Sep 17, 2010
Resident [Any Field]
There are two types of liver biopsies: 1- Random liver biopsy: to evaluate diffuse liver disease such as cirrhosis.
2- Target-selected liver biopsy: to evaluate a hepatic lesion.

Random liver biopsy can be performed via transjugular or percutaneous approaches. Uncorrected coagulopathy is the only absolute contraindication for liver biopsy. Suggested thresholds by Dr. Wael E.A. Saad are:
1- For transjugular biopsy: INR =<1.7-1.9, PLT >=50,000 and aPTT =<60 s.
2- For Percutaneous biopsy: INR=<1.4-1.5, PLT >=50,000-70,000 and aPTT =< 45-50s

It is important to check for presence of ascites, evaluate liver anatomy and assess adjacent organs before procedure utilizing ultrasound.

Pre-biopsy ultrasound examination should be performed to:
1- Determine visibility,
2- Determine access,
3- Evaluate anatomy,
4- Evaluate for ascites,
5- Assess adjacent organs.

For subcapsular lesions, it is important to look for normal hepatic parenchymal segments.

After standard surgical preparation and draping, local infiltrative analgesia will be administered. Sedation can also be used. After choosing the location using ultrasound, an incision is made using an 11-blade scalpel. A coaxial access needle (17- or 19-gauge) can be passed across the hepatic capsule in the direction shown by ultrasound. Coaxial access needle can be used for multiple passes without multiple capsular punctures. It is also used for the embolization of the tract with Gelfoam or coils.

Then, an automated spring-loaded core-biopsy needle (18- or 20-gauge) passed to the end of the coaxial needle and fired. For lesion biopsies, needle should be fired outside of the lesion to include normal hepatic parenchyma. One to five cores are obtained.

.Post-biopsy ultrasound examination is for documentation and confirming the absence or presence of capsular or subcapsular hematoma. Bed rest for 1-4 hours and avoiding strenuous activity for 24-48 hours are recommended. Abdominal and/or shoulder pain is the most common complication and is seen in 37% of patients. Narcotics are usually not required. Mortality is not reported in US-guided biopsy literature. Bleeding/hypotension is reported in 1.5% of patients..
Oct 11, 2010
Medical Student
What are the situations (besides coagulopathy& severe ascites) where you'd want to do a transjugular biopsy vs. using a percutaneous approach? Are there others?

Oct 3, 2010
Attending Physician
So, yes we would do a transjugular liver biopsy in high risk ptients from a bleeding stand point .

ie coagulopathy or perhaps ascites.

But, I also can measure right atrial pressures, hepatic vein pressures, and a wedged hepatic venous pressure. Then using hat we calculate the corrected sinusoidal pressure. If the corrected sinusoidal pressure is 6 or greater it is indicative of portal hypertension.

We can also do transjugular renal biopsies in a similar fashion.
Sep 17, 2010
Resident [Any Field]
It is also important to note that ascites is not an absolute contraindication for liver biopsy and it can be easily addressed with paracentesis prior to biopsy. However, as Dr. V. mentioned above in the setting of severe disease with coagulopathy, transjugular approach is preferred.