The specimen quality of endoscopic ultrasound-guided liver biopsy (EUS-LB) for benign liver disease evaluation depends on the technique and type of needle used. Using a 19-gauge (19 g) fine needle biopsy (FNB) needle with 3 actuations and wet suction (WS) or slow stylet pull is the current preferred practice. We conducted a randomized prospective multicenter trial to compare wet suction (WS) to slow stylet pull (SP) technique to compare histologic yields, length of procedure, and adverse events (AE).

This prospective randomized trial (NCT03245580) included patients undergoing EUS-LB for parenchymal biopsy at 6 centers in the United States in 2020-2021. A 19 g Franseen tip EUS needle was used for all procedures. For WS, the needle was flushed with saline, and a 20 ml suction syringe with 3 to 5 ml of fluid was used. For SP, a slow pullback of stylet was used. Pathologist was blinded for tissue interpretation.

One hundred fifty-three patients across 6 tertiary centers were included, with 75 patients in the WS arm and 78 patients in the SP arm. Histologic outcomes were superior in WS compared with SP [aggregate specimen length (46.5 vs. 34.5 mm, P<0.001), length of longest fragment (14 vs. 11 mm, P<0.001), and number of complete portal tracts (16 vs. 11.5, P<0.001)]. The overall ability to make a histological diagnosis was higher in WS (99% vs. 92%). Procedure length and AE did not differ between groups.

The use of WS compared with SP for EUS-LB resulted in superior specimen yields. Total procedure time and adverse events were similar for both techniques.

The practice of endoscopic ultrasound-guided liver biopsy (EUS-LB) is becoming more common due to its proven safety and effectiveness. For accurate diagnosis, it is vital to secure ample tissue specimens. However, gauging the volume of tissue specimens accurately poses a challenge with existing methods. Additionally, determining the most suitable fine-needle biopsy (FNB) needle requires further study. Our aim was to contrast the tissue surface areas obtained using Franseen and Fork-tip needles and to identify factors affecting tissue volume.

This retrospective study analyzed liver tissue samples collected through EUS-LB using 19-gauge Franseen and Fork-tip needles from patients suffering from diffuse liver diseases, conducted in our hospital from April 2019 to April 2022. We primarily focused on measuring hepatic tissue surface area and portal tract count, alongside examining patient-related factors that could influence tissue surface area.

The study involved 20 cases for each type of needle. The comparison revealed no significant disparities in the total liver tissue surface area (22.0 mm2 vs. 22.6 mm2, P = 0.45) or in the portal tract counts (30 vs. 20, P = 0.16). No adverse incidents were noted in either group. Both univariate and multivariate analyses highlighted that fibrosis and metabolic dysfunction associated steatotic liver disease (MASLD) presence were significant determinants of the total hepatic tissue area (P = 0.04, P < 0.05; and P = 0.02, P = 0.03, respectively).

The capabilities of both needles in acquiring liver tissue were comparably effective. The volume of tissue was affected by the severity of fibrosis and the occurrence of MASLD.

With the rapid development of endoscopic ultrasound (EUS), diagnostic and therapeutic platforms have emerged that are applicable in hepatology. New tools such as EUS-guided portal pressure measurement (in combination with EUS-guided liver biopsy) or EUS-guided variceal obliteration using coils and glue present attractive procedures that can potentially overcome the limitations of current gold standards. In this review article, we provide an overview of these new 'endo-hepatology' techniques and highlight their current role in the treatment of liver diseases.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing public health concern worldwide. Liver biopsy is the gold standard for diagnosing and staging MASLD, but it is invasive and carries associated risks. In recent years, there has been significant progress in developing noninvasive techniques for evaluation. This review article discusses briefly current available noninvasive assessments and the various liver biopsy techniques available for MASLD, including invasive techniques such as transjugular and transcutaneous needle biopsy, intraoperative/laparoscopic biopsy, and the evolving role of endoscopic ultrasound-guided biopsy. In addition to discussing the various biopsy techniques, we review the current state of knowledge on the histopathologic evaluation of MASLD, including the various scoring systems used to grade and stage the disease. We also explore current and alternative modalities for histopathologic evaluation, such as whole slide imaging and the utility of immunohistochemistry. Overall, this review article provides a comprehensive overview of the progress in liver biopsy techniques for MASLD and compares invasive and noninvasive modalities. However, beyond clinical trials, the practical application of liver biopsy may be limited, as ongoing advancements in noninvasive fibrosis assessments are expected to more effectively identify candidates for MASLD treatment in real-world settings.

Endoscopic ultrasound (EUS)-guided interventions on the liver such as diffuse biopsy and portal pressure gradient measurement are emerging as potential alternatives to percutaneous procedures. The purpose of this editorial was to address all the indications that could potentially make an EUS-guided approach a possible alternative to the percutaneous procedures with respect to the proce-dures that could join the EUS examination such as upper endoscopy for gastro-esophageal varices, pancreaticobiliary investigation with EUS, and other potential advantages in terms of patient safety. The issue of a holistic gastroenterologist approach was also discussed along with the potential for developing clinical research.

The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.

Gastrointestinal endoscopy has long been a reliable backbone in the diagnosis and management of hepatobilary disorders and their complications. However, with evolving non-invasive testing, personalised medicine has reframed the utility and necessity of endoscopic screening. Conversely, the growing interest and use of endoscopic ultrasound (EUS) and advanced endoscopy within gastrointestinal units has also opened novel diagnostic and therapeutic avenues for patients with various hepatobiliary diseases. The integration of "advanced endoscopy" within the practice of hepatology is nowadays referred to as "endo-hepatology". In essence, endo-hepatology consists of two pillars: one focusing primarily on disorders of the liver parenchyma, vascular disorders, and portal hypertension, which is mainly captured via EUS, while the other targets the hepatobiliary tract via endoscopic retrograde cholangiopancreatography and advanced imaging. Applications under the umbrella of endo-hepatology include, amongst others, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, coil and glue embolisation of gastric varices as well as cholangioscopy. As such endo-hepatology could become an attractive concept wherein advanced endoscopy might reinforce the medical management of patients with hepatobiliary disorders and their complications after initial basic work-up. In this review, we discuss current trends and future developments within endo-hepatology and the remaining hurdles to overcome.

There is dramatically increased incidence of several liver diseases worldwide; thus, an unmet need to diagnose and stage these pathological entities heralds the wide application of liver biopsy (LB) techniques. The ways of LB are versatile, including percutaneous LB, transjugular LB, and more recently an approach of minimal invasiveness, that is, EUS-guided LB (EUS-LB). In this review article, we come to the conclusion that EUS-LB may serve as a feasible, reliable, and safe alternative to percutaneous LB and transjugular LB in terms of improved diagnostic yield, excellent sampling performance, and controlled adverse events among patients with focal, infiltrative, and parenchymal liver diseases. Furthermore, extensive efforts have been made to optimize and refine several technical pillars within EUS-LB modality such as the selection of needle size/type, priming manner of biopsy needle, and choice of pass/actuation technique, all of which aim at obtaining better specimen quantity and quality. Another advantageous aspect and unique property pertinent to EUS-guided modality indicate that multiple screening, surveillance, and intervention procedures can be combined into one single endoscopic session. Accordingly, some pilot studies have clarified the clinical usefulness by integrating EUS-LB with simultaneous measurement of portal pressure gradient or examination of liver stiffness. However, more studies, in particular, randomized controlled trials or real-world evidence, are practically warranted to elucidate the validity and safety of EUS-LB as a regular/routine part of managing liver diseases.

Liver biopsy (LB) remains essential for the diagnosis and staging of parenchymal liver diseases. Endoscopic ultrasound-guided LB (EUS-LB) has emerged as an attractive alternative to percutaneous and transjugular routes. We aimed at comparing the adequacy of samples obtained by EUS-LB with percutaneous LB.

A single-center, randomized, controlled clinical trial was designed. Patients undergoing LB were randomly assigned to EUS-LB or percutaneous LB groups. EUS-LB was performed with a 19-gauge Franseen core needle through a transduodenal and transgastric route. Percutaneous LB was performed with a 16-gauge Tru-Cut needle. The main outcome was the percentage of adequate samples obtained. Secondary outcomes were the percentage of accurate histologic diagnosis, number of complete portal tracts (CPT), total and longest specimen length (TSL and LSL), sample fragmentation, adverse events, and patients' satisfaction. An adequate specimen was defined as TSL ≥20 mm and including ≥11 CPT.

Ninety patients were randomized (44 to EUS-LB and 46 to percutaneous LB) and included in the analysis. The percentage of adequate tissue samples was 32.6% and 70.4% for percutaneous LB and EUS-LB, respectively ( P < 0.001). A final histologic diagnosis was provided in all cases but one. TSL was longer after EUS-LB (23.5 vs 17.5 mm, P = 0.01), whereas the number of CPT was similar in both groups. Sample fragmentation occurred more often after EUS-LB ( P < 0.001). No differences in adverse events were found. Satisfaction reported with both procedures was high.

EUS-LB is safe and accurate and may be considered an alternative to percutaneous LB for the evaluation of parenchymal liver diseases.

Interventional endoscopic ultrasound has fueled remarkable advancements in the field of therapeutic procedures, revolutionizing minimally invasive interventions for a diverse range of conditions. This review highlights the latest breakthroughs and advancements in therapeutic endoscopic ultrasound, showcasing its potential to transform patient care.

Over the past decade, the number of endoscopic procedures relevant to patients with liver disease not only increased but also altered and expanded in terms of indications and applications. "Endohepatology" refers to the integration of advanced endoscopy within the practice of hepatology with endoscopic ultrasound as one of the main pillars. Current applications under the umbrella of endohepatology focus on advanced diagnostics and oncological, vascular, and metabolic interventions. These involve, among others, endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided coil and glue embolization of gastric varices. In addition to its conceptually attractive technical and innovative characteristics, endohepatology is also an appealing practical option for daily practice because it can be offered as a "one-stop clinic" intervention where comprehensive endoscopic diagnostic and/or therapeutic testing is performed in a single outpatient visit. In this review, we will discuss current trends and future developments within endohepatology and the remaining hurdles to overcome.

Recent years have seen the emergence of endoscopic-ultrasound-guided liver biopsy (EUS-LB) as an effective alternative to traditional (percutaneous or transjugular) liver biopsy techniques. Comparative studies have demonstrated that both endoscopic and non-endoscopic approaches are similar in terms of diagnostic adequacy, accuracy, and adverse events; however, EUS-LB offers the advantage of reduced recovery time. Additionally, EUS-LB enables the sampling of both lobes of the liver as well as the advantage of portal pressure measurements. However, EUS-LB may be argued to have a high cost, although this procedure can be cost-effective if bundled with other endoscopic procedures. Approaches utilizing EUS-guided liver therapy, such as the administration of chemotherapeutic agents and EUS elastography, are in development, and their optimal integration into clinical care is likely to emerge in the coming years. In the present review, we evaluate the available literature on EUS-LB indications, contraindications, variations in needle biopsy techniques, comparative outcomes, advantages and disadvantages, and future trends and perspectives.

Vibration-controlled transient elastography (VCTE) is a validated test for assessing liver fibrosis but may be unreliable in select patients, including those with morbid obesity. The limitations of VCTE may be overcome by EUS-guided shear wave elastography (EUS-SWE).

This single-center, prospective, nonrandomized tandem study compared the diagnostic accuracy of EUS-SWE and VCTE in consecutive patients undergoing liver biopsy sampling because of unreliable noninvasive testing. EUS-SWE of the left and right lobes were separately performed and then compared with VCTE. Liver elasticity cutoffs for different stages of fibrosis were estimated in 3 ways: optimized sensitivity and specificity using the Youden index; and with sensitivity and specificity fixed at 90% each, Diagnostic accuracy for fibrosis was compared with liver histology using the area under the receiver-operating characteristic curve (AUROC). The primary outcome was the diagnostic accuracy of EUS-SWE for advanced fibrosis. Secondary outcomes were diagnostic accuracy of VCTE, EUS-SWE for left and right hepatic lobes for significant/advanced fibrosis, and cirrhosis.

Forty-two patients (39 men, aged 54.5 ± 12.1 years) underwent EUS-SWE, VCTE, and liver biopsy sampling. The cross-validated AUROCs for advanced fibrosis were as follows: VCTE, .87 (95% confidence interval [CI], .76-.97); EUS-SWE left lobe, .8 (95% CI, .64-.96); and EUS-SWE right lobe, .78 (95% CI, .62-.95). The corresponding AUROCs for cirrhosis were as follows: VCTE, .9 (95% CI, .83-.97); EUS-SWE left lobe, .96 (95% CI, .9-1); and EUS-SWE right lobe, .9 (95% CI, .8-1). VCTE was unreliable in 8 patients who successfully underwent EUS-SWE. There was no statistically significant difference in the AUROCs for EUS-SWE and VCTE.

EUS-SWE correlates well with liver histology and is a safe and reliable diagnostic test for assessing liver fibrosis with accuracy comparable with VCTE. (Clinical trial registration number: NCT04533932.).

The 9-member Editorial Board of the American Society for Gastrointestinal Endoscopy performed a systematic literature search of original articles published during 2021 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals on endoscopy-related topics. Votes from each editorial board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study, with a focus on 3 criteria: significance, novelty, and global impact on clinical practice. The 10 areas identified collectively represent advances in the following endoscopic topics: colonoscopy optimization, bariatric endoscopy, endoscopic needle sampling and drainage, peroral endoscopic myotomy, endoscopic defect closure, meeting systemic challenges in endoscopic training and practice, endohepatology, FNA versus fine-needle biopsy sampling, endoscopic mucosal and submucosal procedures, and cold snare polypectomy. Each board member contributed a summary of important articles relevant to 1 to 2 of the consensus topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2021.

EUS has become an increasingly used diagnostic and therapeutic modality in the armamentarium of endoscopists. With ever-expanding indications, EUS is being used in patients with liver disease, for both diagnosis and therapy. EUS is playing an important role in providing additional important information to that provided by cross-sectional imaging modalities such as computerized tomography and magnetic resonance imaging. Domains of therapy that were largely restricted to interventional radiologists have become accessible to endosonologists. From liver biopsy and sampling of liver lesions to ablative therapy for liver lesions and vascular interventions for varices, there is increased use of EUS in patients with liver disease. In this review, we discuss the various diagnostic and therapeutic applications of EUS in patients with various liver diseases.

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA) from focal liver lesions are indicated in selected cases, but there has been no previous comparison of needle types of the same size. The aim of our study was to compare the histologic diagnostic accuracy and adequacy of cores obtained with EUS-FNB needles in contrast to those obtained with FNA needles in focal liver lesions. This prospective one-center study included patients with left lobe hepatic focal lesions with contraindications for percutaneous liver biopsy or need for EUS for concomitant lesions. Each patient had one pass of 22G EUS-FNB (Franseen) needle and one pass of 22G EUS-FNA in a crossover manner, without macroscopic on-site evaluation. Each sample was analyzed separately for histologic adequacy and diagnosis. The final diagnosis was based on histology results or on imaging follow-up in the case of negative biopsies. The EUS-FNB samples (n = 30) were found to be more adequate for histologic analysis, with more cellularity and longer tissue aggregates than the EUS-FNA samples (n = 30). The accuracy of EUS-FNB was 100%, whereas that of EUS-FNA was 86.7% (p = 0.039). No post-procedure complications were noted. The 22G EUS-FNB needle proved superior to 22G EUS-FNA in terms of tissue acquisition diagnostic accuracy and histologic adequacy in focal liver lesions.

Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a minimally-invasive alternative to the traditional (percutaneous or transjugular) liver biopsy techniques for the diagnosis of liver parenchymal diseases. Po-tentially, EUS-LB combines the advantages of percutaneous and transjugular liver biopsy in addressing focused sampling in addition to measuring portal pressure. Additionally, EUS-LB facilitates access to both the lobes of the liver which is not considered with the traditional percutaneous liver biopsy. Multiple studies have compared EUS-LB with conventional liver biopsy and reported comparable diagnostic yield, increased acquisition of complete portal tracts, and longer specimen length as compared to the traditional approaches. EUS-LB is associated with lesser post-procedural pain and shorter recovery time, while providing lower risk of complications when compared to traditional liver biopsy. Innovations in needle types, needle sizes and suction techniques have aimed at further optimizing the EUS-LB technique. This review article updates current literature with focus on the variations in the technique and equipment used for EUS-LB, and compares EUS-LB with traditional methods of liver biopsy.

Endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as a safe and effective alternative to percutaneous and trans-jugular approaches for hepatic tissue acquisition. It has shown superior diagnostic yield for the targeted approach of focal lesions, less sampling variability, improved patient comfort, and safety profile. These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue. In this review, we provide an update on the recent evidence of EUS-LB for the evaluation of liver disease.

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.