ABC Medical Notes.com

About

• Provides information on the structural integrity of the liver and the type and degree of injury and/or fibrosis
• There is evidence that only people who do a minimum number of biopsies a year should do them.
• Nowadays done under radiological guided control
• The patient must be cooperative which is quite evident but is important for many tests.
• Biopsy of a surgically resectable malignancy should be avoided as the risk of seeding malignancy and of bleeding is significant.

Indications

• Investigation of suspected liver disease;
• Unexplained hepatomegaly;
• Persistently abnormal liver biochemistry
• Assess the degree of fibrosis (scarring) or cirrhosis;
• Drug-induced liver disease ("DILI");
• Tumour biopsy (primary or metastatic)
• Assessing liver damage in inheritable conditions (e.g. haemochromatosis);
• Pyrexia of unknown origin/ assessment for tuberculosis.

Risks

• Death 1 in 10,000 to 12,000
• Significant bleeding in 3 in 1,000
• Bile peritonitis in 1 in 1,000 biopsies

Check

• FBC/Clotting. If the transjugular route is chosen, then a group and save is also required. If the PT >4s or platelets < 60 medical staff may plan to transfuse the patient with fresh frozen plasma (FFP) or platelets during the procedure or before the procedure. If it is done before the procedure a repeat PT/PTT and FBC must be checked to ensure the desired effect has been achieved.
• USS: an ultrasound of the abdomen to determine the size and position of the liver. The presence of ascites or any significantly abnormal coagulation profile (as described above) would indicate preference for the transjugular route.

Percutaneous route

• Performed by the doctor using a biopsy needle through the intercostal space to the liver.
• A portable ultrasound machine is used to identify a safe position to take the biopsy from.
• This method is usually preferred for patients with normal clotting and who are not obese.
• The patient can have sedation if they want. This is performed by medical staff

Ultrasound-guided liver biopsy method

• This is done in the radiology department using an ultrasound scanner to see the liver during the biopsy procedure.
• This method is preferred for obese patients or for patients where sometimes the doctor is unable to see the liver clearly with the portable ultrasound scan
• This is performed by an interventional radiologist after obtaining informed consent

Transjugular route

• A transjugular liver biopsy is performed by inserting a special Trucut needle through a catheter placed in the hepatic vein, via the jugular vein, into the liver to obtain a tissue sample.
• This method is preferred for patients with abnormal clotting times and patients who may have ascites.
• Another advantage is that pressure in the liver veins (to assess the presence of "portal hypertension") can also be measured at the same time (BSG guidelines 2004).
• The patient is sedated. It is performed by interventional radiologists after obtaining written, informed consent.
• Is useful in patients with a bleeding diathesis or in whom the percutaneous technique is otherwise contraindicated

Contraindications

• Usual Contraindications to percutaneous liver biopsy: Uncooperative patient; Prolonged prothrombin time* (> 4 seconds) (BSG guidelines 2004), Platelets* < 60 x 10⁹/litre (Grant et al, 2004), Ascites, Extrahepatic cholestasis. * Do Transjugular.

Cautions

• Informed Consent and coooperative patient
• Platelet count must be > 80 x 10⁹/L (Others quote 50-60)
• Prothrombin time must be within 4 seconds of normal and if not then Vitamin K 10 mg IV may be given to exclude Vitamin K deficiency and then clotting rechecked
• Aspirin or NSAID or Clopidogrel should be avoided during the week before