Definition
Assisting with a liver biopsy is a critical nursing responsibility that demands precision, sterile technique, and vigilant monitoring. It involves supporting the physician during the collection of liver tissue for diagnostic evaluation.
Purpose
- To diagnose liver disease through histologic study.
- Identify diseases such as cirrhosis, hepatitis, fatty liver disease, or liver cancer.
- Evaluate the extent of liver damage or fibrosis, especially in chronic liver diseases.
- Determine how well a treatment plan is working for liver-related conditions.
- Clarify findings from blood tests, imaging studies, or unexplained symptoms.
Types of biopsy
There are three main types of liver biopsy procedures, each suited to specific medical conditions and patient needs:
- Percutaneous Liver Biopsy:
- This is the most common method, where a needle is inserted through the skin into the liver to collect a tissue sample.
- It is minimally invasive and typically performed under local anesthesia.
- Transjugular Liver Biopsy:
- This method involves inserting a catheter into a vein in the neck (jugular vein) and guiding it to the liver to obtain a tissue sample.
- It is often used for patients with bleeding disorders or fluid in the abdomen (ascites), as it reduces the risk of bleeding.
- Laparoscopic Liver Biopsy:
- This involves making small incisions in the abdomen and using a laparoscope (a thin tube with a camera) to guide the biopsy.
- It is typically used when a direct view of the liver is needed or when other abdominal issues are being addressed simultaneously.
Contraindications
- Severe thrombocytopenia.
- Local infection of the lung base.
- Prolonged prothrombin time or any other known bleeding disorder.
- Peritonitis.
- Massive ascites.
- Uncooperative client.
- Extrahepatic obstructive jaundice, especially with an enlarged gallbladder.
Articles
A sterile tray containing the following:
- Sponge holding forceps.
- Syringe 5 ml with needles to give local anesthesia.
- Liver biopsy needles with stylet (Vim Silverman or Menghini biopsy needle).
- Specimen bottles with cork.
- Bowl to take cleaning lotion.
- Aspiration syringe, if aspiration biopsy is to be done.
- Dissecting forceps.
- Dressing towels or slit towel.
- Cotton balls, gauze pieces, and cotton pads.
- Gown, gloves, and masks.
Clean tray containing the following:
- Mackintosh and towel.
- Kidney tray.
- Spirit, iodine, and tincture benzoin.
- Lignocaine 2%.
- Apron.
- Adhesive plaster and scissors.
- Formalin 10% to preserve the biopsy specimen.
- Shaving set.
Preparation of the Patient
Preparing to assist with a liver biopsy involves several critical steps to ensure patient safety and the success of the procedure:
- Medical History Review:
- Confirm the patient’s medical history, including any bleeding disorders or liver conditions.
- Ensure the patient has undergone necessary blood tests, such as clotting studies (PT/INR) and platelet count.
- Medication Adjustments:
- Advise the patient to stop taking blood-thinning medications like aspirin or anticoagulants at least a week before the procedure.
- Ensure the patient continues other prescribed medications unless instructed otherwise.
- Fasting:
- Patients are typically required to avoid eating or drinking for several hours before the biopsy.
- Consent and Communication:
- Explain the procedure to the patient, addressing any concerns or questions.
- Obtain informed consent before proceeding.
- Clothing and Accessories:
- Advise the patient to wear loose, comfortable clothing and remove any jewelry or metallic items.
Procedure
| Nursing action | Rationale | |
| Before procedure | ||
| 1. | Explain the procedure to the patient and family and inform him how he has to cooperate. | Helps in obtaining cooperation of the patient and reduces anxiety. |
| 2. | Obtain informed consent from the patient. | Prevents litigation of staff members. |
| 3. | Ensure that patient’s coagulation profile is in normal limits. | Prevents bleeding complication during the procedure. |
| 4. | Check baseline vital signs and record. | Helps in obtaining baseline data. |
| 5. | Instruct patient to be NPO for 6-8 hours before the procedure. | Prevents risk of aspiration during the procedure. |
| 6. | Administer premedication (analgesia, sedation) as per physician’s instruction. | |
| 7. | Instruct patient to refrain from ingesting aspirin, NSAID or anticoagulants 2 weeks before the procedure. | Prevents bleeding tendencies. |
| During procedure | ||
| 8. | Make the patient to lie down in supine position or in left lateral position with right arm elevated. | This position helps for easy insertion of needle. |
| 9. | Shave and clean the 8th and 9th intercostal space at the incision site. | |
| 10. | Instruct patient to take several deep breaths and to hold the breath while the needle is introduced through the intercostal or subcostal tissues into the liver. | Avoids puncturing of the diaphragm. |
| 11. | The special needle assembly is rotated to separate a fragment of tissue and then is withdrawn. | |
| 12. | Assist physician to seal puncture site with tincture benzoin and apply pressure dressing. | |
| 13. | Collect the specimen in a sterile container, label it, and send to laboratory. | |
| 14. | Instruct patient to lie on his right side. | |
| After procedure | ||
| 15. | Record the procedure with date, time, method used, and complications, if any. | Acts as a communication between staff members. |
Postprocedural care
- Monitor vital signs every 15 minutes for 2 hours, and every 60 minutes for 4 hours.
- Assess for tachycardia and decreasing blood pressure which may indicate hemorrhage.
- Check the puncture site by monitoring the dressing, palpating the surrounding area for crepitus, and observing for hematoma formation.
- Observe for pain in the right upper quadrant of the abdomen caused by a subscapular accumulation of blood or bile, or at the right shoulder as a result of blood on the undersurface of the diaphragm.
- Maintain the client on bed rest in right lateral position for 24 hours following the procedure to reduce the risk of hemorrhage and bile leakage.
- Give vitamin K if prescribed.
- Administer post-procedure medications on an individual basis, depending on the client’s physical status.
- Assess respiratory status for manifestations of dyspnea.
- Check abdominal girth every hour for first 12 hours.
Complications
Immediate complications
- Abdominal pain.
- Pneumothorax.
- Injury to the stomach, pancreas, small and large intestines, kidney, inferior vena cava and diaphragm
Late complications
- Hemorrhage.
- Shock and collapse.
- Bile peritonitis.
Special Consideration
- Confirm the patient’s medical history, including bleeding disorders or liver conditions.
- Ensure necessary blood tests, such as PT/INR and platelet count, have been conducted to assess clotting ability.
- Verify that blood-thinning medications have been stopped as per the healthcare provider’s instructions.
- Monitor for any contraindications, such as severe coagulopathy or infection at the biopsy site.
- Explain the procedure to the patient, addressing any concerns or questions.
- Obtain informed consent and ensure the patient understands the risks and benefits.
- Maintain strict sterile conditions to minimize the risk of infection.
- Ensure all equipment, including the biopsy needle and antiseptic solution, is properly prepared.
- Assist the patient into a supine position with their right arm raised above their head to expose the liver area.
- Ensure the patient remains still during the biopsy to prevent accidental injury.
- Observe the patient for signs of discomfort, bleeding, or complications during the procedure.
- Monitor vital signs closely to detect any adverse reactions.
- Monitor the patient for delayed complications, such as bleeding, infection, or bile peritonitis.
- Position the patient on their right side for 2-4 hours to apply pressure to the biopsy site and reduce bleeding risk.
- Record the procedure details, including the type of needle used, patient tolerance, and any complications.
- Ensure the biopsy specimen is properly labeled and sent for analysis.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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