Liver biopsy provides histologic information about liver structure and evidence of liver injury. This information can be essential in both diagnosis and management and in staging of fibrosis. Although only a small core of tissue is obtained, it is usually representative, even for focal lesions.
Percutaneous liver biopsy is usually performed at the bedside with ultrasound guidance. Ultrasound guidance is preferred because its use provides the opportunity to visualize the liver and target focal lesions. Additionally, a transjugular approach performed under fluoroscopy can obtain liver tissue and indirect measurements of portal pressures.
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) (1, 2). Biopsy is especially valuable for detecting infiltrative liver disorders and is required for clarifying allograft problems (ie, ischemic injury, rejection, biliary tract disorders, viral hepatitis) after liver transplantation. Serial biopsies, commonly performed over years, may be necessary to monitor disease progression.
Indications for Liver Biopsy*
Condition | Use |
|---|---|
Unexplained liver test abnormalities | Diagnosis |
Alcohol-related liver disease, metabolic dysfunction–associated fatty liver disease and steatohepatitis | 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 performed) |
Use of hepatotoxic medications (eg, methotrexate)Use of hepatotoxic medications (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
Contraindications
Absolute contraindications to liver biopsy include the following (2):
Patient’s inability to remain still and to maintain brief expiration for the procedure
Suspected vascular lesion (eg, hemangioma)
Altered coagulation/hemostasis status
Severe hypofibrinogenemia (as in the case of disseminated intravascular coagulation [DIC])
Extrahepatic biliary obstruction
Determination of the procedural-related bleeding risk is complex and should be individualized, as classical markers of hemostasis (platelet count, international normalized ratio [INR]) have been shown to inaccurately predict bleeding tendency in patients with advanced liver disease. For this reason, current guidelines do not specify parameter cutoffs prior to liver biopsy (either percutaneous or transvenous). Viscoelastic assays may also be used to assess hemostatic status in patients with liver disease, though validated cutoffs for bedside procedures, including liver biopsy, have not been established.
Relative contraindications include profound anemia, peritonitis, ascites, severe obesity, and a subphrenic or right pleural infection or effusion. Nonetheless, percutaneous liver biopsy is otherwise sufficiently safe to be performed on an outpatient basis. Associated mortality is approximately 0.01 to 0.02% (3, 4). One common complication is pain at the biopsy site. Major complications (eg, intra-abdominal hemorrhage, bile peritonitis, lacerated liver, pneumothorax) develop in approximately 1 to 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,centripetal adiposity, or if indirect portal pressure measurements are needed. 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 most patients, but yields smaller tissue samples. Complication rate is low; 0.6% bleed from puncture of the liver capsule (5). This route allows for the simultaneous measurement of intra- and posthepatic venous pressures, which can be useful in the elucidation of portal hypertension.
Occasionally, liver biopsy is performed during surgery (eg, laparoscopy); a larger, more targeted tissue sample can then be obtained.
References
1. Gopal P, Hu X, Robert ME, Zhang X. The evolving role of liver biopsy: Current applications and future prospects. Hepatol Commun. 2025;9(1):e0628. Published 2025 Jan 7. doi:10.1097/HC9.0000000000000628
2. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD; American Association for the Study of Liver Diseases. Liver biopsy. Hepatology. 2009;49(3):1017-1044. doi:10.1002/hep.22742
3. Thomaides-Brears HB, Alkhouri N, Allende D, et al. Incidence of Complications from Percutaneous Biopsy in Chronic Liver Disease: A Systematic Review and Meta-Analysis. Dig Dis Sci. 2022;67(7):3366-3394. doi:10.1007/s10620-021-07089-w
4. Graf M, Graf C, Ziegelmayer S, et al. Complications of image-guided liver biopsies: Results of a nationwide database analysis. PLoS One. 2025;20(5):e0323695. Published 2025 Jun 2. doi:10.1371/journal.pone.0323695
5. Dohan A, Guerrache Y, Dautry R, et al. Major complications due to transjugular liver biopsy: Incidence, management and outcome. Diagn Interv Imaging.96(6):571-577, 2015. doi: 10.1016/j.diii.2015.02.006
