A liver biopsy is a procedure that involves obtaining a small piece of liver tissue, which is then analyzed in the laboratory. Liver biopsy may be recommended to diagnose a problem or determine the severity of liver disease.
Reasons for a Liver Biopsy
As a general rule, a liver biopsy is recommended only when the results would influence a management decision. Some of the more common indications are in patients with:
- Non-alcoholic fatty liver disease (NAFLD) — NAFLD is a condition in which there is increased amounts of fat in the liver, sometimes in association with inflammation or scarring. NAFLD is the most common reason for liver biopsy.
- A variety of different types of liver disease, such as chronic hepatitis B or C, primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis, hemochromatosis or Wilson’s disease. A biopsy can provide information about the severity of liver injury. Unexplained liver disease or abnormal liver function tests (blood tests that reflect injury to the liver)
- Monitoring the liver following a liver transplant
- A liver biopsy may also be helpful in people with unexplained fevers, those with certain rare metabolic diseases, and a variety of other less common disorders.
Preparation for a Liver Biopsy
Prior to a liver biopsy, a healthcare provider will check blood tests that reflect how well the blood clots. Normal blood clotting is important to prevent bleeding after the biopsy.
- Patients should not take medications that can increase the risk of bleeding. These include the following
- Aspirin or aspirin-containing medications
- Other nonsteroidal antiinflammatory drugs (NSAIDS) such as ibuprofen (eg, Motrin®, Advil®), and naproxen (eg, Aleve®). NSAIDs are contained in a variety of over-the-counter preparations.
- Anticoagulant medications such as warfarin (Coumadin®)
- Certain medications for people with heart conditions (such as abciximab [Reopro®], dipyridamole [Persantine®], ticlopidine [Ticlid®], and clopidogrel [Plavix®])
- Some herbal therapies (such as fish oil or ginkgo biloba).
Patients should carry a list of their medications, including over-the-counter medications, herbs, and vitamins. This can be discussed with the physician before the biopsy to determine if any medications need to be stopped temporarily.
It is common to perform an ultrasound examination of the liver and gallbladder area before the biopsy so that the physician can confirm which biopsy site is optimal. An ultrasound is a painless test that uses sound waves to visualize the liver and related structures. Ultrasound examinations are not done for every patient in every institution; the need to do that test will be determined by the doctor who does the biopsy.
Patients should have nothing to eat or drink for six hours before the procedure; some patients may be allowed to have a light breakfast only, such as tea or coffee and toast. Some doctors recommend eating a small amount of fat (such as butter or margarine) with breakfast, which will empty the gallbladder and potentially decrease the risk of gallbladder injury during the biopsy.
Patients will need to arrange to have someone accompany them home after the biopsy because sedative medications are often used. A friend or family member can also help pass the time during the few hours of observation following the biopsy.
Liver Biopsy Procedure
Most liver biopsies are done in a hospital. Upon arrival for the biopsy (usually in the early morning), the healthcare providers involved in the procedure will review the patient’s medical history, including medications and allergies. Some patients will have an intravenous line placed (a needle is inserted into a vein) so that fluid and medications can be administered if needed.
A patient may be given pain-relieving and sedative medications prior to the procedure to minimize discomfort and anxiety. Because patient cooperation is needed during a liver biopsy, the patient is not given medication to induce sleep. Patients should go to the bathroom shortly before the biopsy since they will be required to lie in bed for at least two hours after the procedure.
During the biopsy, the patient lies on their back near the right edge of the bed. The right arm will be under the head. The doctor will locate the best site for the biopsy by tapping (called percussing) with a finger against the side of the chest after the patient completely exhales (breathes out and holds the breath). This causes the lungs to become smaller and brings the liver upwards toward the chest. It also reduces the risk that the biopsy needle will injure organs near the liver. To ensure that the biopsy is performed during exhalation, the doctor may rehearse controlled breathing by asking the patient to breathe in deeply and then exhale completely while holding the breath as the doctor counts to four. It is important to follow these breathing instructions closely.
A local anesthetic will be injected into the skin; this causes a burning sensation. A tiny incision will be made into the skin so that the needle will pass through easily. The biopsy itself only takes a few seconds as the biopsy needle is passed quickly in and out of the liver. Some doctors use an automated liver biopsy device, which can make a clicking sound when the biopsy needle is deployed. The patient will be told to resume breathing after the biopsy. A small bandage will be applied to the biopsy site; stitches are not needed.
Complications of a Liver Biopsy
A liver biopsy is a very safe procedure when performed by experienced physicians. Only 2 to 3 percent of patients require hospitalization after a liver biopsy.
Discomfort —Approximately 25 percent of patients experience discomfort at the biopsy site, right upper abdomen, or right shoulder after a liver biopsy. The discomfort is usually dull, mild, may be worse during breathing, and lasts for only a short time (a few hours to less than 24 hours). Less commonly, patients have mild discomfort that lasts longer than 24 hours.
The discomfort can be treated with a mild pain medication, such as acetaminophen (Tylenol®). In patients with liver disease, a dose of less than 2000 mg over 24 hours is safe. NSAIDs (ibuprofen, naproxen) should be avoided for 5 to 7 days after the biopsy. Patients with ongoing or severe pain may be a sign of a more serious problem, and should be reported to the physician.
Low blood pressure — Low blood pressure immediately after a liver biopsy occurs in about 10 to 20 percent of patients. It is usually due to a vasovagal reaction, which causes the blood vessels in the body to dilate and the heart rate to slow (similar to what occurs when a person faints). The reaction can be reversed with medications if needed, but it usually responds to intravenous fluids, pain medications, or observation. Persistent low blood pressure or a falling blood pressure may indicate bleeding.
Bleeding — Significant bleeding after a liver biopsy occurs in approximately 0.3 percent of biopsies (3 in 1,000). Bleeding usually becomes apparent within three to four hours. The bleeding often stops on its own, but if it persists, a blood transfusion may be needed. Surgery or angiography (a procedure in which the bleeding site is identified and treated) may be required if the bleeding is severe or does not stop on its own.
Bile peritonitis — The liver and ducts within it contain bile, a substance that helps digest food. Leakage of bile after a liver biopsy can cause irritation of the lining of the abdomen, a condition called bile peritonitis. This occurs in less than 1 in 1,000 biopsies. It usually resolves on its own. Removal of the gallbladder may be required if the leakage is due to gallbladder injury.
Infection — In people with certain forms of liver disease (such as primary sclerosing cholangitis), bacteria can be released into the blood as a result of the biopsy. Preventive antibiotics are sometimes recommended for these patients. Infection of the biopsy site is rare.
Perforation — The biopsy needle may inadvertently pierce organs that are adjacent to the liver. These include the lungs, kidney, small intestine, and gallbladder. Fortunately, this does not usually cause a serious problem.
Postprocedure Care Following a Liver Biopsy
Following the biopsy, the patient will be asked to lie on their right side for two hours. A nurse will monitor the patient’s blood pressure and pulse periodically for several hours. Many people watch television or a video, read, or talk with friends or family.
In addition to resting the day of the biopsy, patients should plan to take it easy for the next five to seven days. In general, patients should restrict heavy lifting (no more than 15 to 20 pounds) for a week, avoid blood thinning medication for several days, and call with any concerning symptoms, including the following:
- Severe pain at the biopsy site or shoulder
- Shortness of breath
- Chest pain
- Bleeding from the biopsy site
- Fever (temperature greater than 100.4º F or 38º C)
- Abdominal pain
- Weakness, sweating
- Heart palpitations
Biopsy results — The biopsy report is usually available within a few days to a week after the biopsy. Patients usually have a follow-up appointment to discuss the results of the biopsy and what treatment (if any) is needed.
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