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Liver Biopsy

By

Christina C. Lindenmeyer

, MD, Cleveland Clinic

Last full review/revision Dec 2019| Content last modified Dec 2019
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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.

Percutaneous liver biopsy is usually done at the bedside with ultrasound guidance. Ultrasound guidance is preferred because its use provides the opportunity to visualize the liver and target focal lesions.

Indications

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

Table
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Indications for Liver Biopsy*

Condition

Use

Unexplained liver test abnormalities

Diagnosis

Diagnosis and staging

Chronic hepatitis (viral or autoimmune)

Diagnosis and staging

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

Diagnosis

Suspected rejection or another complication after liver transplantation

Diagnosis

Liver donor status

Evaluation

Hepatosplenomegaly of unknown cause

Diagnosis

Unexplained intrahepatic cholestasis (usually primary biliary cholangitis [primary biliary cirrhosis], primary sclerosing cholangitis or drug-induced liver injury)

Diagnosis

Suspected cancer or unexplained focal lesions

Diagnosis

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

Diagnosis (culture is done)

Use of hepatotoxic drugs (eg, methotrexate)

Monitoring

* 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)

Contraindications

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, international normalized ratio [INR] > 1.5)

  • Severe thrombocytopenia (< 50,000/microliter)

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. Associated mortality is about 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 hours—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, ascites, and/or centripetal adiposity. 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. This route allows for the simultaneous measurement of intra- and post-hepatic venous pressures, which can be useful in the elucidation of portal hypertension.

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

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