicating a serious complication such as intraperitoneal hemorrhage or biliary leak.

Bleeding comprises a second group of complications. Presentations include subcapsular or parenchymal hematoma, hemobilia, and free intraperitoneal hemorrhage.

Intrahepatic or subcapsular hematomas are the most common of the bleeding complications and are noted on approximately 23% of postbiopsy sonograms. Such findings often are incidental, without associated clinical symptoms. They occur at similar rates after either blind or laparoscopy-guided modalities, but incidence may be influenced by needle type and imaging technique. Large hematomas are a rare cause of biliary obstruction. Symptomatic hematomas should be imaged by means of US but usually respond to conservative treatment with analgesics.

Hemobilia presents as biliary colic, gastrointestinal bleeding, and jaundice. It is a rare complication of biopsy; one study of 68,276 biopsies reported four instances of hemobilia. Clinical presentation ranges from chronic anemia to rapid exsanguination. Hemobilia typically develops later than other complications. The average time to onset of symptoms is 5 days after the procedure, but onset may occur earlier. Conservative treatment often is sufficient. However, if clinically significant hemobilia is present, angiography is the modality of choice because both diagnosis and intervention can be accomplished with a single procedure.

Biliary peritonitis is another noteworthy complication, albeit a rare one. Severe abdominal pain and vasovagal hypotension herald its occurrence. Analgesics and fluid management usually are sufficient, but persistence of the condition may necessitate endoscopic retrograde cholangiopancreatography (ERCP) with stent placement.

Intraperitoneal hemorrhage is the most serious of the bleeding complications. It is an early occurrence, most often observed during the first few hours following the procedure, though reports of this complication developing as late as 24 hours after the procedure have been noted. Late hemorrhage is associated with a poor outcome. The overall rate of occurrence of peritoneal hemorrhage in a large study was 0.32%. Factors associated with increased risk of free bleeding include increased age, hepatic malignancy, multiple needle passes, and cirrhosis.

Abdominal pain and persistent hemodynamic instability, presenting as tachycardia and hypotension, are typical of significant bleeding. Early diagnosis via US is preferred. Treatment includes aggressive fluid management and blood and platelet transfusion, if indicated. An angiographer and a surgeon should be alerted early in the process to facilitate rapid intervention if needed. Angiography with potential embolization is the preferred intervention.

A review by Midia et al found that bleeding of any kind occurred in up to 10.9% of image-guided liver biopsies (major bleeding, 0.1-4.6%; minor bleeding, up to 10.9%); however, the overall bleeding rate was below 2%. [23] Patient-related risk factors that were identified as potentially indicative of an increased risk of postbiopsy bleeding included the following:

  • Patient age >50 years or < 2 years
  • Inpatient status
  • Comorbidities or concurrent diagnoses
  • Coagulation status (3.3% bleeding rate for international normalized ratio [INR] 1.2-1.5 vs 7.1% rate for INR >1.5)

Procedure-related risk factors included the following [23] :

  • Needle size (cutting biopsy vs fine-needle aspiration)
  • Presence of a patent track on postbiopsy US

Bacteremia, pneumothorax, and accidental biopsy of other organs are rare complications.

The frequencies of the various complications of percutaneous liver biopsy were reported by Reddy and Schiff to be as follows [24] :

  • Pain (0.056-22%) - Pleuritic; peritoneal; diaphragmatic
  • Hemorrhage - Intraperitoneal (0.03-0.7%); intrahepatic and/or subcapsular (0.059-23%); hemobilia (0.059-0.2%)
  • Bile peritonitis (0.03-0.22%)
  • Bacteremia
  • Sepsis (0.088%) and abscess formation
  • Pneumothorax and/or pleural effusion (0.08-0.28%)
  • Hemothorax (0.18-0.49%)
  • Arteriovenous fistula (5.4%)
  • Subcutaneous emphysema (0.014%)
  • Anesthetic reaction (0.029%)
  • Needle break (0.02-0.059%)
  • Biopsy of other organs - Lung (0.001-0.014%); gallbladder (0.034-0.117%); kidney (0.096-0.029%); colon (0.0038-0.044%)
  • Mortality (0.0088-0.3%)