Liver biopsy is usually safe and is currently considered the standard test for assessing liver inflammation and fibrosis, but inevitably suffers from sampling errors, rare complications, and occasionally triggers significant patient anxiety. The above factors have led to a strong interest in the development of non-invasive tests for liver fibrosis. Noninvasive tests have delivered on the promise of reducing the need for liver biopsy, but most hepatologists believe their clinical application is relatively limited. Currently available tests have variable results in detecting progression of intermediate stages of chronic liver disease. Moreover, the lack of validation of these tests is one of their potential drawbacks. The following are indications and contraindications for liver biopsy. Indications Liver biopsy, combined with medical history and physical examination data, is an effective clinical tool for the diagnosis and treatment of liver disease. Depending on the clinical question, the indications for obtaining biopsy specimens are as follows: Abnormal liver laboratory findings Confirmation of diagnosis and prediction Suspected liver tumors Diagnosis of cholestatic liver disease Evaluation of infiltrative or granulomatous disease Evaluation and management of rejection after liver transplantation Evaluation of unexplained jaundice or suspected drug reactions Biopsy specimens may be used to identify or rule out possible etiologies of somatic or laboratory abnormalities. Different diseases may present in the same state and a diagnostic histological pattern may be used in the context of the clinical presentation. For example, fatty infiltration of the liver parenchyma may be present in diseases due to alcohol abuse, hepatitis C, diabetes mellitus, obesity, etc. For each disease state, histologic clues can distinguish them. Another use of liver biopsy is to determine the extent of histologic alterations in the biopsy specimen. This involves a scoring system for the degree of inflammation and fibrosis in the liver as indicated by pathologists. Most scoring systems use grading to report the degree of inflammation and staging to report the degree of fibrosis. For example, a moderate inflammatory response (grade 3) versus cirrhosis (stage 4). A third condition is monitoring disease progression or treatment efficacy. For example, liver biopsy specimens are often used to evaluate and treat rejection after liver transplantation. Repeat biopsies are less frequently used to monitor disease progression, such as primary biliary cirrhosis, chronic hepatitis C, or alcoholic liver disease. Contraindications to liver biopsy are as follows: Prolonged prothrombin time (PT), international normalized ratio (INR) >1.6 Thrombocytopenia, platelet count < 60,000/μL Ascites (transjugular route preferred) Difficult body type (transjugular route preferred) Suspected hemangioma Suspected endocyst infection Uncooperative patients