What is Liver Biopsy?Liver biopsy is an invasive diagnostic medical procedure performed to obtain a small sample of liver 4tissue for diagnostic testing • What: In percutaneous liver biopsy, the tissue sample is obtained using a needle that is inserted

through the skin, subcutaneous tissues, intercostal muscles, peritoneal cavity, and into the liver. Other types of liver biopsy techniques include intravascular tissue sampling via the hepatic vein (i.e., transjugular liver biopsy) and intraabdominal biopsy during laparoscopy or laparotomy. This Nursing Practice & Skill paper focuses on percutaneous liver biopsy

• How: Liver biopsy is a sterile procedure, which is typically performed by needle aspiration with a specialized hollow Menghini needle that is attached to a syringe. The radiologist or gastroenterologist may use computed tomography (CT) scanning or ultrasound (US) imaging to guide the needle to the chosen biopsy site. A piece of hepatic tissue is snipped, withdrawn from the biopsy site, and placed in a container with formalin, a preservative. The specimen container is labeled and sent to the laboratory for analysis

• Where: Liver biopsy is usually performed as an outpatient procedure, but may also be performed in hospitals as an inpatient procedure. Liver biopsy should be performed in a facility with an approved laboratory, blood bank, access to inpatient hospital beds in case the patient needs to be admitted to a hospital, and personnel to monitor the patient for up to 6 hours following the biopsy

• Who: Liver biopsy is typically performed by a specialist in gastroenterology or hepatology, or by a radiologist. Pre- and postprocedure care is performed by registered nurses who possess clinical and technical competence regarding care of patients undergoing liver biopsy. Registered nurses may also assist the clinician during the procedure. Family members are typically present during the procedure

What is the Desired Outcome of Liver Biopsy?The desired outcome of liver biopsy is to obtain a specimen of liver tissue for laboratory analysis to aid 4in diagnosing liver disease and in assessing various circumstances, including

evaluation of unexplained jaundice •evaluation and staging of cirrhosis •assessment of suspected cancerous tumors (e.g., hepatocellular carcinoma, cholangiocarcinomas, •angiosarcomas, metastatic tumors) determination of iron content in hemochromatosis (i.e., a condition of excess iron storage in the liver) •evaluation following repeated abnormal results of liver function studies •assessment of unexplained hepatic inflammation or enlargement •evaluation and management of rejection following liver transplantation •

Why is Liver Biopsy Important?Liver biopsy is a valuable diagnostic tool for identifying abnormalities in liver tissue that imaging studies 4and serum laboratory tests cannot accurately detect or diagnose. Liver biopsy is the standard diagnostic test to evaluate the etiology and extent of hepatic disease in patients with abnormal hepatic laboratory test results, to confirm a hepatic diagnosis and prognosis, when hepatic cancer is suspected, to confirm cholestatic liver disease, to evaluate fatty liver disease, to manage patients with liver transplantation, and to determine the cause of unexplained jaundice or suspected drug reactions

Facts and FiguresCirrhosis and other chronic liver diseases are common disease-related causes of death in the United 4States, accounting for 9.7 deaths per 100,000 persons. Nearly 29,000 people in the U.S. die each year from chronic liver disease and cirrhosis (Xu et al., 2010) Paul Ehrlich is credited for performing the first documented diagnostic percutaneous liver biopsy in 4Germany in 1883 (Zaman et al., 2011)In the late 1950s, Giorgio Menghini developed a 1-second aspiration technique that made the procedure 4easier and safer; this led to its broadened use (Zaman et al., 2011)The typical liver biopsy specimen is 1/50,000th the size of an adult liver (Zaman et al., 2011) 4August 26, 2011

ICD-950.11

AuthorAmy E. Beddoe, RN, PhD

ReviewersEliza Schub, BSN, RN

Cinahl Information Systems

Glendale, California

Nursing Practice CouncilGlendale Adventist Medical Center

Glendale, California

EditorDiane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems

Liver Biopsy: Assisting with

NURSINGPRACTICE

& SKILL

Published by Cinahl Information Systems. Copyright©2011, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Sixty percent of all complications associated with liver biopsy occur in the first 2 hours after the procedure; 96% of complications occur in the first 424 hours after biopsy (Karamshi, 2008)Postprocedure pain occurs in 25% of patients undergoing liver biopsy (Arora et al., 2011) 4Piercing the liver more than 3 times during a single biopsy is associated with the increased risk of bleeding (Arora et al., 2011) 4Hemobilia (i.e., bleeding into the bile ducts and gallbladder) is a rare complication of liver biopsy. Only 4 cases have been reported in more than 468,000 patients who underwent liver biopsy (Arora et al., 2011)Death caused by liver biopsy occurs in 1 per 10,000–12,000 patients (Arora et al., 2011) 4

What You Need to Know Before Assisting with Liver BiopsyLiver biopsy is generally considered safe and is currently the standard method to evaluate for liver inflammation and fibrosis. However sampling 4errors, rare complications, and significant patient anxiety sometimes occur The vast majority of patients undergoing liver biopsy do not develop complications, but when complications develop they can be serious. 4Complications of liver biopsy include

pain •Pain is the most common adverse effect of liver biopsy –Pain is located either at the biopsy site or is referred to the right shoulder –Pain is typically managed by a single dose of analgesia –Prolonged or protracted pain following biopsy may require hospitalization –

hypotension •Hypotension is usually caused by a vasovagal response –Hypotension may also be a sign of hemorrhage –Hospitalization may be necessary –

hemorrhage •Most cases of hemorrhage occur within 3–4 hours of liver biopsy –The signs and symptoms of hemorrhage may be associated with the location of bleeding. Not all patients have symptoms –

Subcapsular hemorrhage is usually asymptomatic; it may cause pain 4

Intrahepatic hemorrhage is usually asymptomatic 4

Intraperitoneal hemorrhage is the most serious form of hemorrhage; it is rare 4

Hemobilia is very rare 4

unintentional biopsy of other organs (e.g., lung, kidney, colon) •biliary peritonitis •pneumothorax or hemothorax •transient bacteremia •

Contraindications to liver biopsy are 4a platelet count below 60,000/mm • 3

prolonged international normalized ratio (INR; i.e. > 1.5) •abnormally high prothrombin time (PT) •suspected hepatic tumor containing a large number of blood vessels (e.g., hemangiomas) •history of unexplained bleeding •blood diathesis (e.g., hemophilia) •suspected hepatic echinococcal hydatid (fluid-filled) cysts •infection in the right pleural cavity, below the right side of the diaphragm, or in the abdominal wall at the site where the biopsy would otherwise •take placesegment of bowel overlying the biopsy site as visualized by US or CT scanning •recent use (within the last week) of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or antiplatelet medications •morbid obesity •ascites •lack of available surgical or interventional radiology backup personnel to manage complications •lack of availability of transfusion products (e.g., platelets, packed red blood cells) •any preexisting serious medical conditions that potentially increase the risk of biopsy complications including encephalopathy, liver failure with •severe jaundice, severe congestive heart failure, or being of advanced age

Although percutaneous liver biopsy can be performed as an outpatient procedure, small children and infants who will typically require general 4anesthesia to remain still during the procedure require hospitalization. Pediatric patients may also require sedation for 6 hours following the procedure so that they remain calm in the early post-procedure periodPrior to the procedure, patients are typically asked to take nothing by mouth (i.e., be NPO) for 8 hours. The puncture site for the percutaneous liver 4biopsy is usually located in the upper right hand quadrant of the abdomen, on the midaxillary line at the 7th or 8th intercostal space. The patient must assume a supine position during the procedure with the right arm extended above the head

The nurse should use pillows and rolled towels to assist the patient into a comfortable position •The exact site location of the puncture site for the biopsy is confirmed by the treating clinician through percussion and US or CT scan guidance •

The nurse should show the patient how to hold his or her breath for approximately 10 seconds during the procedure and practice this •immediately before the procedure. Holding the breath helps to reduce the size of the lung field, while bringing the liver closer to the surface of the abdominal wallThe liver sample taken is typically about 1.5 cm in length and 1.2–2 mm in diameter. This amount of tissue contains about 6–8 portal triads and •is considered adequate for laboratory analysis

If there are no complications associated with liver biopsy, the patient typically goes home 2–6 hours following the procedure 4Coughing or straining should be avoided if possible for 4 hours after the procedure •Patients typically feel sore at the biopsy site for up to 1 week and should avoid heavy lifting or strenuous activities for that week •

When the patient goes home, he or she should be able to easily return within 30 minutes to the hospital or outpatient center where the procedure 4was performed if complications develop

A friend or family member should stay with the patient during the first night following liver biopsy and provide care as well as transportation •to the hospital, if required for severe pain; shortness of breath; chest pain; bleeding from the biopsy site; fever greater than 100.4 °F/38 °C; abdominal pain; weakness, lightheadedness or sweating; and/or heart palpitations

Biopsy results are typically obtained within 1 week 4The patient should return to the clinician for a scheduled follow-up visit to receive the biopsy results •

The patient’s safety is the registered nurse’s primary responsibility during liver biopsy. Therefore, it is critical that nurses be familiar with the 4following:

Facility protocol regarding liver biopsy, if available •Anatomy and physiology of the hepatobiliary system •Sterile technique •

Preliminary steps to be taken before assisting with liver biopsy include the following: 4Check the treating clinician’s order for liver biopsy •Review facility protocol for liver biopsy, if available •Verify completion of facility informed consent documents •Review the patient’s history/medical record to assess for •

a history or presence of any contraindications to liver biopsy –results of laboratory tests (e.g., PT) to verify they are within normal limits –current medications –

Aspirin and NSAIDs (e.g., ibuprofen) interfere with clotting and should not be taken for at least 1 week prior to the biopsy 4

any allergies (e.g., to latex, medications, other substances); use alternative materials as appropriate –Gather prescribed medications 4

Local anesthesia (e.g., lidocaine 1% or 2%) is used to numb subcutaneous skin and the liver capsule during the liver biopsy •Patients with high anxiety are sometimes given a small dose of oral or intravenous (I.V.) benzodiazepine (e.g., lorazepam) •Rarely adult patients are prescribed medications for conscious sedation such as midazolam or fentanyl •

Gather the appropriate supplies, which typically include the following: 4Nonsterile gloves •Sterile surgical garb (e.g., sterile gloves, eye protection, gown, and mask) for self and treating clinician •I.V. set-up if necessary •Liver biopsy equipment, which is available in a prepackaged kit (i.e., liver biopsy tray) and typically includes the following items: •

Core biopsy needle, preferably 16 gauge, 4.5 inches –Facility-approved antiseptic solution (e.g., povidone-iodine) –Specimen containers with formalin –One injection needle: 21 gauge, 1.5 inches, with 3 mL syringe –One injection needle: 25 gauge, 1 inch, with 3 mL syringe –Sterile drapes/towels –Three 10 mL normal saline solution (0.9%) vials –One #11 surgical scalpel and blade –Three cotton swabs or 4 X 4 inch gauze pads –Two 10 mL syringes –Sterile gauze and tape for bandage –

Emergency medical equipment (e.g., crash cart, oxygen) •Vital signs equipment •

How to Assist with Liver BiopsyIdentify the patient according to facility protocol 4Assess the patient’s and/or family member’s understanding of the procedure 4

Explain the purpose of liver biopsy; answer any questions •Explain the equipment that will be used; explain the clicking noise that the biopsy needle will make •

Perform hand hygiene and apply nonsterile gloves 4

Provide the appropriate level of assistance for the patient to dress in a hospital gown 4Assess baseline vital signs 4Establish I.V. access or confirm patency of an existing I.V. line, if I.V. access is necessary 4Describe and review the breath-holding technique during the procedure; practice full expiration and breath holding with the patient 4Reinforce the importance of remaining still during the procedure 4Administer medication for sedation or pain as ordered 4Assist the patient into a supine position with the right arm extended above the head to maximally expand the intercostal spaces beneath which the 4liver is locatedPrepare the patient for determination of the location of the liver (e.g., by CT scanning, US imaging, or percussion) 4

The biopsy site is usually located on the midaxillary line at the 7th or 8th intercostal space •Once identified, the treating clinician marks the site with a surgical pen •

Remove and discard nonsterile gloves 4Perform hand hygiene and apply sterile surgical garb according to facility protocol 4Prepare a sterile surgical tray with the necessary equipment per facility protocol 4Perform sterile draping of the patient per facility protocol 4Maintain a conversation with the patient throughout the procedure to assess the patient’s level of pain and anxiety, and to monitor for complications 4related to the procedureFollow facility protocol to assist the treating clinician as he or she performs the following steps, noting that certain steps may be delegated to the 4nurse clinician:

The skin is disinfected with 3 cotton swabs or gauze pads soaked in povidone-iodine using circular motions, starting closest to the puncture site, •and moving outward to cleanse the skinA local anesthetic (e.g., lidocaine) is injected into subcutaneous tissue and into the liver capsule. The nurse clinician may be responsible for •cleansing the top of the vial and holding it so the treating clinician can insert the needle and draw up the required amount of anestheticThe patient is assessed to determine whether the anesthetic has taken effect •A small incision is made at the selected skin site •

As the treating clinician inserts the biopsy needle through the incision, ask the patient to take deep breaths, exhale completely, and hold his/her breath 4Assist the patient in remaining still as the specimen is obtained 4Instruct the patient when to breathe again and to breathe normally 4Assist the treating clinician with placement of the specimen in the sterile specimen container 4Assist with the application of a dressing at the incision site 4Assist the patient onto the right side using a pillow to support the lower right rib cage; instruct the patient to lie on his or her right side for at 4least 2 hoursLabel the specimen container and arrange prompt delivery to the laboratory 4Discard used supplies and perform hand hygiene 4Document the following in the patient’s medical record: 4

Date and time of the liver biopsy •Laboratory tests ordered •All medications administered •Patient’s tolerance of the procedure •Clinical assessment information (e.g., vital signs, level of pain/anxiety/consciousness, cardiovascular, pulmonary, condition of dressing) before •and after the procedureThe type of dressing and any medication applied to the puncture site •The presence of bleeding or drainage at the site •Patient and/or family member teaching •

Other Tests, Treatments, or Procedures That May be Necessary Before or After Liver BiopsyBefore liver biopsy, a complete physical exam and history is performed including a review of patient’s current medications and coagulation studies 4(e.g., PT, INR, platelet count)After the procedure, the patient requires close monitoring for bleeding and other complications associated with the procedure; elements of 4monitoring may include assessment, laboratory evaluation, and imaging studies

Depending on the patient’s overall health, whether sedation was used, and whether complications occurred, vital signs and pain level should be •assessed every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every hour for the next 4 hours, and then every 4 hours until the patient is stable or until patient dischargeAny changes in the patient’s clinical status should be immediately reported to the treating clinician, including increasing pulse rate, decreasing •blood pressure, increased pain intensity, and feelings of apprehension

What to Expect After Liver BiopsyThe patient will 4

have tolerated the procedure well without anxiety •

have minimal postprocedural pain •not experience any complications; alternately, any complications will be promptly detected and treated •

Red FlagsMonitor closely for signs and symptoms of hemorrhage (e.g., severe pain, abdominal distention, hypotension, tachycardia, mental status changes) 4Dyspnea may indicate pneumothorax following liver biopsy 4

What Do I Need to Tell the Patient/Patient’s Family?Reinforce postprocedure education, including the need to remain still and remain in bed on the right side for at least 2 hours without eating or drinking 4Advise that a friend or family member should stay with the patient during the first night following liver biopsy to provide care as well as potential 4transportation to the hospital within 30 minutes of developing any adverse signs or symptomsAdvise that the patient will feel soreness at the biopsy site for up to 1 week and that he or she should avoid coughing or straining for 4 hours after 4the biopsy, if possible, and should avoid heavy lifting or strenuous activities for 1 week after the biopsyDirect patient to report severe pain at the biopsy site or shoulder; shortness of breath; chest pain; bleeding from the biopsy site; fever greater than 4100.4 °F/38 °C; abdominal pain; weakness, lightheadedness or sweating; and/or heart palpitations Explain that the biopsy report is typically available within 1 week. The patient should return to the clinician for a scheduled follow-up visit to 4receive the biopsy results

ReferencesAltman, G. B. (2010). Special procedures. In • Fundamental & advanced nursing skills (3rd ed., pp. 1435-1442). New York: Delmar Cengage Learning.Arora, G., Ayoub, W. S., & Keeffe, E. B. (2011). Percutaneous liver biopsy. • Medscape Reference. Retrieved August 22, 2011, from http://emedicine.medscape.com/article/149684-overviewColeman, J., McGinnis, C., Fort, L. (2010). Hepatic, biliary, and pancreatic disorders. In S. M. Nettina, • Lippincott manual of nursing practice (9th ed., pp. 717-718). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.Karamshi, M. (2008). Performing a percutaneous liver biopsy in parenchymal liver diseases. • British Journal of Nursing, 17(12), 746-752.Xu, J., Kochanek, K. D., Murphy, S. L., & Tejada-Vera, B.,(2010). Deaths: Final data for 2007. • National Vital Statistics Reports, 58(19), 5. Retrieved August 22, 2011, from http://www.cdc.gov/NCHS/data/nvsr/nvsr58/nvsr58_19.pdfZaman, A., Ingram, K., & Flora, K. D. (2011). Diagnostic liver biopsy. • Medscape Reference. Retrieved August 22, 2011, from http://emedicine.medscape.com/article/1819437-overview