Correspondence
Pain Experienced During Percutaneous Liver Biopsy
To the Editor:
Percutaneous liver biopsy for the diagnosis of liver disease
is a well-established, widely and routinely used procedure
with low morbidity.
1
However, it is invasive and often
considered painful by patients. We conducted a pilot study
aimed at grading the intensity of pain experienced by patients
during liver biopsy to determine whether or not prophylactic
analgesia might be needed.
Thirty consecutive adult patients (19 men, 11 women;
mean age 42 6 11 years) undergoing a first percutaneous
liver biopsy (for chronic hepatitis C in 22; alcohol-induced
liver disease in 5; miscellaneous in 3) were included after
written informed consent was given. Exclusion criteria were
(1) abdominal ultrasound revealing a contraindication such
as intrahepatic bile duct dilatation, focal liver lesion, hydatid
disease, or massive ascites; (2) clotting disorders such as
prothrombin less than 50% of normal or cephalin kaolin time
exceeding 1.5 times the normal control time, or platelet count
below 10
5
/mm
3
, or Ivy’s bleeding time exceeding 4 minutes;
(3) ongoing analgesic treatment; (4) comprehension diffi-
culty. Before starting the procedure patients were taught in a
standard way by the same investigator how to use a visual
analogue scale (VAS) scoring from 0 to 100 mm to grade the
intensity of pain experienced during liver biopsy. On that
scale, the left end point, 0, was defined as no pain and the
right end point, 100, as the worst pain the patient could
imagine. There were no further marks on the line. The
intensity of pain was indicated by the distance in millimeters
from the left end point. Liver biopsy was performed at
bedside according to the Menghini technique
2
by the same
senior operator after adequate local anesthesia with lidocaine
1% (10 mL). Patients were asked to grade on the VAS the
intensity of pain experienced during liver biopsy, at the end of
procedure (D0), and the next day at discharge (D1) to
validate the reproducibility of results.
All liver specimens could be obtained at first passage. Mean
VAS pain scores were 28 6 3 mm (range, 5-91) at D0 and
30 6 4 mm (range, 6-95) at D1, respectively, (r 5 .78; P ,
.0001) (Fig. 1). Six out of 30 patients (20%) experienced
severe pain (i.e. VAS .40 mm). All were men, with chronic
hepatitis C in 5 cases.
The intensity of pain experienced during biopsy has not
been specifically studied in the literature probably because
pain is usually short in duration and deemed as minor by
most hepatologists. However, we have observed using the
VAS, the validated and recommended method to grade pain,
3
that the mean pain score at D0 was close to 30 mm with a
maximum range of 91. Similar results were obtained at D1.
Such a pain score, similar to that of other minor procedures,
such as venous cannulation, is usually considered mild to
moderate and requires analgesia.
4
Furthermore, 20% of the
patients experienced severe pain during liver biopsy. Most of
these patients had chronic hepatitis C, the main indication for
liver biopsy in our series like in many other centers. Patients
with chronic hepatitis C are usually young and asymptomatic
and thus consider liver biopsy a major ordeal. Moreover,
during the course of chronic hepatitis C, repeated liver
biopsies may be necessary for management of patients.
5
Those who experienced severe pain and were not provided
adequate analgesia may thus be lost to follow-up after the first
biopsy. Over the past decade, the importance of liver biopsy
for diagnosis, therapeutic decisions, and for monitoring has
considerably grown with liver transplantation and the use of
interferon alfa for chronic hepatitis B and C. It is likely that
the number of liver biopsies will continue to increase in the
coming years, with over 1 million people infected by hepatitis
C virus worldwide,
6
with the promising results of the
combination of ribavirin and interferon alfa for treatment of
patients with chronic hepatitis C,
7,8
and with the need to
repeat liver biopsy during follow-up of patients with chronic
liver disease.
In conclusion, the results of this pilot study suggest that,
although deemed as minor, pain experienced during percuta-
neous liver biopsy should be taken into consideration and
that patients should be provided adequate prophylactic
analgesia.
Acknowledgment: The authors are grateful to Professor
Dan Benhamou for his helpful comments.
LAURENT CASTE
´
RA, M.D.
ISABELLE NE
`
GRE, M.D.
KAMRAN SAMII, M.D.
CATHERINE BUFFET, M.D.
Department of Hepatology and Gastroenterology,
Department of Anesthesia and General Intensive Care
Hoˆpital Biceˆtre
Universite´ Paris-Sud,
Le Kremlin-Biceˆtre, France
REFERENCES
1. Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following
percutaneous liver biopsy—a multicentre retrospective study on 68276
biopsies. J Hepatol 1986;2:165-173.
FIG. 1. Pain scores measured by the VAS at the end of the procedure (D0)
and the next day (D1). Individual data; mean values are indicated by the line.
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