Post written by Muhammad Nadeem Yousaf, MD, and Harry R. Aslanian, MD, from the Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA.

In our video case series, we present endoscopic ultrasound (EUS) imaging of common benign and malignant liver lesions. The cases presented include: liver cyst and hemangioma, cirrhosis, portal vein thrombosis, hepatocellular carcinoma, and metastatic liver lesions including pancreatic adenocarcinoma, neuroendocrine tumor, and squamous cell carcinoma. EUS imaging following transjugular Intrahepatic portosystemic shunt (TIPS) and gastric bypass surgery are also presented.

EUS can be an important tool in the evaluation of liver disease. Benign hepatic lesions are common and metastatic lesions may be difficult to identify. Recognition of metastatic lesions is important as it may significantly change a patient’s stage and treatment options. In addition, EUS often provides good access for tissue sampling of liver lesions.

Hepatic lesions may be subtle. Torqueing the EUS probe to scan through the liver in motion may assist in the recognition of a lesion indicated by the disrupted pattern of the normal liver parenchyma, vessels, and bile ducts. Hepatic metastases may be hypo or hyperechoic rounded structures depending upon the vascularity of lesions and the site of primary tumor.

When performing FNA (fine needle aspiration) or FNB (fine needle biopsy), it is helpful to target lesions close to the EUS probe to minimize the amount of liver parenchyma traversed. The trajectory of the needle for distant lesions typically cannot be modified once the needle has been passed into the liver. Hepatic metastases are typically very cellular. FNA with 25-gauge needles may safely and effectively diagnose malignancy. The high cellularity of hepatic metastases may provide a cell block with dedicated FNA or FNB sampling.

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