Liver Biopsy: Understanding Test Purpose and Results
Medically reviewed by Jay N. Yepuri, MD, MS
A liver biopsy is a medical procedure that removes a small piece of liver tissue to be viewed under a microscope to check for signs of liver damage or disease. Several types of biopsies exist. They are usually performed on an outpatient basis under local or general anesthesia.
Your healthcare provider may order a biopsy if you have signs of liver disease, including cirrhosis, hepatitis, or liver cancer. A biopsy can also help establish how severe the disease is, what treatments are most appropriate, and how well you are responding to treatment.
The article explains why a liver biopsy may be ordered and what to expect before, during, and after the procedure. It will also walk you through how the results are interpreted on the pathology report.
Why Did My Provider Order a Liver Biopsy?
A liver biopsy can be used to diagnose, evaluate, or manage liver disease or liver damage.
A biopsy may be ordered if a liver problem cannot be definitively diagnosed with blood or imaging tests. Your healthcare provider may recommend the procedure when:
You have symptoms of liver disease, such as jaundice (yellowing of the skin and eyes due to a high bilirubin buildup in the blood), hepatomegaly (enlarged liver), or ascites (fluid accumulation in the belly)
Your blood liver enzymes are abnormally high (indicating that your liver is inflamed or injured)
An abnormality is seen on an ultrasound or X-ray, such as a liver tumor or lesion
Liver biopsies can also help establish the severity of the disease (referred to as staging) and the rate of disease progression (referred to as grading).
Although liver biopsies are used somewhat less frequently today due to advances in noninvasive diagnostic tools such as liver elastography, they remain the gold standard for the diagnosis or staging/grading of many liver conditions, including:
A liver biopsy can also help inform treatment decisions (based on the type, stage, and grade of the disease) and predict the likely outcome of treatment (referred to as the prognosis). This includes the management of the transplanted organ in people who have undergone a liver transplant.
Related: How Liver Cancer Is Diagnosed
Types of Liver Biopsy
The three main types of liver biopsies have specific indications and risks. These types include:
Percutaneous: This is the most common type of liver biopsy. It involves the insertion of a needle into the upper abdomen to obtain a sample of the liver tissue.
Transjugular: For this procedure, a flexible tube is threaded through a vein in your neck to the liver to obtain a tissue sample. This may be used if you have a bleeding disorder that makes the percutaneous biopsy risky or a condition (like ascites) that prevents you from reaching the liver through the belly.
Laparoscopic: This is a surgical procedure that uses a specialized scope and tools to obtain a tissue sample through tiny incisions in the abdomen. Laparoscopy may be used if there is diffuse (scattered) liver disease or other reasons for abdominal surgery.
Percutaneous and transjugular biopsies are usually performed with local anesthesia that numbs the biopsy site.
Laparoscopic biopsies are generally performed under general anesthesia (which puts you fully to sleep) or monitored anesthesia care (which induces what's known as twilight sleep, anesthesia that makes you insensitive to pain without being unconscious).
What Does a Liver Biopsy Cost?
While the price of a liver biopsy can vary based on where you live, a 2018 review in Hepatology reported that costs start at roughly $1,500 for a traditional percutaneous biopsy, soaring into the tens of thousands of dollars for more complex transjugular or laparoscopic procedures.
Speak with your insurance provider to understand what your plan covers, including any co-pay or coinsurance costs. To better defray expenses, be sure that all of your providers—including your anesthesiologist and treatment facility—are in-network providers.
Related: What Are the Risks of Liver Surgery?
Pain and Other Risks of Liver Biopsy
As with all medical procedures, risks are associated with a liver biopsy. The risks vary by the procedure used and your age, general health, and preexisting medical conditions.
Pain
Pain at the biopsy site is the most common complication of a liver biopsy, affecting between 30% and 50% of people who undergo the procedure. However, the pain tends to be mild and readily treated with pain medications.
With a percutaneous biopsy, the pain will often clear within a few minutes or hours. With transjugular and laparoscopic biopsies, the pain may be longer lasting and require stronger medications.
If the pain does not go away or gets worse, call your healthcare provider, as this may be a sign of an infection or internal bleeding.
Bleeding
Bleeding is a less common complication of a liver biopsy. According to the National Institute of Diabetes and Digestive and Kidney Diseases, only 1 of every 2,500 to 10,000 liver biopsies results in severe bleeding.
Severe bleeding may be caused by the accidental perforation of an artery or adjacent organ, such as a lung. In people with portal hypertension (high blood pressure in the portal vein of the liver), severe bleeding can occur if a distended blood vessel in the liver is accidentally nicked.
To reduce the risk of bleeding, you will be asked to stop certain medications that thin the blood a week or so before the procedure. These include:
Anticoagulants like Jantoven (warfarin) and Plavix (clopidogrel)
Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, Advil (ibuprofen), Aleve (naproxen), or Indocin (indomethacin)
Certain herbal supplements like turmeric and ginkgo biloba
Blood Testing Before a Liver Biopsy
To ensure the biopsy can be performed safely, your healthcare provider will order tests to see how well your blood clots, including:
Platelet count: This measures how many blood-clotting platelets you have in your blood.
Prothrombin time (PT): This test measures how long it takes for your blood to clot.
Infection
Infection is a rare but possible complication of a liver biopsy. Studies suggest that the risk of infection hovers between 0.01% and 0.1% in people who undergo a percutaneous biopsy. With a laparoscopic biopsy, the risk may be higher if wound care instructions are not adhered to.
As with internal bleeding, the risk of infection is largely associated with the accidental puncture of organs such as the colon, lungs, kidneys, liver, or gallbladder.
The accidental puncture of a lung can also lead to pneumothorax (a collapsed lung) or hemothorax (the buildup of blood in the space between the lung and chest wall). Both are serious conditions requiring emergency medical treatment.
Related: Know the Signs of Internal Bleeding
Day of the Liver Biopsy
A liver biopsy is performed in a hospital or outpatient center, usually in the morning. It may be performed by a gastroenterologist (digestive system specialist), hepatologist, (liver specialist) general surgeon, or interventional radiologist (a specialist trained in X-ray or ultrasound-guided medical procedures).
You may be asked to stop eating or drinking six to eight hours before the biopsy to avoid vomiting (which can occur with anesthesia or anxiety). Some healthcare providers may allow a little food or liquid beforehand. Double-check to be sure.
A percutaneous liver biopsy usually takes less than 30 minutes to complete (although the actual extraction of tissue takes a few seconds). Because they are more complex and invasive, transjugular or laparoscopic biopsies can take 60 minutes or longer to complete.
Before
You will be asked to change into a hospital gown for the procedure. Your vital signs (including pulse, blood pressure, and blood oxygen) will be taken, and an intravenous (IV) line may be placed into a vein in your arm to deliver medications, anesthesia, or contrast dyes for imaging.
If you are especially anxious, you may be given a low-dose sedative like Ativan (lorazepam) to help calm you down.
During
A liver biopsy is performed in a procedure room in one of several different ways.
For a percutaneous liver biopsy:
You will lie on your back on the procedure table with your right elbow out to your side and your right arm held above your head.
An ultrasound will map the position of your liver and the site of the needle insertion.
After your skin is cleaned, a topical numbing agent like lidocaine/novocaine is applied.
A very small (less than 5 millimeters) incision is made on the skin above the liver.
A hollow needle is inserted into the incision to obtain a small sample of liver tissue. (You may feel pressure as the needle is inserted but no outright pain.)
The incision is closed with surgical tape and a bandage.
For a transjugular liver biopsy:
You will lie on your back on a procedure table outfitted with a special X-ray called a fluoroscope.
An ultrasound will map the position of the jugular vein on one side of your neck.
After the skin is cleaned, a local anesthetic is injected around the biopsy site.
A very small incision (less than 5 millimeters) is made on the neck to access the jugular vein.
A thin, flexible tube called a catheter is inserted into the incision. (You may feel a sudden jolt of pain in your shoulder as the tube is first inserted but little discomfort thereafter.)
The catheter is threaded through the network of veins until it reaches the liver.
A contrast dye is injected into the tube to help visualize the liver on the fluoroscope.
A needle is threaded through to the catheter and into the liver to obtain a tissue sample.
The incision is closed with surgical tape and a bandage.
For a laparoscopic liver biopsy:
You will lie on your back on a procedure table.
Anesthesia is delivered through the IV line to put you partly or fully asleep.
After the skin is cleaned, two or three small incisions (1.0 to 1.5 centimeters) are made in the abdomen to accommodate a lighted scope (called an endoscope) and specialized surgical tools.
Using the scope to guide the procedure, a tissue sample is taken using a needle, scissors, or a scalpel.
The incision is closed with stitches and a bandage.
Related: What Are the Risks of General Anesthesia?
After
After the biopsy, you are wheeled into the recovery room where you will be transferred to a hospital bed and monitored for two to four hours. During this time, your vital signs will be regularly checked to ensure there are no signs of internal bleeding (such as a sudden drop in blood pressure).
To better ensure a safe recovery, you would also be positioned in bed in a specific way, as follows:
If you had a percutaneous biopsy, you would lie on your right side. As more of your liver is situated on the right side of your body, lying this way places pressure on the organ and helps stop any bleeding.
If you had a transjugular biopsy, the upper part of your body would be elevated at a 30- to 45-degree angle. At this angle, the diaphragm (the muscle that separates the chest and the abdominal cavities) puts pressure on the liver to help stop bleeding.
If you had a laparoscopic biopsy, you may be placed either on your right side or flat on your back, depending on how the liver was accessed during surgery.
You may feel a dull ache in your upper right abdomen and lingering pain in your shoulder if you've had a transjugular biopsy.
If the pain is severe, let your healthcare provider know. They can recommend medications like Tylenol (acetaminophen) for milder pain or prescribe Tylenol 3 (acetaminophen with codeine) for more severe pain.
Before you are discharged, some facilities will want to perform a computed tomography (CT) scan to check for any signs of internal bleeding. This is especially true if larger samples of tissue were taken.
Once the care team is assured that you are stable and fully recovered from anesthesia, you will be released to return home.
Can I Drive Myself Home?
People exposed to general anesthesia or a sedative like Ativan (lorazepam) will need to have someone to drive them home. Others may want to do so just to be safe.
Your healthcare provider may also recommend that someone stay with you overnight in case of an unexpected complication.
Managing Pain After Liver Biopsy
Once you've returned home, you will need to take it easy for one to three days and avoid exerting yourself for up to one week. This includes avoiding exercise or lifting anything heavier than 10 pounds (including children). Doing so may increase the risk of bleeding or disrupt larger incisions.
With that said, you should make an effort to walk every day. This aids healing by increasing blood circulation and prevents constipation and pneumonia. Start with short walks and increase slightly each day.
You may experience soreness around the incision site for up to a week. While Tylenol can help, you can also apply an ice pack or cold compress to the wound for 10 to 15 minutes several times daily. Use a cloth barrier to avoid frostbite or saturating the incision.
Always follow your healthcare provider's wound care instructions. If you have any problems with healing or your symptoms are not improving, call your provider immediately.
When to Call 911
Seek immediate medical help if you have signs of infection or internal bleeding, such as:
High fever with chills
Increasing pain, redness, swelling, or bleeding at the incision site
Dizziness, lightheadedness, or fainting
Severe abdominal, shoulder, or chest pain
Sudden abdominal swelling
Nausea and vomiting
Shortness of breath
A racing or pounding heart
Related: How to Care for a Surgical Incision
Liver Biopsy Results and Terms to Know
Once the liver tissue sample is taken to the laboratory, it will be examined under a microscope by a medical specialist known as a pathologist.
The process, called histopathology, involves submitting the sample to various stains and chemicals to look for abnormalities in cells or cell groupings, signs of fibrosis (scarring) or necrosis (tissue death), or the abnormal accumulation of compounds like fat, white blood cells, or toxins.
Based on the findings, the pathologist will issue a pathology report within a few days to a week describing whether or not you have an infection, injury, or cancer of the liver.
The report will include a diagnosis, a description of the findings, and the pathologist's comments. Among some of the terms you may encounter are:
Biopsy adequacy: This establishes whether the sample taken is adequate to render an accurate diagnosis.
Gross description: This describes a tissue sample's color, size, and weight as seen by the naked eye.
Predominant pattern: This is the main pattern and distribution of hepatocytes (liver cells) seen under the microscope. Different patterns suggest different diseases or conditions.
Nuclear pattern: This is how normal or abnormal the cells look, including how similar or different they are to each other. Major variations in size and shape generally indicate cancer.
Lobular disarray: This is when the normal architecture of hepatocytes is disrupted, often with the infiltration of inflammatory cells and signs of necrosis. These patterns may indicate viral hepatitis or autoimmune hepatitis,
Portal pattern: This describes the pattern of cells in the vessels and ducts of the liver. Changes in these cells may indicate cirrhosis or chronic hepatitis.
Steatotic pattern: This is the infiltration of fat into liver tissues, the percentage of which is diagnostic of ARLD and MASLD.
If cancer cells are found, the pathology report may include the following information:
Liver cancer type: Hepatocellular carcinoma is the most common form of liver cancer. Other types include cholangiocarcinoma and angiosarcoma.
Cancer stage: This describes how advanced the cancer is, ranging from stage 1 through stage 4. As a rule, the lower the number, the less the cancer has spread.
Cancer grade: This describes how quickly or slowly the disease is progressing based on how abnormal the cells look, ranging from grade 1 (slow-growing) to grade 3 (aggressive).
Based on these and other findings, your healthcare provider can select the most appropriate treatments specific to your condition, general health, and prognosis.
Related: How Liver Cancer Is Treated
Summary
A liver biopsy is a procedure used to extract a sample of liver tissue to diagnose, evaluate, or manage a liver condition. It is most commonly done by inserting a needle through your abdomen into the liver (percutaneous biopsy) but can also be done through a vein in your neck (transjugular biopsy) or with minimally invasive surgery (laparoscopic biopsy).
Once the sample is obtained, it is evaluated by a pathologist. Based on the pattern, size, and shape of liver cells and other factors, the biopsy can tell whether you have liver damage, disease, infection, or cancer. It can also help describe how severe the condition is and how rapidly or slowly it is progressing.
Related: METAVIR Scores on a Liver Biopsy
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