Liver Biopsy

A liver biopsy is a procedure whereby small pieces of liver tissue are removed in order to be sent to a laboratory for examination. It is very helpful in the diagnosis of diseases that affect the liver.

There are several potential approaches to procuring tissue for a liver biopsy. These are discussed below.

Percutaneous Liver Biopsy

In a percutaneous liver biopsy procedure, local anesthesia is used to numb the skin where a small incision is made. A needle the diameter of a pen refill is then passed through the skin and into the liver, where a specimen is obtained. Multiple biopsies may be taken. In these circumstances, the physician establishes where the liver lies by percussing or tapping on the skin overlying the liver and listening to the sound to find an area of dullness, under which the liver lies. Patient cooperation is critical during the procedure.

Percutaneous Image-Guided Liver Biopsy

A percutaneous image-guided liver biopsy is similar to the one described above except that the needle is guided by CT scan or ultrasound images. This is often helpful when the disease process is localized to discrete spots in the liver.

Laparoscopic Liver Biopsy

A laparoscopic liver biopsy may be done solely for the purpose of obtaining the biopsy specimen or may be part of another operative procedure. Small incisions are made in the abdomen and instruments are introduced through trocars to obtain the biopsy specimens. The laparoscope is a telescope that magnifies the objects it sees and allows excellent visualization of the liver surface. Ultrasound can be used as part of this procedure.

Open Surgical Liver Biopsy

Open liver biopsies are rarely performed today unless they are part of another operative procedure. When an open biopsy is done, the surgeon may choose to use a biopsy needle or may surgically excise a small wedge of liver tissue.

There are two main reasons why your doctor may request that you undergo a liver biopsy. (Some of the more common diagnoses for which a liver biopsy is ordered are listed in the next section.)

• Diagnosis: A liver biopsy is a very important and helpful test in the diagnosis of numerous diseases that affect the liver and bile ducts. A small piece or pieces of tissue are removed from your liver and sent for examination. In most cases, this allows establishment of a very specific diagnosis.

• Monitoring: A liver biopsy can help your doctor monitor the effectiveness of therapy that you are receiving for a disease that affects the liver. Likewise, it can provide a warning if certain therapies you are receiving are damaging the liver.

• Liver biopsy: Diagnostic purposes 
  
  
  • Alcoholic liver disease
  
  
  
  • Elevated liver enzymes of unknown cause 
  
  
  
  • Biliary tract obstruction/jaundice
  
  
  
  • Fatty liver disease
  
  
  
  • Hemochromatosis
  
  
  
  • Wilson disease
  
  
  
  • Autoimmune liver disease
  
  
  
  • Alpha1-antitrypsin deficiency
  
  
  
  • Possible injury due to drug therapies
  
  
  
  • Hepatitis B
  
  
  
  • Hepatitis C
  
  
  
  • Hepatomegaly (liver enlargement) of undetermined cause
  
  
  
  • Cancers that originate in the liver
  
  
  
  • Cancers that spread (metastasize) to the liver from other sites
  
  
  
  • Noncancerous tumors or abnormalities in the liver 

• Liver biopsy: Monitoring therapy
  
  
  • Chronic viral hepatitis  
  
  
  
  • HIV/AIDS
  
  
  
  • Liver transplantation (to rule out rejection or infection)

Although their occurrence is rare, you should be familiar with the signs and symptoms of complications related to a liver biopsy. Liver biopsy is a routine procedure. However, emergency surgery to control severe bleeding or to repair accidental injury to surrounding organs and even death are well described complications of liver biopsy. The following list briefly describes the signs and symptoms of potential complications of liver biopsy.

• Fever: Development of a fever following a liver biopsy may indicate the presence of infection. It is best to check with your doctor.

• Pain, swelling, redness or discharge around the needle insertion sites or any incisions that were made: These are signs that a wound infection is present. You should see your doctor.

• Chest pain: This complaint should always be investigated. Call your doctor or emergency services immediately.

• Shortness of breath: Patients who develop shortness of breath should seek medical attention immediately.

• Dizziness or fainting: These are possible signs of blood loss and should prompt you to contact your doctor or emergency services immediately.

• Nausea or vomiting: Persistent nausea or vomiting needs attention to ensure that there are no intra-abdominal complications related to your liver biopsy.

• Worsening abdominal pain: This can be caused by bleeding, leakage of bile, or other problems that will need medical attention. Consult with your doctor as soon as possible.

• Abdominal swelling or bloating: Intestinal problems or internal bleeding can manifest as abdominal swelling or bloating. Patients experiencing this problem should call their doctor as soon as possible.

The preceding section lists potential complications of liver biopsy. The accompanying text describes when and why medical attention should be sought.

|Questions to Ask the Doctor|

1. Why do I need a liver biopsy?

2. What approach will be used to perform my liver biopsy?

3. Is there a time before the procedure that I should stop eating and drinking (or is it even necessary to stop eating and drinking)?

4. Do I need someone to come with me or pick me up after the procedure?

5. How long will I have to stay in the hospital after the procedure?

6. Will I be given any sedatives or other medications?

7. What types of risks are associated with a liver biopsy?

8. What exactly is done during the liver biopsy?

9. Will my activities be restricted following the liver biopsy, and for how long?

10. How soon after the procedure can I return to work?

11. Are there any medications I should stop taking before the procedure?

12. If there are medications that need to be stopped before the procedure, when can I start them again after the procedure?

There are also important items of information that you should share with your doctor if known. These include the following:

1. A history of prolonged bleeding following surgical or dental procedures

2. Any medication allergies

3. Other allergies such as those to shellfish or x-ray contrast agents

4. Use of aspirin, Coumadin, nonsteroidal anti-inflammatory drugs, or other medications that interfere with blood clotting

5. A history of any allergies or adverse affects related to anesthetic agents

Your biopsy specimen will be sent for several tests. What types of tests are performed depends on the diagnosis your doctor is trying to make. Examples of some of the more common tests used to examine liver biopsy specimens include the following:

• Light microscopy with or without special stains



• Electron microscopy



• Bacterial cultures



• Virology testing



• Tumor markers



• Iron content analysis on liver biopsy to rule out hemochromatosis

Depending on where your biopsy is performed (office or outpatient site, x-ray department, operating room) and the approach used (surgical vs. nonsurgical), one or more of the following treatment options will apply to you:

• Intravenous fluids

• Sedative drugs

• Pain killers

• Local, regional, or general anesthesia

• Antibiotics

• Antinausea drugs

• Supplemental oxygen

Following the procedure, you will be monitored until your doctor is satisfied with your recovery. Monitoring measures will include instruments that provide information about one or more of the following:

• Blood pressure

• Heart rate and rhythm

• Breathing rate

• Oxygen levels (saturation) in your bloodstream

• Urine output

Some practitioners advise that the patient be positioned on the right side for up to 2 hours and then on their back for the remainder of 24 hours total.

|Self-Care at Home|

Your doctor may restrict your activity initially. This should be discussed directly with your doctor. Otherwise, you are free to resume normal activities and eating habits.

After the doctor receives the results of your liver biopsy, you will receive further instructions. If a clear diagnosis has been made, treatment options will be discussed, as will the prognosis for the particular disease. If no clear diagnosis has been made, further testing or even a repeat biopsy may be indicated.

If the liver biopsy was ordered to monitor therapy, changes in your medications or other treatments may be ordered.

|Follow-up|

Your doctor will want to make a follow up appointment with you to ensure that the biopsy sites or incisions are healing well and that there have been no complications referable to the liver biopsy.

He or she will also want to discuss the biopsy results with you as outlined in the section above.

|Support Groups and Counseling|

Many national level organizations offer the opportunity to participate in counseling or support groups. Your doctor or other health care personnel may be able to refer you to local chapters. Some of the Web sites listed in the next section offer information on how to find local support groups.

More information may be provided by literature available in your doctor's office. Many Web sites now offer detailed information related to liver biopsies and liver diseases in general. A list of Web links is provided below.

|Web Links|

American Association for the Study of Liver Diseases

American Gastrointestinal Association

American Liver Foundation

Centers for Disease Control and Prevention, Hepatitis Branch, Viral Hepatitis

Hepatitis Foundation International

National Council on Alcoholism

National Institute of Diabetes and Digestive and Kidney Diseases

National Transplant Society

liver biopsy, percutaneous liver biopsy, percutaneous image-guided liver biopsy, laparoscopic liver biopsy, open liver biopsy, Tru-Cut needle biopsy, core needle liver biopsy, hepatitis A, hepatitis B, hepatitis C, alcoholic liver disease, cirrhosis, biliary cirrhosis, fatty liver disease, hemochromatosis, hepatomegaly, liver enlargement, liver cancer, liver tumors, complications of liver biopsy, liver transplant

Author: Michael AJ Sawyer, MD, Clinical Assistant Professor, Department of Surgery, University of Hawaii at Manoa; Consulting Staff, Department of Surgery, Kaiser Permanente Medical Center of Honolulu.

Coauthor(s): Elizabeth M Sawyer, MD, CPT, MC, Staff Physician, Department of Surgery, Tripler Army Medical Center; Kathryn L Hale, MS, PA-C, Medical Writer, .com, Inc.

Editors: Robert J Fingerote, MD, MSc, BSc, Consulting Staff, Department of Medicine, Division of Gastroenterology, Queensway-Carleton Hospital of Ottawa, Canada; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Julian Katz, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Drexel University College of Medicine.