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