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A liver biopsy is a procedure that involves obtaining a small piece of liver tissue, which is then analyzed in the laboratory. It may be recommended to help establish a diagnosis or to determine the severity of injury from a disease that has already been diagnosed. A liver biopsy is often an essential piece of information that doctors need to help guide your care.
Liver biopsies are most commonly performed “percutaneously (through the skin). As a result, most patients can go home within two to four hours of the procedure. Other methods of obtaining liver tissue may be required in circumstances in which the percutaneous approach is undesirable or unsafe.
The suggestion by a doctor that you should have a biopsy is bound to produce anxiety in most people. The word “biopsy” brings up concerns about cancer, and additionally, most people worry about whether the biopsy will hurt.
The technique for percutaneous liver biopsy has been performed since the 1950s with a high degree of safety. Every effort will be made to make your biopsy as comfortable as possible.
As a general rule, a liver biopsy is recommended only when the results would influence a management decision. Some of the more common indications are in patients with:
A liver biopsy may also be helpful in people with unexplained fevers, those with certain rare metabolic diseases, and a variety of other less common disorders.
In most hospitals, liver biopsies are performed by gastroenterologists, hepatologists, radiologists, and occasionally by surgeons at the time of abdominal operations.
Prior to your liver biopsy, your doctor will check blood tests that reflect how well your blood clots. Normal blood clotting is important to prevent bleeding after the biopsy. You should not take medications that can increase the risk of bleeding. These include aspirin, aspirin-containing compounds or other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (eg, Motrin®, Advil®, naproxen (eg, Aleve®), blood-thinning medications such as warfarin (Coumadin®), certain medications for people with heart conditions (such as abciximab [Reopro®], dipyridamole [Persantine®], ticlopidine [Ticlid®], and clopidogrel [Plavix®]), and some naturalistic therapies (such as fish oil or ginkgo balboa). It is important to know that NSAIDs are contained in a variety of over-the-counter preparations, so you might not be aware that you are taking them. The best thing to do is to show your doctor the complete list of medications that you are taking including over-the-counter medications. Your doctor can recommend when and how you can interrupt taking these drugs so that your biopsy can be performed safely.
It is common practice to perform an ultrasound examination of the liver and gallbladder area so that the physician who does the biopsy can confirm that the chosen site is appropriate. An ultrasound is a painless test in which sound waves are used to visualize the liver and related structures.
The day of the biopsy you may be instructed to have nothing to eat or drink after midnight before the procedure or to have a light breakfast only, such as tea or coffee and toast. Some doctors recommend having a small amount of fat (such as butter or margarine) with your breakfast, which will empty the gallbladder, possibly making it less likely that the gallbladder will be injured during the biopsy.
You will need to arrange to have someone accompany you to your home after the biopsy since you may receive medications that will temporarily impair your ability to drive. A friend or family member can also help pass the time during the few hours of observation following the biopsy.
Antibiotics are not given routinely prior to a liver biopsy. Exceptions are patients with primary sclerosing cholangitis, in whom antibiotics are frequently given before the biopsy to lessen the risk of infection.
Some conditions make it unsafe to perform a percutaneous liver biopsy. In general, these include:
When you arrive for the biopsy (usually in the early morning), the team of doctors and nurses involved in your procedure will review your medical history, including any medications you take and any allergies to medications. In some institutions, a nurse will start an intravenous line (put a needle in a vein in your arm) so that fluid and medications can be administered if needed. Putting in an intravenous line feels just like a pinprick, no worse than having your blood drawn.
The doctor will review the procedure with you and ask you to sign a consent form. The consent form will summarize the reasons for the biopsy, risks, and alternatives.
You may be given analgesic and sedative medication prior to the procedure to minimize discomfort and anxiety, although many doctors (and some patients) prefer not to use them because your cooperation is needed during the liver biopsy.
During a percutaneous biopsy, you will be lying on your back near the right edge of the bed. Your right arm will be under your head. The doctor will locate the best site for the biopsy by tapping (called percussing) with his finger against the side of your chest after you have completely exhaled (you breathe in and breathe out and hold your breath). The site will be marked with a felt pen.
Your skin will be cleansed with an alcohol and an iodine solution, and the area will be draped with sterile towels. A local anesthetic will be injected into the skin; you will feel this as a burning sensation. A tiny incision will be made into the skin so that the needle for biopsy will pass through easily.
Most doctors perform a liver biopsy at “end-expiration” (ie, when you have completely breathed out). This has the effect of making the right lung smaller and bringing the liver upward toward the chest, thereby making it less likely that the liver biopsy needle will injure any organs adjacent to the liver. To help assure that the biopsy is performed during end-expiration, your doctor may rehearse controlled breathing with you by asking you to breathe in deeply and then exhale completely while holding your breath out until your doctor counts to four. At the time of the biopsy, it is very important for you to cooperate with breathing instructions.
The biopsy itself takes only one second, during which time the biopsy needle is passed quickly in and out of the liver, suctioning a small cylindrical sample of liver tissue. Some doctors use automated liver biopsy devices, which can make a clicking sound when the biopsy needle is deployed. You will be told to resume breathing after the biopsy. A small bandage will be applied to the biopsy site; stitches are not needed. You will be asked to lie on your right side for two hours to place pressure against the biopsy site to decrease the possibility of bleeding.
Following the biopsy, you will be asked to lie on your right side for two hours. A nurse will check your blood pressure and pulse every 15 minutes and ask how you are feeling. Afterward, you will be monitored less frequently for another two to six hours. Many people watch television, a video, read, or talk to friends or family. Lunch is often provided.
A liver biopsy is a very safe procedure when performed by experienced operators. Only two to three percent of patients require hospitalization after a liver biopsy due to complications. Mortality from this procedure is very rare, occurring in only 1:12,000 persons. The following are some of the more common complications that have been described.
In addition to resting the day of the biopsy, you should plan to take it easy for the next five to seven days. In general, you will be instructed to restrict heavy lifting (no more than 15 to 20 pounds) for a week, avoid blood-thinning medication for several days, and to call your doctor with any concerning symptoms such as:
Most often the biopsy report will be available within a week. Patients usually have a follow-up appointment to discuss the results of the biopsy and what treatment (if any) is needed.
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