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Liver biopsy

The module will teach you:

  1. What are the contraindications of liver biopsy
  2. What you need to do before you start the actual procedure
  3. How to locate the site for the biopsy
  4. The trolley- what you need on it
  5. The actual procedure
  6. The aftercare

What are the contraindications of liver biopsy

  1. Ascites
  2. Uncorrected coagulopathy or thrombocytopenia
  3. Uncooperative patient

What you need to do before you start the actual procedure

  1. Check Platelet count and clotting and must have group and save
    • Within 7-10 days of the procedure- in most outpatient cases where liver disease is stable or within last 24-48hours if inpatient with fluctuating clotting/platelets
    • Safe platelet count if >60,000/mm3. Will need platelet transfusion if count is <40,000/mm3
    • PT if <4sec prolonged it is ok, if >4sec prolong then use FFP to bring it down
  2. Will need fasting for 6hours. Can take medications with sips of water.
  3. Take written informed consent
    • Potential benefit should outweigh the risk.
    • There should be clear understanding on both side the need for the biopsy
    • Mortality <0.1%, significant hemorrhage ( Hb drop of more than 2g/dL) <0.3%, pain 30% and puncture of other viscus 0.01-0.1%
  4. Prophylactic antibiotic to be given to patients with valvular heart disease or those at risk of bacteraemia
  5. Anxious patient might need sedation with midazolam ( rarely needed)

How to locate the site for the biopsy

  1. Percuss in the Mid Axillary line with deep breath in and look for liver dullness – so you know how far down the lung can go. And then go one intercostals space down to avoid causing a pneumothorax.
  2. This is normally 7/8/9 intercostal space
  3. Mark rib space ( pressure impression of a plastic needle cover)
  4. In some hospitals radiologist will mark the spot after a quick ultrasound screen
  5. If patient is known to have abnormal area in the liver or you want to biopsy an area of interest – then the biopsy has to be done by the radiologist ( real-time)

The trolley- what you need on it

  1. Menghini needle ( 1.9x 120mm) and a 20ml syringe for suction
  2. Picture1 and 2: The Menghini needle inside the pack: The needle and the stopper( the other two pieces are not used normally)

  3. Biopsy pot and histology form
  4. Local anaesthesia ( 1%Lignocaine, 10ml syringe, one green needle and one orange needle)

  5. Picture3: Local anaesthesia

  6. Scalpel
  7. Sterile gloves
  8. Dressing pack

The actual procedure

  1. Patient lies flat
  2. Lift the bed high enough so that you can do the biopsy standing
  3. Clean the area with antiseptic solution
  4. Infiltrate L/A with a orange needle first – raise a skin bleb- then go perpendicularly down – remember to suck before you inject to avoid injecting into blood vessels
  5. Change to a green needle and advance needle perpendicularly ( remember the neurovascular bundle runs along the lower edge of the rib and avoid that)
  6. Then you might feel that the needle is scratching the liver capsule ( withdraw then) or sometime your needle tip will actually be in the liver ( gently supporting the needle will show the syringe to swing side to side with normal respiration- again withdraw)
  7. Judge that distance ( normally to reach liver capsule it requires three quarter of the length of the green needle and add another 3-4cm to be in actual liver parenchyma
  8. Mark the required depth on the Menghini needle
  9. Actual action –
    • Put the metal stopper inside the needle( prevents the tissue to be sucked up inside the syringe)
    • A tiny incision with the scalpel before you go in with the Menghini needle
    • Say ‘take a deep breath in, deep breath out and hold it, hold it, hold it and while you are saying this- introduce the needle
    • Introduce up to the mark as judged before ( put your index finger at the mark which will act as reminder) into the liver
    • Suck up to 10ml ( remember the tissue is cut with the needle but you need strong suction to break it off from the parenchyma)
    • Come out still saying ‘hold it hold it’
  10. You need a decent core of tissue- 2-3cm in length. Make up to three passes to achieve this. When in doubt whether you have obtained liver tissue or just blood/fat- remember liver tissue will sink at the bottom of the pot.

  11. Picture4: Decent core of liver tissue

  12. Air flush the needle into the biopsy pot- that should expel the tissue from the inside of the needle into the pot
  13. Don’t forget to write accurate and relevant clinical history for the histopathologist- particularly mentioned about alcohol, drugs, viral profile, serological profile and your exact clinical question
  14. Picture5: Pot and the form

The aftercare

  1. Patient lies on right lateral position for 1 hour and then on back
  2. Prescribe prn Paracetamol/codeine
  3. Vital signs to be checked every 15mts for two hours post biopsy, thwn every 30mts for another two hours and then hourly for a total of six hours
  4. Patient can go home after 6hours if ok
  5. Should have a responsible person to stay with on the first post biopsy night and should be able to return to hospital within 30mts if need arise

Liver- The photo is centered on a normal liver lobule taken by core needle biopsy.


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