Is "Uncomplicated Ultrasound-Guided Liver Biopsy" an Appropriate Impression?
Yes, "uncomplicated ultrasound-guided liver biopsy" is an appropriate and standard impression for documenting a liver biopsy procedure that was performed without adverse events. This terminology accurately conveys that the procedure was completed successfully using ultrasound guidance and that no complications occurred during or immediately after the intervention.
Rationale for This Impression
Standard Documentation Practice
The term "uncomplicated" is clinically meaningful because it explicitly communicates that no adverse events occurred during the procedure, which is essential information for subsequent clinical management 1.
Specifying "ultrasound-guided" is important because it documents the technique used, which has implications for complication rates and diagnostic accuracy 1.
This impression format aligns with standard radiology reporting conventions where the procedural approach and outcome are clearly stated 1.
Clinical Significance of the Term "Uncomplicated"
Major complications from liver biopsy occur in 0.5-2.2% of cases, with mortality rates of 0.07-0.09%, making documentation of an uncomplicated procedure clinically relevant 1.
Minor complications such as pain, bleeding requiring transfusion, or hemobilia occur in 2.5-15% of cases, so explicitly stating "uncomplicated" confirms none of these occurred 1, 2.
The majority of complications occur within the first hour of observation, and documenting an uncomplicated immediate post-procedure period provides reassurance about the patient's initial recovery 1.
Importance of Documenting Ultrasound Guidance
Ultrasound guidance reduces major complication rates from 2.2% (percussion-palpation technique) to 0.5% by avoiding gallbladder, large vessels, colon, and lung 1.
The use of ultrasound guidance (whether real-time or marking technique) is a quality indicator that should be documented in the procedural report 1.
Ultrasound guidance improves diagnostic yield and allows for safer needle placement, particularly in patients with obesity, small livers, or ascites 1.
What Should Be Included Beyond This Basic Impression
While "uncomplicated ultrasound-guided liver biopsy" is appropriate, a complete procedural report should also document:
Needle type and gauge used (typically 18-gauge for core biopsies) 1.
Number of passes performed (multiple passes show a trend toward increased adverse events with OR 2.32) 2.
Adequacy of specimen obtained (presence of portal tracts, specimen length) 1.
Immediate post-procedure vital signs (should be monitored every 15 minutes for the first hour) 1.
Patient positioning during recovery (though right lateral decubitus positioning may not be necessary and can increase pain) 1.
Common Pitfalls to Avoid
Do not omit documentation of the guidance technique used, as this affects interpretation of complication risk and quality metrics 1.
Ensure adequate observation time is documented (recommended 2-4 hours post-procedure, though some centers safely discharge after 1 hour) 1.
Document any minor symptoms even if they did not constitute complications (such as transient pain that resolved without intervention) 1.
If tract plugging with Gelfoam was used, this should be specified as it represents a modified technique with potentially lower bleeding risk 3.