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Guidelines on the Use of Liver Biopsy in Clinical Practice from the British Society of Gastroenterology, the Royal College of Ra

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Guidelines on the Use of Liver Biopsy in Clinical Practice from the British Society of Gastroenterology, the Royal College of Ra Guidelines Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, Gut: first published as 10.1136/gutjnl-2020-321299 on 28 May 2020. Downloaded from the Royal College of Radiologists and the Royal College of Pathology James Neuberger ,1 Jai Patel,2 Helen Caldwell,3 Susan Davies,4 Vanessa Hebditch,5 Coral Hollywood,6 Stefan Hubscher,7 Salil Karkhanis,8 Will Lester,9 Nicholas Roslund,10 Rebecca West,5 Judith I Wyatt,11 Mathis Heydtman12 ► Additional material is ABSTRact Risks of percutaneous liver biopsy include published online only. To view Liver biopsy is required when clinically important bleeding, organ perforation, sepsis and death. please visit the journal online Bleeding occurs in up to 10% with major bleeding (http:// dx. doi. org/ 10. 1136/ information about the diagnosis, prognosis or gutjnl- 2020- 321299). management of a patient cannot be obtained by occurring in less than 2%. Risk factors for bleeding safer means, or for research purposes. There are from percutaneous biopsy include older age, comor- For numbered affiliations see bidities, indication for biopsy and coagulation. end of article. several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A There is little conclusive evidence that operator Correspondence to wide choice of needles is available and the approach status and number of passes significantly affects the Dr James Neuberger, Liver Unit, and type of needle used will depend on the clinical risk of bleeding. Mortality associated with biopsy is University Hospitals Birmingham state of the patient and local expertise but, for non- less than 1 in 1000. NHS Foundation Trust, lesional biopsies, a 16-gauge needle is recommended. Haematological parameters in many patients Birmingham B15 2PR, UK; with liver disease are abnormal, with disturbance of jamesneuberger@ hotmail. co. uk Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation both thrombolysis and coagulation; the traditional Received 2 April 2020 or antiplatelet medication. A greater understanding measures of platelet count and prothrombin time Revised 23 April 2020 do not give an accurate reflection of the coagula- Accepted 24 April 2020 of the changes in haemostasis in liver disease allows for a more rational, evidence- based approach to peri- tion status of the patient. It is recommended that for biopsy management. Overall, liver biopsy is safe but non- lesional biopsies, in patients with liver disease, a there is a small morbidity and a very small mortality so transvenous route should be used if the international patients must be fully counselled. The specimen must normalised ratio (INR) is >1.4. For percutaneous http://gut.bmj.com/ be of sufficient size for histopathological interpretation. lesional biopsies, the INR should be <2.0. There is Communication with the histopathologist, with access no evidence that fresh frozen plasma is effective in to relevant clinical information and the results of other reducing bleeding and is not recommended. investigations, is essential for the generation of a Most liver biopsies are obtained by radiologists, clinically useful report. but there is little clear evidence that this is associated with reduced complications or increase in adequate samples. on October 2, 2021 by guest. Protected copyright. Although there is little convincing evidence that obtaining percutaneous liver biopsy under imaging EXECUTIVE SUMMARY guidance reduces complications, we recommend Histopathological interpretation of a liver biopsy is that where possible, liver biopsy should be obtained indicated when information for diagnosis, manage- under ultrasound guidance; where this is not appro- ment, treatment or prognostication is not avail- priate, we recommend that the liver should have able from non- invasive techniques. Liver biopsy is been imaged within 3 months of the biopsy (or more also indicated for research purposes where there is recently if there has been any change in the condi- appropriate ethics approval and consent. tion of the patient) to enable planning of the optimal Patient consent should be obtained prior to the biopsy site. biopsy. Information provided should include the We recommend the use of automated cutting- type © Author(s) (or their benefits and risks of liver biopsy, alternatives where needles and that full core biopsy needles are used, employer(s)) 2020. Re- use appropriate, and follow- up arrangements. The provided that the operator is sufficiently experienced permitted under CC BY- NC. No information should be given verbally and supple- in the use of these needles. We recommend that a commercial re- use. See rights mented with written information in a format that and permissions. Published 16 G needle should be used for the percutaneous by BMJ. is understandable by the patient and, where appro- approach, although an 18 G needle should be used priate, their carers. Where possible, this informa- for percutaneous biopsy of a solid lesion, and the To cite: Neuberger J, Patel J, tion should be given several days before the biopsy length of the sample should be at least 20 mm. Caldwell H, et al. Gut Epub ahead of print: [please by a healthcare practitioner who is familiar with the There should be clear communication between include Day Month Year]. techniques and with enough time for the patient to the clinician requesting the biopsy, the person doi:10.1136/ ask questions. Consent should be confirmed imme- obtaining the biopsy and the histopathologist gener- gutjnl-2020-321299 diately prior to the biopsy. ating the report. The request form should include Neuberger J, et al. Gut 2020;0:1–22. doi:10.1136/gutjnl-2020-321299 1 Guidelines the indication(s) and all relevant clinical and other information to Complications ensure that the procedure is done as safely as possible and that Complications are uncommon but there may be some mild pain the histopathologist has all the necessary information. The biopsy or discomfort in the area of the biopsy. In a small number of Gut: first published as 10.1136/gutjnl-2020-321299 on 28 May 2020. Downloaded from report should clearly deal with the clinical indication(s) for the cases there is some minor bleeding that soon stops. biopsy and conclude with a concise diagnostic summary. The After a biopsy, patients should seek medical advice when: report should be given in a timely fashion. For biopsies obtained ► Bleeding occurs from the site of the biopsy. outside a specialist liver centre, the reporting pathologist should ► The biopsy site becomes red, angry looking or swollen. have access to a second opinion from a liver centre. ► A high temperature (fever) develops. ► The biopsy site is still painful after a few days and painkillers Research and audit questions do not help. In many aspects of liver biopsy, the evidence is weak. We recom- In more severe and rarer cases, a blood transfusion and/or an mend that there should be local and national audits for the major operation is required to deal with the bleeding. On occasion it is complications of liver biopsy; these should include evaluation of possible for bile to leak from the liver internally. There is a small the various types of liver biopsy needle used to provide evidence risk that the small wound will become infected after the biopsy. for the safest and most effective needle units, and clinicians under- taking liver biopsies should ensure their own and centre’s compli- Different techniques for undertaking a liver biopsy cation rates are within accepted range; we recommend that there There are various approaches to obtaining a liver biopsy. should be national standards, evidence- based where possible, about the training and competencies of those obtaining liver biopsies; we Percutaneous liver biopsy recommend that there is further research into the haematological Percutaneous liver biopsy is the most common type of biopsy. It parameters that preclude safe percutaneous biopsies and into inter- involves inserting a thin needle through the skin into the liver ventions to reduce the risk of bleeding after liver biopsy and removing a small piece of tissue. Before the procedure, you will be asked to lie on your back or on your left side. The skin LIVER BIOPSY GUIDELINES: PATIENT/LAY SUMMARY over the liver region is then cleaned and prepared by applying A fuller lay summary is given in online supplementary material. antiseptic. Some local anaesthetic is then injected into a small area of skin and tissues just over a part of the liver (usually Introduction between two lower ribs on the right-hand side) to make the skin A liver biopsy is a diagnostic test, which involves the removal of in this area numb. A special hollow needle is inserted through a small quantity of tissue from the liver, usually done under local your skin into the liver. The clinician will ask you to breathe anaesthetic, to allow microscopic examination of the liver. in and then out and then hold your breath while the needle is inserted into the liver. The needle will remove a small sample of Purpose of a liver biopsy liver tissue for further examination. The clinician obtaining the There are many causes of liver disease and it is sometimes diffi- biopsy may be guided by an ultrasound scanner or CT scan for greater accuracy. Such scans are painless. Imaging can potentially cult to diagnose and work out the best treatment using other http://gut.bmj.com/ tests such as non- invasive imaging techniques or blood tests. reduce the risk of complications. Contrast- enhanced ultrasound 1 The main reasons for a liver biopsy are to may be of use in those with advanced chronic liver disease. ► help clarify diagnosis; A blind liver biopsy is where the biopsy is done without ► determine severity of liver damage or grade of tumour; imaging guidance. The guidelines state that a blind liver biopsy ► help predict prognosis in a person with a known diagnosis; should not be performed without recent liver imaging (within ► inform treatment decisions; the preceding 3 months) and this imaging should be reviewed ► monitor disease progression or response to treatment; before undertaking a biopsy.
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