How Is a Transjugular Liver Biopsy Done?

In a transjugular liver biopsy, the doctor inserts a catheter through the jugular vein in the neck and threads it down to the liver to collect a tissue sample. This is less invasive than a traditional liver biopsy.

A transjugular liver biopsy is an intravenous technique to obtain liver tissue sample for a biopsy. The doctor inserts the biopsy needle, covered in a thin, flexible sheath, through the jugular vein in the neck down into the liver’s primary vein (hepatic vein) to access the liver.

A classic liver biopsy is performed with a long needle inserted through the abdominal wall into the liver (percutaneous liver biopsy). 

The transjugular liver biopsy is considered safer for some patients, since the doctor can avoid puncturing the gallbladder and the liver’s protective covering (liver capsule).

A transjugular liver biopsy is usually performed when percutaneous liver biopsy is not feasible. The transjugular approach is considered by some to yield insufficient tissue samples, but with advancement in the field of surgical instruments, this technique is becoming more popular.

A liver biopsy is performed to diagnose liver disease by testing the liver tissue in a laboratory. A liver biopsy is used to

• Diagnose liver diseases that can’t be identified by less-invasive tests
• Obtain tissue from a liver abnormality found in imaging tests
• Diagnose and stage the severity of liver diseases such as
  • Liver cirrhosis
  • Liver cancer
  • Nonalcoholic fatty liver disease
  • Hepatitis
  • Primary sclerosing cholangitis
  • Genetic liver diseases
• Monitor the liver after a transplant
• Develop and review treatment for liver disease

A transjugular liver biopsy is performed in people with diffuse liver disease and one or more of the following conditions:

• Bleeding disorder (coagulopathy)
• Severe collection of fluid in the abdomen (ascites)
• Blood-filled cavities in the liver (peliosis hepatis)
• Failed percutaneous biopsy
• Morbid obesity

A transjugular liver biopsy may be performed in combination with certain other procedures such as

• Venogram: X-ray of the veins with injection of contrast dye
• Transjugular intrahepatic portosystemic shunt (TIPS): creating a shunt between the hepatic vein and portal vein to reduce portal hypertension

A transjugular liver biopsy is performed under local anesthesia and mild sedation for adults, and general anesthesia for children. The patient does not feel any pain during the procedure but may have some post-procedure pain that can be managed with painkillers.

An interventional radiologist performs a transjugular liver biopsy as an outpatient procedure in the radiology lab, unless the patient is already hospitalized for care.

Preparation

Prior to the procedure the patient may be required to

• Undergo imaging tests, and blood tests to check coagulation parameters and liver function.
• Undergo corrective treatment if blood coagulation is abnormal.
• Avoid eating anything for eight hours prior to the procedure.
• Check with the doctor before taking any regular medications.
• Inform the doctor of any allergies, or if pregnant.

Procedure

The interventional radiologist

• Administers painkillers and mild sedation through an IV line.
• Administers local anesthesia at the puncture site over the right jugular vein in the neck.
• Makes a small incision on the skin at the needle insertion site.
• Punctures and inserts a thin tube, into the jugular vein.
• Advances the tube through the right jugular vein into the right hepatic vein, with guidance from ultrasound images.
• Injects contrast dye through the tube for a venogram, performed with continuous X-ray (fluoroscopy) images.
• Inserts the biopsy needle through the tube into the vein.
• Extracts tissue samples from the region where the liver is connected to the hepatic vein.
• Withdraws the tube and the biopsy needle with the liver tissue, gently back through the veins and out of the jugular vein.
• Controls bleeding at the puncture site and applies bandage over it.

A transjugular liver biopsy may take up to an hour to complete. The patient’s blood pressure and heart rate will be monitored for a few hours after the procedure. The patient will be able to leave the same day and resume normal activities within a day.

The patient must avoid heavy lifting and strenuous activities for a week after the procedure. Further treatment of the patient will depend on the liver biopsy results.

The transjugular liver biopsy procedure is considered a relatively safe procedure even for children and the elderly. There is low level radiation exposure. 

Potential complications include the following:

• Bleeding, if occurring at the biopsy site, usually drains into the hepatic vein. 
• Bone marrow transplant patients are more at risk for bleeding from the hepatic artery, which may require transfusion and other treatments
• Liver capsule puncture and abdominal pain
• Allergic reaction to the dye material
• Neck hematoma
• Blood in the biliary tract (hemobilia)
• Abnormal connection (fistula) between hepatic artery and portal vein or bile ducts
• Bile leak
• Irregular heartbeat (arrhythmia)
• Lung collapse (pneumothorax)
• Injury to the jugular vein wall causing collection of blood in the tissue inside the vessel wall (pseudoaneurysm)
• Death