Liver biopsy is still the gold standard for evaluation of acute and chronic liver diseases, despite achievements regarding noninvasive diagnosis and staging in liver diseases. Transjugular liver biopsy (TJLB) has proved a good option when ascites and/or significant coagulopathy precludes a percutaneous approach. Because diagnostic hemodynamic procedures can be performed during the same session, it is useful in many clinical settings, regardless of the absence of percuteaneous contraindications. TJLB is a safe technique able to provide good-quality specimens with a low rate of complications. This article presents an overview of TJLB that discusses the technique, applicability, indications, contraindications, complications, and diagnostic accuracy.

Keywords

Transjugular liver biopsy

Tru-Cut needle

Menghini needle

Tissue sample quality

Liver specimen

Ultrasound guidance

HVPG

Cirrhosis stage

Key points

Introduction: nature of the problem

Despite new advances in the noninvasive diagnosis of chronic liver disease (CLD), liver biopsy is still the gold standard for evaluation of acute and chronic liver injury.1,2 Recently, liver biopsy has been questioned because of drawbacks, such as sampling error3,4 and intra- and interobserver variability5; however, the role of liver biopsy in diagnosis of liver disease remains highly valuable. Liver biopsy remains essential for the diagnosis of some liver diseases, such as nonalcoholic steatohepatitis, abnormal liver tests from unknown origin, or autoimmune hepatitis. Moreover, TJLB is indicated particularly in patients with fulminant hepatitis or acute liver failure of unknown cause; in the setting of bone marrow transplantation, where it helps to differentiate between sinusoidal obstruction syndrome, graft-versus-host disease, recurrent malignancy, and drug toxicity6,7; and in patients with alcoholic hepatitis where histologic alterations have prognostic relevance.8

TJLB was first described in 1964 in dogs,9 and in 1967 a transjugular catheterization of the hepatic veins was first performed in humans as an approach to the biliary tract for cholangiography.10 TJLB is usually performed when ascites and/or a significant coagulopathy preclude a percutaneous approach due to the risk of severe hemorrhage. Given that it is possible to measure hepatic hemodynamics during the same procedure, however, TJLB is used even in the absence of contraindications for PLB. TJLB may increase the probability of obtaining a good biopsy sample by performing several passes without increasing the risk of complications. This article presents an overview of TJLB. The technique, applicability, indications, contraindications, complications, and diagnostic profitability and outcomes of the different sampling approaches are discussed.

Indications/Contraindications

TJLB is an effective and safe technique for obtaining liver tissue in patients with end-stage liver disease and entails lower incidence of hemorrhagic complications than PLB.11 As a consequence, TJLB has traditionally been indicated for conditions where there is a high risk of bleeding.12 Other common indications of TJLB are morbid obesity, small livers, or suspicion of hepatic peliosis.13 Patients with heart failure and cirrhosis14 often need a careful assessment of liver function that may include HVPG assessment and TJLB15 to evaluate the need of combined heart and liver transplantation. Box 1 summarizes the indications of TJLB.

There is no specific contraindication for TJLB and the risk-benefit ratio should be evaluated on a case-by-case basis. TJLB should be avoided when central venous access is absent (inferior vena cava obstruction) or in cases of polycystic liver disease, suspicion of cholangitis, and uncontrolled sepsis. Box 2 summarizes some of the relative contraindications.

TJLB is not indicated in patients with focal hepatic lesions. In special circumstances, however, when PLB is contraindicated and there is strong indication of biopsy, TJLB could be performed under external US guidance.

Technique/Procedure

Preparation