LIVER BIOPSY AND LIVER ASPIRATION –
Procedure, Preparation and
After Care of the Client
LIVER BIOPSY
Liver biopsy may be an open or closed procedure. In an open biopsy, a wedge of the liver is removed for study and the remaining edges are sutured together. It necessitates a general anaesthetic and a major abdominal incision. The advantage of this type of procedure is that the visualization of the entire liver allows the biopsy specimen to be removed from the grossly altered tissue area.
The open biopsy may be too drastic for a client with an acute process of the liver disease.
A needle biopsy of the liver is a common procedure and is of considerable diagnostic value. It can be done by using a ‘Vim Silverman’s needle’ or a ‘Menghini needle’. The Vim Silverman’s needle is a cannula with a slitted probe. It is introduced into the liver substance and rotated to get a biopsy. The Menghini needle is the best. The nail in the cannula allows fluid to pass but prevents the biopsy specimens from being fragmented by violent aspiration into the syringe. Sections are cut from the cylindrical specimens obtained. Haemorrhage and biliary peritonitis are the complications.
A combination of peritoneoscopy with needle liver biopsy enables a tissue sample to be taken directly from a focal abnormality. It has the advantage of direct visualization of the site of biopsy with minimum trauma.
The Site of Liver Biopsy and Positioning of the Client
The site of the puncture is usually in the hypochondriac region in the 8th or 9th intercostal space (whichever is duller to percussion). The site is also determined by X-ray examinations and by Scanning. Client lies in supine position with his right side as close to the edge of the bed as possible. A pillow is placed under the left side and the client places his right hand behind his head turning his face away from the procedure.
PROCEDURE
The client is placed in the desired position. Local anaesthesia is given. The client is asked to inhale and exhale several times, finally to exhale and to hold his breath at the end of expiration. Holding the breath immobilizes the chest wall and the diaphragm. Penetration of the diaphragm, thereby, is avoided and the risk of lacerating the liver is minimized. The physician promptly introduces the biopsy needle via intercostals or subcostal route, and penetrates the liver. The special needle assembly is rotated to separate a fragment of tissue or tissues may be aspirated. The needle is withdrawn. The entire procedure is completed within 5 to 10 seconds. The client may resume breathing. The cylindrical specimens that are trapped in the needle are collected and sent for histopathological examinations.
GENERAL INSTRUCTIONS
1. A liver biopsy should never be attempted until the presence or absence of a bleeding tendency on the part of the client has been ascertained, and if present, it is corrected. The prothrombin time and the platelet counts are determined and these must be within normal limits.
2. The client’s co-operation is essential for performing a liver biopsy. He should be explained about the procedure and reassured to win his confidence and co-operation.
3. Instruct the client to breath-in and breath-out and to hold and to hold the breath on command. Holding the breath during the liver biopsy is essential to prevent injury to the diaphragm and liver substance.
4. The contra-indications of liver biopsy are: uncooperative person, prolonged prothrombin time, thrombocytopenia, blood dyscrasias, extrahepatic obstructive jaundice with enlarged gall bladder, cancer of the liver, infection of the lower lobe of the right lung.
5. Watch the complications of the liver biopsy during and after the procedure. The complications of liver biopsy are: haemorrhage, shock and collapse, perforation of the abdominal viscera, pneumothorax, injury to the diaphragm, bile peritonitis. Watch for the pallor, sweating, restlessness, dyspnoea, rising pulse rate, abdominal pain and vomiting in order to detect the early signs of complications.
6. Keep ready two points of cross matched blood before sending the client for biopsy, to be used in case of emergency during or in post biopsy period.
The client should be instructed to take complete bed rest for 24 hours following liver biopsy. He should be under constant observation to prevent complications.
Preparation of the Client for Liver biopsy
1. The client should be admitted to the hospital prior to the liver biopsy and he should remain at least for 24 hours after the biopsy procedures.
2. Since the clients with liver diseases are prone to bleed, their blood is checked for prothrombin time, platelets count, bleeding time and clotting time etc. The results should be within normal limits.
3. The procedure is likely to cause anxiety in the client. The client should be explained about the procedure to ensure his co-operation.
4. The client is taught to regulate his breathing as a preparation for the biopsy. He may practice how to stop breathing on command.
5. The client should be given injection vitamin K for several days prior to the biopsy to prevent haemorrhage.
6. Shave and clean the area as for a surgical procedure.
7. Check the client’s blood pressure, pulse and respiration carefully and record it on the nurse’s record before sending the client to the examination room, for future reference.
8. Get a written consent from the client or client’s relatives.
9. Make sure that two pints of blood of the same group should be available at the time of surgery in case any emergency arise.
10. Keeps the client fasting for 6 to 8 hours prior to the liver biopsy. A laparotomy may be anticipated, if any complications arise during the procedure.
11. Give sedation to the client, if he is apprehensive.
12. Change the client’s garments into hospital clothing.
13. Drape the client exposing only the site of puncture.
14. Keep the client in a desired position as close to the edge of the bed as possible.
Arrange all the articles according to convenience of the doctor.
15. The nurse should remain with the client explaining the procedure and encouraging him to maintain the desired position. She should observe the client carefully and record the vital signs. Any change in the vital signs should be reported to the doctor immediately.
Preparation of Articles
A Sterile covered tray containing
1. Sponge holding forceps.
2. Syringe (5 ml) with needles to give local anaethesia.
3. Liver biopsy needles with stilettes. (Vim Silverman’s or Menghini biopsy needle).
4. Specimen bottles with cork.
5. Bowls (small) to take cleaning lotion.
6. Aspiration syringe, if aspiration biopsy is to be done.
7. Dissecting forceps.
8. Dressing towels or slit.
9. Cotton balls, gauze pieces, and cotton pads.
10. Gown, gloves, masks.
An unsterile tray containing
1. Mackintosh and towel
2. Kidney tray and paper bag.
3. Spirit, iodine, Tr. Benzoin etc.
4. Lignocaine 2 percent
5. Apron for the doctor
6. Adhesive plaster and scissors
7. Formalin 10 percent to preserve the biopsy.
After Care of the Client
1. Immediately after a biopsy, place a cotton pad over the site and assist the client to turn on his right side. Place a pillow under his costal margin and ask him to remain in the same position, recumbent and immobile, for several hours. In this position the liver capsule at the site of penetration is compressed against the chest wall and the escape of blood or bile through the puncture wound is impeded. The right side position also helps to exert pressure by the abdominal contents against the liver and decrease the bleeding from the biopsy site.
2. Check the client’s pulse, respiration and blood pressure at 10 to 20 minutes for the first few hours then half hourly and then hourly for 24 hours; or until his general condition remains satisfactory. Any change in the vital signs may indicate the presence or progress of hepatic bleeding, the most frequent complication of liver biopsy.
3. Watch for the complications of liver biopsy. The early signs that indicate the complications are pallor, sweating, restlessness, dyspnea, rising pulse rate, abdominal pain and vomiting. The complications of liver biopsy are haemorrhage, shock and collapse, bile peritonitis, pneumothorax, injury to the stomach, pancreas, small and large intestine, kidneys, inferior vena cava and diaphragm.
4. The specimen is carefully collected and sent to the histopathology lab with proper labels and a requisition form.
5. Vitamin K is administered in the post biopsy period also.
6. The site of biopsy is treated aseptically.
LIVER ASPIRATION
Liver aspiration is an introduction of a needle into the liver substance to drain an abscess. Usually the liver abscesses respond to specific treatment, e.g., treatment with metronidazole. If there is lack of response to the specific therapy, the needle aspiration may be done. The preparation of the client and after care of the client etc. are as that of liver biopsy. Instead of liver biopsy needles, long aspiration needles with wide bore are introduced into the liver to remove the thick pus.