Percutaneous Liver Biopsy

Shreya Sengupta, MD

Liver biopsy has a central role in the evaluation of patients with suspected liver disease and can assess the nature and severity of disease. It can also be useful in monitoring the efficacy of various treatments. There are several methods for performing liver biopsy, which include percutaneous, transjugular, or laparoscopic biopsy; endoscopic ultrasound or computer tomography (CT)-guided approach is also being used. Although percutaneous liver biopsy is safe and routinely performed, a transjugular approach should be considered when standard liver biopsy is contraindicated.¹ New noninvasive tests have reduced the need for liver biopsy, but this procedure continues to have a role in the diagnosis of some liver disease, resolving questions regarding stages of fibrosis, and for addressing research questions.²

INDICATIONS

1. Diagnosis
- a. Multiple parenchymal liver diseases
- b. Abnormal liver tests of unknown etiology
- c. Fever of unknown origin
- d. Focal or diffuse abnormalities on imaging studies
- e. Hepatic mass—imaging can be diagnostic for HCC and certain types of cholangiocarcinoma (hilar) should not be biopsied; however, biopsy can be considered in certain situations
2. Prognosis—staging of known parenchymal liver disease
3. Management—developing treatment plans based on histologic analysis³
- a. Rejection in the transplanted liver

CONTRAINDICATIONS

Specifying contraindications to liver biopsy is difficult given the scarcity of data. Contraindications will vary depending on the physician and local expertise, and most of the contraindications listed below are considered to be relative. In clinical practice, patients who are uncooperative, are morbidly obese, or have an increased risk of bleeding are of greatest concern.¹,³

Absolute Contraindications

1. Uncooperative patient
2. Severe coagulopathy (no set cutoff for INR (international normalized ratio) but may consider INR > 2 as severe coagulopathy)
3. Infection of the hepatic bed
4. Extrahepatic biliary obstruction
5. Inability to identify an adequate biopsy site by percussion and/or ultrasound

Relative Contraindications

1. Ascites
2. Morbid obesity
3. Possible vascular lesions
4. Amyloidosis
5. Hydatid disease

PREPARATION

1. Complete a history and physical examination, assessing for personal or family history of excessive bleeding.
2. Review medications, particularly those known to affect bleeding parameters.
3. Evaluate coagulation status with prothrombin time, platelet count, and a complete blood count prior to the biopsy. Bleeding time may be considered, particularly in patients with renal failure or a history of excessive bleeding.
4. Obtain written informed consent.
5. There is no clear evidence in the literature regarding fasting status. Some centers recommend NPO (nil per os) status prior to the procedure, while other centers advocate for a preprocedural light snack to avoid a vasovagal response and to ensure that the gallbladder is contracted.

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