The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [444]
Complications
Infection
There is a risk of urinary infection in approximately 5% of cytoscopies performed. If an infection were to occur, relevant prescribed antimicrobial therapy may be required (Rodgers et al. 2006).
Liver biopsy
Definition
Liver biopsy involves percutaneous puncture using a biopsy needle and removal of a small piece of the liver (Al Knawy and Shiffman 2007).
Anatomy and physiology
The liver is the largest organ in the body. It weighs between 1 and 2.3 kg and is a highly vascular organ. It is incompletely covered by a layer of peritoneum and enclosed in a thin inelastic capsule. There are four lobes in the liver, with the two most obvious ones being the large right lobe and the smaller left lobe which is wedge shaped. The caudate and quadrate lobes are on the posterior surface (Waugh et al. 2006).
Functions of the liver
The liver has many functions including:
carbohydrate metabolism and contributing to maintenance of plasma glucose levels
fat metabolism
protein metabolism
defence against microbes and breakdown of erythrocytes
detoxification
inactivation of hormones
bile secretion
heat production
storage of some vitamins, iron, copper and glycogen (Waugh et al. 2006).
Evidence-based approaches
Rationale
A liver biopsy is an invaluable tool for diagnosing or monitoring conditions affecting the liver, such as cirrhosis, inflammation or hepatitis of various causes and some metabolic liver disorders (Al Knawy and Shiffman 2007).
Indications
Diagnosis of cirrhosis.
Diagnosis of cancer both primary and secondary.
Miliary tuberculosis.
Amyloidosis.
Contraindications
An unco-operative or confused patient.
Severe purpura.
Coagulation defects.
Prolonged clotting time.
Increased bleeding time.
Severe jaundice.
Under 3 years of age.
Current right lower lobe pneumonia.
Current pleuritis (Al Knawy and Shiffman 2007).
Methods of liver biopsy
There are a variety of methods for conducting a liver biopsy. A retrospective study by Manolakopoulos et al. (2007) found that the ultrasound-assisted approach was as safe as the ultrasound-guided approach and both obtained adequate samples.
Percussion palpation approach
This method is also known as the blind approach where the liver is palpated in order to determine the position required for the liver biopsy.
Image-guided approach
Image guidance may be conducted utilizing ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) but the preferred method is ultrasound. The ultrasound method utilizes continuous ultrasound or site marking immediately prior to the procedure (Al Knawy and Shiffman 2007).
Ultrasound-assisted approach
The ultrasound is utilized immediately prior to the procedure and a mark is left on the skin indicating the puncture site. It is also known as the ‘X’ marks the spot technique.
Ultrasound-guided approach
The ultrasound is utilized throughout the procedure where the liver and biopsy needle are viewed in real time (Al Knawy and Shiffman 2007).
Preprocedural considerations
Equipment
Aspiration or suction type needle
There are a few varieties of aspiration or suction type needles such as the Jamshidi, Klatskin and Menghini (Figure 11.5). The Menghini needle has a retaining device to minimize the risk of the sample being aspirated into the syringe and is the most commonly used. It is 6 cm long and approximately 1.4 mm wide.
Figure 11.5 Liver biopsy needles.
Cutting type needles
The Tru-Cut needle utilizes a cutting sheath to obtain the specimen. It is advanced approximately 2–3 cm into the liver and a sample of 12 cm with a diameter of 1 mm is collected.
Pharmacological support
Nursing staff should take a nursing history reviewing social and medical history and determining allergy status. Up to 7 days prior to the procedure, the referring medical team must ensure that a full blood count, clotting screen and biochemistry have been