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Introduction ⬇

A liver biopsy is an invasive procedure that is done to confirm diagnosis of chronic hepatitis and liver cirrhosis, evaluate disease presence and severity, and establish etiology. Cellular material from the liver may be useful in evaluating the status of the liver in diffuse disorders of the parenchyma and in the diagnosis of space-occupying lesions. Liver biopsy is especially useful when the clinical findings and laboratory test results are not diagnostic (e.g., an aspartate aminotransferase level 10–20 times less than the upper defined limit with an alkaline phosphatase level less than 3 times the limit) and when the diagnosis or cause cannot be established by other means (enlarged liver of unknown cause or systemic disease affecting the liver, such as miliary tuberculosis). Other indications for liver biopsy include evaluation of chronic hepatitis, portal hypertension, and fever of unknown origin (tuberculosis and brucellosis) and to confirm alcoholic liver disease.

Procedure ⬆ ⬇

  1. See Fine-Needle Aspirates: Cytologic (Cell) and Histologic (Tissue) Study.

  2. Be aware that in most cases, this is an outpatient procedure.

  3. Remember that the test may be done at the bedside in a designated area, usually under local anesthesia. Obtain specimens with ultrasound or computed tomography (CT) or x-ray guidance and a tissue core biopsy needle that provides histologic and cytologic material, or use an FNA needle, which obtains cytologic material only and is useful for cancer diagnosis but not diagnosis of other liver diseases.

  4. Place tissue specimens in 10% formalin for fixation. Do not place specimens for culture in a fixative. Check with your laboratory for specific instructions for handling special cases (e.g., liver biopsies for copper levels).

  5. Express cytology specimens on glass slides and fix immediately in 95% alcohol. Needle rinses may provide helpful diagnostic material as well.

  6. See Chapter 1 for safe, effective, informed intratest care. See Chapter 12 on endoscopic examination and liver biopsy.

Clinical Implications ⬆ ⬇

Abnormalities in test results of liver biopsies may be helpful in detecting the following liver diseases:

  1. Benign disorders, such as those causing liver cirrhosis, and presence of pathogenic organisms in liver abscess

  2. Metabolic disorders

    1. Fatty metamorphosis

    2. Hemosiderosis

    3. Accumulation of bile (due to hepatitis, obstructive jaundice, malignancy)

    4. Diabetic pathology and Wilson disease

    5. Hepatic cysts (congenital or hydatid)

    6. Malignant processes, such as end-stage lymphoma

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain the purpose, procedure, benefits, and risks of the test. Obtain or confirm a signed, witnessed consent form.

  2. Warn the patient that the procedure usually causes minimal discomfort but only for a short while. Explain that a local anesthetic agent will be injected into the skin.

  3. Remember to ask whether the patient has any allergies or has ever had a reaction to any numbing medicines.

  4. Discontinue all aspirin and nonsteroidal anti-inflammatory drugs for at least 7 days before the procedure. PT, partial thromboplastin time (PTT), blood urea nitrogen, bleeding time, and type L screen cross-match for possible transfusion are usually ordered before biopsy.

  5. Ensure that the patient has not taken anything by mouth for 4–6 hours before the procedure. Ask the patient to lie supine with the right arm above the head. Tell the patient that during the procedure they will be asked to take a deep breath in, blow the air out, and then hold the expired breath.

  6. Make the patient aware that risks include a small but definite risk for intra-abdominal bleeding and bile peritonitis and that percutaneous liver biopsy results in complications in ~1% of cases.

  7. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Clinical Alert

Contraindications include:

  1. Bleeding diathesis (anticoagulant therapy)

  2. Highly vascular lesions

  3. Uncooperative patient

  4. PT in the anticoagulant range; PTT >20 seconds over control; INR >1.3%

  5. Severe anemia (hemoglobin <9.5 g/dL or <95 g/L) or marked prolonged bleeding time

  6. Infection

  7. Platelet count <60,000/mm3 (60 × 109/L)

  8. Marked or tense ascites (risk for leakage)

  9. Septic cholangitis

Posttest Patient Care

  1. Explain to the patient that they may be on strict bed rest for at least 6 hours, lying on the right side or the back, with observation for 24 hours.

  2. Review test results; report and record findings. Modify the nursing care plan as needed. Monitor in a recovery area. Assess pulse, blood pressure, and respiration every 15 minutes for the first hour, every 30 minutes for the next 2 hours, once in each of the next 4 hours, and then every 4 hours until the patient’s condition is stable.

  3. Notify the surgeon if the blood pressure differs markedly from baseline or if the patient is in severe pain.

  4. Have the patient resume previous diet after 2 hours.

  5. Seek additional medical attention immediately if a bleeding episode occurs.

  6. Assess for pain and treat as ordered.

  7. Check a hematocrit level after 6 hours to rule out internal bleeding. A small number of patients need transfusion for intraperitoneal bleeding.

  8. Warn the patient not to cough hard or strain for 2–4 hours after the procedure. Heavy lifting and strenuous activities should be avoided for about 1 week.

  9. Monitor for complications, which may include uncontrolled pain, hemorrhage, peritonitis, bile leakage, lacerations of other organs, sepsis, and bacteremia.

  10. Follow the guidelines in Chapter 1 for safe, effective, informed posttest care.

Interfering Factors ⬆ ⬇

Reported effectiveness of liver aspirates or biopsies varies. Because a very small fragment of tissue, often partially destroyed, is taken in a random manner from a large organ, localized disease may be missed.

  1. False-negative results may be caused by:

    1. Sampling error: Detection rate of liver metastases is approximately 50%–70% with blind biopsy and about 85% (range, 67%–96%) with the use of ultrasound guidance. Also, many diseases produce nonspecific changes that may be spotty, healing, or minimal.

    2. Degeneration or distortion caused by faulty preparation of specimen.

  2. False-positive results may be caused by misinterpretation of markedly reactive hepatocytes.

Reference Values ⬆

Normal

Negative for malignant or other abnormal cells and abnormal tissue

No evidence of local or diffuse liver disease

No evidence of toxic reaction to drugs or inflammatory reactions

No pathogenic organisms present