Approach to liver biopsy
- Arturo Bravo, MD
Arturo Bravo, MD
- Assistant Clinical Professor of Medicine
- University of Texas Health Science Center at San Antonio
- Sunil G Sheth, MD
Sunil G Sheth, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology and Hepatology
- Section Editor — General Hepatology; Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
Histopathologic examination of liver tissue can provide qualitative information about the type and degree of injury and/or fibrosis [1,2]. Pertinent clinical information should be made available to the pathologist so that the histopathological findings can be interpreted in the clinical context .
A guideline from the American Association for the Study of Liver Diseases (AASLD) lists the following indications for liver biopsy :
●Diagnostic evaluation of:
•Focal or diffuse abnormalities on imaging studies
•Parenchymal liver diseaseTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001; 344:495.
- Tapper EB, Lok AS. Use of Liver Imaging and Biopsy in Clinical Practice. N Engl J Med 2017; 377:756.
- Czaja AJ, Carpenter HA. Optimizing diagnosis from the medical liver biopsy. Clin Gastroenterol Hepatol 2007; 5:898.
- Rockey DC, Caldwell SH, Goodman ZD, et al. Liver biopsy. Hepatology 2009; 49:1017.
- Eastwood GL. Liver Biopsy. In: Atlas of Bedside Procedures, 2nd ed, VanderSalm TJ, Cutler BS, Wheeler HB (Eds), Little Brown, Boston 1988. p.393.
- Patel IJ, Davidson JC, Nikolic B, et al. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2012; 23:727.
- Alexander JA, Smith BJ. Midazolam sedation for percutaneous liver biopsy. Dig Dis Sci 1993; 38:2209.
- Reddy KR, Schiff ER. Complications of liver biopsy. In: Gastrointestinal emergencies, 2nd ed, Taylor, Gollan, Steer, Wole (Eds), Williams & Wilkins, Baltimore 1997. p.959.
- Pawa S, Ehrinpreis M, Mutchnick M, et al. Percutaneous liver biopsy is safe in chronic hepatitis C patients with end-stage renal disease. Clin Gastroenterol Hepatol 2007; 5:1316.
- Zakaria N, Knisely A, Portmann B, et al. Acute sickle cell hepatopathy represents a potential contraindication for percutaneous liver biopsy. Blood 2003; 101:101.
- Park MA, Mueller PS, Kyle RA, et al. Primary (AL) hepatic amyloidosis: clinical features and natural history in 98 patients. Medicine (Baltimore) 2003; 82:291.
- Ebert EC, Nagar M. Gastrointestinal manifestations of amyloidosis. Am J Gastroenterol 2008; 103:776.
- McGill DB, Rakela J, Zinsmeister AR, Ott BJ. A 21-year experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology 1990; 99:1396.
- Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol 1986; 2:165.
- Colombo M, Del Ninno E, de Franchis R, et al. Ultrasound-assisted percutaneous liver biopsy: superiority of the Tru-Cut over the Menghini needle for diagnosis of cirrhosis. Gastroenterology 1988; 95:487.
- Riley TR 3rd. How often does ultrasound marking change the liver biopsy site? Am J Gastroenterol 1999; 94:3320.
- Lindor KD, Bru C, Jorgensen RA, et al. The role of ultrasonography and automatic-needle biopsy in outpatient percutaneous liver biopsy. Hepatology 1996; 23:1079.
- Caturelli E, Giacobbe A, Facciorusso D, et al. Percutaneous biopsy in diffuse liver disease: increasing diagnostic yield and decreasing complication rate by routine ultrasound assessment of puncture site. Am J Gastroenterol 1996; 91:1318.
- Smith CI, Grau JE. The effects of ultrasonography on the performance of routine liver biopsy. Hepatology 1995; 22:384.
- Firpi RJ, Soldevila-Pico C, Abdelmalek MF, et al. Short recovery time after percutaneous liver biopsy: should we change our current practices? Clin Gastroenterol Hepatol 2005; 3:926.
- Beddy P, Lyburn IL, Geoghegan T, et al. Outpatient liver biopsy: a prospective evaluation of 500 cases. Gut 2007; 56:307.
- Seeff LB, Everson GT, Morgan TR, et al. Complication rate of percutaneous liver biopsies among persons with advanced chronic liver disease in the HALT-C trial. Clin Gastroenterol Hepatol 2010; 8:877.
- Boyum JH, Atwell TD, Schmit GD, et al. Incidence and Risk Factors for Adverse Events Related to Image-Guided Liver Biopsy. Mayo Clin Proc 2016; 91:329.
- West J, Card TR. Reduced mortality rates following elective percutaneous liver biopsies. Gastroenterology 2010; 139:1230.
- Garcia-Tsao G, Boyer JL. Outpatient liver biopsy: how safe is it? Ann Intern Med 1993; 118:150.
- Janes CH, Lindor KD. Outcome of patients hospitalized for complications after outpatient liver biopsy. Ann Intern Med 1993; 118:96.
- Myers RP, Fong A, Shaheen AA. Utilization rates, complications and costs of percutaneous liver biopsy: a population-based study including 4275 biopsies. Liver Int 2008; 28:705.
- Froehlich F, Lamy O, Fried M, Gonvers JJ. Practice and complications of liver biopsy. Results of a nationwide survey in Switzerland. Dig Dis Sci 1993; 38:1480.
- Huang JF, Hsieh MY, Dai CY, et al. The incidence and risks of liver biopsy in non-cirrhotic patients: An evaluation of 3806 biopsies. Gut 2007; 56:736.
- Hederström E, Forsberg L, Florén CH, Prytz H. Liver biopsy complications monitored by ultrasound. J Hepatol 1989; 8:94.
- Van Thiel DH, Gavaler JS, Wright H, Tzakis A. Liver biopsy. Its safety and complications as seen at a liver transplant center. Transplantation 1993; 55:1087.
- Forssell PL, Bonkowsky HL, Anderson PB, Howell DA. Intrahepatic hematoma after aspiration liver biopsy. A prospective randomized trial using two different needles. Dig Dis Sci 1981; 26:631.
- Lichtenstein DR, Kim D, Chopra S. Delayed massive hemobilia following percutaneous liver biopsy: treatment by embolotherapy. Am J Gastroenterol 1992; 87:1833.
- Ruben RA, Chopra S. Bile peritonitis after liver biopsy: nonsurgical management of a patient with an acute abdomen: a case report with review of the literature. Am J Gastroenterol 1987; 82:265.
- Regev A, Berho M, Jeffers LJ, et al. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection. Am J Gastroenterol 2002; 97:2614.
- Ratziu V, Charlotte F, Heurtier A, et al. Sampling variability of liver biopsy in nonalcoholic fatty liver disease. Gastroenterology 2005; 128:1898.
- Kaw YT, Esparza AR. Cytologic diagnosis of cavernous hemangioma of the liver with fine-needle biopsy. Diagn Cytopathol 1991; 7:628.
- Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Review. Radiology 1991; 178:253.
- Rodgers MS, Collinson R, Desai S, et al. Risk of dissemination with biopsy of colorectal liver metastases. Dis Colon Rectum 2003; 46:454.
- Lundquist A. Fine-needle aspiration biopsy of the liver. Applications in clinical diagnosis and investigation. Acta Med Scand Suppl 1971; 520:1.
- Vargas C, Jeffers LJ, Bernstein D, et al. Diagnostic laparoscopy: a 5-year experience in a hepatology training program. Am J Gastroenterol 1995; 90:1258.
- CHOOSING A ROUTE
- PREPARATION OF THE PATIENT
- Evaluation of coagulation status
- - Approach to patients with abnormal coagulation studies
- Dietary recommendations
- Sedation assessment
- SPECIAL PATIENT POPULATIONS
- Patients with chronic renal failure
- Patients with inherited disorders of hemostasis
- Patients with sickle cell disease
- Patients with amyloidosis
- PERCUTANEOUS NEEDLE BIOPSY
- Choice of needle
- Description of procedure
- Role of image guidance for nontargeted biopsies
- Post-biopsy care
- - Overall rates and mortality
- - Pain
- - Bleeding
- - Transient bacteremia
- - Bile peritonitis
- - Organ injury
- - Other complications
- FINE-NEEDLE ASPIRATION BIOPSY
- LAPAROSCOPIC LIVER BIOPSY
- TRANSJUGULAR LIVER BIOPSY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS