Imaging-guided Parenchymal Liver Biopsy: How We Do It

Abstract

Liver biopsies are performed for both focal and nonfocal lesions (parenchymal). In our center, majority of liver biopsies are performed for parenchymal liver disease. Parenchymal liver biopsy plays a key role in the diagnosis of various diffuse liver dysfunctions. Results of the biopsy help grade the disease, facilitating prognostication, which helps in planning specific treatment strategies. Imaging guidance is gaining wide acceptance as the standard procedure. Ultrasound (US) guidance is currently considered the most cost-effective and safe way to perform parenchymal liver biopsies. Radiologists worldwide and particularly in the United States are increasingly performing this procedure. Radiologists performing biopsies generally use the cutting needle. Different needle sizes, techniques and preference for biopsy of the right or left lobe have been described. We attribute these preferences to prior training and individual radiologist's comfort level. We describe the algorithm followed at our institution for performing percutaneous US-guided parenchymal liver biopsy. While clinical societies have recommended a minimum of 40 liver biopsies as a requirement for proficiency of clinicians, specific to radiology trainees/fellows interested in pursuing a career in intervention, we feel a total of 20 liver biopsies (includes assisted and independently performed biopsies under supervision) should be adequate training.

Keywords: Liver biopsy; percutaneous; ultrasound guidance.

Figure 1

The patient is under constant monitoring with evaluation of the heart rate, blood pressure, and oxygen saturations.

Figure 2

The skin site is prepped and draped in a sterile fashion.

Figure 3

Sterile biopsy procedure pack including the biopsy needle, local anesthetic, and 4 × 4 gauzes.

Figure 4

The local area is anesthetized with a local anesthetic buffered with sodium bicarbonate in a 1 in 20 dilution.

Figures 5 and 6

Under ultrasound guidance, the deep soft tissues and liver pericapsular areas are also infiltrated with local anesthetic.

Figures 7-9

After the patient is instructed to hold his/her breath, under ultrasound guidance, observe as the needle tip crosses the capsule prior to deploying the cutting device.

Figure 10

CT-guided parenchymal liver biopsy with the biopsy needle seen traversing the right liver lobe in this axial CT image.

Figure 11

Frontal fluoroscopic image demonstrates a catheter seen within the right hepatic vein during a transjugular liver biopsy.

Figure 12

Parenchymal liver biopsy: Patient flowchart

Figure 13

After the biopsy needle has been deployed, the specimen is placed within a sterile container filled with formalin.

Figure 14

The size of the specimen is very important for diagnosis and some pathologists recommend that the specimen contain from 6 to 11 complete portal triads for specimen adequacy. This is an adequate size and appearance of a desirable specimen.

Figure 15

Example of a fragmented specimen.

Figure 16

Histology of a portal triad (BD, bile duct; HA, hepatic artery; PV, portal vein).