In a child with tense ascites, what is the preferred method for liver biopsy and what pre‑procedure preparations (coagulopathy correction, ascitic fluid drainage, prophylactic antibiotics) are required?

Liver Biopsy in Children with Tense Ascites

In children with tense ascites requiring liver biopsy, transjugular liver biopsy (TJLB) is the preferred method, with alternative options including total paracentesis immediately before percutaneous biopsy or laparoscopic biopsy. 1

Preferred Biopsy Method

Transjugular liver biopsy should be the first-line approach when tense ascites is present, as it avoids the technical challenges and bleeding risks associated with percutaneous approaches in this setting. 1

Evidence Supporting TJLB in Pediatrics:

• Technical success rates for TJLB in children are excellent at 99.1%, with adequate histological sampling achieved in 97.5% of cases. 2

• TJLB can be performed safely in children as small as 14 kg using appropriately sized catheters (7F for very small children, 9F for larger patients). 3

• Major complication rates are low at 0.5-2.6%, comparable to percutaneous approaches, with the most serious reported complication being supraventricular tachycardia. 3, 2, 4

• Minor complications include bleeding from the entry site (38.78%), transient fever <24 hours (12.24%), and pain requiring analgesia (8.16%). 2

Alternative Approaches When TJLB Is Unavailable:

If transjugular biopsy is not feasible due to lack of interventional radiology expertise or equipment:

• Perform total (large-volume) paracentesis immediately before percutaneous biopsy to eliminate the ascites and reduce the distance between abdominal wall and liver. 1

• Image-guided (ultrasound or CT) percutaneous biopsy after paracentesis does not increase complication rates compared to standard percutaneous biopsy. 1

• Laparoscopic biopsy is another option, which can include therapeutic paracentesis during the same procedure. 1

Pre-Procedure Preparations

Coagulopathy Correction:

• Platelet count should be ≥60,000/mm³ for percutaneous approaches; lower thresholds may be acceptable for TJLB. 1

• INR should ideally be <1.5 for percutaneous biopsy, though the relationship between coagulation parameters and bleeding risk in liver disease is uncertain. 1

• TJLB is specifically indicated when coagulopathy precludes percutaneous biopsy, as it has similar complication rates even with deranged bleeding parameters. 3, 2, 5, 6

• Platelet transfusion or fresh frozen plasma may be considered in severe coagulopathy, though evidence for specific thresholds in children is limited. 1

Ascitic Fluid Drainage:

• For percutaneous approaches, complete therapeutic paracentesis should be performed immediately before biopsy to eliminate technical barriers and reduce bleeding risk into ascitic fluid. 1

• For TJLB, pre-procedure paracentesis is not required as the transvenous route bypasses the peritoneal cavity. 3, 2

• Tense ascites that compromises respiratory effort or severely affects quality of life warrants large-volume paracentesis regardless of biopsy plans. 1

Prophylactic Antibiotics:

• Routine prophylactic antibiotics are not standard for liver biopsy procedures in the absence of biliary obstruction or cholangitis. 1

• If spontaneous bacterial peritonitis is suspected (ascitic fluid neutrophils ≥250 cells/mm³), diagnostic paracentesis should be performed first and antibiotics initiated before proceeding with biopsy. 1, 7

• Bacteremia occurs in up to 14% of percutaneous biopsies of non-infected liver, but clinical significance is unclear. 1

Critical Pitfalls to Avoid

• Do not attempt blind percutaneous biopsy in the presence of tense ascites due to increased distance between abdominal wall and liver capsule, risk of inadequate sampling, and potential for uncontrollable bleeding into ascitic fluid. 1

• Do not delay diagnostic paracentesis when rapidly accumulating ascites is present, as this may indicate portal/hepatic vein thrombosis or spontaneous bacterial peritonitis requiring urgent treatment. 1, 7

• Ensure recent imaging (within 3 months) has been reviewed before any percutaneous biopsy to identify anatomical considerations and confirm liver position. 1

• Recognize that tissue yield from TJLB is inferior to percutaneous biopsy (median 4 vs 5 complete portal tracts), though usually adequate for diagnosis. 4

• General anesthesia is typically required for TJLB in children due to the need for complete cooperation and the technical complexity of the procedure. 3