Liver Biopsy: Proceed With CautionCommentary by Don C. Rockey, MD
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast cancer, presented to an emergency department with jaundice and epigastric pain. An abdominal ultrasound revealed several liver masses and subsequent imaging was consistent with metastatic malignancy of unknown primary source. The patient was admitted directly for an ultrasound-guided liver biopsy. Prior to the procedure, the patient required platelet transfusions, which increased her admitting platelet count of 5000/μL to 71,000/μL (reference range: 150,000–400,000/μL) prior to biopsy. Immediately after the procedure, she was transferred to the floor and began complaining about new abdominal pain. Her blood pressure was noted to be lower than baseline at 88/55 mm Hg, so a call was placed to the covering in-house physician. The physician believed that pain was common after such biopsies and ordered a dose of analgesics, which improved the patient's symptoms.
Over the next 2 hours, the patient's pain worsened and she became increasingly somnolent. When the bedside nurse returned to assess her pain, she found the patient unresponsive and called a code blue. The patient had pulseless electrical activity and the initial assessment also revealed a hematocrit of 14%, a decrease from 28% before the procedure. A massive transfusion protocol was initiated. The patient had a prolonged resuscitation and was transferred to the intensive care unit where she later died of multi-organ failure. The delay in recognizing the post-procedure intraperitoneal hemorrhage led to a detailed review by the hospital's quality committee. The protocols for managing patients following a liver biopsy were noted to be clearer in the outpatient setting where most procedures take place. No such protocols were in place for the less common inpatient liver biopsy at this facility.