Percutaneous liver biopsy protocol

1. A detailed letter with full past medical history, recent clinical examination, investigations to date and the indication for liver biopsy should be sent to the interventional radiology team and the letter placed on Trak. Please also request an "US Guided Biopsy Liver" AND a standard "US Doppler Liver/Portal System" (and for relevant patients "US Elastography" for the day of the procedure
2. When possible, liver biopsy should be performed on an elective list (either a routine GI list or interventional radiology list)
3. The patient should be pre-assessed through the anaeshetic department 48-72 hrs prior to admission, and have Full Blood Count (FBC), Coagulation screen and Group and Save performed, with results available prior to the procedure.
4. When listing a patient for biopsy a full hour should be allocated to the procedure (i.e. 4 points, unless agreed otherwise with the list consultant and anaesthetic staff.
5. All patients should have a bed booked for a single night admission following the procedure; the patient/family advised that an overnight stay is required for observation. 

1. Fasting as per RHCYP guidelines ¹.
2. Admit to the Crichton Ward as per local policies for elective procedures (or the evening before depending upon clinical condition or travelling time from home), ensure that blood results are available and that a valid group and save sample is present in BTS
3. Blood test results MUST be reviewed with the consultant gastroenterologist supervising the list and the interventional radiologist (see checklist) prior to anaesthetic
4. In most cases Liver biopsy should not be carried out in patients with an INR >1.2 and /or platelets <80 x 10⁹/l. Consideration of the need for vitamin K and blood product support (e.g. fresh frozen plasma or platelets) should only be given in patients requiring urgent biopsy (rarely indicated) - discuss any abnormal results with the supervising Paediatric Gastroenterology consultant in all cases.
5. Ascites is also a relative contra-indication to percutaneous liver biopsy- due to the increased risk of haemorrhage.
6. Written consent will be obtained for ultrasound-guided percutaneous liver biopsy by the interventional radiologist and the known complications fully explained by the person performing the procedure.
7. With regard to sample handling, the Paediatric Gastroenterologist supervising the procedure (usually the list consultant) is responsible for correctly labelling samples for pathology (and biochemistry if relevant, e.g. tissue copper) and for any additional blood tests required on the day.

Pulse, respiration, blood pressure to be monitored closely and biopsy site regularly inspected for bleeding, redness and swelling

1. A working cannula should remain in-situ after the procedure until discharge home
2. The patient should remain in bed for a minimum of 2 hrs. For agitated/younger patients, allowing the patient to sit on the parent's lap may be more appropriate.
3. Ensure adequate pain relief is prescribed. If the patient is reviewed and is deemed to require more than paracetamol, the supervising Paediatric Gastroenterologist (on the oncall Paediatric Gastroenterologist if out-of-hours) should review the child immediately or arrange for a Senior member of Paediatric Medical Staff (e.g. Tier 2 registrar) to perform and assessment.
4. VITAL SIGNS
   • Every 30mins for 2 hours, then hourly for 4 hours
   • 4 hourly thereafter
   • Temperature should be taken 4-hourly
   • Do not step down the observation intervals if the observations are abnormal. Seek medical advice and a plan (see below)
5. Oral fluids allowed within 2 hrs and diet after 4 hrs or as per Consultant Anaesthetist and/or Consultant Gastroenterologist advice
6. Patients are to remain overnight on a medical ward to be reviewed by the Gastroenterology team the next morning prior to discharge. In select cases patients may be able to go home the evening of the procedure if deemed safe by a Consultant Paediatric Gastroenterologist ^2,3.
7. The biopsy site should remain covered and kept dry for 48 hours after the liver biopsy during which the patient should refrain from showering. The overlying dressing may be removed after 48hours

1. Hepatic/intraperitoneal bleeding
2. Bowel/kidney injury
3. Pneumothorax
4. Haemothorax
5. Bile leak
6. Infection

1. Observations are outside normal limits for age of child (use PEWS charts) - particularly tachycardia
2. Any signs of bleeding observed; pain and tachycardia are likely early signs.
3. Any signs of pain, redness or swelling around biopsy site
4. Breathlessness
5. Chest pain
6. Abdominal pain
7. Any signs of infection observed
8. If pyrexia >38°C: blood cultures together with FBC and LFTs should be checked and a low threshold for starting IV antibiotics (e.g. Tazocin).

ACTION FOR SUSPECTED BLEEDING

1. ABC - resuscitative measures as required (as per APLS guidelines).
2. Phone 2222 (PET call) if appropriate
3. Consider early Major Haemorrhage Protocol* activation (Phone 2222)
4. Ensure two wide-bore IV cannulae and obtain samples for FBC, coagulation and cross-match.
5. Obtain urgent abdominal ultrasound looking for localised haematoma or haemorrhage. This should be portable and urgent (specify that analgesia escalation is a reason for imaging).
6. Consult with Paediatric Gastroenterology team via oncall mobile (see Contact points page)

*Only accessible via NHS Lothian Intranet

1. Patients often feel some discomfort at biopsy site.
2. The patient may have paracetamol at normal prescribed doses.
3. If the patient/family have any concerns following discharge they should have a low threshold for bringing the child to the Emergency Department for review, especially in the first 24hrs after going home - the phone number for the discharging ward should also be provided as a further point of contact.
4. For further advice within working hours (Weekdays 9am-4pm) a message can be left on the Liver Helpline on 0131 312 0470; out of hours and at weekends, the local Emergency Department should be used for advice/review.
5. The child should not return to school or nursery the day of discharge.
6. The child should avoid playing sport or active games for 7 days after the procedure.
7. Dressing on biopsy site may be removed after 48 hours.