What it is (overview)

A liver biopsy with imaging guidance is a diagnostic test in which a clinician removes a very small tissue sample from the liver so it can be examined under a microscope. It is called “imaging-guided” because real-time imaging—most often ultrasound, and sometimes a CT scan—is used to precisely guide the biopsy needle into the safest and most informative area of the liver. Imaging guidance improves accuracy and helps reduce complications by avoiding blood vessels and nearby organs.

This test does not “measure” a number like a blood test. Instead, it provides a direct look at liver tissue, which can show:

• Inflammation (irritation of liver cells)
• Fibrosis (scarring) and cirrhosis (advanced scarring)
• Fat buildup (fatty liver changes)
• Infection
• Bile duct injury
• Tumors or abnormal growths

Results are typically reported by a pathologist and may include descriptions of the cause of liver injury (when identifiable) and the severity of liver damage, such as the amount of fat, degree of inflammation, and stage of fibrosis/scarring. In plain language, the biopsy can help answer questions like: “Do I have liver disease?”, “How much damage is present?”, and “Is there a specific condition (such as autoimmune hepatitis or a cancer) that explains my abnormal tests or imaging?” Your gastroenterology or hepatology team uses the findings to guide treatment decisions and next steps.

When & why it's usually done

A liver biopsy with imaging guidance may be ordered when blood work and imaging tests suggest a liver problem but do not fully explain what is causing it or how severe it is. It is also used when a definitive diagnosis will change management (for example, starting immune-suppressing medicines, confirming the type of hepatitis, or deciding how aggressively to treat fatty liver disease).

Common reasons a doctor may recommend this diagnostic test include:

• Persistent abnormal liver blood tests (such as elevated ALT/AST, alkaline phosphatase, or bilirubin) without a clear cause
• Suspected fatty liver disease (MASLD/NAFLD) or metabolic liver disease, especially when staging fibrosis is important
• Concern for liver scarring (fibrosis/cirrhosis) to determine stage and guide monitoring and treatment
• Evaluation of hepatitis (viral, autoimmune, medication-related, or other causes) when diagnosis or severity is uncertain
• A liver mass or lesion seen on ultrasound, CT scan, or MRI where a tissue diagnosis is needed (for example, to distinguish benign from malignant findings)
• Possible drug-induced liver injury or toxin exposure when other testing is inconclusive
• Monitoring certain known liver conditions when changes in symptoms, labs, or imaging suggest progression or a new issue

Symptoms and signs that may prompt evaluation for liver disease (and sometimes lead to biopsy) include jaundice (yellow skin/eyes), right upper abdominal discomfort, unexplained fatigue, itching, dark urine, pale stools, swelling in the abdomen/legs, easy bruising, or unintended weight loss. Risk factors include diabetes, obesity, high cholesterol, heavy alcohol use, viral hepatitis exposure, a family history of liver disease, and long-term use of certain medications that can affect liver health.

Common diseases related to it

• Metabolic dysfunction–associated steatotic liver disease (MASLD/NAFLD) and steatohepatitis (MASH/NASH)
• Alcohol-associated liver disease
• Chronic viral hepatitis (hepatitis B and hepatitis C)
• Autoimmune hepatitis
• Primary biliary cholangitis (PBC)
• Primary sclerosing cholangitis (PSC)
• Cirrhosis (advanced liver scarring) and evaluation of fibrosis staging
• Drug-induced liver injury (DILI)
• Hemochromatosis (iron overload)
• Wilson disease (copper overload)
• Liver tumors or lesions (benign or malignant), including hepatocellular carcinoma evaluation in selected cases

Health goals where it may help

• Getting an accurate diagnosis of suspected liver diseases when blood tests and imaging are not enough
• Assessing the degree of liver damage (inflammation and scarring) to understand current liver health
• Staging fibrosis/cirrhosis to guide surveillance plans and reduce long-term complications
• Guiding personalized treatment decisions in gastroenterology/hepatology (for example, choosing or adjusting medications)
• Clarifying the cause of abnormal liver enzymes to support safer medication use and lifestyle planning
• Evaluating a liver mass to determine whether it is benign or cancerous and to plan next steps