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Transjugular Liver Biopsy- Indications, Procedure, and Complications

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Transjugular liver biopsy is a procedure that involves the removal of liver tissue through the jugular vein and hepatic vein. Read on to know more.

Written by

Dr. Janani R S

Medically reviewed by

Dr. Jagdish Singh

Published At November 4, 2022
Reviewed AtNovember 4, 2022

Introduction:

Transjugular liver biopsy is a procedure that removes a small portion of the liver tissue to view the pathological changes at a microscopic level. This procedure is done on patients who have liver disease that has spread all over the liver, bleeding disorders, and ascites (fluid accumulation in the abdomen).

What Is Biopsy?

A biopsy is a procedure where a small portion of the diseased organ or tissue is removed and is viewed under a microscope for any pathological changes. This is a confirmatory test to rule out if the lesion is benign (non-cancerous) or malignant (cancerous).

What Is a Transjugular Biopsy?

A jugular vein is a set of veins present on both sides of the neck. It carries blood from the skull, brain, face, and neck to the heart. In a transjugular biopsy, a catheter (a tube that is thin and flexible) is inserted into the jugular vein and guided to the hepatic vein, then enters the liver to remove the tissue for biopsy. Hepatic veins are blood vessels that carry blood from the liver to the heart.

When Can Transjugular Biopsy Be Performed?

When a patient has the following conditions, a transjugular biopsy is performed:

  • Massive Ascites: Enlargement of the abdomen due to abnormal fluid accumulation.

  • Coagulopathy: It is a condition of excess bleeding or clotting due to decreased levels or absence of blood clotting proteins called clotting factors.

  • Hepatic Peliosis: It is a rare condition where the sinusoid capillaries produce new parts and grow fast, resulting in blood-filled spaces throughout the liver. Sinusoid capillaries are a type of blood vessel in the liver.

  • Morbid Obesity: Morbid obesity is a chronic (developed over time) condition where the BMI of the individual is 40 or BMI 35 and above and has health problems due to being overweight.

  • Failure or Contraindication of Percutaneous Biopsy: When biopsy through the percutaneous liver biopsy technique is not achieved or in conditions like the patient is not cooperative or decreased platelet count, where a percutaneous liver biopsy cannot be performed, transjugular liver biopsy will be performed.

How Is Transjugular Biopsy Performed?

  • The patient is made to lie in a position with their face upward facing the doctor.

  • The right jugular vein is the primary site of choice.

  • The site for biopsy is first cleaned and made sterile (fresh and clean) with an antiseptic (kills germs that cause infection) solution.

  • Medication to sedate (put to sleep) the patient is infused intravenously (through veins)

  • A combination of ultrasound and X-ray is used to guide the procedure.

  • A tiny hole is made in the jugular vein in the neck with a syringe. The jugular vein is approached with the help of ultrasound.

  • An anesthetic solution (a medication that blocks pain during surgery or a procedure) is injected into the site where the jugular vein is spotted.

  • A catheter is inserted through the tiny hole, and it is guided to the hepatic vein with the help of an X-ray.

  • A needle is inserted into the catheter that glides along the hepatic vein into the liver.

  • The tissue surrounding the liver is obtained for further examination.

  • The catheter is removed along with the needle. The biopsy site on the neck is compressed for about five to ten minutes to arrest the bleeding.

What Are the Complications of Transjugular Biopsy?

  • Hemorrhage: Bleeding in the hepatic vein is the most common complication.

  • Liver Capsular Rupture: Rupture or tear in the liver.

  • Pneumothorax: Pneumothorax occurs when the air escapes and fills the lung and the chest wall. This causes the lungs to collapse.

  • Hemobilia: Bleeding into the biliary tract (bile duct).

  • Neck Pain: Pain due to puncture in the neck and position of the neck during the procedure.

  • Hematoma in the Neck: It is a bruise in the neck caused by a collection of blood under the skin after an injury.

  • Infection: The patient will be at high risk of infection as the puncture site is external, and microorganisms easily invade the site.

  • Carotid Artery Puncture: Carotid artery is a blood vessel that carries blood to the head. A puncture or damage to the carotid artery can happen during a transjugular liver biopsy. It results in bleeding and hematoma (bruise) formation.

Is Transjugular Liver Biopsy Performed in Children?

Yes, transjugular liver biopsy is performed in children with high bleeding risk and ascites.

Does Transjugular Liver Biopsy Need Anesthesia?

Yes, in children, transjugular liver biopsy is performed under general anesthesia (a medication given in a gas form to inhale or in an injection form to enable sleep). But in adults, conscious sedation is used. Medications are given to put the patient in a relaxed state, and they do not feel pain, but they can feel the procedures performed on them. This is conscious sedation.

What Protocols to Be Followed Before Transjugular Biopsy?

The doctor or the nurse in charge will give a list of protocols to be followed.

  • A complete blood test will be performed to screen the levels of components of blood like red blood cells, white blood cells, platelets, and prothrombin time (measures the time taken by the blood to clot).

  • The history of allergy to contrast dyes like iodine should be ruled out. If the patient is allergic, an anti-allergic medication like Cetirizine will be administered.

  • If the patient is under blood thinner medications like Levonox, Plavix, or any other medicine of the same class, the medications need to be stopped. A few medications need to be stopped 24 hours before the procedure. A few medications may need to be stopped by consuming five to seven days before the procedure.

  • If the patient has a prosthetic heart valve or a stent, the doctor may need to modify the dose of the blood thinner medication before the procedure.

  • If the patient is diabetic, the medications can be consumed after the procedure is completed.

What Are the Protocols Followed After the Transjugular Liver Biopsy?

  • The band-aid placed on the biopsy site should be removed after 24 hours.

  • The patient is laid in a head-raised position for four hours to reduce the risk of post-biopsy bleeding.

  • The patient is not allowed to move and is made to take rest.

  • The patient is recommended to keep the biopsy site dry for 24 hours. Bathing should be avoided, and towel baths can be done if needed.

  • The patient is restricted from lifting heavy objects or performing heavy exercise for 48 hours (two days).

How Long Does It Take for the Results of Transjugular Liver Biopsy to Be Revealed?

It takes around 10 to 14 days for the results to be dispatched.

Is Transjugular Liver Biopsy Safe?

Yes, it is safe, and life-threatening complications are rare.

How Long Should a Patient Be in the Hospital for Transjugular Liver Biopsy?

It generally takes six hours to be in the hospital. The biopsy procedure is completed in one hour. The recovery time takes four hours.

Conclusion:

Transjugular liver biopsy is an alternate method to the standard biopsy technique. This technique is performed by approaching the liver through the hepatic vein and jugular vein. This technique is indicated in patients with ascites, risk of heavy bleeding, and liver disease that has spread diffusely over the organ.

It is also done when there is a failure in percutaneous liver biopsy. This technique uses ultrasound and X-ray-guided methods to approach the liver. Though this technique sounds complicated and requires six hours to be spent in the hospital until recovery, this procedure does not cause any life-threatening complications. This is a safe method of biopsy for patients who are at high risk of prolonged bleeding and clotting time.

Frequently Asked Questions

1.

When Is Transjugular Liver Biopsy Indicated?

The main indication for a transjugular liver biopsy is for diagnosis of acute alcoholic hepatitis and after a liver transplant to check hemostatic disorders. It is also indicated when diffuse liver disease is associated with severe ascites, coagulation disorder, or a combination of the two conditions. Transjugular liver biopsy can be performed in cases where percutaneous biopsy is contraindicated.

2.

How Is a Transjugular Liver Biopsy Performed?

A catheter is inserted into the vein of the neck with ultrasound and fluoroscopy guidance. Then a tiny needle is inserted through the catheter, which reaches the liver to collect a piece of tissue from the liver. Later the tube is removed, and pressure is applied at the insertion site to stop bleeding.

3.

How Safe Is a Transjugular Liver Biopsy?

 
A transjugular liver biopsy is a usually safe procedure. It has a high success rate and fewer complications. But like all procedures, there's a risk of some complications, which makes it a safe procedure for patients with severe liver disease. The risks associated with this procedure are bleeding, abdominal pain, fever, hypotension, and neck hematoma.

4.

Will Patients Be Sedated During the Transjugular Liver Biopsy?

Transjugular liver biopsy can be done with or without sedation. When sedation is given, it will be given through an intravenous (IV) line in one arm of the patient. Usually, conscious sedation is given, which makes the patient sleepy and pain-free during the procedure.

5.

What Is the Recovery Period of Transjugular Liver Biopsy?

The recovery period after transjugular liver biopsy varies depending on the sedation given to the patient. It is usually between four to six hours, and the IV (intravenous) cannula will be removed after the patient's recovery. The healthcare professionals will advise the level of activity suitable for the patient after the procedure.

6.

Does Transjugular Liver Biopsy Cause Pain?

A transjugular liver biopsy is usually performed under local anesthesia for adults, which provides mild sedation and general anesthesia for children. During the procedure, the patient does not feel any pain or discomfort, but they may experience mild pain after the procedure, and it can be painkillers. Some patients may experience abdominal pain as a complication of transjugular liver biopsy.

7.

What Is a Transjugular Liver Biopsy?

A liver biopsy is a procedure to remove a liver sample for examination. During a normal liver biopsy, a fine needle is inserted from the side of the abdomen into the liver to remove a sample of liver tissue. It can lead to complications like bleeding. In a transjugular liver biopsy, a fine needle enters the liver through the jugular vein in the neck to reach the liver. This is a safe, well-tolerated, and effective technique.

8.

What Is the Cause of Ascites?

Ascites can occur due to high pressure in the liver's blood vessels and decreased levels of a protein called albumin. In severe liver damage, conditions like chronic hepatitis, chronic alcoholism, fatty liver, and cirrhosis can lead to ascites. Also, people with cancer in the stomach can develop ascites. Congestive heart failure, pancreatitis, portal vein thrombosis, and pericarditis are other causes of ascites.

9.

What Is the Cause of Coagulopathy?

The most common cause of coagulopathy is low levels of clotting factors and platelet levels. Some genetic conditions, such as hemophilia and von Willebrand's disease, can also cause coagulopathy by reducing the clotting factors. Other conditions and factors that affect the blood-clotting ability of the body are,
 
-Anticoagulant or blood-thinning medication.
-Blood cancers.
-Liver disease like cirrhosis.
-Long-term use of antibiotics.
-Infections.
-Trauma or injury.
 -Vitamin K deficiency.

10.

What Is Coagulopathy?

Coagulopathy is a condition in which the ability of the blood to form clots is impaired, which can lead to excessive or prolonged bleeding. It can cause uncontrolled internal or external bleeding. Bleeding can occur spontaneously or following an injury or during medical procedures. Coagulopathy can cause uncontrolled internal or external bleeding.

11.

What Is the Treatment for Coagulopathy?

The healthcare specialist may prescribe medications that prevent blood clot formation. They may prescribe contraceptive pills to reduce excessive bleeding during menstruation. Also, medications that contain protein substitutes in the blood are given to ensure reduced bleeding.

12.

What Are the Complications of Transjugular Liver Biopsy?

 
Transjugular liver biopsy is a safe, well-tolerated, and effective biopsy procedure. It also has minor complications that are very rare, which include;
 
- Hematoma (collection of blood) in the neck. - Temporary problems with the voice and facial nerves.
- Puncture of the lung.
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Dr. Jagdish Singh
Dr. Jagdish Singh

Medical Gastroenterology

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