Liver Biopsy: Clinical Pathway
Performing a liver biopsy is the standard of care to evaluate elevated liver enzymes and to stage and grade disease in patients who have an established diagnosis
Coagulation support:
- With single donor platelets if platelet count is less than 70,000 or at procedure attending’s judgment
- With FFP if INR >1.4 or at procedure attending’s judgment
- Ascites
- Anatomical abnormalities
- Inability to correct bleeding diathesis
Frequency of liver biopsy: Follow-up biopsy interval is at the managing MD’s discretion. Interviews with experts (eg. Dr Gary Davis and Eugene Schiff) as well as statements by the NIH allow follow-up liver biopsies in viral hepatitis to judgment disease progression. Typical intervals from both formal and informal surveys indicate that liver biopsies for HCV management at 3-5 years are reasonable. Patients with autoimmune liver disease not responding to therapy may require more frequent liver biopsies.
Pre-Liver Biopsy
Coagulation:
- All patients will have INR and platelet count in the chart and at the MD’s discretion a repeat recent INR and platelet count will be assessed within 2 weeks of the biopsy.
- No ASA for 5 days before liver biopsy
- No NSAID for 1 day before biopsy
- Platelet count <70,000: transfuse platelets
- INR >1.3: use FFP
The Procedure
Size of needle:
Optimal size of liver biopsy for pathologic assessment:
2 cm length
5 mm diameter
Number of passes:
There is no prospective study that statistically correlates the number of passes with increased risk of complications. Standard practice in the US is to do 1-2 passes to obtain tissue for pathology and additional studies as needed. Trends in literature state that more than 1-2 passes may be associated with an increased risk of complications although this data is derived from studies where large, 14 gauge needles, may have been used and liver imaging for liver biopsy was infrequent or not used.
Tissue is commonly needed for quantitative iron and or copper as well as special stains, and molecular testing; thus 2 biopsies may be required to obtain adequate tissue to decrease sampling error, and prevent asking the patients to return for a second biopsy if more tissue is needed.
Post-Liver Biopsy
Observation:
The policy in regards to the length of observation after liver biopsy reflects that all patients are considered for biopsy under imaging, all patients have a coagulation profile in the chart and high risk patients are considered for transjugular or laparoscopic liver biopsy.
For patients with normal vital signs and minimal or no symptoms:
2 hours direct observation by RN
1 hour or more optional observation based on MD and RN judgment of patient’s clinical status and symptoms.
Note: CPMC protocol has been 2 hours for 7 years without mortality or morbidity event related to 2 hour observation interval.
Liver Biopsy Published Data
Yale, Ann Intern med 1993:
Safe to d/c after 4-6 hrs
PT < 3 sec prolonged, plat > 60K
Mayo Gastro 1978:
d/c after 3 hrs if no complications
Mayo Ann Intern Med 1993:
Allowed to leave after 3 hrs.
Swiss DDS 1993:
More deaths if > 80 yrs of age. Fewer complications if operator does more than 50 bx/yr
McGill (Mayo) Gastro 1990:
More bleeding if old
Harvard review NEJM 2001:
Monitor for at least 6 hrs
France Hepatology 2000:
Most without sedation, two passes more complications (no details on type of needle used)
Mostly done as inpatient!
UCSF Am J Clin Path 1990:
Strict bed rest for 6 hours
Italy Digestion 2001:
Follow-up for 6 hours.
Two major complication occurred w/in 2 hrs.
Observation can be reasonably decreased to 4 hrs in outpatient LB
Norway Thromb Haem 1999:
Bleeding time may give better coag info. If prolonged, increased risk of bleed (OR=5)
India J Gastro Hepatol 1989:
Observe pts 6-8 hrs
UW J Clin Gastro 1982:
Reasonable risk if platelets are or can be increased to > 60K
Italy 1986:
Hemoperitoneum occurred only in patients with cirrhosis or cancer
Complications associated with 14 gauge TruCut, observation for up to 24 hours in high risk patients
Patient Handouts