A percutaneous liver biopsy procedure is generally divided into two types: targeted and non-targeted. With both procedures, a sample of liver tissue is used to evaluate either underlying liver disease (non-targeted or random biopsy) or to pathologically evaluate a liver lesion (targeted biopsy). A percutaneous liver biopsy procedure is straightforward that can be accomplished with ultrasound and/or CT guidance. Understanding the indications for a liver biopsy, contraindications, and risks of the procedure will help select and plan for the appropriate procedure and approach.
Liver Biopsy Pre-Procedure Prep
Liver Biopsy Indications
• Elevated Liver Function tests (unknown etiology)
• Hepatitis C
• Progressive diffuse liver disease
• Liver mass concerning for malignancy
• Liver Transplantation workup
Liver Biopsy Contraindications
• Uncooperative patient
• Uncorrectable coagulopathy
• Suspected hemangioma on imaging
• Hold any anticoagulation (See SIR anticoagulation guidelines for specific medications)
• Withhold solid foods for 6 hours for moderate sedation.
• Informed consent
• Labs: Platelets, PT/PTT, INR, Cr, BUN.
• Choose imaging modality CT vs US (US is the most common and efficient for native liver biopsies)
• Review any prior imaging
Liver Biopsy Procedure Steps
Liver Biopsy Position
• A supine position of the patient is most commonly used.
• Preliminary imaging will help avoid local structures including large vessels (IVC, portal vein), gallbladder, pleural space and lung, and colon.
• Ultrasound guided liver biopsy vs CT guided liver biopsy depending on body habitus, available equipment, and lesion vs non focal biopsy.
• Moderate sedation most commonly used. General anesthesia if patient cannot hold still.
Liver Biopsy Procedure
• IV access (18 g preferred)
• Position the patient supine and localize the safest route by imaging
• For lesions- measure the lesion depth from skin surface and choose needle length
• Detect unexpected anatomical barriers like cysts
• Make a skin mark to identify where the percutaneous insertion site will be.
• Prep the site of the skin mark and anesthetize the subcutaneous tissues using 1% local
• Administer Lidocaine down to the liver capsule
• Under imaging guidance, carefully place the tip of the 17 g coaxial needle into the periphery of the liver (usually right hepatic lobe) and verify positioning by imaging. Once in position, pass the 18 g biopsy needle through the coaxial needle to obtain samples.
• 2-3 core biopsy samples are recommended.
• Depending on patient factors, option to administer gelfoam as trocar needle is withdrawn.
• Follow up imaging with US or CT to confirm no immediate bleeding.
Liver Biopsy Aftercare
• Some operators recommend pressure over biopsy site for 1 hour. For the position after a liver biopsy, the patient can lay on their right side over a rolled up towel.
• Close observation of vital signs and symptoms of bleeding for 3-4 hours is absolutely necessary.
• Vital signs should be monitored every 15 minutes for 2 hours, every 30 min for 2 hours, then every hour for 2 hours post procedure.
• If there is worsening pain over the region, re-image with CT or ultrasound and check CBC.
• If bleeding rapidly, blood transfusion and transcatheter embolization may be necessary.
Liver Biopsy Complications
• Perihepatic and subcapsular hematoma
• Arteriovenous fistula or hepatic artery pseudoaneurysm
Liver Biopsy Demos
Ultrasound-Guided Liver Biopsy
Ultrasound-guided needle biopsy of the liver is a very safe and comfortable procedure. It is done under local anesthesia and ultrasound guidance and can be completed in several minutes. It can be used in the diagnosis of many liver diseases including infectious and malignant conditions.
Liver Biopsy Literature
Seminars in Interventional Radiology (Jun 2012)
Transjugular Liver Biopsy
The purpose of this article is to provide a review of the fundamental aspects of the TJLB procedure, including technique, indications, contraindications, results, and complications.
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 Kandarpa, Krishna et al. Handbook of Interventional Radiologic Procedures 2011 p 522
 Rogers, Peter et al. Pocket Radiologist: Interventional Top 100 Procedures 2003 p 307-309
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