Liver Biopsy Procedure, Indications And Contraindications

Liver Biopsy Procedure, Indications And Contraindications

What is a Liver Biopsy?

With a liver biopsy (BYE-op-see), the physician is able to examine a small piece of tissue from your liver for signs of damage or disease. This procedure involves using a special needle to remove tissue from the liver. The physician decides to do a liver biopsy after tests suggest that the liver does not work properly. For example, a blood test might show that your blood contains higher than normal levels of liver enzymes or too much iron or copper. An x-ray could suggest that the liver is swollen. Looking at liver tissue itself is the best way to determine whether the liver is healthy.

Read more: Liver Cancer Causes, Symptoms, Diagnosis, Treatment, Prevention, Nutrition And Other

Liver Biopsy Preparation

Before scheduling your biopsy, the physician will take blood samples to make sure your blood clots properly. Be sure to mention any medications you take, especially those, like blood thinners, that affect blood clotting. One week before the surgery, you will have to stop taking aspirin, ibuprofen, and anticoagulants. You will also have a chest x-ray.

You must not eat or drink anything for 8 hours before the biopsy, and you should plan to arrive at the hospital about an hour before the scheduled time of the surgery. Your physician will tell you whether to take your normal medications during the fasting period and may give you other special instructions.

Liver Biopsy Procedure

Liver biopsy is considered minor surgery and is done at the hospital. The nurse will start an intravenous line to give you medication for the procedure. For the biopsy, you will lie on a hospital bed on your back or turned slightly to the left side, with your right hand above your head. After marking the outline of your liver and injecting a local anesthetic to numb the area, the physician will make a small incision in your right side near your rib cage, then insert the biopsy needle and retrieve a sample of liver tissue. In some cases, the physician may use an ultrasound image of the liver to help guide the needle to a specific spot.

You will need to hold very still so that the physician does not nick the lung or gallbladder, which are close to the liver. The physician will ask you to hold your breath for 5 to 10 seconds while he or she puts the needle in your liver. You may feel a dull pain. The entire procedure takes about 20 minutes.

Two other methods of liver biopsy are also available. For a laparoscopic biopsy, the physician inserts a special tube called a laparoscope through an incision in the abdomen. The laparoscope sends images of the liver to a monitor. The physician watches the monitor and uses instruments in the laparoscope to remove tissue samples from one or more parts of the liver. Physicians use this type of biopsy when they need tissue samples from specific parts of the liver.

Transvenous biopsy involves inserting a tube called a catheter into a vein in the neck and guiding it to the liver. The physician puts a biopsy needle into the catheter and then into the liver. Physicians use this procedure when patients have blood-clotting problems or fluid in the hospital since you will not be allowed to drive after having the sedative. You must go directly home and remain in bed (except to use the bathroom) for 8 to 12 hours, depending on your physician's instructions. Also, be sure not to exert yourself too much for the next week so that the incision and liver can heal. You can expect a little soreness at the incision site, and you might have some pain in your right shoulder. This pain is caused by irritation of the diaphragm muscle (the pain usually radiates to the shoulder) and should disappear within a few hours or days. Your physician may recommend that you take Tylenol for pain, but you must not take aspirin or ibuprofen for the first week after surgery. These medicines decrease blood clotting, which is crucial for healing.

Indications of liver biopsy

1. For patients with viral hepatitis

For patients with viral hepatitis ( Hep. B & C), liver biopsy is used for grading, staging, and the exclusion of comorbidities.

2. Autoimmune hepatitis

The diagnosis of autoimmune hepatitis (AIH) requires the histological demonstration of hepatitis. Biopsy also aids treatment monitoring in AIH. In AIH, liver biopsy is important for securing the initial diagnosis (as an integral component of the diagnosis score) and for treatment monitoring over the course of the disease.

3. In patients with cholestatic liver diseases

In patients with cholestatic liver diseases, liver biopsy is a valuable means of detecting or ruling out the autoimmune disorders in this diseases class, when the laboratory findings are inconclusive. They include:

  • Primary sclerosing cholangitis
  • Primary biliary cirrhosis
  • Overlap syndrome
  • Nutritional-toxic/alcoholic steatohepatitis

4. Fatty-liver disease

Liver biopsy is an aid to the differential diagnosis of fatty-liver disease. Histological examination reveals the degree of fibrosis (staging) and any potential comorbidities.

5. Storage diseases and metabolic diseases

Liver biopsy can provide the initial diagnosis of storage diseases and metabolic diseases of the liver when the laboratory findings are inconclusive. It also enables histological determination of the extent and stage of the disease. They include:

  • Hemochromatosis
  • Wilsons disease
  • Alpha 1 antitrypsin deficiency.

6. Hepatopathy of unknown cause; acute liver failure

In these cases, liver biopsy serves as an aid to etiological diagnosis and prognostication.

7. Biopsy of hepatic nodules

  •  Biopsy of a solitary lesion in a non-cirrhotic liver
Hemangioma and focal nodular hyperplasia (FNH

Liver-cell adenoma is sometimes hard to distinguish from well-differentiated hepatocellular carcinoma.

  •   Biopsy of a solitary lesion in a cirrhotic liver
A solitary hepatic lesion in a patient with known hepatic cirrhosis is likely to be a hepatocellular  carcinoma.

Biopsy usually suffices to differentiate HCC from intrahepatic cholangiocarcinoma (ICC)

  • Biopsy of multiple focal hepatic lesions
Focal liver changes (single or multiple) should be diagnosed by the targeted biopsy of one lesion, as the histological finding serves as the basis for further  treatment and prognostication.

No biopsy is needed, however, when the lesion is clearly a metastasis of a known primary tumor.

Contraindications for Liver Biopsy

A liver biopsy is a procedure which will help in making a definitive diagnosis in certain conditions related to the liver although its contribution towards altering the treatment is not so prominent. Therefore, it is not a frequent investigation that is performed in clinical practice and if performed would require a pre procedure evaluation of the patient before carrying out the biopsy.

How is a liver biopsy performed?

The liver biopsy is performed through different routes although the transcutaneous or through the skin is a common route of entry. Apart from this, transvenous and laparoscopic liver biopsy can also be performed when indicated. The idea of the biopsy is to extract a small tissue sample and this would mean that a small wound be created within the liver substance. Thus, as with any other wound, the biopsy site of the liver will also bleed and in abnormal circumstances the bleeding could become dangerous.

What are the contraindications for performing a liver biopsy?

As described above, in instances were excessive bleeding can take place from the biopsy site or else when there is an increased risk of infections; the liver biopsy is usually contraindicated although in such instances, if the benefits outweigh the risks of doing a liver biopsy, clinicians might decide on going ahead with the liver biopsy after all. But, in general, following are considered contraindications for liver biopsy.

  • When the patient is uncooperative
  • If there is a coagulation problem depicted by a prolonged prothrombin time, low platelet count and excess bleeding time.
  • If a patient has used anticoagulants such as aspirin within the last 7 days.
  • Presence of biliary obstructions and more specifically extrahepatic biliary obstructions.
  • Presence of bacterial cholangitis
  • Accumulation of excess fluids in the abdomen as in the case of ascites.
  • Infections in the region including in the right pleural cavity.
  • Presence of a hemangioma or a vascular tumor.
  • When blood is not available for transfusion in an emergency.

Apart from the above mentioned contraindications, a condition called liver amyloidosis and obesity can also be considered as contraindications that have to be considered before performing a liver biopsy. Although these are categorized as contraindications, there can be instances where a risk assessment allows the clinicians to carefully perform a liver biopsy with minimal risk without any dangerous consequences.

Lastly, it should be mentioned that, a person undergoing liver biopsy will be investigated using a coagulation profile as well as with one or more imaging techniques before performing a liver biopsy and therefore the decision to perform a liver biopsy would most likely to be a well informed clinical decision.