Liver puncture biopsy (liver biopsy) is a simple means of taking liver tissue specimens.
I. Indications and contraindications
(A) Indications
1, abnormal liver function or normal liver function, but there are obvious symptoms and signs, liver puncture can be used to clarify the diagnosis.
2.Differential diagnosis of jaundice or portal hypertension of unknown origin.
3.Diagnosis of hepatomegaly of unknown cause and certain hematologic diseases.
4.To help determine the diagnosis of various types of hepatitis and judge the efficacy and prognosis.
(II) Contraindications
1, systemic failure.
2.Severe anemia.
3.Hemorrhagic tendency.
4.Hepatic encapsulation disease, hepatic hemangioma, extrahepatic obstructive jaundice, ascites, etc.
Second, pre-operative preparation
1.Proper instrumentation, neat clothing and hat.
2.Before the operation, you should understand the basic situation of the patient, explain the purpose, significance and precautions of the puncture to the patient, eliminate the nervousness and obtain the cooperation of the patient, obtain the consent of the patient and his family, and sign the operation consent form.
3. Platelets, clotting time and prothrombin time should be checked before the operation. If there is any abnormality, vitamin K110mg should be injected intramuscularly once a day and rechecked after 3 d. If it is still abnormal, puncture should not be forced.
4. Blood pressure and pulse should be measured and chest X-ray should be performed before puncture to observe the presence of emphysema and pleural hypertrophy, and blood type should be checked for blood transfusion if necessary. Diazepam 10mg should be taken 1h before the operation.
5. Prepare sterile liver puncture kit, sterile rubber gloves, sterile gauze and adhesive tape, sterile swabs, 2% lidocaine injection or 1% procaine (skin test is required), 2% iodine or iodophor, 75% ethanol, treatment tray, multi-head lap band, small sand bag, specimen bottle, sterile saline, methyl violet (gentian violet) solution, etc.
Third, the operation method
1. The patient is placed in a supine position, leaning slightly to the left, with the right side of the body near the edge of the bed, a pillow under the ribs on the right side of the back, and the right arm flexed behind the head. Sitting or semi-recumbent position is used for pus extraction.
2.Puncture site Generally, the puncture should be performed at the 8th and 9th intercostal area in the right axillary midline and at the solid liver tone. For suspected hepatocellular carcinoma, the more prominent nodes should be selected for puncture under ultrasound positioning.
3. Routinely disinfect the skin, lay sterile cavity towel, and use 2% lidocaine for local anesthesia from skin to hepatic peritoneum.
4, Prepare a rapid puncture syringe (needle length 7.0 cm, needle diameter 1.2 cm or 1.6 cm), which is equipped with a steel core plunger of about 2-3 cm in length, through which air and water can pass, but which prevents the liver tissue aspirated into the syringe. The operator connects the 10ml syringe and the liver puncture needle with a rubber tube, checks whether each part is tightly connected, and when there is really no air leakage, sucks 3~5ml of sterile saline and drains the gas inside the syringe.
5, first use the puncture cone to puncture holes in the skin at the puncture point, then use the liver puncture needle to puncture 0.5 ~ 1.0 cm along the upper edge of the rib cage in a vertical direction with the chest wall, and then inject 0.5 ~ 1.0 ml of saline into the syringe to flush out the skin and subcutaneous tissue that may remain in the needle cavity to avoid needle blockage.
6.Aspirate the needle bolus to the syringe 5-6ml scale, causing and maintaining negative pressure inside the needle until the end of the procedure. At the same time, ask the patient to inhale deeply and then hold his breath for a moment at the end of deep exhalation (the patient should be allowed to practice before the operation). At the beginning of the patient’s breath hold, the puncture needle is placed perpendicular to the skin, rapidly pierced into the liver tissue, and immediately withdrawn, and this action is usually completed in about 1s. Absolutely no stirring of the puncture needle is allowed. The puncture depth is usually about 4-6 cm, and the total puncture depth does not exceed 6 cm.
7.After pulling out the liver puncture needle, immediately cover it with sterile gauze, press the puncture site for 5-10 min, then fix it with adhesive tape, and place a sand bag for pressure, and tie the lap band tightly.
8, with saline from the set of needles to flush out the liver tissue obtained in the curved plate, pick out injected into the specimen bottle fixed.
9.After puncture, place the patient, clean up the material, and send the specimen for examination immediately.
10.In recent years, ultrasound-guided puncture biopsy is highly efficient and of good quality. There are two types of needles: suction biopsy needle, generally selected 18G ~ 21G needle, guided by the puncture needle will be biopsy needle into the liver or the edge of the mass a short pause, pumping the needle plug to cause negative pressure after the needle quickly into the liver or mass within 2 ~ 3cm, pause 1 ~ 2s, then rotate to separate the tissue core, or rotate while entering the needle, and finally out of the needle; no negative pressure cutting needle, currently commonly used ejection type tissue “biopsy gun”, needle speed is very fast, 17m/s, to avoid the maximum side damage to the tissue being cut, not only for liver, but also for lung, kidney and other parts of the biopsy, which is the method currently used in our department.
IV. Precautions
When puncturing or removing the needle, the patient must be asked to suspend breathing to avoid hemorrhage due to the needle tip cutting the liver surface. If the puncture is unsuccessful, retreat the needle to the subcutaneous area, change the direction of the puncture if necessary, and repeat the puncture, but not more than three times.
1. Strictly observe the aseptic operation protocol to prevent infection.
2. When puncturing or removing the needle, make sure to ask the patient to suspend breathing in order to avoid hemorrhage due to the needle tip cutting the liver surface. If the puncture is unsuccessful, retreat the needle to the subcutaneous area, change the direction of puncture if necessary, and repeat the puncture, but not more than three times.
3.After puncture, observe the condition closely, rest in bed absolutely within 24h, and measure blood pressure and pulse every 15-30min within 4h. If there is internal bleeding such as rapid and weak pulse, drop in blood pressure, irritability, pallor and cold sweat, it should be treated urgently.
4.If there is local pain after puncture, the cause should be carefully investigated, if it is general tissue traumatic pain, analgesic can be given; if pneumothorax, pleural shock or biliary peritonitis occurs, it should be treated promptly.
5.If liver tumor is suspected and the mass is located in the abdomen which is not suitable for biopsy, fine needle aspiration smear can be used for cytological examination. Specific operations.
(1) skin disinfection and anesthesia at the puncture site, use a 6-8 gauge needle or a small lumbar puncture needle connected to a 20 ml syringe, pierce the abdominal wall to reach the liver peritoneum, pump the syringe core to cause negative pressure and maintain it. The patient is instructed to inhale and hold the breathing action after exhalation, while the puncture needle is quickly punctured into the liver for 1~2 cm and then pulled out, and the little blood or liver tissue fluid aspirated is immediately smear, fixed and then microscopically examined.
(2) Local dressing with sterile gauze, tightening with multi-headed lap band, small sandbag compression for 0.5h, and close observation of pulse and blood pressure for 6h.
(3) Ultrasound-guided fine needle aspiration cytology examination is feasible if available, choose 20-23 G, 15-20 cm long fine needle, guide needle with 18 G, 7 cm long. after stabbing the guide needle into the skin along the probe guide slot under the guidance of sterile aspiration probe, stab the needle from the guide needle, monitor on the fluoroscope into the mass or the intended stabbing point, pull out the needle core, connect the syringe to draw into and maintain the negative pressure state The needle tip is moved back and forth in the lesion 3 to 4 times with a small amplitude under negative pressure, and the needle is removed after the negative pressure is lifted.