A biopsy is a procedure by which a small quantity of tissue is removed for laboratory examination. Liver biopsies are routinely carried out in cases involving Hepatitis C to assess the state of the patients liver, and get an accurate measure of damage levels and disease progression. There is currently no substitute for expert examination of a piece of tissue under a microscope. Changes in treatment guidelines have greatly reduced the need for biopsies, and most patients can now be treated without one. Despite this, the information gained from a biopsy is extremely valuable, and greatly helps decision making by both doctors and patients.

Biopsies are usually performed on a 'day-case' basis. Blood tests are carried out to ensure that the patient's blood has normal clotting characteristics and that excessive bleeding will not occur. (Doctors don't like patients bleeding to death - it is messy, spoils their figures, and causes unnecessary paperwork!) The patient lays on his/her left side, and local anaesthetic is injected between the lower ribs on their right side. A needle is inserted, and withdrawn containing a tiny sliver of liver tissue, which is sent for laboratory examination. The procedure is largely painless, and takes a few minutes. The patient has to remain lying down for six hours after the procedure to reduce the risk of bleeding.

Ultrasound-guided biopsies are becoming more common. With these an ultrasound scanning machine is used to guide the biopsy needle. Statistically they are safer as there is less chance of complications, and they tend to be less painful as areas containing large numbers of nerves can be avoided. I would advise patients going for a biopsy to take a good book with them. Terminal boredom tends to set in after a few hours of enforced bed rest!

The procedure is almost risk free (1 in 10000 chance of complications). Some patients experience pain in the right shoulder (so-called referred pain) for a short time afterwards, and this can be controlled with mild pain killers if necessary.

All the above refers to a conventional 'needle' biopsy. There are alternative methods, although these are less common. One option is a 'trans-jugular' biopsy where a wire with a sampling device at the end is passed down the jugular vein via a small incision in the neck. This is favoured in some circles as there is thought to be less risk of post-procedural bleeding, the sample having been taken from inside the liver, as opposed to outside! There is also the point that areas deep inside the liver may be sampled, which would be difficult with other methods. Occasionally liver biopsy may be performed laparoscopically, particularly if another procedure is being performed at the same time, e.g. gall bladder removal.

There are non-invasive tests being developed in an attempt to reduce the need for biopsies. Although these are heavily promoted in some circles, the accuracy of the results is still open to question. Correlation to biopsy results is good at the top and bottom ends of the scale, but near the middle the chances of an error are far too high for comfort. Unfortunately the middle of the band is crucial as readings in this area generally indicate that deterioration is increasing and treatment should be a high priority. A false reading could have serious consequences in this respect.