Liver biopsy

Role

Liver biopsy provides histological diagnosis, staging (fibrosis), and grading (inflammatory activity) of liver disease - increasingly reserved for cases where non-invasive tests cannot provide sufficient information, given the availability of non-invasive fibrosis assessment alternatives
Indications have narrowed over recent years as non-invasive fibrosis markers (transient elastography/FibroScan, serum fibrosis panels) have matured, though biopsy remains important for specific diagnostic questions non-invasive tests cannot answer

Percutaneous (most common, image-guided or blind), transjugular (preferred with significant coagulopathy/ascites, since the puncture tract stays intravascular, reducing bleeding risk into the peritoneum), or surgical/laparoscopic approach depending on clinical context and risk factors

Indications where biopsy retains a clear role: unexplained liver disease where non-invasive tests have not established a diagnosis, assessing disease activity/staging when this will change management (e.g. autoimmune hepatitis activity, some drug-induced liver injury characterisation), and discordant non-invasive results requiring histological clarification
Non-invasive fibrosis assessment (transient elastography, serum panels) has replaced biopsy for routine fibrosis staging in common conditions (chronic viral hepatitis, MASLD) in most circumstances, reserving biopsy for atypical or discordant presentations

Main risks: bleeding (the most significant complication, higher with coagulopathy/thrombocytopenia - a key reason for choosing the transjugular route in these patients), pain, and rarely bile leak or injury to an adjacent organ
Coagulation status (platelet count, INR) should be assessed and corrected/considered before the procedure, and route chosen accordingly

Autoimmune hepatitis (activity/staging), unexplained transaminitis after non-invasive workup, drug-induced liver injury characterisation, transient elastography (the main non-invasive alternative)

Liver biopsy remains the reference standard for histological diagnosis but is no longer the default first step for routine fibrosis assessment in common liver diseases - it is now reserved for situations where non-invasive testing has been tried and found insufficient, or where a specific histological question cannot be answered any other way

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