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\begin{document}

\title{Outpatient Percutaneous Liver Biopsy is a Low-risk Procedure and has
Steatosis as a New Indication Trend}



\author[1]{Marlone Cunha-Silva}%
\author[1]{Luiza Torres}%
\author[1]{Mariana Franson}%
\author[1]{Tirzah Secundo}%
\author[1]{Marina Moreira}%
\author[1]{Ademar Yamanaka}%
\author[1]{Leonardo Monici}%
\author[1]{Larissa Eloy da Costa}%
\author[1]{Daniel F Mazo}%
\author[1]{Tiago Sevá-Pereira}%
\affil[1]{UNICAMP}%


\vspace{-1em}



  
  \date{May 05, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
BACKGROUND. Histological evaluation has a crucial role in diagnosing
hepatic diseases and percutaneous liver biopsy (PLB) is widely chosen
for this purpose. We aim to describe its indications, the rate and
severity of adverse events (AEs) in an outpatient and ultrasound
(US)-guided setting over 5 years. METHODS. This observational,
single-center, and retrospective study included patients submitted to
PLB between 2015 and 2019. We collected age, gender, coagulation tests,
comorbidities, and number of needle passes. The association between the
variables and outcomes (pain, mild and serious AEs, hospital admission,
surgical treatment, and death) was evaluated using the generalized
estimating equations method. RESULTS. We analyzed 532 biopsies in 524
patients (55.3\% male) aged 49y (13--74y). Almost 39\% had
cardiovascular comorbidities and 18\% had overweight/obesity. Hepatitis
C virus (HCV) chronic infection was the major indication for PLB (47\%),
followed by autoimmune hepatitis/cholestasis (12.6\%), and metabolic
dysfunction-associated fatty liver disease (MAFLD) (12.1\%). The number
of HCV-related biopsies had a remarkable reduction, while MAFLD-related
procedures have progressively raised over time. Around 54\% of the
patients reported pain, which was significantly associated with the
female gender (p=0.0143). Serious AEs occurred in 11 patients (2.1\%);
hospital admission was necessary in 10 cases (1.9\%), but no patient
required surgical approach and there were no deaths. No significant
association was found between the occurrence of AEs and the studied
variables (clinical, laboratory, and number of needle passes).
CONCLUSION. Real-time US-guided PLB is safe to perform in an outpatient
setting and its indications have notably undergone a transition from HCV
to MAFLD over the years. New strategies to prevent biopsy-related pain
are still needed, especially for females.%
\end{abstract}%



\sloppy




\textbf{Outpatient Percutaneous Liver Biopsy is a Low-risk Procedure and
has Steatosis as a New Indication Trend}

Steatosis as a New Reason for Liver Biopsy

\textbf{ABSTRACT}

\textbf{BACKGROUND.} Histological evaluation has a crucial role in
diagnosing hepatic diseases and percutaneous liver biopsy (PLB) is
widely chosen for this purpose. We aim to describe its indications, the
rate and severity of adverse events (AEs) in an outpatient and
ultrasound (US)-guided setting over 5 years.

\textbf{METHODS.} This observational, single-center, and retrospective
study included patients submitted to PLB between 2015 and 2019. We
collected age, gender, coagulation tests, comorbidities, and number of
needle passes. The association between the variables and outcomes (pain,
mild and serious AEs, hospital admission, surgical treatment, and death)
was evaluated using the generalized estimating equations method.

\textbf{RESULTS} . We analyzed 532 biopsies in 524 patients (55.3\%
male) aged 49y (13--74y). Almost 39\% had cardiovascular comorbidities
and 18\% had overweight/obesity. Hepatitis C virus (HCV) chronic
infection was the major indication for PLB (47\%), followed by
autoimmune hepatitis/cholestasis (12.6\%), and metabolic
dysfunction-associated fatty liver disease (MAFLD) (12.1\%). The number
of HCV-related biopsies had a remarkable reduction, while MAFLD-related
procedures have progressively raised over time. Around 54\% of the
patients reported pain, which was significantly associated with the
female gender (p=0.0143). Serious AEs occurred in 11 patients (2.1\%);
hospital admission was necessary in 10 cases (1.9\%), but no patient
required surgical approach and there were no deaths. No significant
association was found between the occurrence of AEs and the studied
variables (clinical, laboratory, and number of needle passes).

\textbf{CONCLUSION.} Real-time US-guided PLB is safe to perform in an
outpatient setting and its indications have notably undergone a
transition from HCV to MAFLD over the years. New strategies to prevent
biopsy-related pain are still needed, especially for females.

\textbf{KEYWORDS:} Liver biopsy, Hepatitis C, Steatosis, Fatty liver
disease, Liver enzymes.

\textbf{WHAT'S KNOWN? (What is already known about this subject?)}

\emph{Percutaneous liver biopsy (PLB) remains essential to elucidate the
etiology and severity of indeterminate liver diseases. It is generally a
safe procedure with a low rate of serious complications. Most previous
studies have assessed the safety of biopsies executed by radiologists
and there are no large reports on the performance of gastroenterologists
and hepatologists with real-time ultrasound guidance.}

\emph{For many years, the indication for PLB has been viral hepatitis,
but that need has been reducing in the era of non-invasive assessment of
liver fibrosis and hepatitis C direct-acting antiviral drugs. So what
would be the reasons for performing liver biopsies in the near future?}

\textbf{WHAT'S NEW? (what does this study contribute to the
literature?)}

\emph{In our study, real-time ultrasound guided liver biopsies were
performed by senior residents in Gastroenterology and Hepatology (in an
outpatient setting). We found similar results regarding the safety even
in a scenario of physicians in training. In addition, the reasons for
PLB have undergone a transformation over the years. It was possible to
notice a remarkable drop in the amount of hepatitis C-related procedures
and a progressive increase in the number of biopsies due to metabolic
dysfunction-associated fatty liver disease (MAFLD), known as hepatic
steatosis.}

\emph{This enthusiasm for MAFLD histological evaluation is quite
relevant, since new therapies are awaited and certainly, the staging of
fibrosis and inflammation should help physicians in choosing the best
therapeutic approach for their patients. This could delay the
progression to cirrhosis and reduce the need for liver transplantation.}

\emph{It is important to highlight that MAFLD has been reported as the
second most common etiology of cirrhosis in explanted livers. We need to
change this scenario. The first step is described in our study: this
trend to perform liver biopsy in patients with steatosis.}

\textbf{INTRODUCTION}

Histological evaluation has a crucial role in diagnosing the etiology
and severity of hepatic diseases, liver tumors, and is useful in the
follow-up after liver transplantation \textsuperscript{1,2}. The
effectiveness of this tool relies on a safe removal of the specimen and
suitable provision of clinical and laboratory data to the pathology
staff\textsuperscript{1-3}.

Several routes are available, such as laparoscopic, endoscopic, or
transjugular \textsuperscript{4} but percutaneous liver biopsy (PLB) is
generally preferable since it is less invasive and less costly compared
to other routes \textsuperscript{2}. Coagulation impairment, low
platelets, ascites, or anatomical changes are also important in this
choice \textsuperscript{1}. Physicians may use three different
approaches: palpation/percussion-guided, image-guided, and real-time
image-guided, most commonly ultrasound (US). Real-time US guidance seems
to reduce the risk of adverse events (AEs) and this makes PLB safe to
perform \textsuperscript{2,3}, whether by
radiologists\textsuperscript{5} or by gastroenterologists and
hepatologists\textsuperscript{6}.

Although the pain has been commonly reported after PLB (30 -- 50\%), it
is usually mild, self-limited, or has a good response to
analgesics\textsuperscript{4,7}. The incidence of serious complications
is low, not exceeding 6\% \textsuperscript{8,9}. Approximately 60\% of
these events occur within the first 2 hours and 96\% in the 24 hours
following the procedure \textsuperscript{10}. The reported incidence of
bleeding ranges from 0.5 to 1.8\% \textsuperscript{11}, but it can be
serious and lead to death if prompt treatment is not carried
out\textsuperscript{1,10}.

In recent years, the main indication for PLB has been the evaluation of
hepatitis C virus (HCV) chronic infection, either to exclude other
etiologies of hepatic damage or to establish the histological stage of
fibrosis and set the appropriate therapy \textsuperscript{12}. However,
that need has been reducing in the era of non-invasive assessment of
liver fibrosis and direct-acting antiviral drugs \textsuperscript{13}.

There are few reports on the purpose and safety of real-time US-guided
PLB performed by hepatologists in a large outpatient cohort. We aim to
describe the indications, as well as the rate and severity of
biopsy-related AEs in a 5-year study.

\textbf{METHODS}

This observational, retrospective, and single-center study involved
individuals submitted to outpatient PLB from January 2015 to December
2019 at the Gastrocentro of the University of Campinas (Unicamp),
Campinas, Brazil. Patients were eligible according to a database record
and subsequently, analysis of manual and electronic medical records was
conducted. The protocol was analyzed and approved by the Ethics
Committee of the University of Campinas (Unicamp) (CAAE:
29553819.9.0000.5404). An informed consent term was applied to the
patients who were still on follow-up at our center.

\textbf{Inclusion criteria:} patients \textgreater{} 12 years old
submitted to US-guided PLB at the Gastrocentro (Unicamp) during the
study period. \textbf{Exclusion criteria:} those with incomplete data in
the medical records. We analyzed gender, age, comorbidities, platelets
count, INR (international normalized ratio), indication for the biopsy,
number of needle passes, as well as PLB-related AEs and outcomes.
Patients submitted to more than one PLB were considered as a new case.

The indications for PLB were classified as follows: HCV, hepatitis B
virus (HBV), autoimmune hepatitis (AIH) / cholestasis, elevated liver
enzymes, metabolic dysfunction-associated fatty liver disease (MAFLD),
and post-transplant follow-up. Other indications, such as suspicion of
drug-induced liver injury, were adjudicated as elevated liver enzymes.

The patients\selectlanguage{ngerman}´ comorbidities were classified as 1) \emph{cardiovascular}
: high blood pressure, diabetes mellitus, dyslipidemia, heart failure;
2)\emph{overweight or obesity} , 3) \emph{chronic kidney disease} ,
4)\emph{neuropsychiatric disorders} , 5) \emph{other} : thyroid,
respiratory, intestinal disorders or acquired human immunodeficiency
syndrome, as described in the medical records. Patients could be
inserted into more than one group of comorbidities.

All the procedures were performed in a real-time US-guided setting and
the operator was a senior resident supervised by a hepatologist.
Patients were instructed to fast for 6 hours and to withdraw
anticoagulants and anti-inflammatory drugs for at least one week before
the biopsy. Insulin and oral antidiabetics were withdrawn on the day of
the procedure. Continuous use medications should not be suspended.

Patients were positioned supine on the bed with his or her right arm
placed above the head. A low dose of intravenous midazolam (2 to 3 mg)
was usually administered. Local anesthesia was performed with lidocaine
2\% after skin sterilization. A Tru-cut 14G needle was used preferably
in the right hepatic lobe accessing through intercostal spaces. The
number of needle passes depended on the operator´s decision. Patients
remained on complete rest and fasting in a comfortable position, under
the monitoring of vital signs, and were discharged after 4 to 6 hours.
They were instructed to return in case of severe pain in the abdomen,
chest or at the puncture site, dizziness, fainting, nausea, vomiting, or
dyspnea.

The PLB-related consequences were divided as follows: 1) \emph{pain} :
complained by the patient at the puncture site, on the right shoulder,
thorax, or abdomen. 2) \emph{mild AEs} : high blood pressure (systolic
blood pressure \textgreater{} 150mmHg), low blood pressure (systolic
blood pressure \textless{} 90mmHg), nausea/vomiting, headache, and
hypoglycemia (\textless{}70 mg/dL on capillary glucometer).
3)\emph{serious AEs} : detection of perihepatic fluid at bedside US
examination, subcapsular bleeding, right-sided hemothorax, and death.
The need for hospital admission and surgical treatment was assessed up
to two months following the procedure.

\textbf{STATISTICAL ANALYSIS}

The Generalized Estimating Equations method was used to evaluate the
association between the variables and pain or complications. The
estimates were calculated by maximum likelihood in order to avoid bias
on the difference in the number of PLB for each patient. Observations
within a given patient were not independent and intra-patient
correlation and variation were introduced into the analysis using a
mixed generalized linear model.

The Chi-square or Fisher's exact tests were used to compare categorical
variables and the Mann-Whitney test for numerical variables. Statistical
analysis was performed using the SAS for Windows version 9.4 system. The
level of statistical significance adopted in the analysis was 5\%.

\textbf{RESULTS}

A total of 569 biopsies were performed during the study period. Due to a
lack of data in the medical records, 37 cases were excluded. Eight
subjects underwent two biopsies, so the study involved 532 biopsies in
524 patients (55.3\% male) with a median age of 49 years (range: 13 to
74), as shown in Table 1.

Regarding laboratory tests, INR value and platelets count were available
in 530 procedures. The median and range (minimal -- maximum) were 1.01
(0.84 -- 1.55) and 200,000/mm\textsuperscript{3} (48,000 --
474,000/mm\textsuperscript{3} Almost 40\% had cardiovascular
comorbidities, around 18\% had overweight or obesity and 2.1\% had
chronic kidney disease. Half of the studied population had no
comorbidities (Table 1).

HCV chronic infection assessment was the major indication for PLB
(47.0\%), followed by AIH / cholestasis (12.6\%) and MAFLD (12.1\%). The
amount of HCV-related procedures has sharply reduced. On the other hand,
the number of MAFLD-related biopsies has progressively raised over the
years, as shown in Figure 1.

The median number of needle passes was 1 (ranging from 1 to 4).
PLB-related pain was reported in 53.6\% of the studied population. To
relieve it, dipyrone was administered in 40.2\% of patients, tramadol in
3.7\%, and both medications in 8.1\%. Eight patients (1.6\%) that
complained of pain did not require any medication. The female gender was
associated with a higher complaint of pain (p=0.0143). There was no
significant influence of other clinical and laboratory variables in the
occurrence of pain (age, comorbidities, platelets count, INR, and number
of needle passes). AEs occurred in 87/532 biopsies (16.4\%); they were
mild in 76 (14.3\%) and serious in 11 (2.1\%) procedures.

The main mild AEs (n=76) were high blood pressure (32/532 -- 6.0\%),
headache (3.6\%), nausea/vomiting (2.4\%), low blood pressure (1.5\%),
and hypoglycemia (0.2\%), as shown in Table 2. The management was oral
captopril, venous dipyrone, venous metoclopramide, venous crystalloid,
and glucose infusion, respectively. Regarding serious AEs (n=11), 5
patients had perihepatic fluid on US, 4 had subcapsular bleeding, and 2
had right-sided hemothorax (Table 2). Ten patients (1.9\%) were admitted
to the hospital due to the following conditions: perihepatic fluid on US
examination (n=4), subcapsular bleeding (n=2), hemothorax (n=2), low
blood pressure with nausea/vomiting (n=1) and intense pain at the biopsy
site (n=1). No one patient required surgical treatment and there were no
deaths, as shown in Table 2. There was no association between the
occurrence of mild or serious AEs and the studied variables (clinical,
laboratory, and procedure-related). Renal function was normal in all the
patients that developed bleeding.

\textbf{DISCUSSION}

In this study, we evaluated a large sample of subjects submitted to
real-time US-guided PLB in an outpatient setting over 5 years. Viral
hepatitis was the main indication for biopsy, similar to previous
reports \textsuperscript{12,14,15}. As the prevalence of HBV chronic
infection in our country is low \textsuperscript{16}, HCV-related
biopsies were more frequent in our sample. Some studies carried out in
other geographic areas enrolled more commonly HBV
patients\textsuperscript{15,17}. Likewise, post-transplant follow-up was
the most common reason for PLB at transplant centers
\textsuperscript{18}. In the pediatric population, the major reported
indications were elevated liver enzymes, AIH, and cholestatic
diseases\textsuperscript{19}.

In our study, the reason for PLB has undergone a transformation over the
years. It was possible to notice a remarkable drop in the amount of
HCV-related procedures and a progressive increase in MAFLD-related
biopsies. As we have mentioned, a reduction in the need for liver biopsy
due to HCV was expected, but other liver diseases still require
histological evaluation to help on the management and
follow-up\textsuperscript{1} -- notably, AIH, small-duct primary
sclerosing cholangitis, anti-mitochondrial antibody--negative primary
biliary cholangitis, drug or herb-induced liver injuries, some HBV
patients, systemic diseases with hepatic involvement, and MAFLD, which
is being intensely studied. As promising therapies are awaited, it is
feasible to predict that histological staging will help physicians in
choosing the best approach to MAFLD patients.

As supposed, pain was the most frequent consequence of
PLB\textsuperscript{1,10,19}. A study involving 54 patients described an
84\% incidence of pain immediately following the PLB and 39\% of the
patients still complained of pain after 24 hours \textsuperscript{14}.
This symptom was associated with anxiety pre-procedure and the female
gender \textsuperscript{14}. We found a 53.6\% incidence of pain and a
significant association with the female gender but we have not studied
patients' complaints prior to the biopsy. Although pain is generally
mild and has a good response to analgesics, local anesthetics do not
seem to prevent it, instead of the use of midazolam or nitrous
oxide\textsuperscript{14}. The real-time image-guided setting may reduce
the incidence of pain, as it provides anatomical ascertain, reducing
trauma to the subcutaneous tissue and hepatic
capsule\textsuperscript{4,17,18}.

According to the literature, the patient's position after the PLB does
not affect the rate and severity of complications \textsuperscript{20},
so our patients decided a comfortable position to rest. At our center,
the protocol is to maintain observation for up to 4 to 6 hours after
PLB, but the most appropriate period has not been well defined in the
literature and it can last from 2 to 8 hours\textsuperscript{4,9,21-23}.

In our study, the incidence of low blood pressure following the PLB was
low (1.5\%), similar to previous reports \textsuperscript{7,20}. It may
occur due to bleeding, vasovagal reflex associated with pain, or even as
a side effect of sedative drugs, such as
midazolam\textsuperscript{4,7,8}. We did not find an association between
low blood pressure and bleeding or pain, possibly due to the low
frequency of such complications in our sample.

The rate of bleeding was also low in our study, similar to the
literature \textsuperscript{3,4,24}. It has already been described that
patients older than 50 years are more likely to progress with
bleeding\textsuperscript{25,26}, but no statistical association between
age and hemorrhage was found in our study. Parente et al.
\textsuperscript{8}reported a higher rate of bleeding after liver
biopsies (2.3\%); however, the studied population had neoplasia, which
is more susceptible to hemorrhage. A higher risk of bleeding is also
expected in patients with platelets count \textless{} 50,000-70,000/mm³
and/or INR \textgreater{} 1.3-1.5 \textsuperscript{3,10,25-27}. Most of
our patients had normal INR and platelets count and there was no
bleeding in the subjects with tests out of these limits, so we did not
find any association between coagulation tests and bleeding.

The need for hospital admission in our sample (1.9\%) was similar to
previous reports, ranging from 1 to 3\% \textsuperscript{3,4,18}. In
addition, there were no more serious complications, such as perforation
of the gallbladder, colon, kidneys, hemobilia, abscess, and
intraperitoneal bleeding. Death following a PLB is extremely rare (up to
0.1\%) \textsuperscript{1,18} and it did not occur in our study.
However, it is essential to notice that, in general, serious
complications and death are more frequent in patients with severe
comorbidities, suspected neoplasia, and cirrhosis, and such individuals
usually undergo in-hospital biopsies at our center.

The real-time US-guided setting seems to reduce the risk of PLB-related
serious complications \textsuperscript{1,3,25,26}. This is not entirely
proven, since some studies have found different
results\textsuperscript{24,28-30}. Other factors must be reminded in
order to improve the safety of PLB, such as the operator experience and
a careful selection of individuals to undergo it in an outpatient
setting\textsuperscript{31}. Although radiologists most commonly perform
US-guided liver biopsies \textsuperscript{5}, gastroenterologists and
hepatologists can also safely execute it \textsuperscript{6}. Our
results showed a low incidence of serious AEs, even in a scenario of
senior residents in training, supervised by a hepatologist.

This study has some limitations: 1) the single-center design may be
associated with bias on patients selection, 2) the retrospective design
and non-uniform descriptions in the medical records may have changed the
rate of AEs, 3) the data collected exclusively from the medical records
may have missed outcomes of patients eventually admitted to other
hospitals, and 4) a non-standardized dose of midazolam for sedation may
have affected the incidence of pain.

\textbf{CONCLUSIONS}

US-guided PLB in an outpatient setting has a low rate of complications
and must keep been considered for selected individuals with
indeterminate liver disease. The reason to perform it is undergoing a
notable transition, where HCV chronic infection has been replaced by
MAFLD. New strategies to prevent biopsy-related pain are still needed,
especially for females.

\emph{Figure legends} :

\textbf{Figure 1 -- Number of indications-related liver biopsies from
2015 to 2019} . AIH: autoimmune hepatitis; MAFLD: metabolic
dysfunction-associated fatty liver disease.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Tapper EB, Lok ASF. Use of Liver Imaging and Biopsy in Clinical
  Practice. \emph{N Engl J Med.} 2017;377(23):2296-2297. doi:
  10.1056/NEJMc1712445.
\item
  Younossi ZM, Teran JC, Ganiats TG, Carey WD. Ultrasound-guided liver
  biopsy for parenchymal liver disease: and economic analysis. \emph{Dig
  Dis Sci.} 1998;43(1):46-50. doi: 10.1023/a:1018815802500.
\item
  Lindor KD, Bru C, Jorgensen RA, Rakela J, Bordas JM, Gross JB, et al.
  The role of ultrasonography and automatic-needle biopsy in outpatient
  percutaneous liver biopsy. \emph{Hepatology.} 1996;23(5):1079-1083.
  doi: 10.1002/hep.510230522.
\item
  Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD. Liver
  Biopsy.\emph{Hepatology.} 2009;49(3):1017-1044. doi:
  10.1002/hep.22742.
\item
  Myers RP, Fong A, Shaheen AA. Utilization rates, complications and
  costs of percutaneous liver biopsy: a population-based study including
  4275 biopsies. \emph{Liver Int.} 2008;28(5):705-712. doi:
  10.1111/j.1478-3231.2008.01691.x.
\item
  DiTeodoro LA, Pudhota SG, Vega KJ, Jamal MM, Munoz JC, Wludyka P, et
  al. Ultrasound marking by gastroenterologists prior to percutaneous
  liver biopsy removes the need for a separate radiological
  evaluation.\emph{Hepatogastroenterology.} 2013;60(124):821-824. doi:
  10.5754/hge121106.
\item
  Filingeri V, Sforza D, Tisone G. Complications and risk factors of a
  large series of percutaneous liver biopsies in patients with liver
  transplantation or liver disease. \emph{Eur Rev Med Pharmacol
  Sci.}2015;19(9):1621-1629
\item
  Parente FVC, Moura EA, Santos JAM, Lima MVA. US-Guided percutaneous
  core liver biopsy: Analysis of 171 cases from a single oncology
  service. \emph{Arq Gastroenterol.} 2018;55(3):208-211. doi:
  10.1590/S0004-2803.201800000-55.
\item
  Patel NJ, Bowman AW. Assessment of Appropriate Recovery Time After
  Liver Biopsy. \emph{J Am Coll Radiol.} 2018;15(9):1266-1268. doi:
  10.1016/j.jacr.2018.04.004.
\item
  Bravo AA, Sheth SG, Chopra S. Liver Biopsy. \emph{N Engl J
  Med.}2001;344(7):495-500. doi: 10.1056/NEJM200102153440706.
\item
  Taykar V, Etzion O, Heller T, Kleiner DE, Rotman Y, Ghany MG, et al.
  Complications of percutaneous liver biopsy with Klatskin needles: a
  36-year single-centre experience. \emph{Aliment Pharmacol
  Ther.}2017;45(5):744-753. doi: 10.1111/apt.13939
\item
  Saadeh S, Cammell G, Carey WD, Younossi Z, Barnes D, Easley K. The
  role of liver biopsy in chronic hepatitis C.
  \emph{Hepatology.}2001;33(1):196-200. doi: 10.5114/ceh.2016.58851.
\item
  Jarcuska P, Bruha R, Horvath G, Simon K, Drazilova S. Evaluation of
  hepatic fibrosis -- access to non-invasive methods, national
  practice/guidelines in Central Europe. \emph{Clin Exp
  Hepatol.}2016;2(1):12-15. doi: 10.5114/ceh.2016.58851.
\item
  Eisenberg E, Konopniki M, Veitsman E, Kramskay R, Gaitini D, Baruch Y.
  Prevalence and Characteristics of Pain Induced by Percutaneous Liver
  Biopsy. \emph{Anesth Analg.} 2003;96(5):1392-1396. doi:
  10.1213/01.ane.0000060453.74744.17.
\item
  Kose S, Ersan G, Tatar B, Adar P, Sengel BE. Evaluation of
  Percutaneous Liver Biopsy Complications in Patients with Chronic Viral
  Hepatitis. \emph{Eurasian J Med.} 2015;47(3):161-164. doi:
  10.5152/eurasianjmed.2015.107.
\item
  Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of
  hepatitis B virus infection: new estimates of age-specific HBsAg
  seroprevalence and endemicity. \emph{Vaccine.} 2012 ;30(12):2212-2219.
  doi: 10.1016/j.vaccine.2011.12.116.
\item
  Cakmakci E, Caliskan KC, Tabakci ON, Tahtabasi M, Karpat Z.
  Percutaneous liver biopsies guided with ultrasonography: a case
  series. \emph{Iran J Radiol.} 2013;10(3):182-184. doi:
  10.5812/iranjradiol.13184.
\item
  Filingeri V, Francioso S, Sforza D, Santopaolo F, Oddi FM, Tisone G. A
  retrospective analysis of 1.011 percutaneous liver biopsies performed
  in patients with liver transplantation or liver disease:
  ultrasonography can reduce complications? \emph{Eur Rev Med Pharmacol
  Sci.} 2016;20(17):3609-3617.
\item
  Almeida P, Schreiber RA, Liang J, Mujawar Q, Guttman OR. Clinical
  characteristics and complications of pediatric liver biopsy: a single
  centre experience. \emph{Ann Hepatol.} 2017;16(5):797-801. doi:
  10.5604/01.3001.0010.2809.
\item
  Costa RS, Cardoso AF, Ferreira A, Costa J, Costa D, Fernandes D, et
  al. What recovery position should patients adopt after percutaneous
  liver biopsy? \emph{Eur J Gastroenterol Hepatol.} 2019;31(2):253-259.
  doi: 10.1097/MEG.0000000000001290.
\item
  McCarty TR, Bazarbashi NA, Njei B, Ryou M, Aslanian HR, Muniraj T.
  Endoscopic Ultrasound-Guided, Percutaneous, and Transjugular Liver
  Biopsy: A Comparative Systematic Review and Meta-Analysis. \emph{Clin
  Endosc.} 2020;53(5):583-593. doi: 10.5946/ce.2019.211.
\item
  Bolia R, Matta J, Malik R, Hardikar W. Outpatient Liver Biopsy in
  Children: Safety, Feasibility, and Economic Impact. \emph{J Pediatr
  Gastroenterol Nutr.} 2017;65(1):86-88. doi:
  10.1097/MPG.0000000000001565.
\item
  Hayatghaibi S, Ashton D, Cleveland H, Kukreja K. Limited
  Post-observation Period in Pediatric Outpatient Ultrasound-Guided
  Liver Biopsies. \emph{Cardiovasc Intervent
  Radiol.}2017;40(12):1899-1903. doi: 10.1007/s00270-017-1720-3.
\item
  Van der Poorten D, Kwok A, Lam T, Ridley L, Jones DB, Ngu MC, et al.
  Twenty-year audit of percutaneous liver biopsy in a major Australian
  teaching hospital. \emph{Intern Med J.} 2006;36(11):692-699. doi:
  10.1111/j.1445-5994.2006.01216.x.
\item
  Midia M, Odedra D, Shuster A, Midia R, Muir J. Predictors of bleeding
  complications following percutaneous image-guided liver biopsy: a
  scoping review. \emph{Diagn Interv Radiol.} 2019;25(1):71-80. doi:
  10.5152/dir.2018.17525.
\item
  Thampanitchawong P, Piratvisuth T. Liver biopsy: complications and
  risk factors. \emph{World J Gastroenterol.} 1999;5(4):301-304. doi:
  10.3748/wjg.v5.i4.301.
\item
  Seeff LB, Everson GT, Morgan TR, Curto TM, Lee WM, Ghany MG, et al.
  HALT--C Trial Group. Complication rate of percutaneous liver biopsies
  among persons with advanced chronic liver disease in the HALT-C
  trial.\emph{Clin Gastroenterol Hepatol.} 2010;8(10):877-883. doi:
  10.1016/j.cgh.2010.03.025.
\item
  tenBerge J, Hoffman BJ, Hawes RH, Enckevort CV, Giovannini M, Erickson
  RA, et al. EUS-guided fine needle aspiration of the liver:
  indications, yield, and safety based on an international survey of 167
  cases. \emph{Gastrointest Endosc.} 2002;55(7):859-862. doi:
  10.1067/mge.2002.124557
\item
  Gilmore IT, Burroughs A, Murray-Lyon IM, Williams R, Jenkins D,
  Hopkins A. Indications, methods, and outcomes of percutaneous liver
  biopsy in England and Wales: an audit by the British Society of
  Gastroenterology and the Royal College of Physicians of
  London.\emph{Gut.} 1995;36(3):437-441 doi: 10.1136/gut.36.3.437.
\item
  Manolakopoulos S, Triantos C, Bethanis S, Theodoropoulos J,
  Vlachogiannakos J, Cholongitas E, et al. Ultrasound-guided liver
  biopsy in real life: comparison of same-day prebiopsy versus real-time
  ultrasound approach. \emph{J Gastroenterol
  Hepatol.}2007;22(9):1490-1493. doi: 10.1111/j.1440-1746.2007.04992.x.
\item
  Westheim BH, Aagenæs I, Østensen AB, Sanengen T, Almaas R. Effect of
  operator experience and frequency of procedure performance on
  complication rate after ultrasound-guided percutaneous liver
  biopsies.\emph{J Pediatr Gastroenterol Nutr.} 2013;57(5):638-643. doi:
  10.1097/MPG.0b013e3182a0c7a5.
\end{enumerate}

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\textbf{Hosted file}

\verb`Table1.docx`  available at \url{https://authorea.com/users/416022/articles/523750-outpatient-percutaneous-liver-biopsy-is-a-low-risk-procedure-and-has-steatosis-as-a-new-indication-trend}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure1/Figure1}

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\end{figure}

\textbf{Hosted file}

\verb`Table2.docx`  available at \url{https://authorea.com/users/416022/articles/523750-outpatient-percutaneous-liver-biopsy-is-a-low-risk-procedure-and-has-steatosis-as-a-new-indication-trend}

-Silva-

\selectlanguage{english}
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