This ASG video tip is sponsored by Braintree, maker of the newly approved Souflave and Soutab. Hello, I'm Samit Tiwani with Rockford Gastroenterology Associates in Rockford, Illinois, and it is my pleasure to bring to you today the ASG video tip on EUS guided liver biopsy. I have no relevant disclosures. As one of the first procedures developed in the burgeoning field of endohepatology, EUS guided liver biopsy has become more widely available and accepted as an alternative to transabdominal and transjugular techniques. Multiple studies have described the success and safety of this technique. We have found several advantages to the EUS approach, including real-time ultrasound guidance, bilateral sampling, which decreases the potential for sampling error, and procedure sedation resulting in decreased patient anxiety and pain with increased satisfaction. We typically use the EUS approach for patients who are undergoing endoscopic procedures for additional indications, as it can easily be combined with EGD for upper GI tract evaluation and EUS for pancreatic opilary pathology. Since embarking on this journey several years ago, our pathologists have also reported improved specimen quality, which has led to increased provider satisfaction as well for both our referring providers and our proceduralists. Before starting the procedure, ensure that it is being performed for an appropriate indication. It is also important to consider the contraindications, including coagulopathy, thrombocytopenia, active anticoagulation or antiplatelet therapy, large volume ascites, and previous gastric surgery, which can be a relative contraindication given the limited access that you may have to the liver. We use a 19-gauge core biopsy needle for the procedure, which has yielded improved specimen quality without fragmentation and with increased numbers of portal tracts. EUS-GUIDE liver biopsy is typically performed using the wet suction technique, which will be described next, although some providers prefer the dry suction technique or slow pull technique using the stylet. To perform the wet suction technique, the stylet is first removed from the needle. The needle is primed with a heparin flush to reduce blood clotting within the needle or it can be primed with saline. The flush remains attached to the needle until just prior to tissue acquisition to preserve the column of fluid within the needle. Identify the target portion of the liver using Doppler to ensure no major vascular structures along the biopsy path. The left lobe of the liver can be examined and biopsied from the stomach, while the right lobe from the duodenal bulb. The suction syringe is set to full suction and attached to the needle. The needle is then introduced approximately one centimeter into the liver parenchyma using a rapid short jab to allow the needle to puncture the gastric or duodenal wall into the liver. Once the needle tip is within the liver parenchyma, the suction is opened and needle actuations are performed. I typically start with a long actuation, several centimeters in length, although sometimes that's not possible and three to four shorter actuations limited to two to three centimeters may be necessary instead. The suction is then closed and the needle is withdrawn from the liver. The contents of the needle are then expressed into a jar of formalin. The adequacy of the biopsy specimen can be difficult to tell due to the presence of blood within the jar, but using an LED flashlight we are usually able to identify and differentiate white worms of tissue representing liver cores. The use of the heparin flush to prime the needle reduces the likelihood of red worms of clot forming, which can be difficult to differentiate from the white liver tissue. Others have described using a sieve or mesh to collect the specimen and wash away the blood from the specimen to allow improved assessment of the adequacy of sampling. Patients are recovered in the endoscopy recovery area following similar protocols to those after FNA. A minority of patients may experience pain after liver biopsy, but this is typically self-limited and does not require additional analgesia after the procedure. It is important to remain vigilant to the risks of complications from the procedure, including bleeding and intrahepatic hematoma, which is usually self-limited, but in rare circumstances may require hospitalization and intervention. In summary, EUS-guided liver biopsy is a safe and effective alternative to transabdominal and transjugular techniques. Benefits include real-time ultrasound guidance, bilateral sampling, and improved patient and provider satisfaction. The 19-gauge F-fine biopsy needle limits fragmentation and improves specimen quality by including more portal tracts. We use the wet suction technique with the needle primed with a heparin flush to reduce clotting, and during specimen retrieval, you want to look for white worms representing the liver cores. Thank you.

EUS guided liver biopsy

procedure advantages

real-time ultrasound guidance

specimen quality

potential complications