Complications Of Percutaneous Liver Biopsy Research Articles

Value and risk of percutaneous liver biopsy in patients with cirrhosis and clinical suspicion of autoimmune hepatitis

ObjectiveThe decision regarding whether to perform a liver biopsy in patients with cirrhosis and clinically suspected autoimmune hepatitis (AIH) remains a challenge. This study aimed to assess the utility and...

S1529 Occult Portobiliary Fistula Following Percutaneous Liver Biopsy

INTRODUCTION: Percutaneous liver biopsies are commonly performed procedures in the diagnostic workup or staging of liver diseases, and bleeding is the most important complication. Hemobilia is defined as bleeding into the biliary tree, and is a rare complication of liver biopsy that classically presents with a triad of GI bleeding, abdominal pain, and jaundice. CASE DESCRIPTION/METHODS: A 44-year-old male underwent an uneventful liver biopsy for workup of hepatic steatosis. The next day he presented to the ER with RUQ abdominal pain and jaundice. Vital signs were normal and physical examination revealed scleral icterus and epigastric tenderness. Liver function tests showed AST and ALT of 2248 U/L and 2915 U/L, respectively, alkaline phosphatase of 200 U/L, and total bilirubin of 23.3 mg/dL with direct bilirubin of 13.9 mg/dL. CT scan revealed small hemoperitoneum and diffuse hepatic steatosis. Ultrasound with doppler showed normal biliary and intrahepatic ducts and patent portal and hepatic veins with normal blood flow. On the fourth hospital day, MRCP revealed moderate right intrahepatic biliary ductal dilatation with associated hemobilia to the level of the biliary confluence (Figure 1). MRI with contrast revealed completely thrombosed right portal vein and branches, and persistent right intrahepatic biliary ductal dilatation (Figure 2). Oral anticoagulation was considered; however, the gastroenterology team felt the liver biopsy caused an iatrogenic portobiliary fistula, leading to the formation of the portal vein thrombus which may have helped seal the fistula. Therefore, the decision was made to hold anticoagulation and discharge the patient. Liver function tests one month later revealed AST and ALT of 20 U/L and 70 U/L respectively. Repeat MRI showed a reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus with recanalization and mild cavernous transformation (Figure 3). DISCUSSION: Given the biliary dilation on MRCP, we suspect that a blood clot at the biliary confluence caused an obstruction leading to acute severe rise in AST, ALT and direct hyperbilirubinemia. Due to the risk of further bleeding and possible tamponade effect of clot, anticoagulating the patient may have worsened the situation. Portobiliary fistulas leading to hemobilia are a rare complication of percutaneous liver biopsy. While GI bleeding, jaundice, or abdominal pain post-biopsy should prompt a diagnostic workup, it should also be kept in mind that there could be uncommon presentations of hemobilia.Figure 1.: MRCP showing moderate right intrahepatic biliary ductal dilatation with associated hemobilia.Figure 2.: Contrast enhanced MRI showing thrombosed right portal vein and branches, and right intrahepatic biliary ductal dilatation.Figure 3.: Follow-up MRI showing reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus.

Percutaneous liver biopsy before organ removal-Impact on organ allocation and costs in liver transplantation

HintergrundDer Stellenwert und die Sicherheit einer perkutanen Leberbiopsie (PLB) bei hirntoten Spendern vor Organentnahme sowie der Einfluss der PLB auf die Organallokation und die Kosten im Rahmen der Lebertransplantation (LT) in der Eurotransplant-Region (ET), werden weiterhin diskutiert.Material und MethodenEine perkutane Leberbiopsie vor Organentnahme erfolgte bei 36 hirntoten Spendern. Die Komplikationsrate, Spendercharakteristika, Ultraschallbefunde, die makroskopische Einschätzung und die histologischen Ergebnisse der PLB wurden analysiert. Zusätzlich wurde eine landesweite Umfrage unter 11 Lebertransplantationsexperten durchgeführt. Der Bedarf einer PLB und ihre Auswirkungen auf den Prozess der Organallokation wurden evaluiert. Mögliche Kosteneinsparungen wurden für verschiedene Szenarien auf der Grundlage von Kostendaten der Deutschen Stiftung Organtransplantation berechnet.ErgebnisseEs wurden keine Komplikationen durch die PLB beobachtet. Die Umfrage ergab, dass das Ergebnis der PLB einen erheblichen Einfluss auf die Allokation von Spenderorganen hat, insbesondere bei solchen mit „extended donor criteria (EDC)“. Die Kostenberechnung ergab ein enormes Kosteneinsparungspotenzial durch eine optimierte Allokation und die Vermeidung unnötiger Organentnahmen.SchlussfolgerungDie PLB ist ein sicheres Verfahren und besitzt ein enormes Potenzial für die Optimierung der Organallokation vor Organentnahme durch eine Reduzierung der kalten Ischämiezeit, Vermeidung unnötiger Verwerfungen von Spenderorganen sowie Kosteneinsparungen. Die klinische Relevanz und der Einfluss der PLB auf die Organallokation konnte durch unsere Daten herausgestellt werden.

2339 Hemobilia-Associated Acute Cholecystitis Post-Percutaneous Liver Biopsy: A Unexpected Sequelae of a Known Complication

INTRODUCTION: Percutaneous liver biopsy is often a part of the diagnostic workup of unexplained abnormal liver enzymes. Known complications include hemobilia and unintentional perforation of an adjacent organ but rarely do these complications lead to sepsis. CASE DESCRIPTION/METHODS: We present a case of a 65-year old female being evaluated for abnormal liver enzymes (ALT 40 U/L, normal alkaline phosphatase) with a positive anti-mitochondrial (titer 1:1280) and anti-nuclear antibodies (titer 1:640). A percutaneous liver biopsy was performed under ultrasound guidance without any immediate complication. The biopsy revealed moderate-to-marked macrovesicula steatosis with focal centrilobular and periportal fibrosis (Stage 1 of 4). Five days later she presented to the emergency department with persistent RUQ pain, fevers and melena. Vitals notable for temperature of 39.3 °C. Physical examination revealed RUQ tenderness to palpation. The leukocyte count was 5.04 K/uL (predominantly neutrophils), AST 558 U/L, ALT 350 U/L, ALP 287 U/L, total bilirubin 1.9 mg/dL. CT abdomen demonstrated only cholelithiasis without other abnormalities. An abdominal ultrasound showed gallbladder sludge and wall thickening with a negative Murphy’s sign (Figure 1). Blood cultures were positive for Klebsiella pneumonia and IV antibiotics were started. Over the ensuing several days, the patient had worsening abdominal pain and developed melena. Imaging was remarkable for hyperdense material within the gallbladder. An endoscopic ultrasound was performed which revealed moderate amount of hyperechoic material in the gallbladder consistent with clotted blood. Given concern that an infected blood clot in gallbladder was a source of bacteremia, a laparoscopic cholecystectomy was performed. The surgical gallbladder specimen showed acute hemorrhagic acalculous cholecystitis. Postoperative course was uncomplicated and the patient was discharged home feeling back to normal. DISCUSSION: Hemobilia is a well-recognized complication of percutaneous liver biopsy, although this case is unusual because it appears to have led to acalculous cholecystitis and Klebsiella bacteremia. Blood, similar to sludge, can accumulate and mimic obstructive processes such as acute cholecystitis and acute pancreatitis. This case highlights the importance of early recognition of delayed complications of percutaneous liver biopsy.

Venobiliary fistula with haemobilia: a rare complication of percutaneous liver biopsy

We describe a case of a 36-year-old man with a history of chronic hepatitis C who presented with abdominal pain 3 days after undergoing a percutaneous ultrasound-guided liver biopsy. Initial...

Letter: complications of percutaneous liver biopsy with Klatskin needles—methodological issues

Linked ContentThis article is linked to Takyar et al, and Takyar and Koh papers. To view these articles visit https://doi.org/10.1111/apt.13939 and https://doi.org/10.1111/apt.14170.

Complications of percutaneous liver biopsy with Klatskin needles: a 36-year single-centre experience.

Liver biopsy is the gold standard in evaluating liver diseases but is susceptible to complications. Safety data on aspiration needle biopsies remain limited. To evaluate the safety of percutaneous liver biopsy performed with Klatskin needle. Clinical and biochemical data were retrospectively retrieved from sequential subjects who underwent liver biopsy with Klatskin needle from 1978 to 2015. Subjects with complications underwent thorough chart reviews for hospital course. Of 3357 biopsies performed, complications occurred in 135 (4%) biopsies with 33 (1%) resulting in major complications. Severe pain occurred in 78 (2.3%) subjects and bleeding occurred in 21 (0.6%) subjects. Biliary injury occurred in 8 (0.2%) biopsies. Three subjects died as a result of massive intraperitoneal bleeding. Compared to viral hepatitis, biopsies performed with certain diagnosis had significantly higher odds of major complications: NRH (OR: 17), DILI (OR: 20), GVHD (OR: 32) and HCC (OR: 34). Subjects with major complications had higher pre-biopsy median AP (153 vs. 78 U/L, P < 0.001), ALT (105 vs. 64 U/L, P < 0.05), AST (62 vs. 47 U/L, P < 0.02), along with marginally lower total bilirubin (1.0 vs. 0.7 mg/dL, P < 0.01) and albumin (3.7 vs. 4.0 g/dL, P < 0.001). By multivariate backward logistic regression, platelets ≤100 K/μL and aPTT >35 were independent risk factors of post-biopsy bleeding. Klatskin needle liver biopsies are safe with rare procedural morbidity. Our data suggests certain acutely ill subjects and those with systemic illnesses may be at higher risk of major complications. Clinicians should weigh the risks and benefits of liver biopsy in these patients with other alternative approaches.

Multiple biopsy passes and the risk of complications of percutaneous liver biopsy.

To minimize the sample variability of liver biopsy, the tissue length should be at least 25 mm. Consequently, more than one biopsy pass is needed with cutting biopsy needles. We aimed to investigate the risk factors of biopsy-related complication, including the number of biopsy passes. All consecutive liver biopsies performed between 2005 and 2014 were included. Biopsies were ultrasound assisted and performed with cutting biopsy needles. A complication was an event where the patient visited a healthcare provider because of biopsy-related complaints. Complications followed by hospitalization 2 or more days or intervention were considered severe. In total, 1806 liver biopsies were analyzed. Overall, 102 (5.6%) complications were observed, of which 31 (1.7%) were severe. One (0.06%) patient died. Common complications were pain (n=75/102; 74%) and bleeding (n=34/102; 33%). Two biopsy passes were not associated with an increased risk of complications compared with one biopsy pass [odds ratio (OR): 1.59; 95% confidence interval (CI): 0.83-3.04; P=0.16], whereas three or more biopsy passes increased this risk compared with one (OR: 2.97; 95% CI: 1.38-6.42; P=0.005) or two biopsy passes (OR: 1.87; 95% CI: 1.10-3.19; P=0.021). The risk of severe complications was not influenced by the number of biopsy passes (P>0.24). Hepatic malignancy (OR: 3.21; 95% CI: 1.18-8.73; P=0.022) and international normalized ratio 1.4 or more (OR: 7.03; 95% CI: 2.74-18.08; P<0.001) were risk factors of severe complications. Severe complication rate and mortality were low. Performing multiple biopsy passes was not associated with severe complications, whereas hepatic malignancy or elevated international normalized ratio were associated with an increased risk.

Complications of blind versus ultrasound-guided percutaneous liver biopsy in children

Background and study aimsLiver biopsy is a well-established procedure in the diagnosis and follow-up of liver diseases. Complications of liver biopsy are rare but potentially lethal. The aim of this study was to evaluate the complications of percutaneous liver biopsy and to compare the complications of blind and ultrasound-guided percutaneous liver biopsy in paediatric wards of Nemazee Hospital of Shiraz in the south of Iran. Patient and methodTo complete the questionnaire, registered information of liver biopsies due to different causes in paediatric patients between 2008 and 2012 was retrospectively reviewed. All children aged between 0 and 18years, who underwent liver biopsy (due to any indication), participated in this study. ResultsLiver biopsies were obtained from 210 patients. Seven of 210 cases were excluded due to unreliable data. A total of 209 liver biopsies were done in the rest of the cases (n=203). Of all cases of liver biopsies, 22 (10.5%) experienced complications after biopsy. Pain (n=7) was the most frequent complication in 22 cases of liver biopsy. Mortality rate was one (0.5%) due to rupture of subcapsular haematoma. In terms of complication (p=0.592), there was no significant difference statistically between patients with blind liver biopsy (n=16) and patients with ultrasound-guided liver biopsy (n=6). ConclusionIn terms of complications, there was no significant difference when the patients were evaluated with and without ultrasound-guided biopsy.

Hemorrhage as a Complication of Percutaneous Liver Biopsy

Percutaneous biopsies of the abdominal solid organs, particularly the liver, are among the most well-established and frequently performed interventional procedures. While offering lower morbidity than open surgical biopsies, these procedures are not risk free and postbiopsy hemorrhage is one of the most frequently encountered complications. Interventionists must therefore be well versed in preprocedure patient optimization, postbiopsy evaluation, and management of hemorrhagic complications.

Pseudoaneurysm and hemobilia in a neonate

Hemobilia, arterial-biliary fistula, and pseudoaneurysm are rare complications of percutaneous liver biopsy in a neonate. We present the management of persistent hemobilia in a previously premature 2877 g neonate. Despite the ongoing correction of coagulation parameters and multiple large volume transfusions our patient's hemobilia persisted. We eventually controlled the arterial-biliary fistula using a selective endovascular embolization technique not commonly used in patients of this size. The pseudoaneurysm was no longer visible on outpatient follow up ultrasound 21 days after embolization. Pseudoaneurysm should be considered in the neonate with persistent hemobilia after percutaneous liver biopsy. Angiography can be both diagnostic and therapeutic in the management of hepatic pseudoaneurysm and arterial-biliary fistula after percutaneous liver biopsy.

Endoscopic Management of Biliary Leak After Liver Biopsy

Introduction: Percutaneous liver biopsies are considered quite safe with a rate of fatal complications <1/1000. Biliary leak with biliary peritonitis is a rare (0.03-0.22%) but known complication of percutaneous liver biopsy. Larger extra hepatic duct injury with this procedure is extremely rare. It may present as frank peritonitis with systemic response, hence the likely hood of it responding to conservative management is less. HIDA scan is diagnostic. ERCP along with sphinctrotomy and stent placement in common bile duct is the procedure of choice. We report a case of common hepatic duct injury after CT guided liver biopsy which to the best of our knowledge has not been reported in literature. Case: A 46-year-old lady with a history of autoimmune hepatitis presented with epigastric pain radiating to right flank, associate with nausea and vomiting. A CT guided liver biopsy was done 5 days before presentation. On examination she had pulse of 100/min, BP 94/53 & temperature 99.2 F. Abdomen was tender all over with guarding in the right upper quadrant and hypoactive bowel sounds. Initial labs showed total WBC of 10.6, total bilirubin 2.4 mg/dl and direct bilirubin 1.0 mg/dl. CT scan abdomen revealed fluid surrounding the liver and HIDA scan showed extra hepatic biliary leak. She was initially managed conservatively with nothing by mouth, intravenous fluids, pain medications and antibiotics; however her condition did not improve in 48 hours. ERCP (endoscopic retrograde cholangio pancreatography) was done which showed high-grade biliary leak at the common hepatic duct. A CBD stent was placed. Patient's clinical condition improved significantly after the therapeutic ERCP and was subsequently discharged home. One week follow-up HIDA scan revealed no extra hepatic biliary leak. Six weeks later, stent was removed via ERCP and repeat cholangiogram did not demonstrate any contrast extravasation. Conclusion: In conclusion, extra hepatic biliary duct injury is an extremely rare but potentially life threatening complication of liver biopsy. One should consider it in the differential diagnosis of abdominal pain after liver biopsy as prompt endoscopic treatment can be lifesaving.Figure A: Endoscopic Cholangiogram showing high grade biliary leak at the level of common hepatic (arrow). Figure B. Endoscopic Cholangiogram 6 weeks later showing no leak.

A fatal case of hemoperitoneum after ultrasound-guided liver biopsy in a patient with intravascular large B-cell lymphoma

An autopsy case of fatal complication of percutaneous liver biopsy targeting a rare type of large B-cell lymphoma is presented. A 79 year-old man was referred to the hematology unit of a hospital because of anemia with thrombocytopenia and hepatosplenomegaly. Results of inguinal lymph node biopsy were inconclusive. To investigate a mass lesion in the liver visualized by ultrasonography, image-guided liver biopsy was performed following platelet infusion. The patient became unresponsive 6 h post procedure because of hypotension due to intraperitoneal hemorrhage of undetermined origin. Autopsy revealed hemoperitoneum but failed to identify any macroscopic intra- or extrahepatic vascular injuries. Histopathological investigation disclosed infiltration of atypical lymphocytes into the systemic organs including the lymph nodes, spleen, liver, and lungs. Prominent hemophagocytosis was also noted. The lymphoma cells were exclusively accumulated within vascular and sinusoidal structures, and diagnosed with immunohistochemistry as Asian variant of intravascular large B-cell lymphoma. Massive blood extravasation was presumed to originate directly from the markedly dilated liver sinusoids filled with erythrocytes, macrophages and tumor cells, under the condition of impaired hemostasis. Although the biopsy was thought to have been correctly performed, this case would be instructive for evaluation of the indications and risks associated with liver biopsy.

Tension Hemothorax: A Dreaded Complication of Percutaneous Liver Biopsy

Tension Hemothorax: A Dreaded Complication of Percutaneous Liver Biopsy

Pseudoaneurysm Formation After Ultrasound-Guided Liver Biopsy in an Obese Child

Pseudoaneurysm formation is a rare complication of percutaneous liver biopsy, the incidence of which can be reduced by using ultrasound (US) guidance. We describe an obese 11-year-old male who underwent US-guided liver biopsy for persistently elevated transaminases. He subsequently developed anemia, melena, and hemobilia as noted on esophagogastroduodenoscopy. He was found to have a pseudoaneurysm with an arterial-biliary fistula as well as pancreatitis from bleeding into the common bile duct. Although US-guided liver biopsies are safe procedures to perform in children, complications can occur and should be considered in any child with anemia after biopsy, especially in association with hemobilia.

Acute ischemic injury due to a giant intrahepatic hematoma: A complication of percutaneous liver biopsy

We present the case of a patient with chronic hepatitis B who developed an extensive intrahepatic hematoma, associated with a 30-fold elevation in serum alanine aminotransferase levels, following percutaneous liver biopsy. The patient was hypertensive but without hemorrhagic diathesis by routing tests done before biopsy. There was no concomitant intraperitoneal hemorrhage and no blood transfusions were required, despite a 9% drop in hematocrit. The complication was associated with short-lived, mild-to-moderate abdominal pain, easily relieved by paracetamol analgesics. The intrahepatic hematoma, as followed by computed tomography, resolved within 8 months. This case indicates that extensive intrahepatic hematoma and associated ischemic injury may infrequently complicate a liver biopsy and that hypertension may be a predisposing factor.

An Unusual Complication of Percutaneous Liver Biopsy (PLB)

An Unusual Complication of Percutaneous Liver Biopsy (PLB)

Pylephlebitis After CT-Guided Percutaneous Liver Biopsy

Pylephlebitis After CT-Guided Percutaneous Liver BiopsyRicha Tandon1, Ashley Davidoff2, Michael G. Worthington3 and John J. Ross3Audio Available | Share

Gallbladder polyp as a manifestation of hemobilia caused by arterial-portal fistula after percutaneous liver biopsy: A case report

Outpatient percutaneous liver biopsy is a common practice in the differential diagnosis and treatment of chronic liver disease. The major complication and mortality rate were about 2-4% and 0.01-0.33% respectively. Arterio-portal fistula as a complication of percutaneous liver biopsy was infrequently seen and normally asymptomatic. Hemobilia, which accounted for about 3% of overall major percutaneous liver biopsy complications, resulted rarely from arterio-portal fistula We report a hemobilia case of 68 years old woman who was admitted for abdominal pain after liver biopsy. The initial ultrasonography revealed a gallbladder polypoid tumor and common bile duct (CBD) dilatation. Blood clot was extracted as endoscopic retrograde cholangiopancreatography (ERCP) showed hemobilia. The patient was shortly readmitted because of recurrence of symptoms. A celiac angiography showed an intrahepatic arterio-portal fistula. After superselective embolization of the feeding artery, the patient was discharged uneventfully. Most cases of hemobilia caused by percutaneous liver biopsy resolved spontaneously. Selective angiography embolization or surgical intervention is reserved for patients who failed to respond to conservative treatment.

Haemobilia causing acute pancreatitis after percutaneous liver biopsy

A 55-year-old diabetic woman was admitted to our department because of severe epigastric pain. The plasma amylase and lipase levels were markedly elevated and computed tomography showed inflammation of peripancreatic tissue with no enlargement of pancreas (Balthazar C). The patient had been previously cholecystectomized and denied excessive consumption of alcohol. Four days before development of acute pancreatitis she underwent a percutaneous liver biopsy (1.4 mm Menghini-type needle) for chronic elevation of alanine aminotransferase, without immediate complication. Before liver biopsy the platelet count and prothrombin time were normal. The liver histology was consistent with clinical diagnosis of non-alcoholic steatohepatitis. A lateral-view duodenoscopy showed blood coming from the orifice of ampulla of Vater. An urgent endoscopic cholangio-pancreatography (ERCP) revealed blood clots in the dilated main bile duct (Panel A). After papillotomy the clots were extracted from biliary duct by Dormia basket and the biliary tree was perfused with thrombin solution through the nasobiliary catheter. On the following day the cholangiography showed no clots inside the biliary tree (Panel B). Haemobilia is an unusual complication of percutaneous liver biopsy (6/10,000 cases). The time interval from biopsy to development of clinical symptoms related to haemobilia ranges from several hours to 25 days [1]. Haemobilia is an uncommon cause of acute pancreatitis, which is believed to be induced in the same way as gallstone pancreatitis. Selective hepatic angiography with arterial embolization is recommended procedure to stop the intractable haemobilia [2]. In our patient the bleeding was not profuse and ERCP was successful in both the diagnosis of haemobilia and evacuation of the biliary clot.