These are the author's disclosures. EUS liver biopsy is emerging as an alternative form of tissue acquisition to percutaneous or IR-guided liver biopsy. Recent studies have shown adequate specimen acquisition and an enhanced safety profile. EUS-guided liver biopsy has been found to be extremely safe. The most common complications are mainly due to bleeding events. During IR-guided biopsies, a coaxial needle is used which allows for gel foam injection if bleeding is encountered. This coaxial design allows for tissue specimen retrieval prior to gel foam injection. The downside of coaxial needle is that the needle is much larger in diameter. These 15-18 gauge needles could not be used during endoscopy and therefore gel foam cannot be used as a salvage technique. To summarize our endoscopic technique, we performed EUS liver biopsy with a 19-gauge FNA needle. A total of one pass and three actuations are performed to obtain liver specimen. EFLOW color doppler is used to identify potential bleeding within the liver biopsy tract. If persistent color flow is seen within the biopsy tract after 2-3 minutes, about 25% of the needle contents are pushed back into the needle tract using the FNA stylet. This is the blood patch that is used as a mechanical barrier to facilitate in achieving hemostasis and preventing post-liver biopsy bleeding. Clinical implications include prevention of post-liver biopsy bleeding in addition to salvaging liver specimen in order to obtain a pathology diagnosis. The first case is a 65-year-old male with a past medical history of reflux type 2 diabetes hyperlipidemia and elevated LFT since 2004. He had a positive ANA, SMA, and IgG concerning for autoimmune hepatitis. The patient was referred for EUS liver biopsy. Here we perform EUS guided liver biopsy with a 19-gauge FNA needle. With this particular needle, we perform one pass with a total of three actuations. Actuation 1. Actuation 2. Actuation 3. Following our final actuation, we perform EFLOW color doppler to ensure no active bleeding within the biopsy tract. You can see here that the EFLOW is picking up active flow within the needle tract. At this point, we do not want to withdraw the FNA needle out of the liver. We simply allow for hemostasis to occur by waiting 2-3 minutes. If flow persists, as in this case, we reintroduce the stylet into the FNA needle and deliver the most distal 25% of the needle content, which includes blood clot and potentially some liver specimen. As the stylet is pushed into the needle, we can see hypoechoic material enter the needle tract. This is our blood patch, which results in cessation of blood flow towards our needle and thereby resulting in hemostasis. We are now able to safely remove the needle without risk of bleeding. The second case is a 52-year-old female with past medical history of insulin-dependent diabetes, obesity with a BMI of 35, and abnormal LFTs. Initial blood work was suspicious for autoimmune hepatitis with a positive ANA 1-160, elevated IgG levels, however, negative SMA. Therefore, patient was referred for US liver biopsy for further evaluation. We again use a 19-gauge FNA needle and perform 1 pass with 3 actuations. After final actuation, eFLOW Doppler again shows flow within the biopsy tract. We can see here that flow persists after waiting two to three minutes, therefore salvage technique with blood patch was performed. Persistent color e-flow is seen within the biopsy tract, therefore the stylette is reintroduced into the FNA needle and here we can see hypoechoic material entering the biopsy tract which acts as which represents our blood patch. We can see here that the e-flow shows that the color Doppler does not flow proximally, therefore it is now safe to remove our needle. In conclusion, post-liver biopsy bleeding is a common complication. Currently there are no endoscopic therapies to assist in preventing post-liver biopsy bleeding. We describe a technique where a blood patch is delivered into the biopsy tract in order to achieve hemostasis and in so doing helping prevent post-liver biopsy hemorrhage.

EUS liver biopsy

alternative to percutaneous biopsy

IR-guided liver biopsy

19-gauge FNA needle

EFLOW color doppler