Liver Biopsy

Mary Raina Angeli Fujiyoshi, MD

 Introduction
 Histopathological assessment of the liver is the mainstay in the
evaluation and management of patients with liver disease.
 There are several routes or approaches to liver biopsy, however, for
most patients, percutaneous liver biopsy is the most preferred route
since it is less-invasive and less costly.
 Other techniques include:
• Transvenous/transjugular
• Transfemoral
• Endoscopic ultrasound-guided (EUS) liver biopsy
• Laparoscopic liver biopsy
 Indications
Diagnosis
• Multiple parenchymal liver diseases
• Abnormal liver tests of unknown cause
• Fever of unknown origin
• Focal or diffuse abnormalities on imaging studies
Contraindications
Absolute
• Uncooperative patient
• Severe coagulopathy
• Infection of the hepatic bed
• Extrahepatic biliary obstruction
• Significant thrombocytopenia
• Abnormal coagulation indices
• NSAID use (including aspirin) within the last 7 to 10 days
• Suspected hemangioma, vascular tumor or echinococcal cyst

Prognosis Relative
• Staging of known parenchymal liver disease • Ascites
• Morbid obesity
• Possible vascular lesions
• Hemophilia
• Amyloidosis
• Hydatid disease
• Infection within the right pleural cavity
• Infection below right hemidiaphragm

Management
• Developing treatment plans based on histologic analysis
 Patient Preparation
 Prior to performing liver biopsy, educate patients about their liver
disease and other procedures that may provide diagnostic and
prognostic information.
 Carefully inform the patients about the procedure, risks, benefits and
limitations.
 Obtain a written, informed consent.
 Discontinue antiplatelet medications at least 7 to 10 days before liver
biopsy.
 Discontinue anticoagulant medications prior to liver biopsy.
 Types of Biopsy Needle

Figure 1. Aspiration/Suction Needles Figure 2. Cutting-type needles

Image adapted from: Nallapeta et al. 2020. ‘Endoscopic Ultrasound-Guided Liver Biopsy; the Image adapted from: Nallapeta et al. 2020. ‘Endoscopic Ultrasound-Guided Liver Biopsy; the
Pathologist’s Perspective’. Journal of Experimental Pathology. 1(1): pp.1-10 Pathologist’s Perspective’. Journal of Experimental Pathology. 1(1): pp.1-10
 Liver Biopsy Procedure
Patient is placed in a supine position. The right arm
and hand is placed behind the head. Sedative may
be given to reduce anxiety and postprocedural pain.

Point of maximum liver dullness (usually between

6th and 8th ICS) is percussed, and the site is marked.

The skin is prepped and draped. A local anesthetic, lidocaine

1%, is injected on the marked site, over the upper border of
the rib to avoid intercostal vessels. The area from the skin to
the peritoneum is also anesthetized.
 Liver Biopsy Procedure

A small scalpel incision is made on the

marked site.

For spring-loaded or automated needle:

• Device is passed through the skin incision and the biopsy specimen is obtained
with the patient holding his/her breath in expiration.

For suction needle:

• Attach to a 10- or 20-mL syringe containing 5 to 10 mL sterile saline.
• The biopsy needle is passed through the incision until it reaches the peritoneal
cavity.
• A small amount of saline is flushed to eliminate any fat tissue that may have
entered the needle.
• With the patient holding his/her breath in expiration, suction is applied, and
biopsy is performed, minimizing the time the needle is within the liver.
 Postoperative Management
 Place patient in right decubitus position for 2 hours, followed by a supine
position for 1 hour.
 Monitor vital signs (especially pulse rate and blood pressure) as follows:
• Every 15 minutes for the 1st hour
• Every 30 minutes for the next 2 hours
• Every hour until discharge
 Check biopsy site every 30 minutes for signs of bleeding.
 Discuss and provide written postprocedure instructions before discharge.
 Ask the patient to immediately call if he/she experiences abdominal pain,
fever, weakness, dyspnea, excessive bleeding from the biopsy site, blood
in stools.
 Complications
Complications Management
Pain • Acetaminophen with codeine or meperidine
- Most common complication
- Dull, worse with inspiration
- Resolves completely within a few hours
Bleeding • Intraperitoneal hemorrhage: immediate
- 3 categories of bleeding: arrangements for blood, platelets, and plasma should
• Intraperitoneal hemorrhage be made and a surgeon and interventional radiologist
• Hematoma should be alerted
• Hemobilia • Hematoma: conservative treatment
• Hemobilia: supportive care
Transient bacteremia • Use of prophylactic antibiotics is not recommended
Bile peritonitis • IV fluids
- Should be suspected in patients who develop the • Broad spectrum antibiotics
abrupt onset of abdominal pain with peritoneal signs
(typically within a few minutes of the biopsy)
 References
1. Nallapeta N, Rao D, Ali AH, Sharma N, Ibdah JA, Hammoud GM. 2020.
‘Endoscopic Ultrasound-Guided Liver Biopsy; the Pathologist’s Perspective’.
Journal of Experimental Pathology. 1(1): pp. 1-10
2. Neuberger J, Patel J, Caldwell H, Davies S, Hebditch V, Hollywood C, Hubscher S,
Karkhanis S, Lester W, Roslund N, West R, Wyatt JI, Heydtmann M. 2020.
‘Guidelines on the use of liver biopsy in clinical practice from the British Society
of Gastroenterology, the Royal College of Radiologists and the Royal College of
Pathology’. Gut. 69: pp. 1382-1403
3. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD. 2009. ‘Liver
Biopsy’. Hepatology. 49(3): pp. 1017-1044