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Evidence‐based approaches

Rationale

A liver biopsy is an invaluable tool for diagnosing or monitoring conditions affecting the liver, such as cirrhosis, inflammation or hepatitis of various causes, and some metabolic liver disorders. The risks, although small, must be weighed against the potential benefits (Pagana and Pagana [177], Tannapfel et al. [237]).

Indications

Liver biopsy is indicated in the following circumstances:

diagnosis of cirrhosis
diagnosis of cancer, both primary and secondary
miliary tuberculosis
amyloidosis
viral hepatitis for grading, staging and exclusion of co‐morbidities
diagnosis of autoimmune diseases affecting the liver
grading and staging of chronic hepatitis B or C.

Contraindications

Liver biopsy is contraindicated in the following circumstances:

an unco‐operative or confused patient
severe purpura
coagulation defects
prolonged clotting time
increased bleeding time
severe jaundice
patient under 3 years of age
current right lower lobe pneumonia
current pleuritis (Pagana and Pagana [177], Tannapfel et al. [237]).

Methods of liver biopsy

There are a variety of methods for conducting a liver biopsy. The ultrasound‐guided technique is considered the standard (Tannapfel et al. [237]).

Percussion palpation approach

The percussion palpation approach is also known as the ‘blind approach’. The liver is palpated in order to determine the position required for the liver biopsy.

Image‐guided approach

Image guidance may be conducted using ultrasound, CT or MRI, but the preferred method is ultrasound. The ultrasound method utilizes continuous ultrasound or site marking immediately prior to the procedure (Al Knawy and Shiffman [5], Pagana and Pagana [177]).

Ultrasound‐assisted approach

The ultrasound is utilized immediately prior to the procedure and a mark is left on the skin indicating the puncture site. It is also known as the ‘X marks the spot’ technique. This technique has been shown to yield larger tissue samples, require fewer needle passes and have a decreased biopsy failure rate than the non‐ultrasound‐assisted approach (Di Teodoro et al. [49]).

Ultrasound‐guided approach

The ultrasound is utilized throughout the procedure with the liver and biopsy needle viewed in real time. This method is simple, reasonably fast, inexpensive and safer than other methods. In 1% of cases, significant complications have been reported with a mortality of 0.1% (Tannapfel et al. [237]).

Transjugular liver biopsy

When the percutaneous approach is contraindicated due to coagulopathy, vascular tumours, ascites or failed percutaneous attempts, the transjugular technique is indicated and is a safer approach (BSG [27]). The biopsy needle is inserted via the hepatic vein and this approach avoids the peritoneum and liver capsule (Keshava et al. [115]).