Top tips regarding EUS-guided liver biopsy

Post written by David L. Diehl, MD, FACP, FASGE, from the Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA.


The editors of GIE wanted a Top Tips section in the Journal in 2022, and I feel very honored to be asked to craft an article for this series on “Top tips regarding EUS-guided liver biopsy.”

Our Advanced Endoscopy section at Geisinger Medical Center has considerable experience with the EUS-guided liver biopsy (EUS-LB) procedure. Since our hepatologists stopped performing percutaneous liver biopsies themselves several years ago, we have taken on almost the entire liver biopsy workload at our hospital, except for the few LBs that require a transjugular approach. Even with non-invasive, indirect measures of hepatic fibrosis (eg, FibroScan), there remain many LB referrals from our hepatologists.

In the years that we have been performing EUS-LBs, we have persistently worked to figure out the best method for this procedure, including technique, needle selection and preparation, and measures to ensure safety. These techniques have been developed using data from prospective randomized trials that we have been able to perform because of the large volume of EUS-LB procedures at our institution.

The Top Tips discussed in this article are listed below, but I encourage you to look at the original manuscript for a deeper dive on each of the 10 points:

  1. Talk to your hepatologists and other referring physicians to inform them that you are performing an EUS-guided liver biopsy.
  2. Talk to your pathologists to let them know that you will be performing EUS-guided liver biopsies.
  3. Check procedure indication and need for additional procedures during the same EUS-LB session.
  4. Check procedure contraindications.
  5. Select the biopsy needle.
  6. Prepare the biopsy needle.
  7. Assess the biopsy target in the liver, and avoid inadvertent splenic biopsy.
  8. Use an optimal and safe needle biopsy technique.
  9. Retrieve specimen without introducing fragmentation, and assess adequacy of biopsy.
  10. Assess the patient after biopsy.

EUS-guided liver biopsy has emerged as an important technique, and around it has developed the field of endoscopic hepatology. The ability to directly measure portal pressures and calculate the portal pressure gradient by EUS-guided vascular puncture (EUS-PPG) is a newer technique that will replace some of the transjugular procedures that are needed now. The ability to perform EUS-PPG together with EUS-LB and endoscopic variceal assessment in a single session is allowing a “1-stop shop” for comprehensive evaluation of liver disease. The future is bright!


Right hepatic lobe is identified, and biopsy is performed with the echoendoscope placed in the duodenal bulb.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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