Route of Liver Biopsy – Percutaneous, EUS, TJLB, Laparoscopic: How to Choose?

A liver biopsy is usually the most specific test to assess the nature and severity of liver diseases, such as multiple parenchymal liver disease, abnormal liver tests of unknown etiology and fever of unknown origin. In addition, it can be helpful in monitoring and detecting focal or diffuse abnormalities in imaging studies.

Several methods are currently available for obtaining liver tissue: percutaneous biopsy, transjugular biopsy, EUS and laparoscopic biopsy. Each of these methods has its advantages and disadvantages.

Plugged liver biopsy (PLB), a modification of percutaneous liver biopsy, is performed in patients with impaired coagulation where transjugular liver biopsy (TJLB) is unavailable. It also provides greater access to both hepatic lobes, thereby increasing the adequacy and yield of tissue. Additionally, this method is cost-effective, requires less technical skills, is suitable for patients who are obese, and results in lower post-procedure discomfort. Hence, it can be used in various clinical settings.

On the other hand, TJLB is known to reduce the overall risk of complications associated with PLB. This method can also be used in a patient with coagulopathy and acute liver failure.

However, noninvasive methods are gaining acceptance at present. They are also considered reliable and applicable tools for predicting the course of liver cirrhosis, such as EUS-LB. This method can diagnose the presence of liver disease that progresses in a zonal fashion, such as primary sclerosing cholangitis, viral hepatitis and nodular regeneration. In contrast, some of the disadvantages associated with this are the complexity and expensive nature of the procedure.

The laparoscopic method can be used to visualize the peritoneum and to decide between operation and conservative treatment strategies in cases of peritoneal carcinomatosis. Also, this is used to biopsy hepatic masses when vascular structures limit the transcutaneous approach.

Remember, “One size does not fit all”, so an individualized approach is the key to finding an appropriate modality. Furthermore, the choice of one technique over the other depends on the following:

• Availability
• Personal preference
• Clinical situation.