Sections

Overview

Background

Percutaneous liver biopsy is a procedure in which a long needle is introduced through the skin, subcutaneous tissues, intercostal muscles, and peritoneum into the liver to obtain a specimen of liver tissue.^{[1, 2]}This procedure is usually performed on an outpatient basis. The patient is then observed for a few hours in the hospital or the ambulatory unit. It is safe in pediatric^{[3, 4, 5]}as well as adult patients, with a low complication rate.

The liver biopsy needle used can be one of the following three types:

Cutting needle
Suction needle (discussed in this article)
Spring-loaded needle

This topic focuses on the technical aspects of performing a percutaneous liver biopsy. For a more detailed discussion of the theoretical aspects, see Diagnostic Liver Biopsy.

Indications

Indications related to initial diagnosis include the following:

Evaluation of abnormal liver test results, if all other workup is unrevealing ^[6]
Determination of stage of fibrosis and grade of inflammation for chronic hepatitis B and hepatitis C ^[7]
Evaluation of autoimmune hepatitis
Evaluation of a liver mass that does not exhibit typical imaging features of hepatocellular carcinoma (HCC)
Quantitative estimation of iron in hemochromatosis
Quantitative estimation of copper in Wilson disease
Estimation of the severity of alcoholic liver disease
Evaluation of drug toxicity
Evaluation of the suitability of a donor liver for transplantation
Diagnosis and staging of nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH)
Evaluation of unexplained jaundice
Diagnosis of cholestatic liver disease
Evaluation of infiltrative or granulomatous disorders
Evaluation of liver injury from immunosuppressive agents (methotrexate)

Indications related to surveiilance during treatment include the following:

Follow-up evaluation while on antiviral treatment for chronic hepatitis C (rare)
Monitoring of disease activity of autoimmune hepatitis during treatment (may assist in determining if therapy can be discontinued)

Indications relevant to the patient who has undergone a liver transplant include the following:

Diagnosis of acute cellular rejection
Diagnosis of chronic rejection
Diagnosis of recurrent hepatitis C
Diagnosis of posttransplant lymphoproliferative disorder
Diagnosis of cytomegalovirus (CMV) hepatitis
Protocol biopsies to monitor for fibrosis or inflammation (particularly in patients who received liver transplants to treat liver failure in chronic hepatitis C)

Contraindications

Contraindications include the following:

Uncooperative patient ^[8]
Inability to identify a suitable biopsy site by means of either percussion or ultrasonographic (US) guidance
Prolonged (>1.5) international normalized ratio (INR) ^[9]
Decreased platelet count (< 60,000/μL)
Bleeding diathesis (eg, hemophilia)
Recent use (within the last 7 days) of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) or antiplatelet class of medications
Unavailability of blood products for transfusion
Morbid obesity of patient
Ascites
No backup support available from surgery or interventional radiology in case of a complication
Suspected hemangioma or hepatic echinococcal cysts
Abdominal-wall infection over the identified biopsy site
Infection in the right pleural cavity or below the right hemidiaphragm
Bowel overlying biopsy site (on US or other abdominal imaging)

Best practices

Generally, performance of percutaneous liver biopsy should adhere to the following guidelines, which are modified from the American Gastroenterological Association’s 1989 position statement^[10]:

The patient must be able to easily return to the hospital where the procedure was performed within 30 minutes of developing any adverse symptoms
A reliable individual must be available to stay with the patient during the first night after the liver biopsy and provide care and transportation to the hospital, if necessary
The patient should not have any preexisting serious medical problems that might increase the risk of complications from the biopsy (eg, encephalopathy, ascites, liver failure with severe jaundice, significant extrahepatic obstruction, significant coagulopathies, or serious comorbidities such as severe congestive heart failure); also, patients should not be very old, very young, or so anxious that they require sedation
The facility where the biopsy is to be performed should have an approved laboratory, blood banking unit, easy access to an inpatient bed, and personnel to monitor the patient for 6 hours after the biopsy (however, according to recommendations from the American Association for the Study of Liver Diseases [AASLD], a period of 2-4 hours may suffice ^[11])
The patient should be hospitalized after biopsy if any evidence exists of bleeding, bile leak, pneumothorax, or other organ puncture; hospitalization is suggested if the patient’s pain requires more than one dose of an analgesic in the first 4 hours after the biopsy

Periprocedure

Karamshi M. Performing a percutaneous liver biopsy in parenchymal liver diseases. Br J Nurs. 2008 Jun 26-Jul 9. 17 (12):746-52. [QxMD MEDLINE Link].
Myers RP, Fong A, Shaheen AA. Utilization rates, complications and costs of percutaneous liver biopsy: a population-based study including 4275 biopsies. Liver Int. 2008 May. 28 (5):705-12. [QxMD MEDLINE Link].
Almeida P, Schreiber RA, Liang J, Mujawar Q, Guttman OR. Clinical Characteristics and Complications of Pediatric Liver Biopsy: A Single Centre Experience. Ann Hepatol. 2017 Sep-Oct. 16 (5):797-801. [QxMD MEDLINE Link].
Bolia R, Matta J, Malik R, Hardikar W. Outpatient Liver Biopsy in Children: Safety, Feasibility, and Economic Impact. J Pediatr Gastroenterol Nutr. 2017 Jul. 65 (1):86-88. [QxMD MEDLINE Link].
Weldon CB, Madenci AL, Tiao GM, Dunn SP, Langham MR, McGahren ED, et al. Evaluation of the diagnostic biopsy approach for children with hepatoblastoma: A report from the children's oncology group AHEP 0731 liver tumor committee. J Pediatr Surg. 2020 Apr. 55 (4):655-659. [QxMD MEDLINE Link].
Gilmore IT, Burroughs A, Murray-Lyon IM, Williams R, Jenkins D, Hopkins A. Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London. Gut. 1995 Mar. 36 (3):437-41. [QxMD MEDLINE Link].
Sporea I, Popescu A, Sirli R. Why, who and how should perform liver biopsy in chronic liver diseases. World J Gastroenterol. 2008 Jun 7. 14 (21):3396-402. [QxMD MEDLINE Link].
Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med. 2001 Feb 15. 344 (7):495-500. [QxMD MEDLINE Link].
Grant A, Neuberger J. Guidelines on the use of liver biopsy in clinical practice. British Society of Gastroenterology. Gut. 1999 Oct. 45 Suppl 4:IV1-IV11. [QxMD MEDLINE Link].
Jacobs WH, Goldberg SB. Statement on outpatient percutaneous liver biopsy. Dig Dis Sci. 1989 Mar. 34 (3):322-3. [QxMD MEDLINE Link].
Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD, American Association for the Study of Liver Diseases. Liver biopsy. Hepatology. 2009 Mar. 49 (3):1017-44. [QxMD MEDLINE Link].
Hall TC, Deakin C, Atwal GS, Singh RK. Adequacy of percutaneous non-targeted liver biopsy under real-time ultrasound guidance when comparing the Biopince™ and Achieve™ biopsy needle. Br J Radiol. 2017 Dec. 90 (1080):20170397. [QxMD MEDLINE Link].
Varela-Ponte R, Martínez-Lago N, Vieito-Villar M, Martin Carreira-Villamor J. Impact of risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy of space-occupying lesions. Radiologia (Engl Ed). 2022 Nov-Dec. 64 (6):497-505. [QxMD MEDLINE Link].
Caturelli E, Giacobbe A, Facciorusso D, Bisceglia M, Villani MR, Siena DA, et al. Percutaneous biopsy in diffuse liver disease: increasing diagnostic yield and decreasing complication rate by routine ultrasound assessment of puncture site. Am J Gastroenterol. 1996 Jul. 91 (7):1318-21. [QxMD MEDLINE Link].
Hakime A, Barah A, Deschamps F, Farouil G, Joskin J, Tselikas L, et al. Prospective comparison of freehand and electromagnetic needle tracking for US-guided percutaneous liver biopsy. J Vasc Interv Radiol. 2013 Nov. 24 (11):1682-9. [QxMD MEDLINE Link].
Govender P, Jonas MM, Alomari AI, Padua HM, Dillon BJ, Landrigan-Ossar MF, et al. Sonography-guided percutaneous liver biopsies in children. AJR Am J Roentgenol. 2013 Sep. 201 (3):645-50. [QxMD MEDLINE Link].
Howard R, Karageorge G, van Harselaar K, Bell M, Basford P, Schultz M, et al. Post-procedure surveillance in liver biopsy: how long is long enough?. N Z Med J. 2008 Aug 22. 121 (1280):8-14. [QxMD MEDLINE Link].
Firpi RJ, Soldevila-Pico C, Abdelmalek MF, Morelli G, Judah J, Nelson DR. Short recovery time after percutaneous liver biopsy: should we change our current practices?. Clin Gastroenterol Hepatol. 2005 Sep. 3 (9):926-9. [QxMD MEDLINE Link].
Filingeri V, Sforza D, Tisone G. Complications and risk factors of a large series of percutaneous liver biopsies in patients with liver transplantation or liver disease. Eur Rev Med Pharmacol Sci. 2015 May. 19 (9):1621-9. [QxMD MEDLINE Link].
McGill DB, Rakela J, Zinsmeister AR, Ott BJ. A 21-year experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology. 1990 Nov. 99 (5):1396-400. [QxMD MEDLINE Link].
Froehlich F, Lamy O, Fried M, Gonvers JJ. Practice and complications of liver biopsy. Results of a nationwide survey in Switzerland. Dig Dis Sci. 1993 Aug. 38 (8):1480-4. [QxMD MEDLINE Link].
Midia M, Odedra D, Shuster A, Midia R, Muir J. Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review. Diagn Interv Radiol. 2019 Jan. 25 (1):71-80. [QxMD MEDLINE Link]. [Full Text].
Jing H, Yi Z, He E, Xu R, Shi X, Li L, et al. Evaluation of Risk Factors for Bleeding After Ultrasound-Guided Liver Biopsy. Int J Gen Med. 2021. 14:5563-5571. [QxMD MEDLINE Link]. [Full Text].
Bissonnette J, Riescher-Tuczkiewicz A, Gigante E, Bourdin C, Boudaoud L, Soliman H, et al. Predicting bleeding after liver biopsy using comprehensive clinical and laboratory investigations: A prospective analysis of 302 procedures. J Thromb Haemost. 2022 Dec. 20 (12):2786-2796. [QxMD MEDLINE Link]. [Full Text].
Ioannidis O, Malliora A, Christidis P, Pramateftakis MG, Kotidis E, Mantzoros I, et al. Hemobilia Caused by Arterioportal Fistula Following Percutaneous Liver Biopsy Complicated by Acute Cholecystitis and Review of the Literature. Curr Health Sci J. 2022 Apr-Jun. 48 (2):235-241. [QxMD MEDLINE Link]. [Full Text].
Giri S, Agrawal D, Gopan A, Varghese J, Tripathy T. Diagnostic outcome and safety of plugged liver biopsy in high-risk patients: a systematic review and meta-analysis. Acta Radiol. 2023 Jan 24. 2841851231151513. [QxMD MEDLINE Link].
Kim SJ, Won JH, Kim YB, Wang HJ, Kim BW, Kim H, et al. Plugged percutaneous biopsy of the liver in living-donor liver transplantation recipients suspected to have graft rejection. Acta Radiol. 2017 Jul. 58 (7):771-777. [QxMD MEDLINE Link].
Orlando G, Goffette P, Gravante G, Ciccarelli O, Lerut J. Successful treatment of haemothorax following percutaneous liver biopsy using interventional radiology: importance of arterial anatomical variations. Transpl Int. 2008 Jul. 21 (7):708-10. [QxMD MEDLINE Link].
Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol. 1986. 2 (2):165-73. [QxMD MEDLINE Link].
Garcia-Tsao G, Boyer JL. Outpatient liver biopsy: how safe is it?. Ann Intern Med. 1993 Jan 15. 118 (2):150-3. [QxMD MEDLINE Link].
Boschuetz N, Gray M, Bari K. Portal Vein Thrombosis After Percutaneous Liver Biopsy. Clin Gastroenterol Hepatol. 2018 Jan. 16 (1):e5-e6. [QxMD MEDLINE Link]. [Full Text].
Schaffler-Schaden D, Birsak T, Zintl R, Lorber B, Schaffler G. Risk of needle tract seeding after coaxial ultrasound-guided percutaneous biopsy for primary and metastatic tumors of the liver: report of a single institution. Abdom Radiol (NY). 2020 Oct. 45 (10):3301-3306. [QxMD MEDLINE Link].

Media Gallery

Percutaneous liver biopsy. Deeper injection of local anesthetic.
Percutaneous liver biopsy. Infiltrating skin at biopsy site.
Percutaneous liver biopsy. Aspirating saline.
Percutaneous liver biopsy. Switching to biopsy needle.
Percutaneous liver biopsy. Making skin nick.
Percutaneous liver biopsy. Penetrating tissue planes.
Percutaneous liver biopsy. Biopsy needle inside liver.
Percutaneous liver biopsy. Taking plunger out.
Percutaneous liver biopsy. Transferring liver biopsy specimen to formalin bottle.
Percutaneous liver biopsy. Aspirating lidocaine.
Percutaneous liver biopsy. Patient lying on right side.
Percutaneous liver biopsy. Ultrasonography of liver.
Percutaneous liver biopsy. Hepatic parenchyma and blood vessels as seen on ultrasonography.
Percutaneous liver biopsy. Marking biopsy site.
Percutaneous liver biopsy. Liver biopsy tray.
Percutaneous liver biopsy. Sterile drape application.
Percutaneous liver biopsy. Percussion over liver.
Percutaneous liver biopsy. Preparing field.
Ultrasound-assisted percutaneous liver biopsy. Video courtesy of George Y Wu, MD, PhD.

of 19

Author

Gaurav Arora, MD, MS Assistant Professor of Internal Medicine, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Gaurav Arora, MD, MS is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Coauthor(s)

Walid S Ayoub, MD Clinical Assistant Professor of Medicine, Division of Gastroenterology and Hepatology and Liver Transplant Program, Stanford University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Joseph K Lim, MD Associate Professor of Medicine, Director, Yale Viral Hepatitis Program, Section of Digestive Diseases, Yale University School of Medicine

Joseph K Lim, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The authors gratefully acknowledge the unnamed patient who graciously agreed to be photographed during the procedure for this article.

The authors and editors of also gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Medscape Drugs & Diseases thanks George Y Wu, MD, PhD, Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine, for assistance with the video contribution to this article.

Percutaneous Liver Biopsy

Background

Indications

Contraindications

Technical Considerations

Best practices

References

Tables

Contributor Information and Disclosures

What would you like to print?