The risk of discontinuing antiplatelet or anticoagulant medications must be weighed against the potential risk of bleeding during or after liver biopsy; in each case, the pros and cons of medication discontinuation versus the need for assessment of liver histology should be considered carefully.
Once a decision to biopsy is made, several different techniques may be used to obtain liver tissue. The blind technique is only used to obtain random liver samples and thus provides only parenchymal histology. While simple to perform, because of the emergence of widespread and easy-to-use imaging equipment, it has largely been replaced by one of the image-guided procedures, most often transthoracic image-assisted biopsy. With this technique, the physician evaluates the location of the liver in relation to typical landmarks in the transthoracic approach, the ribs , marks the optimal site, and then proceeds with the biopsy.
Variations of this technique include transthoracic real-time image-guided and subcostal real-time image-guided techniques. Additionally, the use of computed tomography as an image-guidance tool has gained popularity. In practice today, biopsy of mass lesions is always image guided and is typically performed with real-time imaging, as in the patient in this case.
Liver Function Tests
The transjugular approach, which refers to inserting a catheter into a major vein in the neck to access the liver for tissue, is typically reserved for patients in whom there are concerns about bleeding or in whom the liver is not approachable with a percutaneous approach. The transjugular approach also provides the added advantage of allowing portal pressure measurements by assessing the hepatic venous pressure gradient.
Preferences for the various techniques vary and are greatly influenced by local experience and expertise. Although evidence is limited, the safety of the different techniques appears to be similar. There are many potential complications of liver biopsy Table 2. The most common is pain. Pain may occur locally at the skin incision site, but the most common and concerning type of pain is that caused by puncture of the liver with subsequent bleeding and stretching of its capsule.
It should be recognized that all patients have bleeding from the liver after biopsy. This is because the liver is highly vascular, and by definition, the liver must be punctured in the course of the biopsy. Bleeding usually stops within several minutes 7 ; however, a feared complication of liver biopsy is ongoing bleeding. Severe bleeding is uncommon, occurring in 1 to to 10, patients 6 undergoing biopsy to obtain random liver histology.
Liver Biopsy | Kaiser Permanente
Further, the most feared complication, death after liver biopsy, is usually related to aggressive hemorrhage. Death occurs in approximately 1 in 10, patients. Thus, this patient's severe abdominal pain after the biopsy was a clue that she had significant bleeding. In terms of the risk of complications, multiple factors play a role Table 3.
The risk of bleeding and death are likely higher in certain groups of patients, though available data is extremely heterogeneous and inexact. In this author's experience, complications are greater in hospitalized patients, many of whom have substantial underlying co-morbidities. It should also be pointed out that liver biopsy must only be performed in patients who are capable of being cooperative with the procedure.
The risk of bleeding also varies with non—patient-related factors such as operator experience, the number of passes used to perform the biopsy, and a variety of technical issues. The latter include the type of needle used, the caliber of the needle, and whether image-assisted guidance was performed. Finally, while liver biopsy can be performed in essentially any location, ranging from an outpatient surgery center to radiology or gastrointestinal procedural suite or even an inpatient bed, a core principle is that the patient must be carefully and rigorously monitored after the procedure.
The risk of bleeding is greatest immediately after biopsy, which makes careful post-procedure observation essential. In the hour following the procedure, this patient was noted to have low blood pressure, which almost certainly was another sign of bleeding. The optimal observation time is currently controversial, but ranges between 1 to 3 hours. This stems in part from a large study of post-biopsy monitoring where the complication rates did not vary after recovery time was shortened from 6 hours to 1 hour.
In keeping with this evidence, the American Association for the Study of Liver Disease AASLD guidelines state the following: "Vital signs must be frequently monitored at least every 15 minutes for the first hour after liver biopsy. This is true no matter where or how the biopsy is performed and helps to ensure capture of vital signs early enough to detect potential adverse patient outcomes and to mitigate the risk of complications.
Indications for liver biopsy consist of i diagnosis, ii prognosis or staging, and iii management. It's always critical to consider the yield and value of pursuing a liver biopsy, which includes weighing the risks and benefits for each patient. The absence of best practices forces providers to individualize treatment plans. The most common complication after liver biopsy is pain. Severe abdominal pain should increase the concern for a significant bleeding complication. Careful monitoring is always required following liver biopsy, particularly in the first hour.
Percutaneous liver biopsy
Don C. Coagulation disorders and hemostasis in liver disease: pathophysiology and critical assessment of current management. Tripodi A, Mannucci PM. Abnormalities of hemostasis in chronic liver disease: reappraisal of their clinical significance and need for clinical and laboratory research. J Hepatol.
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Review article: the prothrombin time test as a measure of bleeding risk and prognosis in liver disease. Aliment Pharmacol Ther. Complication rate of percutaneous liver biopsies among persons with advanced chronic liver disease in the HALT-C trial. Clin Gastroenterol Hepatol. Clinical utility of viscoelastic tests of coagulation in patients with liver disease. Liver Int. Liver biopsy. Caldwell S, Northup PG. Bleeding complication with liver biopsy: is it predictable? Short recovery time after percutaneous liver biopsy: should we change our current practices?
Complications of liver biopsy Complications of liver biopsy Complications of liver biopsy Bleeding Death Pneumothorax Hemothorax Perforation of viscous organs Inadvertent biopsy of the kidney Bile peritonitis Infection bacteremia, abscess, sepsis Hemobilia Table 3. Preventing complications of central venous catheterization. Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system.
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- The liver biopsy procedure.
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Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. When missing a 'zebra' can land you in court. Diagnostic error in stroke—reasons and proposed solutions. A liver biopsy is a safe procedure when performed by an experienced doctor. Possible risks include:. In a transjugular procedure, a thin tube is inserted through a large vein in your neck and passed down into the vein that runs through your liver. If you have a transjugular liver biopsy, other infrequent risks include:. Before your liver biopsy, you'll meet with your doctor to talk about what to expect during the biopsy.
This is a good time to ask questions about the procedure and make sure you understand the risks and benefits. When you meet with your doctor, bring a list of all medications you take, including over-the-counter medications, vitamins and herbal supplements. Before your liver biopsy, you'll likely be asked to stop taking medications and supplements that can increase the risk of bleeding, including:. Your doctor or nurse will let you know if you need to temporarily avoid any of your other medications. Before your biopsy, you'll have a blood test to check your blood's ability to clot. If you have blood-clotting problems, you may be given a medication before your biopsy to reduce the risk of bleeding.
You may be asked not to drink or eat for six to eight hours before the liver biopsy. Some people can eat a light breakfast. You may receive a sedative before your liver biopsy. If this is the case, arrange for someone to drive you home after the procedure. Have someone stay with you or check on you during the first night.
Many doctors recommend that people spend the first evening within an hour's driving distance of the hospital where the biopsy is done, in case a complication develops. What you can expect during your liver biopsy will depend on the type of procedure you'll undergo. A percutaneous liver biopsy is the most common type of liver biopsy, but it isn't an option for everyone.
Your doctor may recommend a different form of liver biopsy if you:.webdisk.openpress.alaska.edu/22087.php
Ultrasound-Guided Liver Biopsy
A liver biopsy is done at a hospital or outpatient center. You'll likely arrive early in the morning. Your health care team will review your medical history, including the medications you take. Your liver tissue goes to a laboratory to be examined by a doctor who specializes in diagnosing disease pathologist. The pathologist will look for signs of disease and damage to the liver. Your biopsy report should come back from the pathology lab within a few days to a week. At a follow-up visit, your doctor will explain the results.