Digestive Diseases and Nutrition

Liver Biopsy

A liver biopsy is a procedure that is intended to obtain a small sample or piece of the liver so it can be examined under the microscope. The purpose for the biopsy is for one or more of the following reasons:

  • Establish the presence (or absence) of disease entity in the context of elevated liver enzymes undiagnosed by blood tests
  • Establish the nature of an incidental liver lesion (a mass or a tumor) that is seen on liver imaging tests (ultrasound or CT scan), with or without abnormal liver enzymes
  • Assess the degree of liver damage (staging) in a previously diagnosed liver disease such as hepatitis C or fatty liver disease.
Once the above is achieved, a specific treatment can be initiated accordingly, if applicable.

Liver biopsy is done as an outpatient procedure at Florida Hospital Tampa or Tampa General Hospital. All three main types of liver biopsy remove liver tissue with a needle that has a built-in automatic mechanism (that is, after needle insertion, you will hear clicking sound as the needle removes a tissue sample); however, each takes a different approach to needle insertion. Liver biopsy can be performed through the skin (percutaneous route), the jugular vein in the right side of the neck (transjugular route), and during an abdominal surgery (laparoscopic route).

Prior to liver biopsy, blood will be drawn to determine its ability to clot. Certain medications that inhibits normal clotting function such as oral warfarin sodium (Coumadin®), or injection ardeparin (Indeparin®), dalteparin (Fragmin®), enoxaparin (Lovenox®, Clexane®, Cutenox®), fondaparinux (Arixtra®), should be avoided for 3-5 days prior to liver biopsy (you will be instructed). Also, medications that inhibit platelets function should be avoided for one week prior to liver biopsy. These include oral medications such as anagrelide (Agrylin®), clopidogrel (Plavix®), dipyridamole/aspirin (Aggrenox®), cilostazol (Pletal®), dipiridamole (Persantine®), ticlopidine (Ticlid®), and aspirin or injection medications such as abciximab (Reopro®), tirofiban (Aggrastat®), eptifabatide (Integrilin®). A telephone or face-face interview at the performing facility will also be conducted to further explain the procedure and answer any questions. Patients with severe liver disease often have blood clotting problems that can increase the risk of bleeding after the procedure. This problem can be addressed on the morning of the procedure by giving certain blood products to temporarily improve the clotting problems.

Patients who desire sedation for the procedure should not eat or drink for 8 hours before the liver biopsy. All patients should arrange a ride home, as driving is prohibited for the 24-hour period after the procedure. Mild sedation is sometimes used during liver biopsy to help patients stay relaxed. Unlike general anesthesia where patients are unconscious, patients can communicate while sedated and able to hold their breath momentarily while the actual biopsy is obtained. Sedatives are often given through an intravenous (IV) catheter placed in a vein. The IV can also be used to give pain medication, if necessary, after the procedure. Transient pain at the IV and liver biopsy sites is expected. There is always a risk of medication reaction to the sedatives or the topical anesthetic (numbing medications).

For the percutaneous route (most often route), the performing physician often uses ultrasound, computerized tomography (CT), or other imaging techniques to help find the liver and avoid sticking other organs with the biopsy needle. For this reason, a specialized radiologist (x-ray doctor) is the one performing the procedure.

Liver BiopsyDuring the procedure, the patient lies on his/her back on a table with their right hand resting above their head. A local anesthetic (numbing medication) is applied to the area where the biopsy needle will be inserted. This will cause transient burning sensation. An IV tube is used to give sedatives during, and pain medications during or after the procedure. The doctor makes a tiny incision (less than a quarter of an inch) on the right side of the chest wall between the ribs where the liver exists (see image) but sometimes in the abdomen, and inserts the biopsy needle. Patients will be asked to exhale and hold their breath while the needle is inserted and a liver sample is quickly withdrawn. Several samples may be collected, requiring multiple needle insertions. After the biopsy, patients must lie on their right side for up to 2 hours to reduce the risk of bleeding. Patients are then monitored an additional 2 to 4 hours after the biopsy before being sent home.

Transjugular liver biopsy provides smaller liver samples so it is not the preferred method of liver biopsy. It is reserved for patients with significant blood clotting disorders or when excess fluid is present in the abdomen, a condition called ascites. Transjugular biopsyDuring the procedure, patients lie on their back on an x-ray table and a local anesthetic is applied to the right side of the neck (see image). If needed, an IV tube is used to give sedatives and pain medication. A small incision is made in the neck and a specially designed hollow tube called a sheath is inserted into the jugular vein as a conduit. The doctor threads the sheath down the jugular vein, along the side of the heart, and into one of the hepatic (liver) veins, which are located above the liver. To see the veins, the doctor injects liquid contrast material into the sheath. The contrast material lights up when seen under x-ray, highlighting the blood vessels and showing the proper location of the sheath. The doctor threads a biopsy needle through the sheath and into the liver and a liver sample is quickly withdrawn. Several samples may be collected, requiring multiple needle insertions. The sheath is carefully withdrawn and the incision is closed with a bandage. Patients are monitored for 4 to 6 hours for signs of bleeding. 

Laparoscopic liver biopsy is done at the time of surgery for another indication, e.g. gallbladder removal, etc. There is no special preparation or this procedure apart what you should do for the surgery itself.

Pain at the biopsy site is the most frequent risk of percutaneous liver biopsy, occurring in about 20 percent of patients. The risk of excessive bleeding, called hemorrhage, is about 1 in 500 to 1 in 1,000. Risk of death is about 1 in 10,000 to 1 in 12,000. If hemorrhage occurs, a blood transfusion may be necessary and bleeding may stop on its own. If it does not, a procedure called angiography (visualization of blood vessels with contrast injection under x-ray to identify the bleeding site) and embolization (deployment of a special plug), can be used to stop the bleeding. In extreme cases, surgery can also be used to stop a hemorrhage. Other risks include puncture of other internal organs such as the lungs or bile ducts, infection, leakage of bile inside the abdomen at the biopsy site, and spread of cancer cells (if biopsy was directed at a suspected or known tumor), called cancer seeding. Transjugular liver biopsy carries an additional risk of adverse reaction to the contrast material. For any concerns or potential complication post-liver biopsy, you will need to notify the facility where the biopsy had taken place to properly and expediently address any concerns.