Liver biopsy

Definition

A liver biopsy is a procedure to remove a small piece of liver tissue, so it can be examined under a microscope for signs of damage or disease. Your doctor may recommend a liver biopsy if blood tests or imaging techniques suggest you might have a liver problem. A liver biopsy also is used to determine the severity of liver disease. This information helps guide treatment decisions.

The most common type of liver biopsy is called percutaneous liver biopsy. It involves inserting a thin needle through your abdomen into the liver and removing a small piece of tissue. Two other types of liver biopsy — one using a vein in the neck (transjugular) and the other using a small abdominal incision (laparoscopic) — also remove liver tissue with a needle.

Why it's done

A liver biopsy may be done to:

• Diagnose a liver problem that can't be otherwise identified
• Obtain a sample of tissue from an abnormality found by an imaging study
• Determine how severe liver disease is — a process called staging
• Help develop treatment plans based on the liver's condition
• Determine how well treatment for liver disease is working
• Monitor the liver after a liver transplant

Usually your doctor performs a liver biopsy only after you've had blood tests to check your liver function and imaging tests, such as ultrasound. Ultrasound uses sound waves to create images of your internal organs and tissues.

Your doctor may recommend a liver biopsy if you have:

• Abnormal liver test results that can't be explained
• A mass (tumor) or other abnormalities on your liver as seen on imaging tests
• Ongoing, unexplained fevers

A liver biopsy also is commonly performed to help diagnose and stage certain liver diseases, including:

• Nonalcoholic fatty liver disease
• Chronic hepatitis B or C
• Autoimmune hepatitis
• Alcoholic liver disease
• Primary biliary cirrhosis
• Primary sclerosing cholangitis
• Hemochromatosis
• Wilson's disease

Risks

A liver biopsy is a safe procedure when performed by an experienced doctor. Possible risks include:

• Pain. Pain at the biopsy site or in the upper right shoulder is the most common complication after a liver biopsy. Most people expect the pain to be worse than it actually is — usually a mild discomfort. If pain bothers you, you may be given a narcotic pain medication, such as acetaminophen with codeine (Tylenol/Codeine).
• Bleeding. Excessive bleeding, called hemorrhage, is the most serious risk of liver biopsy. Severe bleeding may require you to be hospitalized. You may need a blood transfusion. Surgery or a procedure to visualize blood vessels (angiography) and stop the bleeding (embolization) also may be required.
• Infection. Rarely, bacteria may enter the abdominal cavity or bloodstream.
• Accidental injury to a nearby organ. In rare instances, the needle may stick another internal organ, such as the gallbladder or a lung, during a liver biopsy.
• Abdominal pain. Temporary or prolonged pain in your abdomen may occur if you have a transjugular or laparoscopic procedure.

In a transjugular procedure, a thin tube (catheter) is inserted through a large vein in your neck and passed down into the vein that runs through your liver. If you have a transjugular liver biopsy, other infrequent risks include:

• Collection of blood (hematoma) in the neck. Blood may pool around the site where the catheter was inserted, potentially causing pain and swelling.
• Temporary problems with the facial nerves. Rarely, the transjugular procedure can injure nerves that affect the face and eyes, causing short-term problems such as a drooping eyelid.
• Temporary voice problems. You may be hoarse, have a weak voice or lose your voice for a short time.
• Puncture of the lung. If the needle accidentally sticks your lung, the result may be a collapsed lung (pneumothorax).

The majority of complications happen within two hours of a liver biopsy, and almost all occur within 24 hours. Two to 3 percent of people having a liver biopsy need to be hospitalized because of a complication. The chance of death from a liver biopsy is about 1 in 10,000 and usually results from severe bleeding.

How you prepare

Before your liver biopsy, you'll meet with your doctor to talk about what to expect during the biopsy. This is a good time to ask questions about the procedure and make sure you understand the risks and benefits.

Medications
When you meet with your doctor, bring a list of all medications you take, including over-the-counter medications, vitamins and herbal supplements. A week before your liver biopsy, you'll likely be asked to stop taking medications and supplements that can increase the risk of bleeding, including:

• Aspirin, ibuprofen (Advil, Motrin, others) and other nonsteroidal anti-inflammatory drugs (NSAIDs)
• Blood-thinning medications (anticoagulants), such as warfarin (Coumadin)
• Fish oil
• Ginkgo

Your doctor or nurse will let you know if you need to temporarily avoid any of your other medications.

Blood draw
Before your biopsy, you'll have blood drawn to check its ability to clot. If you have blood-clotting problems, you may be given a medication before your biopsy to reduce the risk of bleeding.

Diet
You may be asked not to drink or eat for six to eight hours before the liver biopsy. Some people can eat a light breakfast.

Care after the biopsy
Liver biopsy is a same-day outpatient procedure, but you won't be able to drive for 12 hours afterward if you're given sedative medications. You should arrange for someone to drive you home and stay with you during the first night. Many doctors recommend that people spend the first evening within an hour's driving distance of the hospital where the biopsy is done, in case a complication develops.

What you can expect

Percutaneous liver biopsy, the most common type, isn't an option for some people. Your doctor may use a different form of liver biopsy if you:

• Could have trouble holding still during the procedure
• Have a history of or likelihood of bleeding problems or blood-clotting disorders
• Might have a tumor involving blood vessels in your liver
• Have an abnormal amount of fluid in your abdomen (ascites)
• Are very obese
• Have a liver infection

If you aren't a candidate for percutaneous liver biopsy, you may have a transjugular liver biopsy, also called transvenous liver biopsy. Laparoscopic liver biopsy isn't used often, but may be recommended if you have cancer, an infection, a mass in your abdomen or ongoing abdominal pain. Laparoscopic biopsy allows your doctor to obtain tissue samples from a larger or more targeted area.

Before the procedure
A liver biopsy is done at a hospital or outpatient center. You'll likely arrive early in the morning. Your health care team will review your medical history, including the medications you take.

Just before your biopsy you will:

• Undress and put on a hospital gown
• Have an intravenous (IV) line placed, usually into a vein in your arm, so that you can be given medications if you need them
• Possibly be given a sedative to help you relax during the procedure
• Use the toilet if needed, because you'll need to remain in bed for at least three hours after the procedure

During the procedure
Before or during liver biopsy, your doctor might use ultrasound to help locate the liver and mark the place to insert the needle. Some doctors locate the liver by tapping on the abdomen (percussion). In certain situations, ultrasound might be used during the biopsy to guide the needle into your liver.

The steps involved in liver biopsy vary according to the type:

• Percutaneous biopsy. You'll lie on your back on a table with your right hand resting above your head. Your doctor will apply a numbing medication (local anesthetic) to the area where the needle will go in. The doctor then makes a small incision in your abdomen, near the bottom of your rib cage, and inserts the biopsy needle. The biopsy itself takes just a few seconds. As the needle passes quickly in and out of your liver, you'll be asked to exhale and hold your breath. A small bandage will be placed on the incision — no stitches are needed.
• Transjugular biopsy. You'll lie on your back on an X-ray table. Your doctor applies a numbing medication to one side of your neck, makes a small incision and inserts a flexible plastic tube (catheter) into your jugular vein. The tube is threaded down the jugular vein and into the large vein in your liver (hepatic vein). Your doctor then injects a contrast dye into the tube and makes a series of X-ray images. The dye shows up on the images, allowing the doctor to see the hepatic vein. A biopsy needle is then threaded through the tube, and one or more liver samples are quickly removed. The catheter is carefully removed, and the incision on your neck is covered with a bandage. Transjugular biopsy takes 30 to 60 minutes.
• Laparoscopic biopsy. During general anesthesia, you'll lie on your back on an operating table, and your doctor will make one or more small incisions in your abdomen. A plastic tube-like instrument called a cannula is then inserted into the incision, and your doctor pumps gas into your abdomen to inflate it. Using special tools, including a lighted video camera, the doctor inserts a needle through the tube to remove liver samples. Then the tube is removed, and the incision is closed with stitches that later dissolve.

After the procedure
After the biopsy, you can expect to:

• Be taken to a recovery room. A nurse will monitor your blood pressure, pulse and breathing.
• Rest quietly for two to four hours, or longer if you had a transjugular procedure.
• Be given written instructions about your recovery.
• Feel some soreness where the needle was inserted. This may last up to a week.

Someone else should drive you home. Most people get back to their usual activities within a day or two after a liver biopsy. Avoid lifting more than 10 to 15 pounds for at least 24 hours. Your liver tissue goes to a laboratory to be examined by a doctor who specializes in diagnosing disease (pathologist). The pathologist will look for signs of disease and damage to the liver.

Call your doctor if you experience:

• Severe pain at the biopsy site or in your shoulder
• Shortness of breath
• Chest pain
• Bleeding from the biopsy site
• Fever over 100.4 F (38 C)
• Abdominal pain
• Weakness, lightheadedness or sweating
• Heart palpitations

Results

Your biopsy report should come back from the pathology lab within a few days to a week. At a follow-up visit, your doctor will explain the results. You may be diagnosed with a liver disease, or your liver disease may be given a stage or grade number based on how severe it is — mild, moderate or severe. Your doctor will discuss what treatment, if any, you need.