Liver Biopsy-Types, Indications, and Procedure

A liver biopsy is a procedure in which a small piece of liver tissue is removed so that it can be examined under a microscope to detect liver disease.

Read more about Liver Anatomy, Structure and Function

Liver biopsy is recommended if symptoms, blood tests or imaging studies suggest that the person might have liver disease. This information obtained from the biopsy helps in guiding treatment decisions.

Read more about Types of Biopsies and their applications

Types of Liver Biopsy

Percutaneous liver biopsy.

It is the most common type of liver biopsy. A thin needle is inserted into the liver through the abdomen and a sample of liver tissue is taken out. It is carried out under local anesthesia.

Laparoscopic liver biopsy.

A thin tube or laparoscope is put into the skin after giving a tiny cut or incision. This laparoscopic tube has a tiny video camera attached to it which helps to see the organs inside the abdomen on a computer screen. A needle is inserted through another tube which removes the liver sample. This is carried out under general anesthesia.

Transvenous or Transjugular liver biopsy

A small incision is made in the neck. A thin, hollow, flexible tube is inserted through the jugular vein in the neck, down into the liver. A needle is inserted through this tube which removes a sample of liver tissue. This method is used for people who have bleeding disorders or the presence of ascites (fluid around the abdomen). It is carried out under local anesthesia.

Indications of Liver Biopsy

• Persistently abnormal Liver Function Tests
• Unexplained hepatomegaly  (enlargement of the liver)
• Unexplained splenomegaly (enlargement of the spleen)
• Unexplained jaundice
• In the case of liver cirrhosis, to determine the type, cause, and activity of the disease
• To evaluate the course of chronic hepatitis
• In fever of unknown cause, to diagnose or rule out military tuberculosis, sarcoidosis or malignancy
• An abnormality in the liver found on investigations done for other purposes including ultrasound, CT scan or nuclear scan.

The various diseases which can be diagnosed using liver biopsy include:

• Alcoholic liver disease
• Viral hepatitis
• Chronic active hepatitis
• Chronic persistent hepatitis
• Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH)
• Autoimmune hepatitis
• Hemochromatosis
• Primary biliary cirrhosis or cholangitis
• Biliary atresia
• Primary sclerosing cholangitis
• Reye syndrome
• Wilson disease
• Amoebic liver disease
• Pyogenic liver abscess
• Disseminated coccidiomycosis
• Hepatocellular carcinoma
• Hodgkin and Non-Hodgkin lymphoma
• Metastasis to liver

When Should a Liver Biopsy Not Be Done – Contraindications of Liver Biopsy

• Decreased ability of blood to clot reflected by increased prothrombin time (PT) / international normalized ratio (INR) greater than 1.6
• Coagulation disorders like hemophilia
• Platelet count lower than 60,000/μL
• Ascites (presence of fluid around the abdomen). In such a case, the transjugular route is preferred
• Severe obstructive jaundice which may lead to leakage of bile resulting in severe bile peritonitis
• Suspected hemangioma
• Hydatid cyst liver
• Uncooperative patient

How to Prepare for a Liver Biopsy

Detailed medical history and a thorough physical examination are carried out before performing the liver biopsy to assess the overall health condition of the patient.

Blood tests are carried out to check the ability of the blood to clot. These include Prothrombin time (PT) or INR. In case the PT is prolonged, vitamin K injection is given so as to reduce the risk of bleeding. If PT still remains prolonged (INR> 1.6), then liver biopsy should not be performed.

The doctor should be informed about all the medications that a person is taking. Of special importance are the following medicines:

• Pain killers including aspirin, ibuprofen, etc
• Blood-thinning medications such as anticoagulants (warfarin, etc)
• Vitamin or herbal supplements

All such above mentioned medicines or supplements can increase the risk of bleeding. Hence these medicines are to be temporarily stopped before undergoing a liver biopsy.

The patient may be asked not to drink or eat for six to eight hours before the procedure.

A sedative may be given before the procedure so as to relax the patient. Since the sedative is likely to make the patient feel drowsy for a few hours, it is best to be accompanied by someone who drives the patient back home.

Procedure

A liver biopsy may be performed as an outpatient procedure or part of a small stay in a hospital.

It may be carried out in a procedure room or in the radiology department if a specific area of the liver needs to be biopsied such as under ultrasound guidance.

Steps of percutaneous liver biopsy:

• The patient is asked to remove all clothing, jewelry, hairpins, etc
•  A surgical gown is given to be worn by the patient
• An IV (intravenous) line may be started in the arm or hand. Sedatives may be given in some patients to relieve anxiety.
• The patient is made to lie on his or her back with the right side of the body close to the edge of the bed.
• The site of the biopsy in the liver is determined by pressing on the abdomen. An ultrasound or CT scan may be used to find the exact spot of biopsy.
• The skin over the site of the biopsy is cleaned with an antiseptic solution.
• A local anesthetic is injected into the skin. This is felt like a brief stinging sensation.
• The biopsy needle is put through the skin and into the liver very quickly. Slight pressure is felt as the needle is passed into the liver. Mild pain may be felt in the shoulder during the procedure. This occurs due to irritation of the phrenic nerve which passes down the shoulder and is present near the liver.
• The patient is asked to hold his or her breath while the needle is inserted and taken out of the liver. This enables correct placement of the needle at the desired site as it prevents the chest wall and diaphragm from moving.
• The needle along with the biopsy sample is removed.
• If more than one liver sample is required, the patient is again asked to hold the breath while the needle is inserted and taken out of the liver quickly.
• Pressure is applied to the biopsy site so as to stop bleeding.
• A sterile dressing is applied on the skin at the site of the biopsy.
• The liver tissue samples removed are put in a jar containing 10% formalin and sent to a pathology lab for testing.

Aftercare

After the procedure, the patient is taken to a recovery room for a few hours.

Vitals including blood pressure, pulse, and breathing rate are measured.

The patient should avoid coughing hard or staining for a few hours after the biopsy.

The patient is asked to lie on the right side and rest for about 3- 4 hours. Lying on the right side puts pressure on the biopsy site.

The blood samples may be taken after a few hours to check for any possible internal blood loss.

If everything is normal, the patient may be discharged after a few hours.

At home, the patient is instructed to be on bed rest for some time.

Any intense activity, including lifting heavy weights should be avoided for several days up to a week or even longer.

Pain medicines can be taken for a few days as the site of biopsy may feel sore.

The presence of any of the following symptoms after biopsy must be reported to the healthcare provider at once.

• Fever or chills
• Severe pain at the site of biopsy or anywhere else in the body
• Redness, swelling, or bleeding from the biopsy site
• Shortness of breath or difficulty in breathing
• Rectal bleeding

Depending on the health of the patient, other specific instructions may be given to the patient.

Complications of Liver Biopsy

Pain

It is the most common complication after a liver biopsy. The pain` usually occurs in the right upper abdomen or right shoulder. Medicines for pain are usually given after the procedure.

In the majority of the cases, the pain is mild and goes away within a few hours. If however, the pain is severe or is not relieved, it could indicate damage to other organs or the presence of internal bleeding. In such a case, further investigations may be carried out to find the cause of the pain.

Bleeding

Internal bleeding from the biopsy site is a serious complication of liver biopsy. It may result in severe pain which is not relieved by medicines or may cause low blood pressure or increased heartbeat.

Another procedure or surgery may be required to stop the bleeding. In the case of excessive blood loss, blood transfusions may be given to the patient.

Other complications which can occur are:

• Injury to nearby organs like gallbladder or kidney
• Injury to the lung causing its collapse or pneumothorax
• Infection leading to sepsis
• Complications due to anesthesia

References

•  Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD. American Association for the Study of Liver Diseases position paper: liver biopsy. Hepatology. 2009;49(3):1017–1044.
• Dohan A, Guerrache Y, Boudiaf M, Gavini JP, Kaci R, Soyer P. Transjugular liver biopsy: indications, technique, and results. Diagnostic Interventional Imaging. 2014;95(1):11–15.