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Liver Biopsy

by Nicholas T. Orfanidis, MD

Liver biopsy provides histologic information about liver structure and evidence of liver injury (type and degree, any fibrosis); this information can be essential not only to diagnosis but also to staging, prognosis, and management. Although only a small core of tissue is obtained, it is usually representative, even for focal lesions.

Liver biopsy is usually done percutaneously at the bedside or with ultrasound guidance. Ultrasound guidance is preferred because its complication rate is slightly lower and it provides opportunity to visualize the liver and target focal lesions.


Generally, biopsy is indicated for suspected liver abnormalities that are not identified by less invasive methods or that require histopathology for staging (see Indications for Liver Biopsy*). Biopsy is especially valuable for detecting TB or other granulomatous infiltrations and for clarifying graft problems (ischemic injury, rejection, biliary tract disorders, viral hepatitis) after liver transplantation. Serial biopsies, commonly done over years, may be necessary to monitor disease progression.

Indications for Liver Biopsy*



Unexplained liver test abnormalities


Alcoholic liver disease or nonalcoholic steatosis

Diagnosis and staging

Chronic hepatitis (viral or autoimmune)

Diagnosis and staging

Heavy metal storage disorders (eg, hemochromatosis, Wilson disease)


Suspected rejection or another complication after liver transplantation


Liver donor status


Hepatosplenomegaly of unknown cause


Unexplained intrahepatic cholestasis (usually primary biliary cirrhosis or primary sclerosing cholangitis)


Suspected cancer or unexplained focal lesions


Unexplained systemic illness (eg, fever of unknown origin, inflammatory or granulomatous disorders)

Diagnosis (culture is done)

Use of hepatotoxic drugs (eg, methotrexate)


*Generally, biopsy is indicated for suspected liver abnormalities that are not identified by less invasive methods or that require histopathology for staging.

Gross examination and histopathology are often definitive. Cytology (fine-needle aspiration), frozen section, and culture may be useful for selected patients. Metal content (eg, copper in suspected Wilson disease, iron in hemochromatosis) can be measured in the biopsy specimen.

Limitations of liver biopsy include

  • Sampling error

  • Occasional errors or uncertainty in cases of cholestasis

  • Need for a skilled histopathologist (some pathologists have little experience with needle specimens)


Absolute contraindications to liver biopsy include

  • Patient’s inability to remain still and to maintain brief expiration for the procedure

  • Suspected vascular lesion (eg, hemangioma)

  • Bleeding tendency (eg, INR > 1.2 despite receiving vitamin K, bleeding time > 10 min)

  • Severe thrombocytopenia (< 50,000/mL)

Relative contraindications include profound anemia, peritonitis, marked ascites, high-grade biliary obstruction, and a subphrenic or right pleural infection or effusion. Nonetheless, percutaneous liver biopsy is sufficiently safe to be done on an outpatient basis. Mortality is 0.01%. Major complications (eg, intra-abdominal hemorrhage, bile peritonitis, lacerated liver) develop in about 2% of patients. Complications usually become evident within 3 to 4 h—the recommended period for monitoring patients.

Other routes

Transjugular venous biopsy of the liver is more invasive than the percutaneous route; it is reserved for patients with a severe coagulopathy. The procedure involves cannulating the right internal jugular vein and passing a catheter through the inferior vena cava into the hepatic vein. A fine needle is then advanced through the hepatic vein into the liver. Biopsy is successful in > 95% of patients. Complication rate is low; 0.2% bleed from puncture of the liver capsule.

Occasionally, liver biopsy is done during surgery (eg, laparoscopy); a larger, more targeted tissue sample can then be obtained.

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