Pain After Percutaneous Liver Core Needle Biopsy: Comparing The Intercostal And Subcostal Routes

Introduction:
Percutaneous liver biopsy is a common procedure worldwide. It is now used as the reference standard for diagnosing most parenchymal liver disease. Pain is a common complication after liver biopsy. It is important to control the pain as much as possible. This is important for patients’ comfort and it also makes the patients cooperative in cases of possible repeated biopsies.
Percutaneous liver biopsy can be performed via subcostal or intercostal routes. It is recommended to perform it via subcostal route whenever possible. this is believed to decrease the complications like pneuomothorax. There are a few studies that evaluated the effect of biopsy access on the patients’ pain and discomfort. In this article we evaluated the pain experienced by patients after needle biopsy of the liver and compared it between subcostal and intercostal approaches.
 Material and Methods:
A hundred and twelve patients referred to our clinic for ultrasound guided liver biopsy were randomized into two groups. Percutaneous liver biopsies were performed through subcostal approach in one group and inter-costal approach in the other group. A visual assessment score (VAS) for pain was recored in all patients immediately after the procedure and in the second and fourth hours. The level of anxiety was also evaluated with Spielberger questionnaire immediately before the procedure. The patients were monitored after the procedure for hemorrhage (ultrasound was performed and free fluid or subcapsular hematomas were searched for) and pneumothorax (CXR if there was any complaint of respiratory discomfort).
 Results:
A hundred and twelve consecutive patients referred for liver biopsy entered in our study. Core needle biopsy was performed via intercostal route in 54 (48.2%) and via subcostal route in 58 (51.8%) of patients. There were 46 (41.1%) male patients and 66 (58.9%) female patients in our study. The primary outcome of the study was pain that was evaluated using VAS scale in the 0, 2 and 4 hours after the procedure. There was no significant difference in the pain between male and female patients. There was no significant difference in the pain between the intercostal and subcostal group immediately after the procedure (p value: 0.055), but we found a significant difference in pain between these two groups at the second (p value: 0.001) and fourth (p value: 0.001) hours after the procedure.
We also found no significant correlations between the patient’s age and pain at 0 (p value: 0.936), 2 (p value: 0.285) and 4 (p value: 0.617) hours.
We did not find any significant correlation between the level of anxiety and pain at 0 (p value = 0.115) and 4 hours (p value = 0.057), but there was a significant correlation between the level of anxiety and pain at 2 hours post-procedure (p value = 0.017).
 Discussion:
The pain after liver biopsy was not statistically different in two groups immediately after the procedure, but the difference was significant in the second and fourth hours after the biopsy. This suggests that all ultrasound guided liver biopsies should be performed via subcostal approach whenever technically feasible. We also should consider continuing the analgesics in patients to whom biopsy has been performed with intercostal approach.
This study did not show any significant difference in pain between males and females. Patients’s age and their anxiety levels were not correlated with the level of pain. There was also no significant difference in pain between patients with parenchymal liver disease and those with focal liver lesion. It seems that biopsy route is the only non-operator factor that influences the level of pain experienced during percutaneous liver biopsy.