**5. Complications**

When performing a LB, should be aware of multiple potential complications that may occur after biopsy.At the time that informed consent is obtained, it is reasonable to outline these complications clearly, warn the patient of the potential pain, and mention in a general state‐ ment that other complications, albeit rare, can occur.

Although the percutaneous biopsy is invasive, associated complications are rare, occurring in up to 6%, and 0.04% to 0.11% can be life threatening [33].

The different complication rates were attributed to variation in technique and to differences in the needles used, as well as differences in the severity of the liver disease and selection criteria in different centers.

The most common complication after percutaneous LB is pain [55]. Approximately 25% of patients have pain in the right upper quadrant or right shoulder; the pain is usually dull, mild and brief. Right upper-quadrant pain does not seems to be related to approach (i.e. subcostal vs. intercostal) [56]. The mechanism of pain following percutaneous biopsy is most likely a result of bleeding or possibly bile extravasation from the liver puncture wound, with subsequent capsular swelling, although the exact mechanism remains uncertain [57]. When present, pain can generally be managed with small amounts of narcotics. A decision about when to investigate with imaging and/or to hospitalize the patient for observation due to pain should be made on a case-by-case basis.


A LB is precluded by tense ascites, because the liver will bounce away from the needle, thereby preventing adequate sampling of tissue, and the ascites will provide insufficient tamponade in case of bleeding. In patients with tense ascites requiring a LB, a transvenous approach is commonly recommended. Acceptable options include total paracentesis per‐ formed immediately prior to percutaneous biopsy or transvenous or laparoscopic biopsy.

Relative contraindication is morbid obesity; in this case, transjugular biopsy is a logical al‐

A standard LB is probably contraindicated by extrahepatic biliary obstruction, bacterial cholangitis, and the risk of bleeding after LB appears to be increased in patients with a

Although LB in patients with mass lesions is usually safe, biopsy of known vascular lesions (ie hepatic hemangioma) should generally be avoided [51]. Patients who require LB and who have a large vascular lesion identified on imaging should undergo the procedure using real-time image guidance. Biopsy of potentially malignant lesions should be undertaken with care because it is believed that tumour vessels are more likely to bleed [51] and it can

Biopsy of infectious lesions is generally safe. In the past, the presence of an echinococcal cyst was considered a contraindication to LB, because of the possibility of disseminating cysts throughout the abdomen and the risk of anaphylaxis. However, with recent advances in

When performing a LB, should be aware of multiple potential complications that may occur after biopsy.At the time that informed consent is obtained, it is reasonable to outline these complications clearly, warn the patient of the potential pain, and mention in a general state‐

Although the percutaneous biopsy is invasive, associated complications are rare, occurring

The different complication rates were attributed to variation in technique and to differences in the needles used, as well as differences in the severity of the liver disease and selection

The most common complication after percutaneous LB is pain [55]. Approximately 25% of patients have pain in the right upper quadrant or right shoulder; the pain is usually dull, mild and brief. Right upper-quadrant pain does not seems to be related to approach (i.e. subcostal vs. intercostal) [56]. The mechanism of pain following percutaneous biopsy is most likely a result of bleeding or possibly bile extravasation from the liver puncture wound, with subsequent capsular swelling, although the exact mechanism remains uncertain [57]. When present, pain can generally be managed with small amounts of narcotics. A decision

treatment, echinococcal cysts can be aspirated safely under ultrasound guidance [54].

known hematologic malignancy involving the liver [28].

be also associated with a risk of tumour spread [52,53].

ment that other complications, albeit rare, can occur.

in up to 6%, and 0.04% to 0.11% can be life threatening [33].

ternative.

10 Liver Biopsy - Indications, Procedures, Results

**5. Complications**

criteria in different centers.

Transient hypotension, due to vasovagal reaction, can occur, particularly in patients who are frightened or emotional.

Major complications were defined as life threatening or those that required hospitalization, prolonged hospitalization or those that resulted in persistent or significant disability. Most serious complications occur within 24 hours of the procedure, and 60% happen within 2 hours; between 1% and 3% of patients require hospitalization [33].

The most common serious complication is bleeding because of transection of a vascular structure [26]; bleeding may occur in the absence of pain. Mild bleeding, defined as that suf‐ ficient to cause pain or reduced blood pressure or tachycardia, but not requiring interven‐ tion, occurs in about 1/500 biopsies [58]. Severe bleeding is defined clinically by a change in vital signs with imaging evidence of intraperitoneal bleeding. Such bleeding has been esti‐ mated to occur in between 1 in 2.500 to 1 in 10.000 biopsies after a percutaneous approach for diffuse liver disease [59]. Although very rare, clinically significant intraperitonealhemor‐ rhage is the most serious bleeding complication of percutaneous LB; it usually becomes ap‐ parent within the first 2-3 hours after the procedure [26]. Free intraperitoneal blood may result from laceration of the liver capsule caused by deep inspiration during the biopsy or may be related to a penetrating injury of a branch of the hepatic artery or portal vein. The likelihood of hemorrhage increased with older age, presence of cirrhosis or liver cancer, and number of passes (≥ 3) with the needle during biopsy. The relationship between LB compli‐ cations and the number of needle passes is well documented [51]. The frequency of compli‐ cations increased with the number of passes performed at a rate of 26.4%, with one pass vs. 68% with two or more passes (*P*< 0.001) [38]. An additional factor in determining the risk of hemorrhage may be the type of needle used; cutting needles are more likely to result in hemorrhage than suction needles [26]. Severe bleeding requires hospitalization and is most often managed expectantly with placement of intravenous catheters, volume resuscitation by the administration of intravenous fluids and blood transfusion as necessary. If hemody‐ namic instability persists for a few hours despite the use of aggressive resuscitative meas‐ ures, angiography with selective embolization of the bleeding artery or surgery (to ligate the right hepatic artery or resect a section) is required.

operator had performed more than 100 biopsies [64] In contrast, Chevallier et al. showed that the operator's experience did not influence either the final histological diagnosis or the

In adult series, the rate of major complications associated with transjugular LB is low (0.5%; liver puncture-related, 0.2%; non-liver puncturerelated,0.3%), considering that it is currently performed in patients with coagulopathy [41]. Minor complications were significantly more frequent with Menghini needle, possibly related with the difficulty in controlling the depth

> Hypotension Abdominal pain

Biliary fistula Haemobilia

Factors associated with liver and non-liver puncture related complication rates included number of passes (liver puncture-related), young age, and number of transjugular biopsies.

The complications after laparoscopic LB include perforation of a viscus, bleeding, hemobilia, laceration of the spleen, leakage of ascitic fluid, hematoma in the abdominal wall, vasovagal

The most quoted mortality rate after percutaneous LB is less than or equal to 1/10.000 biop‐ sies. Mortality is typically related to bleeding. Mortality is highest among patients who un‐ dergo biopsies of malignant lesions. Cirrhosis is another risk factor for fatal bleeding after LB. Mortality after transvenous biopsy was 0.09% [41] in adult series, but may reflect the se‐ lection of higher risk patients for this intervention. Indeed, mortality is significantly higher in children; smaller livers and horizontal hepatic veins may increase the technical difficulty and risk of capsular perforation, which might be minimized by combined fluoroscopic and

Ventricular arrythmia Pneumothorax Respiratory arrest

Subclinical capsular perforation Small hepatic hematoma Hepatic-portal vein fistula Hepatic artery aneurysm

Liver Biopsy: An Overview http://dx.doi.org/10.5772/52616 13

degree of pain suffered by patients [66].

**MINOR**

Pyrexia

Neck pain Carotide puncture

**MAJOR**

Neck hematoma, bleeding

Transient Horner's syndrome Transient dysphonia Arm numbness/palsy Supraventricular arrhythmia

Large hepatic hematoma Intraperitoneal haemorrhage

US guidance [68].

Inferior vena cava or renal vein perforation

**Table 4.** Complications of transjugular liver biopsy

reaction, prolonged abdominal pain, and seizures [67].

of puncture increasing the risk of capsular penetration [46].

Subclinical bleeding leading to intrahepatic or subcapsular hematomas may be noted after LB even in asymptomatic patients. It is occurs in up to 23% of patients [60] and can be de‐ tectable by US. Large hematomas may cause pain associated with tachycardia, hypotension, and a delayed decrease in the hematocrit [33]. Conservative treatment of hematomas is gen‐ erally sufficient.

After tranvenous biopsy bleeding is extremely rare because of the Glisson capsule is not breached except as a procedural complication from within the liver [61].

The least common of the hemorrhagic complications is hemobilia, which usually presents with the classic triad of gastrointestinal bleeding, biliary pain, and jaundice [26] approxi‐ mately 5 days after the biopsy [62].

Transient bacteremia has been reported in 5.8 to 13.5 percent of patients after LB [63], and although such bacteremia is generally inconsequential, septicaemia and shock can rarely oc‐ cur in patients with biliary obstruction and cholangitis.

Biliary peritonitis caused by puncture of the gallbladder is rare (0.00001% frequency) but can be fatal [64].

Pneumothorax, hemothorax, subcutaneous emphysema, perforation of any of several organs (lung, colon, and kidney), subphrenic abscess are other complications reported with LB. Pneumothorax may be self-limited but may require more aggressive intervention depending on the severity of symptoms. Visceral perforation is usually managed expectantly. In most situations, observation is all that is required, although surgical intervention may be needed in the case of gallbladder puncture and persistent bile leak, or in the case of secondary peri‐ tonitis.

Differences in complication rates, either minor or major, have been reported between the blind and US-guided LB. The use of US guidance can prevent inadvertent puncture of other organs or large intrahepatic vessels. US may also reduce the incidence of major complica‐ tions such as haemorrhage, bile peritonitis, pneumothorax, etc.

With respect to the impact of the experience of the operator to the rate of complications, the evidences are controversial. A survey performed in Switzerland showed that the complica‐ tion rate of percutaneous LB was mainly related to the experience and training of the opera‐ tor, in particular a lower complication rate was reported for physicians who performed more than 50 biopsies a year [65]. Another study showed that the rate of complications in percutaneous LB was 3.2% if the operator had performed <20 biopsies, and only 1.1% if the operator had performed more than 100 biopsies [64] In contrast, Chevallier et al. showed that the operator's experience did not influence either the final histological diagnosis or the degree of pain suffered by patients [66].

In adult series, the rate of major complications associated with transjugular LB is low (0.5%; liver puncture-related, 0.2%; non-liver puncturerelated,0.3%), considering that it is currently performed in patients with coagulopathy [41]. Minor complications were significantly more frequent with Menghini needle, possibly related with the difficulty in controlling the depth of puncture increasing the risk of capsular penetration [46].


#### **MINOR**

68% with two or more passes (*P*< 0.001) [38]. An additional factor in determining the risk of hemorrhage may be the type of needle used; cutting needles are more likely to result in hemorrhage than suction needles [26]. Severe bleeding requires hospitalization and is most often managed expectantly with placement of intravenous catheters, volume resuscitation by the administration of intravenous fluids and blood transfusion as necessary. If hemody‐ namic instability persists for a few hours despite the use of aggressive resuscitative meas‐ ures, angiography with selective embolization of the bleeding artery or surgery (to ligate the

Subclinical bleeding leading to intrahepatic or subcapsular hematomas may be noted after LB even in asymptomatic patients. It is occurs in up to 23% of patients [60] and can be de‐ tectable by US. Large hematomas may cause pain associated with tachycardia, hypotension, and a delayed decrease in the hematocrit [33]. Conservative treatment of hematomas is gen‐

After tranvenous biopsy bleeding is extremely rare because of the Glisson capsule is not

The least common of the hemorrhagic complications is hemobilia, which usually presents with the classic triad of gastrointestinal bleeding, biliary pain, and jaundice [26] approxi‐

Transient bacteremia has been reported in 5.8 to 13.5 percent of patients after LB [63], and although such bacteremia is generally inconsequential, septicaemia and shock can rarely oc‐

Biliary peritonitis caused by puncture of the gallbladder is rare (0.00001% frequency) but

Pneumothorax, hemothorax, subcutaneous emphysema, perforation of any of several organs (lung, colon, and kidney), subphrenic abscess are other complications reported with LB. Pneumothorax may be self-limited but may require more aggressive intervention depending on the severity of symptoms. Visceral perforation is usually managed expectantly. In most situations, observation is all that is required, although surgical intervention may be needed in the case of gallbladder puncture and persistent bile leak, or in the case of secondary peri‐

Differences in complication rates, either minor or major, have been reported between the blind and US-guided LB. The use of US guidance can prevent inadvertent puncture of other organs or large intrahepatic vessels. US may also reduce the incidence of major complica‐

With respect to the impact of the experience of the operator to the rate of complications, the evidences are controversial. A survey performed in Switzerland showed that the complica‐ tion rate of percutaneous LB was mainly related to the experience and training of the opera‐ tor, in particular a lower complication rate was reported for physicians who performed more than 50 biopsies a year [65]. Another study showed that the rate of complications in percutaneous LB was 3.2% if the operator had performed <20 biopsies, and only 1.1% if the

breached except as a procedural complication from within the liver [61].

right hepatic artery or resect a section) is required.

cur in patients with biliary obstruction and cholangitis.

tions such as haemorrhage, bile peritonitis, pneumothorax, etc.

erally sufficient.

can be fatal [64].

tonitis.

mately 5 days after the biopsy [62].

12 Liver Biopsy - Indications, Procedures, Results

**Table 4.** Complications of transjugular liver biopsy

Factors associated with liver and non-liver puncture related complication rates included number of passes (liver puncture-related), young age, and number of transjugular biopsies.

The complications after laparoscopic LB include perforation of a viscus, bleeding, hemobilia, laceration of the spleen, leakage of ascitic fluid, hematoma in the abdominal wall, vasovagal reaction, prolonged abdominal pain, and seizures [67].

The most quoted mortality rate after percutaneous LB is less than or equal to 1/10.000 biop‐ sies. Mortality is typically related to bleeding. Mortality is highest among patients who un‐ dergo biopsies of malignant lesions. Cirrhosis is another risk factor for fatal bleeding after LB. Mortality after transvenous biopsy was 0.09% [41] in adult series, but may reflect the se‐ lection of higher risk patients for this intervention. Indeed, mortality is significantly higher in children; smaller livers and horizontal hepatic veins may increase the technical difficulty and risk of capsular perforation, which might be minimized by combined fluoroscopic and US guidance [68].
