Liver biopsy remains the gold standard for diagnosis of many liver conditions as viral hepatitis with confounding co-morbidities, non-alcoholic fatty liver disease, and autoimmune liver diseases.

Types of Liver Biopsy-

• Percutaneous biopsy- it is guided by ultrasonography. Limitations- uncooperative patient, coagulopathy, ascites, suspicion of vascular tumour or echinococcal cyst. Complications- intraperitoneal bleeding, liver hematoma, hemobilia, transient bacteremia, pneumothorax, hemothorax, transient discomfort at the biopsy site, and mild, transient arterial hypotension due to a vasovagal reaction.
• Transjugular biopsy- done via percutaneous puncturing of the right internal jugular vein, the introduction of a catheter in the right hepatic vein, and a needle biopsy of the liver through the catheter. 

Indication- all contraindicated cases of percutaneous liver biopsy.

• Laparoscopic biopsy: rarely used for chronic liver diseases.

Indications for Liver Biopsy in various Chronic Liver Diseases

Chronic hepatitis C

Although now non-invasive methods have greatly replaced biopsy, it remains important in invalid non-invasive tests of fibrosis, an association of HCV infection with other causes of chronic liver injuries including alcohol abuse, obesity, diabetes, making it difficult to determine the role of each cause.

Chronic hepatitis B

liver biopsy remains the traditional method to determine the extent of inflammation and fibrosis, but Elastography may also be utilized for decisions on treatment indications. 

Alcoholic liver disease (ALD)

Liver biopsy is used in patients with aggressive forms of ALD requiring specific therapies (e.g. corticosteroids) and in those with other cofactors suspected of contributing to liver disease. The usefulness of serum markers and Liver stiffness measurement is being assessed for hepatic fibrosis in patients with ALD. 

Non-alcoholic fatty liver disease (NAFLD)

Liver biopsy holds pride in being the only procedure that precisely differentiates non-alcoholic fatty liver (NAFL) from NASH.

Autoimmune liver diseases

Liver biopsy remains the gold standard for the diagnosis of autoimmune hepatitis (AIH) and not yet see its substitute, particularly at diagnosis.

HFE-Hemochromatosis

Liver biopsy for this condition has been now replaced by numerous non-invasive methods as-Transient elastography.

Drug-Induced Liver Injuries (Dili)

DILI-induced chronic hepatitis and cirrhosis may require Liver Biopsy for diagnosis and the assessment of fibrosis. E.g. DILI with drugs leading to NASH, Chronic intoxication by vitamin A., DILI with autoimmune features etc.

Although elastography can be employed in follow-up.

Miscellaneous

Liver biopsy hasnt yet seen its replacement in rare chronic liver diseases like Wilsons disease, storage diseases, glycogenosis, amyloidosis and in cases of chronic idiopathic abnormalities.

In conclusion, liver biopsy has seen its replacement with non-invasive methods of evaluation of fibrosis but still, it maintains its supremacy in diagnosing several chronic liver diseases.

Source: Larrey, D, Meunier, L, Ursic-Bedoya, J. Liver Biopsy in Chronic Liver Diseases: Is There a Favorable Benefit: Risk Balance?. Annals of Hepatology, 2017;16(4):487-489. DOI: 10.5604/01.3001.0010.0272