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Techniques of Liver Biopsy

Techniques of Liver Biopsy. Manoj Kumar Sharma Additional Professor Hepatology Institute of Liver & Biliary Sciences New Delhi India. Introduction. Liver Biopsy Diagnosis Prognosis Treatment

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Techniques of Liver Biopsy

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  1. Techniques of Liver Biopsy Manoj Kumar Sharma Additional Professor Hepatology Institute of Liver & Biliary Sciences New Delhi India

  2. Introduction Liver Biopsy Diagnosis Prognosis Treatment PercutaneousTransvenousLaproscopic

  3. PERCUTANEOUS LIVER BIOPSY

  4. Preparation - I History Physical Exam Drug Review Clotting Parameters PATIENT EDUCATION Light meal (2-4 hrs) GB emptying Less risk of Puncture/Vasovagal response PP Hyperemia !!? ?? Bleeding risk

  5. Preparation - II PT > 4 secs INR > 1.5 in 4wksPercutanous Liver Bx Platelet < 60,000 Transvenous Route

  6. Antiplatelets and percutaneous Liver Biopsy • Thomas D. Atwell. AJR Am J Roentgenol2010;194(3):784–9 Liver bx: Stop 7 days restarted 48–72 hours: Alyson N. Fox. Schiffs Diseases of Liver. 2012. Liver Bx: Stop several to 10 days restarted 48–72 hours: Don C. Rockey.Hepatology 2009. ERCP/Spnx: Not necessary to hold for ES. Djohn T Maple. ERCP 2nd Ed: 2013.

  7. Preparation – IIIAntiplatelets and AnticoagulantsPre Procedure

  8. Recommendations • Prior to performance of liver biopsy, patients should be informed about their liver disease ; about liver biopsy including alternatives to, risks, benefits, and limitations of liver biopsy.[Grading of evience: High quality(A); Grading of recommendation: Strong recommendation (1)] • Four hours fasting before the procedure may be considered [C2]. • Anticoagulant medications should be discontinued prior to liver biopsy. Warfarin should generally be discontinued at least 5 days prior to liver biopsy. Warfarin may be restarted 48-72 hours after liver biopsy. [B2] • Antiplatelet medications and nonsteroidal agents should be discontinued approximately 7-10 days before liver biopsy, although there is uncertainty surrounding the need for their discontinuation, which may be restarted 48–72 hours after the procedure. [B2]. • In all patients, the risk of discontinuing anticoagulant medications must be weighed against the (potential) risk of bleeding during/ after liver biopsy [A1]. • Written consent documenting the discussion about the procedure and any potential complications, with the patient and/or a proxy should be obtained. [A1].

  9. Contraindications to Percutaneous Liver Biopsy • Renal failure OR hemodialysis, desmopressin (DDAVP) • Chronic Hemodialysis well dialyzed prior to liver biopsy heparin should be avoided if

  10. Recommendations • Percutaneous liver biopsy with or without image guidance should not be utilized in uncooperative patients [A1]. • Uncoperative patients who require liver biopsy should undergo the procedure under general anesthesia or via the transvenous route [A1] • In patients with clinically evident ascites requiring a liver biopsy, a transvenous approach is generally recommended, although percutaneous biopsy (after removal of ascites) is acceptable [A1]. • In general prothrombin time (PT) ≥4 seconds over control or international normalized ratio (INR) >1.5 or Platelet count <60,000/mm3 is considered as contraindication to Percutaneous liver biopsy. [B2]. • Platelet transfusion should be considered when levels are less than 60,000/mL [C2]. • Conventional coagulation tests like PT (INR), aPTT and platelet counts do not assess hyperfibrinolysis and thrombocytedysfuntion as an event that increases bleeding risk in liver disease patients and hence research to assess role of LIVER_INR or other global hemostatic tests like TEG , and SONOCLOT prior to liver biopsy is needed [C,2]. • The use of plasma, fibrinolysis inhibitors, or recombinant factors should be considered in specific situations, although their effectiveness remains to be established [B2]. • In patients with renal failure or on hemodialysis, desmopressin (DDAVP) may be considered, although its use appears to be unnecessary in patients on stable dialysis regimens [B2] • Patients on chronic hemodialysis should be well dialyzed prior to liver biopsy, and heparin should be avoided if possible [B2].

  11. Technique of Percutaneous Liver Biopsy 50mcg Fentanyl / 2mg Midazolam Co-operation/Anxiety Supine  R hand below head  Percuss dullness  b/w mid axill and anterio line  Dullness in both inspi and expi +  LA  upper border rib  Inscise  Bx needle inserted  breath hold +/- Although many techniques have been utilized (i.e., performing biopsy at the end of deep expiration, during simple breath-holding, etc.) and some perform liver biopsy without formal breathholding, no study has addressed the use of a breath-hold or which technique is best [Sherlock S. J Hepatol 1985;1:75-85 ].

  12. Use of Imaging in Percutaneous liver biopsy • Ultrasound : to either “mark” the biopsy site or used in real time • Image-guidance for liver biopsy considered in patients with: -Known specific mass lesions -Previous intra-abdominal surgery who may have adhesions, allowing avoidance of vascular or other structures in the latter situation -Small livers that are difficult to percuss -Obese, making it difficult to identify the liver by physical examination -Clinically demonstrable ascites. • The use of ultrasonography has resulted in better outcomes, is cost effective. • Given the fact that real time ultrasound is widely available, its use is preferred over blind percussion technique; however its use is not obligatory [Rockey DC. Hepatology. 2009 Mar;49(3):1017-44].

  13. Biopsy Needles Aspiration Type Cutting Type Menghini KlatskinTru Cut [Manual or Automatic] Automaticautomatic] Jamshidi Vim Silverman

  14. PLUGGED BIOPSY Modified Percutaneous Technique Tract plugging Thrombin/Collagen @breath hold Alternative in  mild coagulation  ascites Larger samples than TVLB [Tobin MV.DigDisSci 1989;34:13-15] • Nonautomatic cutting needles remain in liver for a modestly longer time during the biopsy and may pose additional bleeding risk due to added time [McGill DB . Gastroenterology 1990;99(5):1396–1400.] • Larger bore needles may have a higher risk of bleeding [Piccinino F . J Hepatol1986;2(2):165–73

  15. Recommendations • The use of sedation, preferably light sedation, is safe during Percutaneous liver biopsy [B1]. • Ultrasound guidance with marking of the optimal biopsy site performed preceding biopsy, is preferred, though not mandatory, because it likely reduces the risk of complications from liver biopsy [A1]. • Image-guided liver biopsy is recommended in certain clinical situations including in patients with known intrahepatic lesions (real-time imaging is preferred) Peviousintraabdominal surgery who may have adhesions Patients with small livers that are difficult to percuss Obese patients, and Patients with clinically evident ascites[A1].

  16. Post Procedure Guidelines Right lateral position Observe Vitals q15mins  1st Hour  q30mins  2nd Hour to 4th Hour • The majority of complications occurred within 1 hour during the observation period or within 24 hours after discharge. • Thus, an observation time of 2 to 4 hours after ambulatory percutaneous liver biopsy is safe.[Vuppalanchi R.ClinGastroenterolHepatol2009;7(4):481–6

  17. Recommendations • Vital signs must be frequently monitored (at least every 15 minutes for the first hour) after liver biopsy [B1]. • Percutaneous liver biopsy can be as a daycare procedure and an observation time after biopsy between 2 to 4 hours is safe. [B2].

  18. Transjugular Liver Biopsy

  19. Transjugular Liver Biopsy

  20. Recommendations • TJLB is indicated for patients with diffuse liver disease who need a biopsy and have a either a contraindication to Percutaneous biopsy or require hemodynamic evaluation as part of their diagnostic workup[A1].

  21. Transjugular Liver Biopsy - Continued In general, reports in the literature agree that complication rates are lower during TJLB when compared with the percutaneous or mini-laparoscopy approach [Beckmann MG. Gastroenterol Res Pract 2009;94701428].

  22. Adequacy of Specimens with TJLB • Issues of smaller sample size and fragmentation problems overcome by use of Tru-Cut TJLB methods [Bull HJ. Gut 1983;24(11):1057–60]. • With three passes; the mean length 22mm, with 65% of over 20mm. • 26% had requisite 11 complete portal tracts, which may limit the utility of TJLB specimens for accurate grading and staging of hepatitis [Cholongitas E. Gut 2006;55(12):1789–94.] • 4 passes increased the percent of specimens containing at least 11 portal tracts to 40% (as compared to 26%; P=0.027) [Vibhakorn S.CardiovascInterventRadiol2009;32(3):508–13]. • Although TJLB specimens yield decreased numbers of portal tracts, when contrasted with the risk of percutaneous biopsy in those with contraindications, TJLB provides a valuable alternative for assessment of liver histology.

  23. Surgical-Laproscopic Liver Biopsy • When liver noted abnormal prior to planned surgery or at the time of surgery • Performed typical needle devices or wedge resection • Wedge resection overestimates fibrosis proximity to the capsule • Adequate tissue sampling • Direct (and immediate) control of bleeding • Greater accuracy in diagnosing cirrhosis • Local abdominal wall / intraperitoneal trauma / bleeding • Expensive • Special expertise • Limited use NEW TECHNIQUES  NOTES

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