When is a liver biopsy indicated?

Indications for Liver Biopsy

Liver biopsy should be performed only when clinically important information about diagnosis, prognosis, or management cannot be obtained by safer non-invasive means. 1

Primary Indications

Diagnostic Purposes

• Evaluation of abnormal liver tests of unknown etiology after complete investigation 2
• Diagnosis of parenchymal liver diseases when non-invasive methods are insufficient 2
• Establishing definite diagnosis when multiple etiologies are suspected (approximately 20% of patients with alcohol use disorder and abnormal liver tests have co-existing liver disease) 1
• Investigation of infiltrative or storage diseases 2
• Evaluation of fever of unknown origin with liver involvement 2
• Assessment of focal or diffuse anomalies on imaging studies 2

Disease Assessment and Management

• Determining the degree of fibrosis/cirrhosis in chronic liver diseases 2
• Assessing exact stage and prognosis of liver disease 1
• Suspicion of non-alcoholic steatohepatitis (NASH) requiring histological confirmation 2
• Guiding treatment decisions in cases where histology would change management 1
• Evaluating disease severity when non-invasive tests provide conflicting information 1

Specific Clinical Scenarios

• Chronic hepatitis B: Consider biopsy if ALT is 1-2× ULN to assess for moderate-severe necroinflammation (≥A2) or significant fibrosis (≥F2) 1
• Autoimmune hepatitis: For diagnostic confirmation and prognostic information 2
• Alcoholic liver disease: When non-invasive tests are inconclusive or when suspicion of competing liver disease exists 1

Biopsy Approach Selection

Percutaneous Approach (Standard)

• For patients with normal coagulation (INR <1.4) 1
• Use 16G needle for non-lesional biopsies and 18G needle for lesional biopsies 1
• Specimen length should be at least 20mm 1

Transjugular Approach

• For patients with coagulopathy (INR >1.4) 1
• For patients with significant ascites 1
• Specifically recommended for patients with low platelet count and/or prolonged prothrombin time 1
• When concurrent procedures are needed 2

Image-Guided Approach

• For focal lesions 2
• When percutaneous landmarks are difficult to identify (e.g., obesity) 1

Contraindications

Absolute Contraindications

• Extrahepatic biliary obstruction (high risk of biliary peritonitis) 1, 2
• Uncooperative patient (unless sedation is used) 2

Relative Contraindications

• Bacterial cholangitis (risk of peritonitis and septic shock) 1, 2
• Significant ascites (consider total paracentesis before biopsy or use transjugular approach) 1
• Amyloidosis (consider transjugular approach due to bleeding risk) 1
• Pregnancy (consider risks to mother and baby; may defer non-urgent biopsies) 1

Complications and Risk Management

Major Complications (0.06-0.32% of patients)

• Hemorrhage requiring intervention
• Bile peritonitis
• Pneumothorax
• Death (extremely rare: 0.009-0.12%) 3

Risk Reduction Strategies

• Monitor patients for at least 3 hours after biopsy 1
• Check biopsy site every 30 minutes for signs of bleeding 1
• Discharge only if patient is hemodynamically stable with no evidence of bleeding 1
• Provide written discharge instructions including activity restrictions and warning signs 1
• Advise against strenuous physical activities for 48 hours after biopsy 1

Important Considerations

• The risks of liver biopsy should be carefully weighed against clinical benefits and therapeutic consequences 1
• Liver biopsy is subject to sampling error and variability in interpretation 2
• A second pass should be considered if the initial specimen is inadequate 2
• Ensure proper communication between the requesting clinician, the operator, and the pathologist 1, 2
• The procedure is justified only when the information will directly impact patient management 2

Liver biopsy remains an essential diagnostic tool when used appropriately, with a high benefit-to-risk ratio in properly selected patients 3. However, with the increasing availability of non-invasive diagnostic methods, its use should be limited to situations where it will provide unique and clinically valuable information that cannot be obtained through safer means.