Interventional Ultrasound & Patient Safety

Interventional Ultrasound in Abdominal Imaging

LECTURE
10
Part 1

Liver And Kidney Biopsies

Faiza HaqNawaz
SU91-MSHAW-S23-091
Imaging-guided Parenchymal Liver
Biopsy

Liver biopsy is a procedure to remove small piece of liver so it can be

examined with a microscope for sign of damage or disease .
Indications of liver biopsy
• Multiple Parenchymal liver diseases
• Hepatitis B
• Hepatitis C
• Hemachromatosis
• Wilson’s disease
• cirrhosis
• Nonalcoholic fatty liver
• Drug-induced liver
• Abnormal liver tests of unknown etiology
• Staging of known Parenchymal liver disease Aid in
developing treatment plans based on histological
diagnosis
 Contraindications to Liver biopsy
• Absolute:
 Uncooperative patient •
 PT>4 seconds over control, INR >1.5
 Platelet count less than 60000/mm3.
Unavailability of blood transfusion support.
 Bleeding diathesis.
Bowel overlying biopsy site (on ultrasonography or other abdominal
imaging).
Recent use (within the last 7 days) of aspirin or non steroidal anti-
inflammatory drugs (NSAIDs) or ant platelet class of medications.
 Relative
• • Ascites
• Infection in the right pleural cavity
• Abdominal wall infection over the identified biopsy
site
• Morbid obesity
• Extrahepatic biliary obstruction
• Bacterial Cholangitis
Types of liver biopsy

• Percutaneous Liver Biopsy.

• Tran thoracic ,Sub costal Liver Biopsy
• Tran venous (Transjugular) Liver Biopsy
• Laparoscopic Liver Biopsy
• Endoscopic US-Guided Trans gastric Liver Biopsy.
Types of Liver Biopsy
• Percutaneous liver biopsy. The most common method. You are given
a local anesthetic. A small needle is put into your liver to take a sample.
• Laparoscopic liver biopsy. You are given a general anesthetic. A thin
lighted tube (laparoscope) is put into your skin through a tiny cut or
incision. The tube has a tiny video camera attached. Your provider can
see the inside of your belly on a computer screen. A needle is put
through another tube to remove the sample.
• Transvenous liver biopsy. This method may be used if you have
blood-clotting problems or fluid in your belly. You are given a local
anesthetic. An incision is made into a vein in your neck. A hollow tube
is put through the vein down to your liver. A contrast dye is put into the
tube and X-rays are made. The dye lets the vein show up more clearly
on the X-rays. A needle goes through the tube to your liver. Tissue
samples are removed through the tube.
Prerequisites
• Cooperative patient with clear understanding of the plan.
• Has a chaperone who can observe him or her closely over the
next 24 hours.
• Platelet count > 60,000.
• Prothrombin time < 4 seconds of control.
• INR < 1.5.
• •No clinical history suggestive of coagulopathy .
• •The facility where the biopsy is performed should have an
approved blood bank.
 Types of Biopsy Needle

• Suction needle.
• Cutting needle,Tru Cut.
• Spring loaded needle .
• The ideal biopsy needle should be 1.4 – 1.8 mm in diameter.
• Wider bore needle are associated with higher risk of complications.
• Most institute, most radiologists prefer using 18-G cutting Temno
needle.
Suction needle.
Cutting needle,Tru Cut
Spring loaded needle
 THE PROCEDURE

• When imaging guidance is employed, it can take one of two forms:

• US-guided “marking” in which a mark is made upon the skin
during US examination for a biopsy to be performed later without
imaging guidance or real-time US guidance.
• Histological analyses of samples obtained via blind approach
indicated biopsy of renal tissue, pericolic fat, and myenteric plexus.
• While the most frequent major complication of liver biopsy is
hemorrhage, death from biliary injury including gallbladder
perforation with the blind technique has also been reported.
 Procedure

• Written consent of patient after explaining procedure.

• Place the patient supine, remove pillows, and elevate the right
arm behind the head.
• Mark this location with a surgical pen or other method.
• usually between( 6th -9th ICS)
• Prepare the field with Betadine solution and place sterile
drapes.
• Administer local anesthesia with 1% lidocaine in both
superficial and deep planes.
• Once adequate anesthesia has been obtained, a small nick in the skin
is made with a surgical blade to allow introduction of the biopsy
needle.
• The biopsy needle is introduced within close proximity to the upper
aspect of the lower rib to avoid the intercostal nerve and vasculature.
• As the needle is introduced, a series of several successive "pops"
may be felt.
• Small amounts of saline contained in the syringe are
flushed until resistance is encountered.
• The resistance is the liver edge; at this point, the
needle is withdrawn slightly and flushed again to
remove debris.
• The patient is asked to expire and to hold his/her
breath.
• The liver biopsy is then taken
• During the time of biopsy, the patient is instructed to hold his/her
breath.
• The biopsy is performed with breath held in expiration, to avoid lung
descent .
• Under US guidance, observe as the needle tip crosses the capsule
prior to deploying the cutting device.
• In patients who have difficulty complying with breath holding, they
may be allowed to breathe once the needle tip is deep into the liver
capsular surface.
• The cutting needle is then fired with US documentation of the site.
• Ensuring that the tip of the needle is deep into the capsule
prior to firing reduces the number of passes required to obtain
an adequate specimen. Most institute, most radiologists prefer
using 18-G cutting Temno needle.
• Depending on operator preference and training, the coaxial
technique and guide technique have also been used.
• With US guidance, both lobes of the liver may be assessed in
real time and a favorable approach decided upon.
• Many radiologists now prefer the ease of access to left lobe
via a subxiphoid/subcostal approach.
• This technique is performed near the midline away from major
vessels in the area of the linea alba.
• Radiologists must maintain awareness of the
position of the heart and pericardium, as well as
provide the patient with appropriate breathing
instructions to avoid excessive motion.
• Usually, this involves breath held in inspiration
to bring the left lobe inferior.
• The needle is then directed to the right into the
left lobe of the liver,.
What are the risks and complications?

• Fortunately, side effects are usually rare.

• Sometimes you will notice occasional discomfort at the site of
the biopsy for a few weeks, particularly when you are moving
around.
• Liver biopsy is a safe procedure with few complications
• Some possible complications may include:
• Pain and bruising at the biopsy site
• Bleeding for a long time from the biopsy site, either inside or
outside the body
• Infection near the biopsy site
• Accidental injury to another organ
Bleeding

• There is a small risk of bleeding. This occurs in less than 1 in

100 cases.if there is any bleeding it will usually happen in first
few hours after the bipsy. This is why pt needs to be monitored
for 4-6hrs afterwards. Bleeding usually settles within this
time. It is rare for a blood transfusion to be needed. Very
occasionaslly another procedure may be needed which uses a
small tube placed in artery in groin to block a bleeding blood
vessel in the liver. Rarely an operation may be required.
Pneumothorax

• This can occur in 500 patients.This is when a

small hole is accidently made in the lining of
lungs which allows a tiny amount of air to pass
between the lung and chest wall, causing
breathless to patient. For this usually no
treatment is need imediately and air is gradually
abdorbed by lung lining, usually air need
removing with a needle/aspiration,=,
Bile leak

• This occur in less than 1 in 100 cases. This is as a

result of biopsy needle damaging a small bile
duct in the liver, leading to abdominal pain,but
this normally settles with pain relief over 2 to 3
days.
• https://www.youtube.com/watch?v=2SIZOqJiU
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• https://youtu.be/y2kXIH2y5Vo?si=-
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RENAL BIOPSY
 Renal Biopsy Aiming to
achieve

• a specific diagnosis
• reflect the level of
disease activity .
• provide information to
allow decisions of
treatment .
 INDICATIONS FOR RENAL
BIOPSY
•Unexplained renal failure.
•Nephrotic syndrome.
•Isolated nonnephrotic
proteinuria.
•Isolated glomerular hematuria.
•Renal masses (primary or
secondary)
•Renal transplant rejection.
•Renal transplant dysfunction.
Biopsy Adequacy
• The number of glomeruli in the sample is the major
determinant of whether the biopsy will be
diagnostically informative. A typical useful biopsy
sample will contain 10 to 15 glomeruli .
• An adequate biopsy should provide samples
for : immunohistology and electron microscopy
(EM).
• cores should be viewed after being taken
under microscope to ensure that they
adequate
 Informed Consent
• The patient has the rights to get answers for these basic questions:
What?
• Piece from the kidney
Why?
• Guide treatment
• Tell the prognosis
How?
• Local anesthesia
• US/CT guided or others
• Rest in bed for 8h
• What is the risk benefit?
• What are the precautions
 Precautions
• Standard of care: Precautions (CBC, Coagulation profile, etc.
• Impact of patient and procedure on blood transfusion
• Needle gauge
• Number of needle passes
• Use of anti-platelets
• Age
• Serum creatinine
• Blood pressure
 Contraindications to Renal
Biopsy
 bleeding diathesis
 Inability of the patient to comply with instructions
(Sedation or in extreme cases general
anesthesia
( may be necessary)

 Relative contraindications to renal biopsy are

Hypertension (>160/95 mm Hg), hypotension,
perinephric abscess, pyelonephritis,
hydronephrosis, severe anemia, large renal
tumors, and cysts.
Procedure
 Renal Biopsy Technique
Percutaneous native Renal Biopsy

• Biopsy is performed by nephrologists

• Continuous (real-time) ultrasound guidance
• Disposable automated biopsy needles. (16-
gauge needles)
• The patient is prone, and a pillow is placed under the
abdomen at the level of the umbilicus to straighten
the lumbar spine and to splint the kidneys.
commercially available renal biopsy kit, consisting of an
automatic spring-loaded biopsy system with an 18 G needle and a
1 or 2 cm slit, sterile drapes, sterile gauze, sterile ultrasound gel, a
syringe and needle for anesthesia, a scalpel, and a swab for
surface disinfection.
• Ultrasound is used to localize the lower pole of the kidney (usually the
left kidney).
• A pen mark is used to indicate the point of entry of the biopsy needle.
• The skin is sterilized with povidone-iodine (Betadine) . A sterile fenestrated
sheet is placed over the area to maintain a sterile field.
• Local anesthetic (2% lidocaine ) is infiltrated into the skin at the point
previously marked.
• the ultrasound probe is covered in a sterile sheath.
• A stab incision is made through the dermis to ease passage of the biopsy
needle.
• Under ultrasound guidance, a 10-cm, needle is guided to the
renal capsule.
• As the needle approaches the capsule, the patient is instructed to take a breath
until the kidney is moved to a position such that the lower pole rests just under
the biopsy needle, and then to stop breathing.
• The biopsy needle tip is
advanced to the renal
capsule, and the trigger
mechanism is released, firing
the needle into the kidney .

• The needle is immediately

withdrawn, the patient is
asked to resume breathing,
and the contents of the
needle are examined .
• under an operating microscope to ensure that
renal cortex has been obtained .
• A second pass of the needle is usually necessary to
obtain additional tissue for immunohistology and EM.
• If insufficient tissue is obtained, further passes of the
• needle are made.
• However, passing the needle more than four
times is associated with a modest increase in the
post biopsy complication rate.
• Once sufficient renal tissue has been obtained, the
skin incision is dressed and the patient rolled directly
into bed for observation.
 Post biopsy Monitoring

• After the biopsy, the patient is placed supine

and subjected to strict bed rest for 6 to 8hours.
• The blood pressure is monitored frequently
• urine examined for visible hematuria
• and the skin puncture site examined for
excessive bleeding.
• If there is no evidence of bleeding after 6 hours,
the patient is sat up in bed and subsequently
allowed
• to move.
• If visible hematuria develops, bed rest is
continued until the bleeding settles.