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Liver Biopsy

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 Procedure Information

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Ep 39 How to Take Better Biopsies with Dr. Thor Johnson
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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

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

Liver Biopsy Podcasts

Listen to leading physicians discuss liver biopsy on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #39

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Dr. Thor Johnson discusses his experience with the Argon BioPince biopsy needle for liver, renal and soft tissue biopsies, including tips and tricks for obtaining better biopsy samples with fewer passes. Recorded at SIR 2019 in ATX.

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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.

Imaging Guidance

• Ultrasound guided liver biopsy vs CT guided liver biopsy 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.

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.

Post-Procedure

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

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

Liver Biopsy Demos

Watch video walkthroughs of liver biopsy on the BackTable VI expanded content network.

References

[1] Kandarpa, Krishna et al. Handbook of Interventional Radiologic Procedures 2011 p 522
[2] Rogers, Peter et al. Pocket Radiologist: Interventional Top 100 Procedures 2003 p 307-309


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