Liver Biopsies - What do you need to know?

Liver Biopsies

What do you need to know?

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Introduction Until April 2006, if you had hepatitis C and wanted to undergo subsidised treatment, you needed to have a liver biopsy. This procedure allowed doctors to determine the amount of liver damage you had so that they could determine length of treatments. However, liver biopsy is no longer a requirement for Medicare funded treatment, and people with hepatitis C can now get subsidised antiviral therapy as long as they: • are at least 18 years old, • are not pregnant, breastfeeding, or with a pregnant partner, • are using effective contraception, and • have not previously undergone a course of subsidised interferon therapy.

Furthermore, most liver inspections make use of an ultrasound Fibroscan machine (a separate Hepatitis SA brochure on this procedure is available). Despite this, some people will be advised to undergo liver biopsies in order to monitor their liver damage to help them and their specialist in making a decision about treatment. The following is a description of how liver biopsies are performed at the day procedure unit in the Gastrointestinal Investigation Unit at the Royal Adelaide Hospital.

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Other hospitals may have different policies or slight variations in the procedure itself. For instance, assuming there are no complications, liver biopsies performed at the RAH are day procedures whereas other units may require an overnight stay in hospital following the biopsy. The RAH day unit performs a range of different procedures relevant to the gastrointestinal tract and related organs, including liver biopsies.

What is a liver biopsy?

Basically, a liver biopsy is the removal of a small piece of liver tissue, using a specially designed needle. A small sample of approximately 20mm x 2mm is obtained.

The sample of liver tissue is then taken to a pathologist for examination of the cells, to determine the extent of inflammation and scarring of the liver.

Why have a liver biopsy?

When you have a chronic liver disease such as hepatitis C, the main reason for having a liver biopsy is to diagnose the severity of your liver disease (a disease is called chronic if it has been present for 6 months or more).

Usually, by the time someone has a biopsy, their liver will show some signs of disease because the procedure is only done if a doctor considers it necessary.

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It is not something to be performed lightly. A biopsy gives a much more accurate picture of the exact state of your liver than any other test (such as liver function tests, ultrasound, etc) and helps your doctor determine the best treatment for you.

What happens when you arrive at the Unit?

On the morning of the biopsy you should take your usual medications with a sip of water. However, do not take any aspirin or anti-inflammatory (arthritis) medications as this can increase your risk of bleeding.

You should be prepared to stay for half a day. Bring something to read or watch (with headphones).

When you arrive at the hospital, you first go to the admissions desk. They will direct you up to the unit, where you will be take you to the recovery area and asked to put on a hospital gown. They then record medical observations such as checking your blood pressure and pulse rate so that they know how you are prior to having the biopsy. Then you are taken through to the procedure room.

Liver biopsies are usually first on the procedures list in the morning so that they have plenty of time throughout the day to monitor responses.

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How is a liver biopsy performed?

The liver is located on the right side of your body under the ribcage. When you are brought into the room, you will be asked to lie on your back with your right arm up behind your neck to expose the right side of your body.

An ultrasound machine may be used to locate the best spot to take the biopsy. An ultrasound gives the doctor an idea of how close to the surface your liver is sitting, the depth of your liver, and how close other organs are positioned to your liver. The ultrasound is done in the procedure room immediately prior to having the biopsy.

The doctor will mark your skin where they want the biopsy needle to pass. Then the area is cleaned chlorhexidine swab stick (an antiseptic) and a sterile drape is placed across you. If you have an allergy to chlorhexidine, you need to tell the doctor before having the procedure.

Then you are given intravenous sedation through a small needle in the arm. Next, the doctor does a “theatre scrub� and puts on sterile gloves. All the equipment used is in a sterile pack.

A local anaesthetic called Lignocaine is also used at the biopsy site. Tell the doctor beforehand if you are allergic to any anaesthetics or any other medication.

The local anaesthetic stings as it goes in. Fortunately, this 5

only takes a few seconds, and it then numbs the area.

The anaesthetic is initially placed just under your skin.

Then the doctor inserts the needle in deeper, and as they withdraw the needle, they slowly inject more local anaesthetic. The doctor then makes a small incision in the skin—about 5mm long—to let the needle pass through more easily.

Then the doctor may use a very fine needle called a “spinal needle” to measure the depth to your liver. When the needle is in, they will ask you to breathe in and out.

The movement of the liver allows the doctor to judge whether the needle is actually sitting in the liver, and how far it is from the skin. Once the position of the liver has been identified, the biopsy needle is passed through to the liver and the sample is taken. Very occasionally, the biopsy may not be complete if the doctor has been unable to get a big enough sample. In these cases, they may need to pass the needle a second or a third time.

The actual biopsy itself is over in five seconds. It’s all the preparation beforehand, including identifying where the liver is, that can take a long time. People may often 6

be quite nervous but hardly notice when the actual sample is being taken, and are amazed that it is all over.

Occasionally it can be painful, but you will receive pain relief if you need it.

What happens during my recovery time at the unit?

You will be taken to the Recovery area to rest. You will need to remain in bed for at least 2 hours and cannot have anything to eat or drink for 2 hours after your procedure. This is to ensure there have been no complications. Very rarely, people may need surgical intervention. This has to be done on an empty stomach.

You will be observed for 2-3 hours following the biopsy to ensure no bleeding occurs from the liver. If you have any pain or other problem you should tell the staff in Recovery.

Whilst in Recovery, your blood pressure will be monitored; at first, every 15 minutes, and then progressively less frequently throughout the afternoon.

You will be asked to lie on your back or on your side immediately after the procedure, and after one hour you can sit up slightly.

Generally, people will experience some pain either during or after the procedure. This is usually something that settles reasonably quickly, and is certainly something that Unit staff can help you with. They will monitor your 7

level of pain on a regular basis when you come back out to the recovery area. They do this by using a “pain score” (a way of measuring how much pain you are feeling).

One person’s idea of “pain” might not mean much to somebody else so, up to a point, they can give you more pain relief if you need it.

People can experience pain both at the site and also a referred pain (called shoulder-tip pain) in the right shoulder. You may get back pain from lying down for such a long period of time, so they also need to establish whether the pain has been caused by the procedure or from lying down.

Staff will attempt to have you ready for discharge within 4-5 hours of your arrival. However, please understand that this may not always be possible. Emergency procedures must be given priority.

Can I have visitors in the unit?

Visitors are generally not allowed into the recovery area.

If something does go wrong with a person’s biopsy, they don’t have the room for extra people standing around as this can make it more difficult to provide quality care.

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How do I prepare for a liver biopsy?

Before being admitted for your biopsy, you will need to do several things.

• Tell your doctor about all medications you may be taking. You will be advised to stop taking drugs like aspirin, blood-thinning and anti-inflammatory medication for 7 days before the procedure.

Medications such as these can thin your blood, making it less able to clot.

• Inform your doctor if you have any allergies, especially to iodine or anaesthetics.

• Have relevant blood tests so that your blood count can be established and your blood clotting mechanisms checked. This is needed because biopsies can be performed safely only if your blood clots normally.

• Fast from the midnight before your admission. This means not eating or drinking anything at all from midnight.

• Organise someone to collect you from the unit after your biopsy. Unit staff will contact your lift and let them know what time you can be collected. A phone number to contact them on is required and asked for at time of admission.

• Organise sfor omeone to stay with you overnight. If this is not possible, or you live a long distance from the hospital, you will have to stay in hospital overnight.

This is because internal bleeding can occur after the procedure, and if you collapse at home, you may not be able to ring anyone for help.

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After your biopsy you will need to take it easy and avoid any heavy lifting for three days. If you are working— depending upon what sort of work you do—you may need to take a few days sick leave.

What are the risks?

As with any medical procedure, there are always associated risks. However, a liver biopsy is generally a safe procedure.

Ongoing bleeding is the most obvious risk since the liver is quite a bloody organ. Bleeding can happen at the site, or it can happen internally. As mentioned, blood clotting tests are always checked beforehand. You will be checked routinely to see whether blood is seeping through your dressing. Unit staff keep a very close eye on the site to make sure there is no swelling or bleeding.

The second risk is passing the biopsy needle through another organ. This is extremely rare. A drop in blood pressure or severe pain may indicate that a complication has developed.

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For Further Information and Support You can contact the Hepatitis SA Helpline on (08) 8362 8443 (Adelaide callers) or 1300 437 222 (Freecall for regional callers) for clarification of any of the information in this sheet. You can also contact Hepatitis SA for information on support groups for people with and affected by hepatitis.

If you have any questions relating to biopsies at the Royal Adelaide Hospital, please call the Gastrointestinal Investigation Unit between 9.00am and 3.30pm, Monday to Friday on (08) 8222 4636 and ask to speak to the Triage Nurse.

This booklet is updated from the original 1999 fact sheet written by Trish Ellbourn, Registered Nurse at the Gastrointestinal Investigation Unit, Royal Adelaide Hospital, and the 2013 RAH Consumer Information Sheet ‘Liver Biopsy: Gastrointestinal Investigation Unit’.

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Last update: June 2015 SA Health has contributed funds towards this Program • Cover image © iStock

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