Liver Biopsy Test – Types, Indications and Procedure Cost

The patient will be made to lie down in a comfortable supine position with their right hand under their head. The hepatologist locates the area of the liver biopsy site by abdominal palpation (physical finding) or imaging-guided ultrasonography. In some cases, ultrasonography may be used to guide the needle into the liver during the biopsy.

The operated skin will be sterilised, and the underlying skin and peritoneum will be anaesthetised with a local anaesthetic. The hepatologist will place a small incision or cut with the help of a surgical blade and insert a biopsy needle towards the surface of the liver (5 to 8 cm) without affecting the surrounding blood vessels.



The patient will be said to hold their breath while the needle is inserted into the liver and the biopsy sample is collected. Once the biopsy tissue is collected and the needle comes out of the liver, the patient can feel normal.

Patients who are at severe risk of complications from percutaneous biopsy, such as those with ascites, obese coagulopathy, sickle hepatopathy, probable hepatic amyloidosis, and chronic kidney disease, would greatly benefit from transjugular liver biopsy.

• The patient will be made to lie down in a comfortable supine position, and the region around the neck will be anaesthetised with a local anaesthetic. 
• Interventional radiologists or hepatobiliary surgeons do this procedure with the help of fluoroscopy or X-ray. The radiologists or a hepatobiliary surgeon will now puncture the trans jugular vein, mostly the right internal jugular (in front of the neck, on the right side of the windpipe). 
• Once the radiologists have access to the internal jugular vein, a short guide wire will be inserted through which a selective plastic tube will be threaded down to the right hepatic vein via the inferior vena cava with the help of a fluoroscope or by passing contrast dye into the tube.
• Once the catheter reaches the right hepatic vein, the biopsy needle will be introduced via the catheter and move toward the liver parenchyma. Before inserting the needle into the liver parenchyma, the patient will be asked to hold their breath. Once the biopsy tissue is collected, the patient can breathe normally. The biopsy needle and the catheter will be removed slowly.
  

During a laparoscopic biopsy, the patient will be on general anaesthesia. During the procedure, the patient will be in a supine position, and the hepatobiliary surgeon will make two or more incisions on the patient's abdomen.



Through these incisions, special tools are inserted, including a tiny video camera that provides an internal view on a monitor in the operating room. With the help of the camera view, the surgeon guides the surgical tools towards the liver and removes the tissue samples.

Once the samples are collected, the surgical tools and the camera will be removed, and the incisions will be closed with stitches.

This procedure is generally done by combining an endoscope with an EUS needle accompanied by a suction syringe. 

The patient will be placed in a supine position. The stylet will be removed from the EUS needle, and an anticoagulant will be flushed into the channel. The suction syringe is filled with 2 cc of water, and 20 cc of suction is applied.

This suction syringe with the stopcock closed is now attached to the back end of the EUS needle. The needle and the suction syringe are now passed through a linear echo endoscope.

A linear EUS endoscope is used to find the right hepatic lobe through the duodenal bulb or the left hepatic lobe through the upper part of the stomach. The needle is then passed through the wall of the stomach or duodenum into the liver (left or right). 

The stopcock of the suction syringe is turned on, and 1 to 3 to-and-fro passes will be made through the liver tissue, resulting in the collection of tissue samples. The suction is turned off before the needle is removed from the liver.

This is a change to the percutaneous method that can be used on patients at risk of severe bleeding (coagulopathy or thrombocytopenia). Even though a transvenous biopsy is possible in this group of patients, the plugged method is used when a bigger sample is needed.



The method is similar to the percutaneous approach, but the biopsy tract is plugged with gel foam, thrombin or collagen while the needle is taken off.

Before initiating a liver biopsy test, the interventional radiologist / interventional gastroenterologist / hepatobiliary surgeon would like to know the following, based on which the type of liver biopsy can be finalised:

• Presence of any cardiovascular disease
• Pregnancy status of the patient
• Any known allergies to medications
• Family history of bleeding disorders
• Intake of medications such as blood-thinning agents, over-the-counter, vitamins, herbs, and other dietary supplements, or any other that could affect the biopsy test

The patient needs to stop taking blood thinning agents, anticoagulants, or any other drugs that affect the procedure at least one week before the liver biopsy procedure or as per the hepatologist's suggestion.

The doctor might request to have laboratory tests done 2–7 days before the procedure, including a complete blood count and imaging tests like an ultrasound or computed tomography (CT) scan to view the surrounding organs and determine the best position to insert the biopsy needle.

The interventional radiologist / interventional gastroenterologist / hepatobiliary surgeon will finalise the type of biopsy and notify the patient when it is necessary to check into the hospital. The primary care doctor will describe the process to the patient, and a consent form to sign will be issued to the patient, permitting to proceed with the procedure. Before signing, the patient should thoroughly read the document and clarify if there are any questions. The patient should abstain from drinking and eating for 4 to 6 hours before the biopsy.

A liver biopsy can be performed in an operation theater, hospital bed, or radiology department. The patient will be given a gown. Before the liver biopsy procedure, the patient will be given a sedative to relax, and an intravenous line may be placed in their arm or hand. The patient's blood pressure and heart rate are continuously monitored throughout the procedure.

Based on the patient's condition, the interventional radiologist / interventional gastroenterologist / hepatobiliary surgeon performs any of the following procedures to obtain a tissue sample. 

• Percutaneous liver biopsy
• Transjugular liver biopsy
• Laparoscopic liver biopsy
• Endoscopic ultrasound-guided liver biopsy
• Plugged Biopsy

Once the doctor has the sample tissue(s), these will be sent to the pathologist for further assessment under a microscope.

Following the procedure, the patient may be transferred to a recovery room and monitored for 4 hours while his vital signs are regularly monitored.

The patient might feel mild discomfort or soreness in the upper abdomen, right shoulder, or back. Analgesics will be prescribed, if necessary, by the interventional radiologist / interventional gastroenterologist / hepatobiliary surgeon. For at least 24 hrs after the biopsy, the patient should refrain from engaging in strenuous physical activity.

The patient will be provided with counselling with regard to wound care, diet, and when to resume old medications at the time of discharge.

Liver biopsy recovery time for a patient to get better after a liver biopsy test depends on the type and the person's overall health.



After 5 to 7 days, most people may return to their normal routine. Prior to this, the patient should avoid hard lifting.

These are some potential complications that can arise after a liver biopsy test, typically between one and three hours or within the first 24 hours.



Not much Common

• Right shoulder or back pain
• Bleeding at the site of the biopsy

Very Rare

• Biopsy site infections
• Injury to adjacent organs around the liver
• Hemothorax (blood accumulation between lung and chest wall)
• Pneumothorax (air accumulation between lung and chest wall)

Liver biopsy grading and staging systems

Liver biopsy grading and staging are used to assess liver conditions after collecting liver biopsy samples and are observed under a microscope (histology). The liver fibrosis is measured on various "staging scales," which a hepatologist uses to quantify the extent of the liver damage.

The most appropriate or widely used scales are as follows:

• Batts-Ludwig
• Metavir
• International Association of the Study of the Liver (IASL)