Liver Biopsy Procedure Reasons, Side Effects, Results

For almost a century, physicians have employed liver biopsy to help diagnose the cause and assess the severity of their patients' liver disease. Liver biopsy entails the removal a small sample of liver tissue. That piece of liver tissue is then sent to the pathology laboratory for analysis.

Picture a a woman recieving an ultrasound.

• Physicians typically employ a broad array of blood tests and imaging studies (for example, CT, MRI scans) in an effort to diagnose a patient's liver disease. In some circumstances, those tests do not lead to a diagnosis. A liver biopsy is a key tool in helping the physician make a correct diagnosis of a patient's underlying liver disease.
• In some circumstances, a patient's clinical history, blood tests, or imaging studies may strongly suggest a particular diagnosis. Liver biopsy is used to confirm the physician's clinical suspicions. This is particularly important in view of the fact that many liver diseases require life-long therapy. Making a correct diagnosis is critical before committing the patient to a long course of treatment with a particular drug.
• In other circumstances, blood test results may point to the co-existence of two liver diseases in the same patient at the same time (for example, alcoholic hepatitis as well as chronic hepatitis C). Thus, liver biopsy results may clarify whether a patient is suffering from one or two diseases.
• Liver biopsy results may be used to monitor the effectiveness of therapy. As an example, a patient under long-term medical therapy for autoimmune hepatitis may require a follow-up liver biopsy to determine whether or not therapy is successful at suppressing the hepatitis.
• Liver biopsy also can be used to assess the severity of a patient's condition. As an example, a patient's clinical history and laboratory tests might strongly point to a diagnosis of chronic hepatitis C (CHC). Knowledge of the severity of the patient's chronic hepatitis C will help determine whether the patient needs immediate therapy or whether therapy can be deferred to a later date.

In most circumstances, liver biopsy is being performed to diagnose a condition that affects the entirety of the liver. Whether a patient has a chronic viral infection like chronic hepatitis B or C, or an autoimmune disease like primary biliary cirrhosis, or a metabolic disease like hereditary hemochromatosis, it is anticipated that the underlying disease process affects all regions of the liver equally.

A small piece of tissue that is being removed from the right lobe of the liver is expected to be representative of the disease process that is affecting the liver as a whole. Unfortunately, this expectation is incorrect in some individuals. A minority of patients will have conditions where one area of the liver may be affected more than another area. This may lead to diagnostic inaccuracy.

Other patients require liver biopsy in order to diagnose a mass of tissue within the liver that was identified by an imaging study of the liver. Some masses are benign; others are malignant or cancerous. With so-called "guided" biopsies, the patient undergoes either an ultrasound or a computerized tomography (CT scan) at the time of the biopsy. The physician performing the biopsy (typically an interventional radiologist) uses the results of ultrasound or that scan to guide the biopsy needle to the mass. In CT-guided biopsies, the biopsy is performed while the patient is actually lying upon the CT table.

The key benefit of biopsy is the correct determination of a patient's diagnosis. Once a diagnosis is correctly made, physicians can begin appropriate treatment.

Sometimes, liver biopsy is performed to determine whether or not liver disease is stable or has progressed over a period of time. Uncertainty as to the severity of one's disease can be devastating for some patients. The results of liver biopsy may bring the patient comfort, even if the biopsy shows that the individual's disease has progressed.

Pain or discomfort at the biopsy site is experienced by almost all patients who undergo biopsy. Local anesthesia at the biopsy site or mild sedation at the time of biopsy can help to decrease pain. Post-biopsy pain is typically mild to moderate. It may last from hours to days. Some patients make need a low dose of acetaminophen or even a low-dose of a narcotic pain medicine to diminish post-biopsy pain.

It is common that a small hematoma (for example, "black and blue mark") is seen at the biopsy site. An enlarging hematoma is a worrisome sign that requires the patient to return to the hospital for assessment.

Biopsies of all human tissues are invariably accompanied by some risk of bleeding as a complication. When a biopsy needle enters the liver, it is anticipated that a few drops of blood will leak out of the liver into the abdominal cavity. This should cause no symptoms or problems. Much less commonly, a large amount of blood leaks out of the liver capsule into the abdominal cavity. This may be accompanied by symptoms of severe abdominal or chest pain. Large amounts of bleeding may cause the patient's heart rate to rise or blood pressure to drop. Unexpected significant bleeding may occur after procedures that – from a technical perspective – were performed perfectly. Fortunately, important bleeding only occurs in a small number of patients.

All patients who undergo liver biopsy are monitored after the procedure to make sure they are not experiencing bleeding. If bleeding is suspected, the patient may require overnight observation to make sure that bleeding does not continue. A small minority of patients require blood transfusion to make up for biopsy-associated blood losses. An even smaller number of patients require emergent procedures (for example, surgery) to stop continuing bleeding.

Infrequent complications of liver biopsy include: striking another organ (for example, puncturing the lung, intestine, gallbladder or bile duct) or causing infection. Transjugular liver biopsies can be complicated - infrequently - by injury to the blood vessel or heart arrhythmias.

Ultrasound and CT-guided biopsy of liver masses have their own associated risks. First, there is the issue of "tumor tracking." Biopsy of a malignant (i.e. cancerous) liver mass is associated with a <1% chance of tumor seeding (i.e. depositing a viable cancer cell in the tract created by the liver biopsy needle that subsequently grows into a mass of tumor cells). Also, there is up to a 30% miss-rate associated with biopsy of the malignant mass. Thus, the biopsy of the malignant mass has up to a 30% chance of providing incorrect information, misleading the physician and the patient to believe that a malignant mass might be benign. Therefore, if a strong suspicion for malignancy remains after receiving a "benign" diagnosis, the liver biopsy should be repeated.

In some instances, abdominal imaging studies can help make a diagnosis. As an example, blood tests might suggest that a patient is suffering from iron overload related to hereditary hemochromatosis. Specially tailored MRI scans can help determine whether or not iron overload is truly present without the need for a liver biopsy.

Increasingly, non-invasive approaches are being used to assess the severity of chronic hepatitis C. Commercially available blood tests like Hepascore® and FibroSURE® assess blood levels of hyaluronic acid and other chemicals to help estimate the degree of liver inflammation and fibrosis (i.e. scarring) in patients with chronic hepatitis C.

Fibroelastography utilizes a specially-designed ultrasound unit to non-invasively assess the degree of liver fibrosis is patients with chronic hepatitis C. It remains to be determined whether fibroelastography will provide as accurate an assessment of liver fibrosis in other disease states (for example, chronic hepatitis B or alcoholic liver disease) as in chronic hepatitis C. Fibroelastography is undergoing testing in the United States and is not widely available at this time.

The choice of a liver biopsy technique may be influenced by the disease state that is being investigated and by the patient's underlying medical condition. As an example, a stable out-patient with unexplained abnormal liver function tests and no history of bleeding abnormalities might be an appropriate candidate for percutaneous liver biopsy. On the other hand, a patient with unexplained abnormal liver tests who is undergoing hemodialysis treatment for end-stage renal disease would be expected to have an abnormal tendency for bleeding after a biopsy. The risk of bleeding complications might be reduced by using a transjugular approach. Finally, the patient with unexplained abnormal liver chemistries who is undergoing elective surgery for another reason (for example, surgical treatment of obesity or cholecystectomy to treat chronic gallbladder disease) might be a candidate for liver biopsy during surgery.

The word "percutaneous" means "through the skin." Percutaneous liver biopsies are typically performed by physicians who specialize in gastroenterology/hepatology, interventional radiology or surgery. Traditionally, biopsies were performed using a "blind" technique. With this technique, the physician percusses (i.e. taps) the skin overlying the chest and abdominal wall over the liver in order to identify an optimal site for biopsy. Typically, the site is located between the 8th and 9th ribs on the patient's right side or located below the edge of the rib cage in the right upper abdomen. At present, many physicians use ultrasound to confirm the ideal site to perform the biopsy.

As noted above, the diagnosis of a mass lesion may require the performance of a so-called "guided" biopsy. In guided biopsy, the patient undergoes an ultrasound or CT scan to identify the location of the mass. The physician performing the biopsy, typically an interventional radiologist, uses the results of the scan to guide the biopsy needle into the mass. Typically, the technique for CT-guided biopsy of a mass lesion entails:

• The patient lies upon the CT table.
• An abdomen CT scan is performed to identify the location of the liver mass.
• The patient is gently sedated.
• The interventional radiologist disinfects and anesthetizes the skin over the planned biopsy site.
• The liver biopsy needle is introduced into the skin.
• When the tip of the needle is confirmed to be directed towards the mass, the actual biopsy of the mass is performed.
• The biopsy needle is removed.
• The patient is sent to the recovery room.

Transjugular liver biopsy is typically performed in patients who have a greater-than-average risk of bleeding complications. It also is employed in patients where ascites (i.e. fluid in the abdominal cavity) increases the risk of complications after biopsy. The procedure has been available at most tertiary care centers for the last decade or two. Typically, the technique for transjugular liver biopsy entails:

• The patient is positioned upon his or her back on a fluoroscopy (for example, X-ray) table in the interventional radiology suite.
• The patient is sedated.
• The interventional radiologist disinfects and anesthetizes the skin over the right side of the neck.
• A small incision is made over the right internal jugular vein.
• A catheter is introduced into the right internal jugular vein.
• A guide wire is placed through the catheter, via the superior and inferior vena cava vessels, into the right hepatic vein.
• Its correct position is checked using fluoroscopy.
• A specially designed biopsy catheter system is then introduced over the guide wire and is positioned in the right hepatic vein.
• The actual biopsy needle is introduced via this new catheter.
• The biopsy is performed through the wall of the hepatic vein.
• The catheter is removed.
• The patient is sent to the recovery room.

Intraoperative liver biopsies are typically performed in patients who are undergoing surgery for another reason. Surgery may be performed via an open approach or via a laparoscopic approach, depending upon the needs of the patient. The surgeon may choose to perform a needle biopsy or may choose to remove a small tissue sample from the liver.

In some circumstances, a patient may undergo intraoperative liver ultrasound to identify a liver mass that is difficult to access using a percutaneous biopsy. That mass lesion may then undergo ultrasound-guided liver biopsy while the patient is on the operating room table.

1. Do you have a history of prolonged bleeding following surgical or dental procedures?
2. Do you have allergies or reactions to medications, anesthetic agents, X-ray contrast agents, or shellfish?
3. Are you using aspirin, nonsteroidal anti-inflammatory drugs (for example, ibuprofen), warfarin (Coumadin) or other blood thinners? All of these medications are anticipated to interfere with blood clotting. Their use in the period immediately prior to liver biopsy could increase the risk of bleeding complications after biopsy. Any decision to discontinue such medications needs to be made with advice of the patient's physicians. As an example, some patients on chronic warfarin (Coumadin) therapy can safely discontinue these medications for a week or more without any expectation of complications. Other patients might need to be "bridged" to the procedure by starting an alternate medication like enoxaparin (Lovenox), which is continued up until the night prior to liver biopsy.

1. Why do I need a liver biopsy?
2. What are the benefits of liver biopsy?
3. What are the risks of liver biopsy?
4. Are there alternatives to a liver biopsy?
5. What are the consequences of not undergoing a liver biopsy?
6. What approach will be used to perform my liver biopsy: percutaneous, transjugular, intraoperative?
7. Will the biopsy be performed using ultrasound or CT scan guidance? (Such guidance is not always necessary.)
8. When should I stop eating and drinking prior to my procedure?
9. If I am using blood thinning medications, when do they need to be stopped prior to the procedure?
10. Should I take my other medicines the morning of the biopsy?
11. If I have diabetes, what should I do with the dosing of my diabetes medications?
12. Will I receive sedation or other pain medications during my procedure?
13. How long will I have to stay in the hospital after the procedure?
14. Do I need someone to come with me or pick me up after the procedure
15. Will my activities be restricted following the liver biopsy? If so, for how long?
16. How soon after the procedure can I return to work?
17. If medications (for example, blood thinners) were stopped before the procedure, when can they be restarted?
18. What symptoms do I watch out for after the biopsy?
19. What should prompt me to call my health care provider's office or come to emergency room?
20. When should I return for follow-up?

Usually, patients are not allowed to drive an automobile the day that sedative medications are administered. Patients who are anticipated to receive sedative medications need to arrange for transportation home.

Below, we describe the procedure for ultrasound-guided percutaneous liver biopsy at a typical hospital. It is provided to give patients a sense of what to expect. Not all hospitals or institutions follow the same protocol for procedures.

• Arrive at ambulatory surgery.
• Undergo placement of an intravenous line.
• Go to interventional radiology and meet with the interventional radiologist who will do the procedure.
• Review the reasons for, benefits, risks and alternatives of biopsy with this physician.
• Sign an "informed consent" form to give permission for the procedure to be performed.
• Receive an intravenous sedative medication (this is optional).
• Undergo an ultrasound to identify the ideal site for biopsy.
• The skin over the biopsy site is cleansed.
• A small volume of a local anesthetic is injected in a sterile fashion into the biopsy site.
• A small (~ 5-10 mm long) incision is made in the skin.
• The liver biopsy needle is positioned correctly and the biopsy is performed.
• The patient is transported back to the recovery room.
• The patient awakens.
• The patient is asked to remain still in bed for a few hours (two to five hours).
• Heart rate and blood pressure are monitored by the recovery room nurse.
• Pain medicines are administered, as needed.

Infrequently:

• Check a blood test or order an imaging study to rule out post-biopsy bleeding.
• Infuse intravenous fluids.

The patient is usually discharged home. Unless otherwise stated, patients must avoid aspirin and nonsteroidal anti-inflammatory drugs (for example, ibuprofen) for at least one week after biopsy. The patient is instructed to call the physician immediately in the event that he or she experiences, chest pain, abdominal pain, dizziness, or shortness of breath.

The patient returns for follow-up in the ordering health care provider's office one week later to assess his or her post-biopsy symptoms (if any) and review the biopsy results.

Pain and discomfort

These are common symptoms after biopsy. Typically, pain is localized to the biopsy site. Sometimes, pain is felt over the whole liver. At other times, pain is felt in the chest or in the right shoulder or right shoulder blade. Typically, pain is mild or moderate in intensity. In most patients, no pain medicine is needed. Some patients need a low dose of acetaminophen or a low dose of a narcotic (for example, oxycodone) to relieve pain symptoms. Aspirin and nonsteroidal anti-inflammatory drugs are avoided because they can worsen bleeding. Typically, pain should continue to improve with every passing hour or day. Worsening of pain or a change in the pain pattern in the hours or days after biopsy should prompt:

• a phone call immediately to the responsible physician.
• In all likelihood, immediate return to the emergency room to rule out a post-biopsy complication (for example, bleeding).

As an example, the new onset of chest pain and shortness of breath should prompt a phone call to the responsible physician and immediate return to the emergency room.

Other concerning symptoms

Other worrisome symptoms include:

• Dizziness or fainting.
• Shortness of breath.
• Abdominal swelling or bloating.
• These symptoms should prompt a phone call to the responsible physician and immediate return to the emergency room.

3. Swelling or redness at the biopsy site. Mild swelling or redness may be of no significance. Worsening symptoms should prompt a phone call to the responsible physician and may necessitate an emergency room visit.
4. Fever. Fever is an uncommon symptom after liver biopsy. The occurrence of fever may indicate the presence of infection. It should prompt a phone call to the responsible physician and may necessitate an emergency room visit.
5. Nausea or vomiting. Persistent nausea or vomiting should prompt a phone call to the responsible physician and may necessitate an emergency room visit.

Patients should not return to work on the day of liver biopsy. Patients may return to work as tolerated the day after liver biopsy. Some patients prefer to take a day off from work due to post-biopsy discomfort. Otherwise, patients are free to resume their typical eating and bathing habits and return to normal activities.