Liver biopsy: consensus on indications, contraindications and operating methods guidelines

Introduction Liver biopsy (hereinafter referred to as liver biopsy) has been used for a long time in clinical departments such as liver surgery, transplantation, infection, and gastroenterology as a diagnostic measure for liver diseases.

At present, there is no standard, guideline or expert consensus on liver biopsy in China.

Therefore, the Department of Medical Affairs and the Department of Liver Surgery of Xiangya Hospital of Central South University, together with experts from the Department of Hepatology, Ultrasound Imaging, Intervention and Pathology of this hospital, jointly formulated this expert consensus, which aims to provide a reference for clinical liver biopsy.

1.
Liver biopsy indications Liver biopsy can be divided into liver tissue biopsy to assess diffuse liver disease or biopsy to clarify the nature of liver masses.
The specific indications are as follows: 1.
Unexplained abnormal liver function, cirrhosis, and needs Determine whether there are clinical conditions of liver fibrosis or cirrhosis.

2.
Unexplained hepatomegaly.

3.
Antiviral timing selection for patients with chronic hepatitis B (evaluation of liver fibrosis or inflammatory necrosis), evaluation and monitoring of curative effect, and prognosis judgment.

4.
Consider autoimmune liver disease, including autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, and the so-called overlap syndrome that overlap each other.

Liver biopsy is helpful for diagnosis and treatment plan formulation.

5.
Consider inherited metabolic liver diseases, such as Wilson's disease (hepatolenticular degeneration), hereditary hemochromatosis, α1-antitrypsin deficiency, etc.
Liver biopsy is helpful for diagnosis and treatment plan formulation.

6.
Diagnosis of alcoholic liver disease and non-alcoholic fatty liver disease and determination of liver fibrosis.

7.
For liver abscess, it is recommended that a needle biopsy of the abscess wall (substantial component) be performed at the same time as the catheterization and drainage to exclude malignant tumor.

8.
The nature of the liver mass is unknown (but if the liver mass is indicated for surgery and the patient agrees to surgical resection, no biopsy is necessary).

9.
After liver transplantation, if complications such as rejection or infection are considered, liver biopsy may be considered to assist diagnosis.

2.
Contraindications of liver biopsy The contraindications of liver biopsy are different due to different puncture techniques or different puncture needle models.

Clinically, it is necessary to carefully and fully evaluate the pros and cons to decide whether to implement it.
The necessity, risks and alternative medical plans of liver biopsy should be informed in detail before the operation, and the informed consent form should be signed.

1.
Contraindications for liver puncture (1) Clinical consideration of hepatic hemangioma, hepatic multilocular echinococcosis; (2) Extrahepatic obstructive jaundice; (3) Obvious bleeding tendency, or severe thrombocytopenia, coagulation dysfunction; ( 4) Those who are unconscious or uncooperative with other diseases; (5) Infected lesions on the puncture path.

2.
Increased risk of liver biopsy (1) Decreased platelet count: This consensus should be reasonable to set the platelet count that requires preoperative treatment to 50×109/L.

From several retrospective studies, platelet count ≥50×109/L is relatively safer, while platelet count <50×109/L will increase the risk of hemorrhage after invasive procedures.
At this time, consider the relatively small risk Puncture via intravenous route.

If there is no technical condition for transvenous liver biopsy, it is recommended to consider percutaneous liver biopsy after treatment.

(2) Coagulation dysfunction: The International Normalized Ratio (INR) ≥ 1.
5 is significantly related to the increased risk of death during hospitalization in patients with liver cirrhosis, and is an independent predictor of postoperative bleeding after diagnostic laparoscopy.

However, many other studies suggest that it is not a good predictor of the risk of bleeding after invasive procedures.

Patients with prolonged APTT should be careful to exclude hemophilia.

(3) A large amount of ascites: The liver is separated far from the abdominal wall due to a large amount of ascites, and bleeding or bile leakage after liver biopsy is not easily wrapped and limited by the abdominal omentum, which may cause massive intra-abdominal bleeding or diffuse peritonitis.

Consider puncturing through the vein.

(4) Hepatic amyloidosis: Because of early reports of bleeding and death after liver biopsy, amyloidosis is often listed as a contraindication.

If there is a strong suspicion of liver amyloidosis, subcutaneous fat or rectal biopsy can be done, because most cases of amyloidosis are systemic.

However, if the possibility of liver amyloidosis is low and the cause of hepatomegaly is uncertain, intravenous puncture can also be used.

(5) Cystic lesions of the liver: Modern imaging examinations can usually identify liver cystic lesions, and liver biopsy is generally not required.

Since cystic lesions may be connected to a variety of structures including bile ducts, puncture-related complications (such as bile leakage) have a higher incidence and risk.

Therefore, it is limited to patients with malignant tumors that are difficult to clarify by other examination methods.
Pay attention to avoiding the cyst cavity and puncture the solid component of the lesion during the operation.

(6) Pregnancy: Current studies have shown that puncture during pregnancy may slightly increase the risk of preterm birth.
The pros and cons need to be weighed, and it can be implemented after delivery when the patient's condition permits.

(7) Others: hemophilia, severe anemia is not corrected, the hospital blood bank lacks the rare blood type blood suitable for the patient, severe hypertension, or other life-threatening organ diseases or dysfunction (such as degeneration with acute kidney injury) Patients with compensated liver cirrhosis and chronic renal failure, such patients often have wasting coagulation insufficiency and hypofibrinemia), the risk of complications such as bleeding during and after puncture is increased, and the post-bleeding treatment is more difficult , It is recommended to postpone the liver biopsy, and implement it after the condition improves or the preparation is sufficient.

For example, for patients undergoing chronic renal replacement therapy, dialysis is usually performed before liver biopsy.

It can also be punctured through the jugular vein.

3.
The operation method of liver biopsy should be completed by an experienced doctor under the guidance of color Doppler ultrasound or CT.

The puncture methods can be divided into: 1.
Percutaneous liver biopsy; 2.
Sealed liver biopsy; 3.
Transjugular or femoral vein liver biopsy; 4.
Endoscopic ultrasound guided liver biopsy; 5.
Laparoscopy Liver biopsy; 6.
Liver tumor biopsy.

The following uses the commonly used ultrasound-guided percutaneous liver biopsy and transjugular liver biopsy as examples to introduce the operating methods.

1.
Ultrasound-guided percutaneous liver biopsy (1) Selection of needle: 16 G biopsy needle is recommended for liver tissue biopsy, 18 G biopsy needle is recommended for liver mass biopsy, and liver tissue strip specimens are at least 1.
5 cm long.

(2) Position: lying on the back or on the left, the right side of the body is close to the bed, and the right arm is raised and bent behind the pillow.

(3) Disinfection and anesthesia: Strict aseptic operation, the surgeon wears a mask, hat and sterile gloves, routinely disinfects the puncture local skin, spreads a sterile hole towel, and infiltrates the skin of the puncture point layer by layer with 2% lidocaine.
Muscle and liver capsule.

(4) Percutaneous puncture: Instruct the patient to breathe calmly, and the surgeon will pierce the liver parenchyma under ultrasound guidance with the puncture needle, and fire after reaching the target position.

Coaxial puncture technology: puncture the coaxial needle matched with the biopsy needle to the front of the target lesion, pull out the coaxial needle core, and perform multiple biopsy from different directions through the coaxial outer sheath.
Pull out the coaxial needle.

(5) Bandaging: Sterilize the puncture point, cover and fix with sterile gauze, and bandage the ribs and upper abdomen under pressure for at least 2 hours with multi-head abdominal bands.

2.
Transjugular liver biopsy (1) Choose puncture needle: 18 G or 19 G puncture needle, transjugular liver biopsy kit, 0.
035 inch diameter guide wire, 9 F catheter sheath.

(2) Position: supine position with head tilted to the opposite side of the puncture site.

(3) Disinfection and anesthesia: routine ECG monitoring.

Strictly aseptic operation, the surgeon wears a mask, a hat and sterile gloves, routinely disinfects the puncture local skin, spreads a sterile hole towel, and infiltrates the puncture point layer by layer with 2% lidocaine.

(4) Transjugular puncture: The patient is instructed to breathe calmly.
The surgeon inserts the deep vein puncture needle into the jugular vein, and inserts the guide wire along the puncture needle.
The guide wire is operated through the catheter sheath, superior vena cava, right atrium, and inferior vena cava under visual monitoring.
The vena cava enters the hepatic vein, the hepatic venography confirms the anatomy of the hepatic vein and the position of the sheath head, exits the guide wire, inserts the biopsy needle, asks the patient to hold their breath, and inserts the biopsy needle quickly into the liver parenchyma 1 to 2 cm and then quickly obtains liver tissue specimen.

If the specimen is insufficient, repeat the above steps.

After the puncture is completed, inject the contrast agent to check for abnormalities.

After the operation, withdraw the biopsy needle and catheter sheath.

(5) Bandaging: disinfection of the puncture point, compression to stop bleeding for 3 minutes, bandage the wound; postoperative ECG monitoring and blood oxygen saturation monitoring, and stay in bed for 4 hours.

This article is excerpted from: Xiangya Expert Consensus Compilation Group for Liver Biopsy.
Xiangya Expert Consensus on Liver Biopsy[J].
Chinese Journal of General Surgery, 2021, 30(01):1-8.
For the original text, please see "Read the original text"