Liver Biopsy

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Overview

Overview content for Liver Biopsy is not yet available.

Pre-Procedure

Indications:
• Targeted vs Random (aka: non-targeted, native) liver biopsy

[1] Native liver biopsy
• Diagnose nonfocal liver disease
• Grading and staging of fibrosis/cirrhosis
• Grading and staging of hepatic steatosis
• Hepatitis
• Hemochromatosis
• Wilson disease
• Primary biliary cirrhosis
• Primary sclerosing cholangitis
• Abnormal liver function tests
• Pre Transplant workup
• Fever of unknown origin
• Acute liver failure

[2] Targeted liver biopsy - characterize an indeterminate liver lesion

Contraindications:
Absolute: uncorrectable bleeding diathesis
• Have option for transjugular liver biopsy
• May be able to correct coagulopathy prior to biopsy
Relative:
• Ascites
• Recent liver transplant (within 1 month) - can vary with institution

SIR periprocedural coagulation parameters:
• INR, aPTT, platelets labs recommended
• INR: correct to < 1.9
• Platelets: < 50,000/µl recommend transfusion
• aPTT: correct so that value is < 1.5 control
Suggested laboratory parameters for patients with chronic liver disease
• INR < 2.5
• Platelets: > 30,000
• Consider fibrinogen level

Preprocedural evaluation:
• H&P
• Known indication for referral
• Evaluate patient comorbidities for procedure and anesthesia plan
• Medication review: antibiotics and anticoagulation
Imaging
• Necessary for targeted biopsy and can be helpful for random liver biopsy
• Helps identify target or potential safe area to biopsy
• Is there background of cystic liver disease, biliary obstruction, diffuse metastatic disease, etc.

Procedure

Antibiotic prophylaxis:
• Not recommended

Planning for procedure:
• Ultrasound vs. CT
• Type of imaging will depend on primarily on patient and type of biopsy: targeted vs random biopsy
• For random liver biopsies, US will almost always be adequate
• Targeted liver biopsies will depend a lot on operator preference and lesion location
• Combination US and CT or US with fusion overlay are also options

Procedure
Patient positioning can be important
• Right arm up can widen intercostal space
• Roll under patient's right hip or decubitus position can facilitate more comfortable position for operator if using US
• Plan ahead to make procedure easier

Random or native liver biopsy steps using US guidance below:
• Position patient
• Identify safe access window
• Anestesize skin and soft tissue down to liver capsule
• Small dermatotomy
• Advance 17 g trocar needle into liver parenchyma
• Use US to evaluate and identify potential deep structures such as vessels, other organs or liver lesions
• 18 g biopsy device through trocar
• Take 1-3 core samples
• Remove needle with option to inject gelfoam slurry along tract

Many operator more comfortable with CT for biopsy

Post-Procedure

Postprocedural care
• Bed rest for 2-4 hours
• ~60% of complications occur within first 2 hours and 96% within 24 hours
• Depending on patient clinical status, often performed as outpatient with same-day discharge
• Typically avoid tylenol for patients with underlying liver disease

Complications:
• Pain: typically at biopsy site or referred pain to right shoulder
• Hemorrhage: 0 - 10.9%, likley < 2%
• Infection: rare
• Pleural injury with hemothorax or pneumothorax: < 1%
• Gallbladder or bile injury
• Kidney or bowel injury

Related Procedures

No related procedures.

Step-by-step guidance on how to perform Transjugular Liver Biopsy. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.
 

References

[1] Chan M, Navarro VJ. Percutaneous Liver Biopsy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 2, 2020.
[2] Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions-Part II: Recommendations: Endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. J Vasc Interv Radiol. 2019;30(8):1168-1184.e1. doi:10.1016/j.jvir.2019.04.017
[3] Midia M, Odedra D, Shuster A, Midia R, Muir J. Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review. Diagn Interv Radiol. 2019;25(1):71-80. doi:10.5152/dir.2018.17525
[4] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[5] Midia M, Odedra D, Shuster A, Midia R, Muir J. Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review. Diagn Interv Radiol. 2019;25(1):71-80. doi:10.5152/dir.2018.17525
[6] Vijayaraghavan GR, David S, Bermudez-Allende M, Sarwat H. Imaging-guided Parenchymal Liver Biopsy: How We Do It. J Clin Imaging Sci. 2011;1:30. doi:10.4103/2156-7514.82082
[7] Sporea I, Popescu A, Sirli R. Why, who and how should perform liver biopsy in chronic liver diseases. World J Gastroenterol. 2008;14(21):3396-3402. doi:10.3748/wjg.14.3396
[8] Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med. 2001;344(7):495-500. doi:10.1056/NEJM200102153440706



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Demos

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Tools

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Literature

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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.

The Indian Journal of Radiology & Imaging (Jun 2008)

Transjugular Liver Biopsy: What To Do and What Not to Do.

This article description is not yet available.

 

Podcasts

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Better Biopsies Podcast with Dr. Thor Johnson

Dr. Thor Johnson

Dr. Christopher Beck

Dr. Thor Johnson discusses his experience with the BioPince biopsy needle for liver, renal and soft tissue biopsies, and how to obtain better biopsy samples with fewer passes.

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