A laparoscopy is a procedure using a flexible (bendy) fibre optic tube with a tiny camera and a light on the end. This is called a laparoscope. It is inserted into your tummy through a small cut in your skin ('keyhole') to take pictures of your liver. If needed, a biopsy (see below) of your liver can be taken at the same time. A laparoscopy may also be used to follow up something seen on an X-ray or used alongside certain surgical procedures such as removal of the gallbladder (cholecystectomy) for gallstones.
A laparoscopy is performed under a general anaesthetic. Afterwards it can be painful (you may have a stitch or two), but tablet painkillers are usually enough to dull the pain. It is a good idea to have someone keeping an eye on you for 24 hours afterwards and you should not drive a vehicle during this time.
There are many causes of liver disease and it is sometimes difficult to diagnose a condition based on symptoms and simple blood tests such as liver function tests. Often a liver biopsy is the only way to diagnose your liver disease and identify how advanced it has become.
The first liver biopsy was performed in 1922 and since then it has become a standard procedure. It is considered routine by most specialists, but for a patient about to experience their first liver biopsy it can be an anxious and worrying time. A discussion with your specialist or medical advisor prior to the liver biopsy is useful to help you deal with any unnecessary fears.
A liver biopsy is usually performed in one day and only occasionally requires an overnight stay. Usually you can expect to go home later the same day or in the evening. You must, however, make sure that you receive further information about this when talking to the specialist prior to the procedure.
Your liver biopsy will be performed by a doctor who may be a gastroenterologist, hepatologist or a radiologist. There may also be some difference between individual biopsies other than those described here.
You will need to give your consent (permission) to the medical staff to carry out the biopsy. A blood sample will be taken to check your blood’s ability to clot. This is a routine precaution to ensure the liver biopsy can be performed as safely as possible.
A local anaesthetic is given to you prior to the liver biopsy procedure. This may be above the liver area on the right side of your abdomen and below the ribs, or more likely between the lower ribs on your right side. In some cases a light sedative can be given if you require it, but discuss this with your doctor.
Sometimes the liver biopsy will be done under ultrasound guidance so that the liver can be seen and the biopsy directed by the imaging. You may already have had an ultrasound performed prior to the biopsy.
When the local anaesthetic has started to work (the area will feel numb), you will be asked to lie on your back or on your side, depending on where the doctors decide to insert the biopsy needle. This is a long thin tube that is inserted through your anaesthetised skin. You may be asked to take a few deep breaths before the needle or biopsy device is inserted and to hold your breath. Once the needle is inserted it is withdrawn quickly to remove a very small sample of liver tissue.
The term ‘biopsy’ actually refers to the sample of tissue taken even though you will hear it being used for the procedure itself.
You will then be asked to lie on your right side so that the weight of your body presses on the wound. This is to make sure the wound clots and then heals. It also means that you will need to remain in bed on your side or on your back for up to six or eight hours so you are advised to go to the toilet before the liver biopsy. It may be an idea to take a book to read or a personal music player to listen to. While you are lying in this way you will be regularly checked for pulse and blood pressure to detect any complications early.
There is a very small risk of either internal bleeding or bile leaking from the liver, but this is very uncommon.You may experience pain or discomfort during or after the liver biopsy. Not all people do, but if you experience it there can be varying degrees. You should be provided with enough pain relief after your biopsy, but discuss this with your doctor and nursing staff.
Once you have completed the recovery stage after the liver biopsy you can usually go home. You should arrange to have someone to accompany you because you should not drive or travel on your own. If you have received sedation during your biopsy you should not drive for 12 to 24 hours. If you have any worries after your return home, contact the hospital or your GP.
Your liver biopsy sample is sent to a pathologist (a doctor who identifies diseases by studying cells and tissues) who will examine it under a microscope and produce a report. This is usually in the form of a description and a number that is a measure of any inflammation and/or fibrosis seen in the sample. This may take about two weeks, but it could be longer as services will vary across the country. You will have an appointment to discuss your results with your specialist or medical advisor who will explain the findings and any possible consequences they may have on your health and possible treatment.
Occasionally if the blood clotting is too prolonged or in the presence of ascites it may not be possible to perform a liver biopsy by the conventional route. In these circumstances the liver biopsy may have to be performed via a vein in the neck. This is called a Transjugular liver biopsy. This procedure is usually limited to specialist centres and details would be discussed with you by your consultant or his team.
Liver biopsy is considered the best way for diagnosing liver disease. Other tests that are noninvasive and therefore less uncomfortable are beginning to emerge. These include the use of blood markers to detect or predict the amount of fibrosis and a technique similar to ultrasound known as elastography (FibroScan). This test measures the stiffness of your liver. The more stiffness it finds, the more fibrosis there may be.
However such tests do not differentiate between liver diseases i.e. they are not diagnostic tests but markers of the severity of liver injury. For further information about these tests talk to your specialist or your medical team.
Pathology or Histology
Pathology is the study of diseased tissues. Histology looks at the detailed structure of cells and tissues under the microscope and this is what is studied on a biopsy. The histology is helpful in working out the cause of the liver disease and the stage (how advanced the liver disease is) such as whether there are changes such as cirrhosis.
Percutanaeous Transhepatic Cholangiography (PTC) and Biliary Drainage
This is a procedure that allows the radiologist to examine the bile duct system of your liver. The procedure is done under local anaesthetic and will require a short stay in hospital.
‘Percutanaeous’ means through the skin. In this case a thin needle is passed through your skin and through the liver into a bile duct. A dye is injected so that the bile duct system becomes outlined on X-ray. This picture will show any narrowing or blockages. If the duct is blocked, a flexible tube is inserted and remains in the duct. This will also allow your bile to be drained into a collection bag. Usually, either at the time of the procedure or within a few days, a small wiremesh or plastic tube called a stent will be placed across the blockage to allow the drain to be removed.