Your numbers have been off and now you need a liver biopsy.  What can you expect?  The questions are flooding already.  Is it really necessary?  What is the biopsy procedure like?  Is it scary?  Does it hurt?  What about recovery?

Whew, y’all.  Life has been a bit crazy and I took a break from blogging to ease some of the stress.  As you know from a previous blog post, when I get stressed, my liver numbers go haywire.  And they did.  So I needed to take a step back for a bit (a long bit, as it turns out).

Mr. Graft Diaries and I were moving which is one thing.  But since my numbers were high, there were far more frequent trips for blood draws and tests.  One of these trips was for a liver biopsy, so it seemed appropriate to write a blog about it.

What is a Liver Biopsy?

Let’s start with the basics.  A liver biopsy is a procedure performed to remove a small piece of tissue for testing under a microscope.  It is usually performed in an outpatient setting by a doctor.  In my case, an attending physician oversaw the procedure a hepatology fellow performed.

Types of Liver Biopsy

The most common type is a percutaneous liver biopsy, but there are several.

Percutaneous

Transjugular

I received my first liver biopsy using this method.  My INR was very high (meaning my blood was thin and took longer to clot), and I also had ascites.  Because of these things my doctors preferred this method to minimize complications.

For this procedure, doctors use IV sedatives and a local anesthetic.  A small incision is made in your jugular vein and a tube (sheath) is inserted into the vein.  Contrast dye is injected to make visualization more clear.  The doctor guides a needle down the sheath and through the hepatic vein.  Once in the liver, they collect one or more samples.  This sample is usually much smaller than the percutaneous method.

Laparoscopic

Why Is a Liver Biopsy Necessary?

Doctors will not recommend a liver biopsy right out of the gate.  It’s invasive and carries risks (more on that in a minute).  But before biopsy, there may be one or more other tests done to help with diagnosis:

• Blood tests and changes to medications
• Ultrasound
• MRI
• CT (“CAT” scan)

I had gone through numerous blood tests and medication adjustments.  Still, my liver enzymes (AST and ALT) were still elevated.  At that point, I received an ultrasound.  Doctors found no abnormalities in the liver.  Inflammation was present, but that is expected when liver numbers are high.  So, with no imaging explanation, I received a biopsy to be sure there was no other issue.

Sometimes imaging tests (Ultrasound, MRI, CT) may reveal a mass or other abnormality that cannot be explained.  This could be another reason for a biopsy.

Biopsies are also performed to confirm diagnoses and liver disease severity pre-transplant:

• Non-Alcoholic Fatty Liver Disease
• Wilson’s Disease
• Chronic Hepatitis (B or C)
• Alcoholic Liver Disease
• Biliary Conditions like PBC or PSC

How to Prepare

Your doctor or care team will talk with you about the medications and supplements you take.  They may ask for you to skip medication or supplements that could increase the risk of bleeding.

There will be some pre-procedure blood tests run to check things like your INR (clotting factors).

In most cases, you’ll receive a sedative so you should plan to have someone take you home from your procedure.

What About the Risks?

Different types of liver biopsies involve different risks.  Be sure to discuss with your doctor the specific risks associated with your case.  The most common risk is pain at the incision site.  This is usually very mild (I took acetaminophen later in the day after mine).  If your pain is more severe, you should speak with your doctor.

As with any invasive procedure, there are more serious complications as well.  Keep in mind these are very rare and include bleeding, infection, or damage to surrounding organs.  Your doctor will discuss these with you and advise you on signs to watch for when you go home.

Recovery

I’ll speak about percutaneous liver biopsy here since it is the most common.  After the procedure, you’ll receive a bandage at the incision site and you’ll move into recovery.

In recovery, nurses will monitor your vitals and pain levels.  Additionally, they will check your incision site and likely give you something small to eat and drink.  After a couple of hours, they may want you to get up and walk to be sure you are not having any issues with balance.

There could also be some lifting restrictions for a few days, but anything specific to your case will be discussed with you prior to your discharge.

Fear!

So is a biopsy scary?  Well, it depends on what type of fear you’re talking about.  Certainly, any time you are having a procedure done that involves incisions, it’s a little scary.  But try to remember these are pretty common procedures done by professionals.

Aside from the obvious, “Oh geez, this could hurt and I hate needles!” fear, there is the mental fear.  If you are pre-transplant, there are so many things going on and the whole process is scary.  Hearing about unfamiliar procedures is anxiety-inducing for sure.

Transplant recipients have gone through something that has changed us forever.  We understand the value of life and take the new life we’ve received as something sacred.  We take the right doses of meds on time like it’s our job (right?).  We are mindful of the foods we eat (and don’t eat for that matter).  We take care of our gift because we know that someone made the most incredible decision a person could make and we honor them for it.  Every day.

So when something goes awry with our transplanted organ, we inherently panic a little.  Speaking for myself, it can be challenging to refrain from worst-case scenario thinking when there are bumps in the road.  I teetered on the very narrow line of life and death pre-transplant.  Because of that trauma, fear creeps in thinking of having to go through some of those things again.

Keepin’ It Together

Thankfully, my biopsy this time showed no signs of cellular rejection.  But that’s not always the case.  The first biopsy I received showed De novo Autoimmune Hepatitis.  The second?  Cellular rejection.

Even though I have a tendency to think the worst initially, my own history has shown me that elevated numbers, ultrasounds, biopsies, IV steroids, and medications are all manageable.