Liver Puncture

Liver biopsy is a tissue sampling from the liver for the investigation of diffuse or circumscribed liver changes (round lesions). It is used primarily to confirm the diagnosis when other clinical and laboratory parameters already permit a tentative diagnosis, and to estimate the prognosis. Worldwide, percutaneous sonographically controlled liver puncture according to Menghini has become the accepted standard for this purpose.

Indications (areas of application)

  • Suspected diffuse liver disease
    • Unexplained non-obstructive icterus (jaundice).
    • Chronic hepatitis (hepatitis B, C), including follow-up under therapy.
    • Autoimmune hepatitis* * (AIH; autoimmune hepatitis).
    • Primary sclerosing cholangitis* * (PSC) – chronic inflammation of the extra- and intrahepatic (located outside and inside the liver) bile ducts; associated with ulcerative colitis in 80% of cases; long-term risk of cholangiocellular carcinoma (malignant tumor of the bile ducts of the liver) is 7-15%.
    • Primary biliary cholangitis (PBC, synonyms: non-purulent destructive cholangitis; formerly primary biliary cirrhosis) – relatively rare autoimmune disease of the liver (affects women in about 90% of cases); begins primarily biliary, i.e., at the intra- and extrahepatic (“inside and outside the liver”) bile ducts, which are destroyed by inflammation (= chronic non-purulent destructive cholangitis). In the longer course, the inflammation spreads to the entire liver tissue and eventually leads to scarring and even cirrhosis; detection of antimitochondrial antibodies (AMA); PBC is often associated with autoimmune diseases (autoimmune thyroiditis, polymyositis, systemic lupus erythematosus (SLE), progressive systemic sclerosis, rheumatoid arthritis); Associated with ulcerative colitis (inflammatory bowel disease) in 80% of cases; long-term risk of cholangiocellular carcinoma (CCC; bile duct carcinoma, bile duct cancer) is 7-15%.
    • Toxic liver damage (nutritive-toxic; alcoholic steatohepatitis; drug-toxic).
    • Acute fatty liver of pregnancy
    • Fatty liver (steatosis hepatis): non-alcoholic steatohepatitis (NASH) or alcoholic steatohepatitis (due toDifferentiation of the two and assessment of degree of inflammation and fibrosis).
    • Hepatomegaly (liver enlargement).
    • Cirrhosis of the liver*
    • Hepatic insufficiency/acute liver failure (ALV).
    • Storage and metabolic diseases, e.g., hemochromatosis, glycogenoses, Gaucher’s disease, Wilson’s disease, alpha-1 antitrypsin deficiency (A1AT deficiency; synonyms: Laurell-Eriksson syndrome, protease inhibitor deficiency, AAT deficiency; inherited metabolic disease; also detectable by laboratory chemistry).
    • After liver transplantation (LTx; V.a. rejection; reinfection).
  • Suspicion of granulomatous liver changes.
  • Involvement of the liver in hematological diseases.
    • Z. e.g., lymphoma staging
  • Liver disease with round foci* * * (“hepatic round foci”).
    • Tumors [focal size > 1-2 cm; mandatory after (EASL) puncture; American Association for the Study of Liver Diseases (AASLD) recommends waiver of biopsy if two imaging techniques are unequivocal]
      • Hepatocellular carcinoma (HCC; primary hepatocellular carcinoma) [when liver cirrhosis and solitary liver lesion are confirmed → HCC very likely!]
      • Hepatocellular adenoma (LCA, hepatocellular adenoma) due toDD. HCC; Caveat. High risk of bleeding after puncture!
      • Metastases [waiver of puncture if primary tumor is clear].
    • Hemangioma [no puncture in the absence of symptoms!]
    • Focal nodular hyperplasia (FNH) [no puncture in the absence of symptoms!]

* Laparoscopy including targeted biopsy is more informative for this indication, unless the presence of liver cirrhosis has already been clinically and laboratory proven. Primary biliary cholangitis (PBC, synonyms: nonpurulent destructive cholangitis; primary biliary cirrhosis) can be diagnosed purely by serology (detection of anti-mitochondrial antibody, AMA). * * For the initial diagnosis of the indications marked above, a liver biopsy is of great importance! * * * For dignity assessment, liver biopsy has the greatest sensitivity and specificity.

Contraindications

  • Severe coagulation disorders including platelet aggregation disorders (aggregation) of platelets/platelets).
  • Occlusive icterus (jaundice due to an obstruction of outflow in the area of the draining bile ducts).
  • Echinococcus cysts (dog tapeworm. (Echinococcus cysticus); solitary cysts).
  • Liver hemangiomas (hepatic hematoma; most common benign tumor of the liver).
  • Purulent cholangitis (bile duct inflammation).
  • Right pleural empyema (collection of pus within the pleura) or subphrenic abscess (collection of pus under the diaphragm)
  • Severe emphysema (hyperinflation of the smallest air-filled structures (alveoli, alveoli) of the lungs)
  • Chilaiditi syndrome – displacement and rotation of large intestine and rarely small intestine parts cranial (from foot to head) between the diaphragm (diaphragm) and liver.
  • Lack of consent

Before the puncture

Determination of blood type and coagulation status (thromboplastin time (Quick); partial thromboplastin time (PTT); platelet count). The Quick should not be less than 50% and the PTT should not be prolonged. Platelet count should not be less than 50,000/μl. Before the biopsy, an upper abdominal sonography must be performed to exclude a positional abnormality of the gallbladder. One day before the procedure, patient education about the surgical procedure and possible complications should be performed. Premedication (administration of medications before a medical procedure) is not required.

The surgical procedure

After skin disinfection, local anesthesia (local anesthetic; lidocaine, 0.5-2%) is administered. Percutaneous sonographically controlled liver puncture is performed in the supine position under sonographic view. A suitable intercostal space below the phrenicocostal sinus (diaphragm-rib angle) between the anterior and middle axillary lines is sought in the mid-respiratory position. Puncture is usually performed with the Menghini needle (1.2-1.8 mm diameter) using the so-called second puncture technique. An evaluation of the liver biopsy is only possible with an optimal size of the liver punch cylinders and sufficient number of portal fields. The punch cylinders should have a length of > 15 mm and the number of portal fields should be > 10 per section plane. Note: Laparoscopy (abdominal endoscopy) is more informative than percutaneous liver puncture because it allows macroscopic evaluation of the liver and also allows obtaining sufficiently large biopsy cylinders. Other advantages of laparoscopy include the ability to assess intraperitoneal (Latin intra “inside”, peritoneum “peritoneum”) organs and structures and to intervene if complications arise from the liver biopsy. In patients with severe coagulation disorders, transjugular liver puncture is a good alternative. In this procedure, a catheter inserted through a jugular vein (“transjugular”) is used to probe a liver vein so that a special puncture device can be used to puncture the liver and remove a cylinder of tissue.

After the puncture

Blood pressure and pulse should be taken regularly for the first 24 hours after the puncture: Every quarter hour for the first hour after puncture, then every half hour for two hours thereafter; every four hours thereafter. Caution: Approximately one third of complications are not detected until more than 2 hours after the biopsy! Blood counts should also be checked 24 hours after puncture. Before discharge, the patient should be made aware of the rare complication of late postoperative bleeding and informed of its symptoms.

Potential complications

  • Relevant complications occur in only 0.3-1% of punctures!
  • Postoperative bleeding (especially in infiltrative liver disease) and bile leak are the most common complications
  • Gallbladder injury
  • Injury to other organs (lungs, kidney) is very rare
  • Pneumothorax (accumulation of air next to the lungs).
  • Pleural effusion (increase in fluid between the sheets of the pleura/chest).
  • Hematothorax (accumulation of blood in the thorax).
  • Hemobilia (bleeding within the bile ducts).
  • Bacteremia (washing of bacteria into the bloodstream).
  • Biliary peritonitis (bilious peritonitis).
  • Sepsis (blood poisoning)
  • The lethality (mortality) is less than 0.1