Liver Biopsy

A liver biopsy is done using a needle inserted between two of the right lower ribs to remove a sample of liver tissue. The tissue sample is sent to a laboratory and looked at under a microscope to see if there are any liver problems. A liver biopsy may be done when liver blood tests are abnormal. It may be done when an X-ray, an ultrasound, or a computed tomography (CT) scan shows a problem with the liver. A liver biopsy can also be done to find the cause of jaundiceor to check on cirrhosis, hepatitis, or liver cancer. Why It Is Done A liver biopsy may be done to:

Find the cause of jaundice. A liver biopsy can find certain liver diseases (such as cirrhosis), infections (such as hepatitis), and liver tumors. Find the cause of abnormal blood test results from aspartate aminotransferase (AST) and alanine aminotransferase (ALT) tests. Both ALT and AST levels show liver damage and can help confirm liver disease. See how much the liver is inflamed or scarred by hepatitis or other liver diseases. See whether other liver conditions, such as hemochromatosis and Wilson's disease, are present. Check the response to treatment for liver disease. Determine whether a medicine, such as methotrexate, is causing a toxic effect on the liver. Check the function of a transplanted liver. Find the cause of an unexplained and ongoing fever. Check a liver mass found on an X-ray, ultrasound, or CT scan. How To Prepare Before you have a liver biopsy, tell your doctor if you:

Are taking aspirin, nonsteroidal anti-inflammatory medicines (such as ibuprofenor naproxen), blood thinners (such as Coumadin or heparin), or antiplatelet medicines (such as Plavix). You may be asked to stop taking these medicines at least 1 week before the test to lower the chance of bleeding after the test. Are taking any heart medicines. Are using any herbal supplements. Are allergic to any medicines, including anesthetics. Have had bleeding problems. Are or might be pregnant. Have recently had pneumonia, which may make it hard to do this test. Have a history of fluid buildup in the belly (ascites ). Ascites may make it hard to do this test. If you take insulin, check with your doctor about what you need to take on the day of your test. For a liver biopsy, you will be asked to sign a consent form. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of this test, fill out the medical test information form. Arrange for someone to drive you home after the test because you may be given asedative to help you relax. You will have blood tests done before the liver biopsy to see whether you have any bleeding or blood clotting problems. You may also have an ultrasound test or CT scan of the liver to check the best place to insert the biopsy needle. Do not eat or drink for 10 hours before the test unless your doctor says it is okay. You will empty your bladder before the test. How It Is Done

A liver biopsy is done by a gastroenterologist, hepatologist,radiologist, or surgeon in a clinic or a hospital. A liver biopsy is often done by a radiologist using ultrasound or a CT scan to help guide the biopsy needle. When cirrhosis of the liver or a cancer is suspected, a liver biopsy may be done during alaparoscopy. You will need to take off all or most of your clothes. You will be given a cloth or paper gown to use during the test. Before the test, you may be given a sedative through a vein (IV) in your arm. The sedative will help you relax and remain still. During the test, you will lie on your back with your right arm resting under or above your head and your head turned to your left. Your doctor may tap on your chest and belly to find your liver or he or she may use ultrasound. Your doctor will mark a spot between two of your right lower ribs where the biopsy needle will be inserted. The site will be cleaned with a special soap and draped with sterile towels. The doctor will give you a medicine (local anesthetic) to numb the area where the biopsy needle will be inserted. You may be asked to take a deep breath, blow all the air out, and then hold your breath while the biopsy needle is being inserted and withdrawn. This will take only a few seconds. Holding your breath lowers the chance that the needle will go in yourlung since the lungs are very close to the liver. It is important to remain still during the few seconds it takes for the doctor to collect the tissue sample. The doctor may take another tissue sample from the same spot, but from a different angle. See a picture of the placement of the liver biopsy needle .

As soon as the doctor removes the needle, you can breathe normally. A bandage will be put on the puncture site. The test generally takes 15 to 30 minutes. You will rest in bed and lie on your right side for 2 to 6 hours after the test. Yourpulse, blood pressure, and temperature will be checked often after the biopsy. You can go home if you have no problems after the test. You may eat your regulardiet. But unless your doctor tells you it is okay, do not take aspirin, nonsteroidal anti-inflammatory medicines, blood thinners, or antiplatelet medicines for one week after the biopsy. You may do your regular activities, but do not do strenuous activities or heavy lifting until your doctor says it is safe. How It Feels You may feel a brief sting or burn when the numbing medicine (anesthetic) goes in your skin. When the biopsy needle is inserted, you may again feel a sharp pain for a few seconds. You may feel deep pressure and a dull pain in your belly when the biopsy needle is inserted. After the anesthetic wears off, you may feel a dull pain in your right shoulder. This is called referred pain and generally goes away in about 12 hours. You can take a nonprescription medicine, such as acetaminophen (Tylenol), for the pain. Call your doctor if your pain gets worse or lasts longer than 2 days. A small amount of bleeding from the biopsy site can be expected. Ask your doctor how much drainage to expect. Risks Serious problems from a liver biopsy are rare. Problems can include:

Bleeding, which may need blood transfusions or surgery to correct. A collapsed lung (pneumothorax). Injury to the intestines, gallbladder, or kidney. Infection in the belly (peritonitis). After the test After the test, call 911 or other emergency services immediately if you develop:

Signs of shock. Severe pain in your chest, shoulder, or belly. Moderate to severe difficulty breathing.

After the test, call your doctor immediately if you have:

A lot of bleeding from the needle site. A fast or skipping heartbeat. A fever. Shortness of breath. Increasing pain at the needle site. Blood in your stool. Swelling or bloating in your belly. Results A liver biopsy is done using a needle inserted between two of the right lower ribs to remove a sample of liver tissue. The tissue sample is sent to a laboratory and looked at under a microscope to see if there are any liver problems.

Samples of liver tissue sent to a pathology lab will be looked at under a microscope for liver diseases such as liver cancer or cirrhosis. Other samples of liver tissue may be sent to a microbiology lab to see whether an infection, such as tuberculosis of the liver, is present. Test results are generally ready in 2 to 4 days. If tests are done to find infections, it may take several weeks for the results to be ready. Percutaneous liver biopsy Normal:

The liver tissue looks normal under a microscope. No signs of infection, inflammation, cancer, or cirrhosis are present. Abnormal cells or liver tissue are present. This may be caused by an infection such as hepatitis, liver disease such as cirrhosis, or cancer. If liver cancer is present, the biopsy can help find the type of cancer. If hepatitis is present, the test can be used to see the chance of developing cirrhosis. Test results may also show the severity of cirrhosis.

Abnormal:

What Affects the Test Reasons you may not be able to have the test or why the results may not be helpful include:

Missing a cancer because a needle biopsy collects tissue from such a small area. Not enough tissue is sampled to make a clear diagnosis. What To Think About

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are blood tests done to check liver function. Both ALT and AST levels show liver damage and may be done to help diagnose liver disease. A liver biopsy may be done when AST and ALT levels are very high and no other reason for high levels is found. For more information, see the topics Aspartate Aminotransferase (AST)and Alanine Aminotransferase (ALT). A liver biopsy should not be done on people who have bleeding or blood clotting problems, or certain types of belly infections. A transvenous liver biopsy is another method that may be used. During this test, a radiologist inserts a thin tube (catheter) into a neck vein, which is guided to the liver. A sample can be taken through the catheter. If a larger sample of liver tissue is needed, an open biopsy of the liver may be done at another time, using surgery or laparoscopy. A liver biopsy is sometimes done at the same time as another abdominal surgery. For more information, see the topic Laparoscopy.

A fine-needle aspiration biopsy may be done to get a sample of liver cells and to collect fluid from the liver. If an infection is suspected, a culture may be done on the fluid to see what type of organism is present. A fine-needle biopsy may be done during a CT scan or ultrasound to check for liver problems. For more information, see the topics Computed Tomography (CT) Scan and Abdominal Ultrasound. Other Works Consulted

Chernecky CC, Berger BJ, eds. (2004). Laboratory Tests and Diagnostic Procedures, 4th ed. Philadelphia: Saunders. Fischbach FT, Dunning MB III, eds. (2004). Manual of Laboratory and Diagnostic Tests, 7th ed. Philadelphia: Lippincott Williams and Wilkins. Pagana KD, Pagana TJ (2010). Mosbys Manual of Diagnostic and Laboratory Tests, 4th ed. St. Louis: Mosby.

Liver Enzyme and Function Blood Test Results

Liver enzymes, or liver (hepatic) function tests, are used to determine if the liver is functioning normally or if it has an injury or disease. These tests are drawn from a vein in a doctors office, or if you are hospitalized and a special IV is available it can be drawn from that line without a needle stick.

The liver enzyme test results are typically used together, not individually, to diagnose a liver problem. If the tests indicate a problem, a liverbiopsy may be necessary to confirm the test results. Results can be elevated by many prescription medications and some over the counter drugs and supplements.

AST (Aspartate Phosphatase) Lab Results

This test is typically used to detect a liver injury or an active or chronic liver problem. The heart can also release AST, so it is important to look at the entire set of liver tests, rather than just this one test. AST levels can be dramatically affected by shock, low blood pressure or any other condition that deprives the liver of blood and oxygen.

Normal Level:

Male: 8-46 units/liter

Female: 7-34 units/liter

ALT (Alanine Aminotransferase) Lab Results

This test is used to detect liver injuries and long-term liver disease. Highly elevated levels may indicate active hepatitis from any cause, including virus, alcohol, drug or toxin. Some prescription and over-the-counter medications can cause an increase in ALT levels. ALT levels can be dramatically affected by shock, low blood pressure or any other condition that deprives the liver of blood and oxygen.

Normal level: 5-40 units per liter of blood serum

ALP (Alk Phos, Alkaline Phosphatase) Lab Results

ALP is a substance found in the bile ducts of the liver. Damage or obstruction of the bile ducts may result in elevated levels of ALP.

Normal Level: 13-39 units/liter

Total Bilirubin (T. Bili) Lab Results

This lab test measure the total amount of bilirubin in the blood, including direct and indirect bilirubin. Bilirubin is produced during the normal process of blood cells dying and the liver excretes bilirubin through bile. Too much bilirubin in the blood results in the patient looking yellow, or jaundiced. This test may detect elevated levels of bilirubin before jaundice is present.

Normal Level: 1mg per 100 ml

Indirect Bilirubin (I. Bili) Lab Results

Indirect bilirubin does not dissolve in water. In order to dissolve in water, and be eliminated from the body, it must go to the liver where it is made into direct (water soluble) bilirubin.

Indirect Bilirubin = Total Bilirubin Direct Bilirubin

Direct Bilirubin (D. Bili) Lab Results

Direct bilirubin has been converted into a water soluble form of bilirubin by the liver. The proportion of indirect bili to direct bili may change if the liver has difficulty converting indirect into direct.

Normal Level: .4 mg per 100 ml

Albumin Lab Results

Albumin is a protein made by the liver that is very common in blood plasma, which can be measured in the blood. If the liver has chronic or acute damage, the level of albumin in the blood will typically be low. A low level of albumin can also be caused by poor nutrition.

Normal Level: 3.5-5 grams/100 ml

In science under biology, microbiology or pathology, a form of cellular injury is degeneration. As observed under different microscopes such as light microscopes, electron microscopes, scanning electron microscopes, and forensic microscopes, it is characterized by a disturbance of intracellular metabolism, a swelling of the cell, and an accumulation in the cytoplasm of substances that normally are invisible, absent, or present only in small amounts. In science mainly in pathology or microbiology, the degeneration is named cellular swelling or cloudy swelling, hydropic, vacuolar, fatty, or hyaline degeneration according to the morphologic change or the nature of the abnormally accumulated material. These degenerative changes, as seen through various microscopes such as light microscopes and electron microscopes, vary in severity and usually are reversible. However, severe degenerations may proceed to death of the cells. Cellular Swelling

In pathology through microscopy, most acute infections and toxic conditions are accompanied by some degree of cellular swelling. It is the mildest and most common type of degeneration and is easily reversible. It is best seen in the liver and kidneys and sometimes in the heart with the help of specially designed microscopes that can infiltrate the body. Other terms used for this form of degeneration are parenchymatous degeneration and cloudy swelling, the latter being descriptive of the gross appearance. The affected organ is swollen so that the capsule is tense and the cut surface bulges. The tissue appears more opaque or cloudy than normal, pale, and soft. Under the microscope, the affected cells are swollen and have a granular cytoplasm, the granules being of a protein nature and caused, at least in part, by changes in the mitochondria. The ultrastructural and cytochemical alterations include certain of the changes already described under cellular injury in such as swelling of the mitochondria, vesicular distention of the endoplasmic reticulum, depletion of RNA granules, and reduction in cytoplasmic glycogen. Under the microscopes the swelling of the cell mainly results from an increased water content of the cytoplasm, although increase in the water content of the organ as a whole may not be demonstrable. It has been postulated that the energy function of the damaged mitochondria in disturbed, leading to a diminished output of ATP. As seen through microscopy, the decrease in ATP impairs cellular membrane permeability and the active transport mechanism of the cell, which normally maintain a low concentration of intracellular sodium. The result is an increase in sodium ion within the cell, followed by increased water content. Generally, as observed under a microscope, the nucleus is unaffected in cloudy swelling but in one investigation a decrease in DNA of the nucleus was detected. The RNA of the cell, as noted previously through microscopy, also may be diminished after injury to the cell. Under the microscope, the parenchymal cells of the liver and convoluted tubular cells of the kidney show the change most severely. In microscopy, it is to be noted that postmortem autolysis may produce changes in certain tissues, which simulate those of cellular swelling. Hydropic Degeneration In cellular swelling, as observed in microscopy, there is some inhibition of water into the cell, but in hydropic degeneration this is of greater degree. Hydropic degeneration is a more severe form of cellular injury than cellular swelling but it too, is reversible. As observed in various microscopes such as electron microscopes and forensic microscopes, the cell is swollen, and its cytoplasm is pale and vacuolated or reticulated. The clear vacuoles may be small and multiple or they may be confluent, producing larger vacuoles or a single large vacuole replacing much of the cytoplasm and displacing the nucleus. When larger vacuoles appear, the term vacuolar degeneration often is used. The latter is a characteristic lesion affecting the renal tubular epithelium in dioxane and diethylene glycol poisoning and also in potassium deficiency. In electron microscopy, the cytoplasmic vacuoles in hydropic degeneration are seen to be caused by vesicular distention of the endoplasmic reticulum that is more prominent than in cellular swelling.