Liver Biopsy

Overview

Pre-Procedure Prep

Indications

• Elevated Liver Function tests (unknown etiology)
• Hepatitis C
• Progressive diffuse liver disease
• Liver mass concerning for malignancy
• Liver Transplantation workup

Contraindications

• Uncooperative patient
• Uncorrectable coagulopathy
• Suspected hemangioma on imaging

Pre-Procedure Evaluation

• 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

Procedure Steps

Positioning

• 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.

Imaging Guidance

• Ultrasound vs CT depending on body habitus, available equipment, and lesion vs non focal biopsy.

Sedation

• Moderate Sedation most commonly used. General anesthesia if patient cannot hold still.

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• Depending on patient factors, option to administer gelfoam as trocar needle is withdrawn.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.

Post-Procedure

Post-Operative Care

• Some operators recommend pressure over biopsy site for 1 hour. Patient can lay the 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.

Complications

• Perihepatic and subcapsular hematoma
• Arteriovenous fistula or hepatic artery pseudoaneurysm