Liver biopsy

Objectives: Aetiological diagnosis of liver disease by microscopic examination and culture with identification of the isolated organism.

The biopsy should not be done in uncooperative patients, in patients with a bleeding disorder, an infection of overlying skin, pleura, lung or peritoneum, in patients with suspected liver abscess, severe extrahepatic obstruction, or in patients where the liver is difficult to localize due to ascites.

Test material: Liver tissue.

Equipment: Request form, labels, sterile gauze sponges, antiseptic solution, sterile gloves, sterile towels, lidocaine 1%, syringe, needles, Menghini needle, scalpel blade, sterile saline, plaster.

Procedure 1. The biopsy should only be performed by a physician experienced in the procedure.

2. Check haematocrit, bleeding time, platelet count, prothrombin time, and partial thromboplastin time.

3. Place the patient on his back, right side near the edge of the bed, right hand under the head, and the head turned to the left.

4. Percuss maximal liver dullness between anterior and mid-axillary lines after end of expiration and mark one intercostal space below.

5. Disinfect the skin, drape with sterile towels, and put on sterile gloves.

6. Let the patient practice holding his breath for 10 seconds after full expiration.

7. Infiltrate with local anaesthetic from the skin through the intercostal muscles to the liver capsule, keeping the bevel of the needle at the upper edge of the rib. Do not advance the needle through the capsule into the liver.

8. Assemble the Menghini needle and syringe: insert the "nail" into the proximal end of the needle to prevent aspiration of biopsy specimen into the syringe; fill the syringe (20 mL) with 10 mL sterile saline and attach the needle to the syringe.

9. Make a 4 mm skin incision with the scalpel blade.

10. Insert the Menghini needle through the skin incision and advance the needle parallel to the bed towards the xiphoid into, but not through, intercostal muscles. Flush the needle with 0,2 mL saline.

11. Have the patient hold his breath at full expiration. Apply constant suction on the syringe and with a rapid, smooth motion, advance the needle 4-5 cm into the liver and withdraw. The total duration of this movement should not exceed 1 second.

12. Apply a plaster.

13. Expel the biopsy specimen into a sterile Petri dish.

14. Divide the specimen into two smaller (0,5 cm long) and one larger sample. Inoculate the culture tubes with the smaller samples.

15. Roll the larger sample on to one or two microscopic slides. Place the sample on to filter paper and suspend it in 10% formalin.

16. Have the patient lie on the right side for 2 hours and remain in bed for 8 hours, check pulse and blood pressure frequently, and have a haematocrit taken 4 and 12 hours after the biopsy.

Complications: 1. Haemorrhage, intrahepatic haematoma, haemobilia, bile peritonitis, hepato-portal AV fistula

Aetiology: Laceration of blood or bile vessels due to direct trauma, bleeding disorder, bile leak, respiratory motion.

Prevention: Use biopsy needle 1,2 mm in diameter or less, keep needle in liver less than 1 second, have patient hold breath during biopsy.

2. Pneumothorax

Aetiology: Respiratory motion causing lung laceration, when needle passes through the lung.

Prevention: Use biopsy needle 1,2 mm in diameter or less, keep the needle in the liver less than 1 second; full expiration minimizes chances of the needle passing through the lung.

3. Haemothorax

Aetiology: Laceration of intercostal artery or vein, lung laceration.

Prevention: Pass the needle through the interspace at the upper edge of the rib to avoid the intercostal vessels.

4. Injury to other viscera

Aetiology: Improper needle placement.

Prevention: Precisely determine the liver location before biopsy.

5. Needle fracture

Aetiology: Striking rib with needle.

Prevention: Before rapid needle thrust, assure intercostal placement.

Storage: Leishmania protozoa do not survive long outside the human body, and if the specimen is to be cultured for this organism, it must be processed without delay.

Transportation: The transportation time should be as short as possible, and the specimen should not be kept in a cooling box.

Reporting: The results of the microscopic examination will be available the same day, and, if positive, are reported immediately. Cultures for Leishmania and Histoplasmas are examined twice weekly for 21 days before being reported as negative. Culture for M. tuberculosis may take 2-4 weeks.

Comments: If the laboratory diagnosis is delayed, look for other clinical signs and epidemiological features. In miliary tuberculosis, tubercles may be found in the ocular fundus and on a chest radiogram. Histoplasma capsulatum produces a respiratory illness which rarely progresses into the disseminated form. Histoplasma duboisii is restricted to West, East, and Central Africa and usually has lesions in other organs (lung, skin, bone). Visceral leishmaniasis is widespread and occurs in the eastern part of India, Burma, countries surrounding the Mediterranean littoral and the Red Sea, Iran, Iraq, southern Russia, northern China, East Africa, northeast Brazil, Paraguay, and sporadically in Central America and some of the northern countries of South America.