Castleberry DT, Mann R, Tharian B, Thandassery RB. Endoscopic ultrasound in the management of complications related to cirrhosis- recent evidence. World J Gastrointest Endosc 2025; 17(9): 108549 [DOI: 10.4253/wjge.v17.i9.108549]
Corresponding Author of This Article
Ragesh Babu Thandassery, MD, Associate Professor, DM, Department of Internal Medicine, Division of Gastroenterology, University of Arkansas for Medical Sciences, 4300 W 7th Street, Little Rock, AR 72205, United States. doc.ragesh@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Drew T Castleberry, Rupinder Mann, Ragesh Babu Thandassery, Department of Internal Medicine, Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR 72202, United States
Drew T Castleberry, Rupinder Mann, Ragesh Babu Thandassery, Department of Internal Medicine, Division of Gastroenterology, Central Arkansas Veterans Healthcare System, Little Rock, AR 72202, United States
Benjamin Tharian, Department of Gastroenterology, Orlando Health Digestive Health Institute, Bayfront Health, St. Petersberg, FL 33701, United States
Author contributions: Castleberry DT and Mann R were responsible for manuscript writing; Tharian B was responsible for manuscript editing and endoscopic images; Thandassery RB was responsible for concept of manuscript, manuscript editing and final approval of the manuscript; all authors read and approved of the final manuscript.
Conflict-of-interest statement: The authors have no relevant conflicts of interest to disclose. No funds were received. No Artificial intelligence program was used in the writing of this manuscript.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ragesh Babu Thandassery, MD, Associate Professor, DM, Department of Internal Medicine, Division of Gastroenterology, University of Arkansas for Medical Sciences, 4300 W 7th Street, Little Rock, AR 72205, United States. doc.ragesh@gmail.com
Received: April 17, 2025 Revised: May 25, 2025 Accepted: August 8, 2025 Published online: September 16, 2025 Processing time: 148 Days and 15.8 Hours
Abstract
Advanced endoscopic methods like endoscopic ultrasound (EUS) have recently been applied for the management of complications related to cirrhosis. This includes novel techniques to measure portal pressure gradients, esophageal, gastric, and ectopic varices management, and EUS-assisted treatment of liver tumors. Management of liver tumors has seen significant changes in recent years, and many minimally invasive procedures have been approved, especially in the management of liver cell carcinoma. These are specialized procedures and are performed only in patients with cirrhosis in specialized centers. There are concerns for complications in patients with cirrhosis due to their increased risk of bleeding and the altered hemostatic milieu. This minireview summarizes the recent evidence on using EUS in the management of cirrhosis-related complications.
Core Tip: This minireview discusses various applications of endoscopic ultrasound (EUS)-guided interventions in managing cirrhosis and its complications. We describe updates on the EUS-guided diagnosis and treatment of conditions such as portal hypertension, esophageal and gastric varices, liver biopsy, antitumoral interventions, caudate lobe ablation and sampling, and other indications of EUS-guided procedures, and compare them to the current standards of care. Additionally, we discuss the potential future uses of EUS-guided management, which is currently in its infancy, including antitumoral interventions and the application of artificial intelligence.
Citation: Castleberry DT, Mann R, Tharian B, Thandassery RB. Endoscopic ultrasound in the management of complications related to cirrhosis- recent evidence. World J Gastrointest Endosc 2025; 17(9): 108549
Cirrhosis is the result of chronic liver inflammation and remodeling, resulting in irreversible hepatic fibrosis and loss of normal parenchymal architecture[1]. As the normal liver synthetic function is compromised, liver decompensation can ensue over time. Cirrhosis is the 11th most common cause of death globally and accounts for 3%-5% of deaths worldwide when liver cancer is accounted for[1,2]. The most common cause of cirrhosis is alcohol-related liver disease, followed by non-alcoholic fatty liver disease (now referred to as metabolic-associated fatty liver disease), hepatitis B, hepatitis C, genetic predisposition to hemochromatosis and Wilson's disease, autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis[1]. Cirrhosis can be further categorized as early compensated (asymptomatic) and late decompensated (symptomatic) stage. At a cellular level, the structural changes caused by fibrosis lead to disruption of hepatic microvasculature, thus resulting in increased resistance to the portal blood flow[1]. This increased resistance, combined with increased portal blood flow, results in portal hypertension, which directly and indirectly drives many of the sequelae of decompensated liver cirrhosis.
"Endohepatology" is a term used to describe the emerging field of endoscopic interventions, specifically endoscopic ultrasound (EUS), as a diagnostic and therapeutic approach for managing cirrhosis and its complications. First termed over 10 years ago, "endohepatology" has evolved from a diagnostic modality into a therapeutic intervention with the advancement of technology and gadgets[2]. In this minireview, we will discuss the latest evidence-based advances and practices of EUS in managing cirrhosis-related complications. These include measuring portal pressure gradients, managing esophageal varices (EV), gastric varices (GV), and ectopic varices, and EUS-assisted treatment of liver tumors. In addition, this minireview will also provide insights into future directions and trends in the field.
EUS-GUIDED PORTAL PRESSURE MEASUREMENT
As portal hypertension worsens, clinical symptoms like ascites, hepatorenal syndrome, and gastric and esophageal variceal bleeding manifest[2]. Portal hypertension is defined by measuring a gradient between the portal and hepatic veins, with a gradient of 6-9 mmHg indicating the presence of subclinical portal hypertension and a normal gradient being ≤ 5 mmHg[2,3]. When the portal pressure gradient is ≥ 10 mmHg, it is defined as clinically significant portal hypertension. At this stage, there is an increased risk of ascites, EV bleed, and GV bleed[2]. As the portal pressure gradient rises, the risk of decompensation and mortality increases[2].
Traditionally, portal pressure gradients have been measured through percutaneous transhepatic portal and splenic pulp pressure measurement. These methods were replaced with the current gold standard, hepatic venous pressure gradient (HVPG), which was measured by interventional radiologists using a balloon catheter introduced through the jugular veins to wedge into the hepatic veins. Recently, it has been postulated that EUS-guided portal pressure gradient measurement could pose a reasonable alternative, as endoscopy is a more prevalent and widely available practice[4]. Among the advantages of EUS-guided portal pressure gradient measurement is that hepatic venous and portal pressure can be measured directly instead of indirectly by HVPG (Figure 1)[2]. The first human study utilizing EUS-guided portal pressure gradient measurement was conducted in 2017 by Huang et al[5], which led to the Food and Drug Administration (FDA) approval of EchoTip InsightTM (Cook Medical, IN, United States)[6]. Since that time, several smaller cohort studies have demonstrated the safety and efficacy of EUS-guided portal pressure gradient measurement in routine practice[7-9]. A recent meta-analysis in 2024 evaluated two human studies[5,10] and reported an average success rate of 95.1% (n = 40) of EUS-guided portal pressure gradient measurement[11]. Most recently, in January 2025, Kolb et al[4] published a multicenter, retrospective study with over 300 patients, which concluded that EUS-guided portal pressure gradient measurement was found to be technically safe with a success rate of 97% and demonstrated a strong correlation with clinical parameters of portal hypertension and liver histology. A potential landmark study, the ENCOUNTER study, is still ongoing[12]. This will be a consequential study to evaluate the correlation between calculated portal pressure gradient using the EchoTip InsightTM and direct measurement of HVPG. Both measurements will be simultaneously performed in real time. Recruitment has been completed, and results are awaited[12]. As a result of many of these landmark studies, the American Gastroenterological Association (AGA) supports using EUS-guided portal pressure gradient measurement[13]. Current literature suggests that EUS-guided portal pressure gradient measurement is a safe, more readily available, and accurate method of measuring portal hypertension. However, further studies are needed to determine its efficacy compared to HVPG (Table 1)[2,4-12].
Figure 1 Endoscopic ultrasound-guided portal pressure measurement.
A and B: Appearance of manometer used for measurement of portal pressure measurement using the EchoTip InsightTM; C: Visualization of endoscopic approach to reaching portal venous system; D and E: Needle tip visualized within portal vein; F: Doppler ultrasound view of the portal vein. Courtesy Cook Medical, IN, US, for images A-C.
Table 1 Characteristics of the included studies on endoscopic ultrasound-guided portal pressure measurement.
Though there can be variability in independent practice, EUS-guided portal pressure gradient measurement is generally performed using the steps in Table 2[2]. These steps are generally extracted from the methodology provided by Laleman et al[2]. This technique can serve as a general structure for the procedure.
Table 2 Summarized version of the endoscopic ultrasound-guided portal pressure gradient measurement technique proposed by Laleman et al[2].
General technical steps in performing EUS-guided portal pressure gradient measurement
Survey liver on EUS for potential focal lesions and blunting of liver edge, liver echotexture, gastric varices, and flow in portal and splenic veins
EUS-shear wave elastography then used over left lobe of liver, spleen and then right lobe of liver from duodenum
Best vessel chosen and pulse wave doppler used to confirm. Listen for continuous hum of the portal vein
Typically, middle hepatic vein and left portal vein chosen
Pressure gauge and 25-gauge needle device primed with saline or heparinized saline, manometer placed at phlebostatic axis (4th intercostal space, approximately at level of R atrium)
Needle is then guided through parenchyma to vessel. Enter hepatic vein 2 cm from inferior vena cava convergence
Flush needle with saline, then watch pressure gauge rise until reaches steady state for 1 minute
Measurement repeated until 3 consecutive pressures are close together
Average is the mean hepatic vein pressure
Withdraw needle and apply doppler to ensure there is no hemorrhage
EUS IN THE MANAGEMENT OF GASTRIC, GASTROESOPHAGEAL, AND ECTOPIC VARICES
Varices are common in patients with cirrhosis, occurring in approximately 50% of cases[14]. Among the complications related to cirrhosis, variceal bleeding has a high mortality, about 20% within 6 weeks of a variceal bleeding episode[14]. GV bleeds are less common than EVs but have higher mortality rates[15]. GV have traditionally been classified using the Sarin classification, separating GV into isolated GV (IGV) type 1 and 2 and gastroesophageal varices (GEV) type 1 and 2[15]. Ectopic varices, though a rare cause of upper gastrointestinal bleeding, have a high mortality rate of up to 40%[16].
In addition to transjugular intrahepatic portosystemic shunt (TIPS) and retrograde or antegrade transvenous obliteration, GV with bleeding have been treated using a myriad of endoscopic techniques (Table 3)[5,14-21]. Prophylactic treatment of GV is not usually recommended. For GEV-1, endoscopic variceal ligation and endoscopic sclerotherapy have been used, though the former is recommended due to more successful outcomes[5]. For the treatment of IGV-1 and GEV-2, cyanoacrylate-based tissue adhesive injection and interventional radiology (IR) guided interventions are considered, though head-to-head comparison is lacking[5]. For these varices, obliteration using cyanoacrylate-based tissue adhesives or fibrin glue (with or without EUS-guided coil insertion) is performed in selected centers with expertise and has low risks of complications[5,22]. However, glue or fibrin injection is not very popular in the United States, and it is not approved by United States FDA. Bleeding IGV-1 or GEV-2 usually undergo IR-guided treatment in the United States (combination of TIPS and/or retrograde or anterograde transvenous obliteration)[23]. More recently, EUS technology has been utilized by endoscopists to increase the efficiency of identification and treatment of GV[15]. EUS-guided cyanoacrylate or fibrin glue injection, EUS-guided coil injection, EUS-guided thrombin injection, and EUS-guided combination therapy have been reported in different case series[15,17]. EUS aids in real-time visualization of GV and confirms complete obliteration, thus improving hemostasis efficacy in acute GV bleed[15]. Direct endoscopic injection of GV without EUS can be impaired by blood obscuring the field of vision, and EUS-guided treatment yields higher technical success and lower rebleeding rates[13].
Table 3 Characteristics of the included studies on endoscopic ultrasound management of gastric, gastroesophageal and ectopic varices.
EUS-guided glue injection involves precise injection into the GV with real time EUS visualization. N-butyl-cyanoacrylate is the most commonly used agent[15] and has been shown to be more efficacious than thrombin, gelatin sponge, and alcohol[18]. Coils are sometimes inserted in addition to glue or fibrin injection (Figure 2). Of the EUS-guided monotherapies, the AGA supports EUS-guided cyanoacrylate injection as the recommended method[13], with an efficacy of 94% and a significantly higher rate of gastric variceal obliteration rate when compared to direct endoscopic injection without EUS (83% vs 64%, respectively)[13]. Similar advantages are being observed in ectopic varices as well. Multiple case reports have indicated positive outcomes in the treatment of duodenal and jejunal ectopic varices using EUS-guided coiling and cyanoacrylate injection[16,19].
Figure 2 Endoscopic ultrasound appearance of different cirrhosis related conditions.
A: Endoscopic appearance of isolated gastric varix type 1 (IGV-1); B: Endoscopic ultrasound (EUS) appearance of isolated gastric varix type 1; C: EUS appearance of isolated gastric varix type 1 after glue injection (absence of doppler signal indicating obliteration); D: IGV after coil insertion (fluoroscopy); E: EUS guided liver biopsy sample; F: EUS guided biopsy of liver lesion.
In a recent study, O'Rourke et al[20] suggested that combining two EUS-guided techniques may lead to better outcomes. A recent retrospective review evaluating outcomes in 20 patients receiving EUS-guided coil and thrombin combination procedures demonstrated a 95% success rate and complete obliteration of GV in 85% of patients with a relatively low adverse events rate (10%)[20]. The authors suggested that utilizing an EUS-guided coil and thrombin combination can be a technically safe and effective option in managing high-risk GV or GV with prior treatment failure[20]. In addition, the use of EUS-guided combination therapy with cyanoacrylate with coils was found to have a recurrent bleeding rate of 3.3% compared to cyanoacrylate alone (20%) in a randomized control trial[21]. Future multicenter prospective trials can compare these techniques head-to-head. EUS is also recommended within 48 hours of retrograde or anterograde transvenous obliteration to ensure that varices are completely obliterated; computed tomography is an alternative if EUS expertise is unavailable. If variceal obliteration is incomplete, additional methods like TIPS or further venous obliteration are recommended to prevent rebleed[23]. Early data regarding ectopic varices also suggests that combination therapy with coil embolization with cyanoacrylate injection reduces glue embolization in addition to a greater complete obliteration rate[16].
EUS-ASSISTED LIVER BIOPSY AND TREATMENT OF LIVER TUMORS
The timely and accurate diagnosis of liver disease and staging of fibrosis has relied on liver biopsy for decades (Figure 3). The previous standard of care was liver biopsy performed through percutaneous, transjugular, or surgical methods[17]. In recent years, image-guided liver biopsy has become the standard of care[17]. According to the American Association for the Study of Liver Diseases (AASLD), a biopsy specimen must be 20 mm long and include over 11 complete portal tracts to be considered satisfactory[24]. First published by Mathew[25] in 2007, EUS-guided liver biopsy has gained traction, primarily due to the many advantages the procedure offers compared to traditional methods (Figure 3). These include, but are not limited to, real-time imaging, accessibility to smaller lesions, accessibility to different liver regions regardless of body habitus, and lack of necessity to use invasive procedures such as a vascular puncture[26].
Figure 3 Different methods of liver biopsy-advantages and disadvantages.
Blue boxes indicate advantages and purple boxes indicate disadvantages. EUS: Endoscopic ultrasound.
A systematic review and meta-analysis from 2020 comparing the efficacy and safety of EUS-guided liver biopsy with percutaneous biopsy and transjugular liver biopsy showed no significant difference in biopsy adequacy, adverse events, number of portal triad specimens, and length of longest specimen piece[26]. The study reviewed five randomized controlled trials and observational studies that included 656 patients[26]. The authors concluded that EUS-guided liver biopsy is a safe, minimally invasive procedure with results comparable to percutaneous and transjugular liver biopsies[26]. A more recent 2025 meta-analysis and systematic review of randomized controlled trials by Arruda et al[24] further supported these findings. This study comparing the safety and efficacy of EUS-guided liver biopsy and percutaneous liver biopsy showed no significant differences between diagnostic adequacy, the number of complete portal tracts, longest sample length, total sample length, overall adverse events, and adverse events excluding minor post-procedure symptoms[24]. The analysis included four randomized controlled trials with a sample size of 258 patients. It showed that the diagnostic adequacy rate with EUS-guided liver biopsy was 97.8% compared with percutaneous liver biopsy of 97.4%. Overall adverse events had a pooled rate of 14.8% in comparison with 42.1% in percutaneous biopsy (risk ratios = 0.54, 95%CI: 0.20-1.46, I2 = 68%)[24]. EUS-guided liver biopsy, however, did have lower post-procedure pain scores[24]. Arruda et al[24] also suggested that EUS-guided liver biopsy might be particularly useful in patients undergoing additional endoscopic procedures such as portal pressure gradient measurement or endoscopic shear wave elastography. EUS can also be helpful in targeted biopsies of liver lesions in addition to non-targeted liver parenchymal biopsies. Some liver lesions can be difficult to target through conventional imaging methods, and EUS has an advantage in targeting lesions in the left lobe of the liver. Experts indicate that a 19G needle is preferred over 22G due to the intactness of the core. Modified wet suction with heparin is the preferred EUS biopsy technique. Even though EUS-guided liver biopsy appears promising, related costs, prolonged procedure time, and limited centers with expertise challenge its widespread application.
EUS-GUIDED ANTITUMORAL INTERVENTIONS
EUS allows the endoscopist to identify and access liver lesions that would otherwise be unreachable or too small to locate using traditional methods. Hepatocellular carcinoma (HCC) and other liver lesions can be targeted for treatment with EUS (Tables 4 and 5)[19,24,26-30]. Caudate lobe or left lobe lesions can be challenging to reach with conventional image-guided techniques due to their deeper location adjacent to other organs and major vascular structures. Another versatile technique is EUS-guided antitumoral therapy, which utilizes specialized probes and catheters[31]. Though this approach mechanistically makes sense, it is still in the experimental or preclinical phases[31]. The two modalities studied so far are injection of chemotherapy or sclerosants and ablation through radiofrequency probes[31]. Other techniques that have yet to be explored are cryoablation and interstitial laser coagulation[31]. In 2023, Xu et al[32] published a prospective study of EUS-guided laser ablation in 25 caudate lobe tumors with 100% treatment effectiveness with no procedure-related adverse events. In this study, the liver tumors comprised 14 cases of HCC (56%) and 11 cases of liver metastases (44%). Fifteen tumors were found in the paracaval portion, two in the caudate lobe, and eight in the Spiegel lobe. However, at 27 months follow-up, 15% of patients developed local tumor progression, and 75% observed intrahepatic distant recurrence[32]. Tumor size of > 2 cm appeared to increase the risk of post-procedure local tumor progression[32]. The authors concluded that EUS-guided laser ablation is a viable, safe, and effective method of treating liver tumors in the caudate lobe[32]. As this is an evolving field, more research is necessary to confirm the efficacy of EUS-guided liver tumor treatment modalities and compare the modalities in terms of effectiveness and adverse events.
Table 4 Characteristics of the included studies on endoscopic ultrasound-assisted liver biopsy and treatment of liver tumors.
In treating HCC, caudate lobe lesions have notoriously been difficult to biopsy and ablate. The current standard of therapy is radiofrequency ablation, which involves the percutaneous route guided by ultrasound and CT imaging. This method is technically challenging due to its close proximity to major vessels and other vital organs[27]. A few case reports have been published suggesting the successful use of EUS-guided radiofrequency ablation. De et al[27] described a 64-year-old cirrhotic male with a small HCC lesion in the caudate lobe who underwent successful EUS-guided radiofrequency ablation due to the difficulty of percutaneous radiofrequency ablation and avoidance of multiple liver capsule punctures. The procedure had no complications and may represent a better alternative to the percutaneous route, especially in small caudate lobe lesions[27]. Attili et al[28] performed the first documented EUS-guided caudate lobe tumor ablation in 2018 with no complications using a similar method on a tumor measuring 2.5 cm × 2.0 cm. Katrevula et al[29] also described a successful case, and each of these three studies resulted in a complete response on MRI after 1 month[27]. de Nucci et al[30] performed EUS-guided radio ablation of the caudate lobe on a slightly larger tumor measuring 3.0 cm × 4.5 cm with a 70% reduction in size after two sessions[30]. The four documented cases of EUS-guided radio ablation show promise in smaller-sized tumor ablation in hard-to-reach caudate lobe lesions. Much research is required to explore efficacy and safety further.
OTHER INDICATIONS FOR EUS-GUIDED PROCEDURES
As this review highlights a few of the impactful ways EUS has been utilized in patients with cirrhosis, there are a multitude of additional procedures that EUS has shown to be effective in as well (Table 6)[33-44].
Table 6 Characteristics of the included studies on other endoscopic ultrasound-guided procedures and indications.
EUS-GUIDED LUMEN-APPOSING METAL STENTS IN CIRRHOSIS
One challenging new scenario where EUS is applied in patients with cirrhosis is EUS-guided transmural deployment of lumen-apposing metal stents (LAMS). This procedure can be used in gallbladder drainage, pancreatic fluid collection, endoscopic retrograde cholangiopancreatography (ERCP), trans-gastric interventions, and trans-enteric ERCP. A multicenter case-control study by Nimri et al[33], found EUS-guided transmural deployment of LAMS in cirrhotic patients to have an adverse event rate of 16%-21%, which is lower than other invasive options with higher mortality rates[33]. Gallbladder drainage utilizing LAMS has recently been approved by the United States FDA, signaling a potential increase in popularity[34]. A retrospective review (170 patients) of EUS-guided gallbladder drainage with and without cirrhosis showed technical and clinical success rates of over 93% in both groups, showing the efficacy of EUS-guided gallbladder drainage in cirrhotic patients[35]. In addition to better delineation of local anatomy, EUS Doppler helps to avoid vessels that are prominent with portal hypertension in cirrhosis. A recent case report detailing a case of acute cholecystitis managed with EUS-guided LAMS cholecystojejunostomy in cirrhotic patients indicates there may be viability for an effective non-surgical approach to acute cholecystitis management in this patient population[34].
EUS-GUIDED ELASTOGRAPHY
In order to assess liver fibrosis progression, elastography has historically been performed using vibration-controlled transient elastography (FibroScanTM)[36]. EUS-guided elastography is a newer method that shows promise as a tool that can be easily incorporated into standard EUS examinations. Contrast harmonic EUS and EUS shear wave elastography are the two techniques used to accomplish this. A 2025 prospective cohort study utilizing EUS shear wave elastography (acoustic radiation pulse that propagates through tissue) showed significantly higher liver stiffness in patients with advanced liver disease compared to healthy controls[37]. Additionally, the authors found that left lobe measurements correlated significantly with magnetic resonance elastography[37]. EUS-guided shear wave elastography is further supported by Wang et al[38], who found it to be superior to FibroScanTM and Fibrosis-4 Index in their multicenter cross-sectional study. EUS-guided shear wave elastography was highly accurate, with an area under the receiver-operating characteristic curve of over 0.87 for all major fibrosis thresholds[38]. A prospective cohort study supports this; however, it found significant variability between lobes, with the left lobe having a 3.1 times higher variance in measurements[39]. The authors attribute this to the respiratory movement of the left lobe and recommend using the right lobe for accurate measurement[39]. Though not yet recognized worldwide, a scoring system has been proposed by Fujii-Lau et al[40] to differentiate malignant and benign liver lesions seen on EUS, with a positive predictive value of 88% for malignant lesions. Despite its advantages, EUS-guided elastography only allows visualization of no more than 50% of the liver. However, this is significantly larger than the area of the liver sampled in liver biopsy or with FibroscanTM[36]. Fibrosis in the liver can be patchy and discontinuous, and visualization of a larger area to determine fibrosis reduces sampling error. As more studies examine its clinical practicality, EUS-elastography shows promise in becoming a viable alternative to transient elastography.
The physical examination is a quick and easy method to assess hepatic fibrosis via palpation. However, it is insensitive and can be limited by body habitus[41]. Transient elastography shares these limitations. Endoscopic "palpation" of the liver involves using EUS to view and "endoscopically palpate" the left and right lobes. This allows closer proximation to the hepatic lobes, only separated by the gastric and duodenal walls, and negates body habitus as a confounding issue[41]. A cross-sectional study involving 73 patients comparing transient elastography to EUS palpation concluded that the latter was superior to transient elastography in predicting cirrhosis and was similar to transient elastography in predicting advanced fibrosis[41]. The relatively simple technical aspect of the procedure will surely make EUS-guided liver palpation an attractive and accurate method of assessment of cirrhosis in the future.
EUS-GUIDED PORTOSYSTEMIC SHUNT
Additional uses of EUS include EUS-guided transgastric portosystemic shunt obliteration and EUS-guided intrahepatic portosystemic shunt. EUS-guided shunt obliteration can be helpful in alleviating refractory hepatic encephalopathy and is performed by injecting coils or glue into the spontaneous portosystemic shunt[42]. In a small cohort study, Rathi et al[43] showed a 71% clinical success rate and a complete occlusion rate of 86%. An experimental alternative to TIPS, an EUS-guided intrahepatic portosystemic shunt, has been used in animal models for the decompression of the portal vein using the left hepatic vein[42,44]. This procedure has advances to be made before replacing TIPS, and human data is needed to further determine viability. EUS can also be utilized for portal venous blood sampling, which has been traditionally performed through surgery or TIPS[42]. Using a transgastric transhepatic puncture of the left portal vein or main trunk, EUS-guided portal venous blood sampling is a potentially safer and less invasive method of accessing the gut-liver axis[42].
THE SAFETY PROFILE OF EUS-GUIDED PROCEDURES
Cirrhotic patients are a risk-prone population that deserves special attention when evaluating the safety of procedures (Table 7)[9,11,35,45]. According to AASLD guidelines, bleeding risk can be stratified into low-risk and high-risk procedures. The AASLD recommends against prophylactic transfusions of fresh frozen plasma or platelets regardless of coagulation study results for both low and high-risk procedures in patients with cirrhosis[46]. Cirrhosis represents a unique hemostatic scenario where both pro and anticoagulant pathways are equally compromised, and the traditional markers of risk of hemorrhage are not predictive of bleeding risk in cirrhosis. Some guidelines, however, caution endoscopists with newer and more extensive interventions as the experience is limited[45,46]. EUS-guided gallbladder drainage was demonstrated by Garg et al[35] to have comparable bleeding risk between cirrhotic patients and non-cirrhotic patients, with an adverse event rate of 4.3%. Furthermore, EUS-guided liver abscess drainage and GV management show high success rates with low adverse effects[11]. Choi et al[9] demonstrated the safety of EUS-guided portal pressure gradient measurement and liver biopsy with no significant adverse events in their study. Overall, EUS-guided procedures are generally considered to have a favorable safety profile in cirrhotic patients. However, there are some exceptions, and adverse events somewhat depend on the endoscopist's experience. We recommend using an individualized approach based on the patient's comorbidities and the endoscopist's experience when weighing out the risks and benefits of a procedure.
Table 7 Characteristics of the included studies on safety profiles of endoscopic ultrasound procedures in cirrhosis.
FUTURE DIRECTIONS, INCLUDING THE ROLE OF ARTIFICIAL INTELLIGENCE IN EUS-GUIDED THERAPY
EUS increasingly plays a significant role in hepatology practice, particularly in cirrhotic patients. As the number of diagnostic and treatment techniques increases, combining two or more techniques appears to become more common, such as managing GV with EUS guidance. This transition is already being observed in the literature, where many studies indicate that some of these techniques are more viable when performed in tandem with another technique.
In addition to combination techniques, artificial intelligence (AI) could be on the precipice of revolutionizing EUS applications. AI is already being utilized in ultrasound-based diagnostics and has been demonstrated in some studies to be superior to the sensitivity and specificity of experienced radiologists[47]. In EUS-guided biopsy, AI can be used to identify optimal location and depth for fine-needle aspiration insertion and to evaluate sample adequacy in real-time. Several AI models have been developed and studied retrospectively in pancreatic samples, identifying benign vs malignant liver lesions with accuracies of over 90%[47]. AI has also been utilized to develop endoscopy training augmentation. The BP MASTER model by Zhang et al[48] improved trainee accuracy from 67.2% to 78.4%. This tool was then developed into the EUS-intelligent and real-time endoscopy analytical device (EUS-IREAD), which decreased missed scanning rates of anatomical structures during an EUS procedure from 17.4% to 6.2%[47,48]. AI has helped immensely in improving histological diagnosis through digital imaging techniques such as whole slide imaging[49]. AI enhanced algorithms for EUS guided diagnosis have been studied in pancreatic and other gastrointestinal tumors, and there are no studies on liver lesions. It is only a matter of time before these techniques are widely applied in the endo-hepatology practice. As most AI models to date have been small-scale and used based upon retrospective studies, resources will be needed on a larger scale to create an AI tool robust enough to aid the endoscopist in real-time with diverse situations. Ultimately, AI-aided endoscopy aims to enhance time efficiency and intra-procedural accuracy.
CONCLUSION
The application of EUS in cirrhosis and its complications continue to evolve and advance both diagnostically and therapeutically. Current literature indicates that using EUS-guided portal pressure gradient measurement rivals the safety and accuracy of HVPG and could potentially be a more readily available modality. Early data on the treatment of GV utilizing EUS-guided methods suggests that combining two or more treatment modalities, for example, cyanoacrylate with coils or coils with thrombin, has lower recurrent bleeding rates than a single modality alone. EUS-guided gastric and esophageal variceal treatments have proven to be a safe, viable EV and GV management method. EUS-guided liver biopsy is a feasible alternative to percutaneous and transjugular liver biopsy. Though further research is needed in this area, antitumoral treatments are on the field's cutting edge and could soon make its way into everyday practice. EUS-guided caudate lobe ablation and sampling provide a unique method to reach the notoriously difficult areas by conventional methods. The many other uses of EUS-guided techniques each provide unique advantages with acceptable safety profiles. EUS-guided interventions have shown to be effective alternatives to the current standards of care in the diagnosis and treatment of cirrhosis and its complications. Undoubtedly, EUS-guided interventions will continue to play a larger role in hepatology, and the future of the ever-evolving field appears promising, with larger multicenter trials expected to support the use of EUS techniques further.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: United States
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade C
Creativity or Innovation: Grade B
Scientific Significance: Grade B
P-Reviewer: Kunosic S, PhD, Associate Professor, Bosnia and Herzegovina S-Editor: Luo ML L-Editor: A P-Editor: Zhang L
Kolb JM, Monachese M, Rubin RA, Wang TJ, Choi A, Bazarbashi AN, Brahmbhatt B, Zakaria A, Cortes P, Kesar V, Abel WF, Chen WP, McLaren C, Tavangar A, Singal AG, Taunk P, Wallace MB, Kedia P, Lee D, Abbas A, Yeaton P, Cosgrove N, Kesar V, Chang KJ, Ryou M, Samarasena J. Endoscopic Ultrasound-Guided Portosystemic Pressure Gradient Correlates with Clinical Parameters and Liver Histology.Clin Gastroenterol Hepatol. 2025;S1542-3565(25)00078.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 5][Reference Citation Analysis (0)]
Vanderschueren E, Laleman W, Bonne L, Maleux G, Wagner D, Chyon Y, Calvo A, Sendino O, Gines A, Baiges A, Bruno MJ, Garcia-pagan JC, Van der Merwe S. Endoscopic Ultrasound-Guided Portosystemic Pressure Gradient Measurement vs. Transjugular Balloon Occlusion Measurement (ENCOUNTER): A Multicenter EU Study.Endoscopy. 2025;57:S647-S648.
[PubMed] [DOI] [Full Text]
Robles-Medranda C, Oleas R, Valero M, Puga-Tejada M, Baquerizo-Burgos J, Ospina J, Pitanga-Lukashok H. Endoscopic ultrasonography-guided deployment of embolization coils and cyanoacrylate injection in gastric varices versus coiling alone: a randomized trial.Endoscopy. 2020;52:268-275.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 72][Cited by in RCA: 67][Article Influence: 13.4][Reference Citation Analysis (0)]
Nimri F, Ichkhanian Y, Shinn B, Kowalski TE, Loren DE, Kumar A, Schlachterman A, Tantau A, Arevalo M, Taha A, Shamaa O, Viales MC, Khashab MA, Simmer S, Singla S, Piraka C, Zuchelli TE. Comprehensive analysis of adverse events associated with transmural use of LAMS in patients with liver cirrhosis: International multicenter study.Endosc Int Open. 2024;12:E740-E749.
[RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)][Cited by in RCA: 1][Reference Citation Analysis (0)]
Fujii-Lau LL, Abu Dayyeh BK, Bruno MJ, Chang KJ, DeWitt JM, Fockens P, Forcione D, Napoleon B, Palazzo L, Topazian MD, Wiersema MJ, Chak A, Clain JE, Faigel DO, Gleeson FC, Hawes R, Iyer PG, Rajan E, Stevens T, Wallace MB, Wang KK, Levy MJ. EUS-derived criteria for distinguishing benign from malignant metastatic solid hepatic masses.Gastrointest Endosc. 2015;81:1188-96.e1.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 27][Cited by in RCA: 30][Article Influence: 3.0][Reference Citation Analysis (0)]
Rathi S, Kalantri A, Shastri A, Shree R, Mahesh KV, Taneja S, Chaluvasetty SB, Bhujade H, Verma N, Premkumar M, De A, Kalra N, Singh V, Duseja A. Endoscopic Ultrasound-Guided Transgastric Shunt Obliteration for Recurrent Hepatic Encephalopathy.Am J Gastroenterol. 2023;118:1895-1898.
[RCA] [PubMed] [DOI] [Full Text][Cited by in RCA: 6][Reference Citation Analysis (0)]
Buscaglia JM, Dray X, Shin EJ, Magno P, Chmura KM, Surti VC, Dillon TE, Ducharme RW, Donatelli G, Thuluvath PJ, Giday SA, Kantsevoy SV. A new alternative for a transjugular intrahepatic portosystemic shunt: EUS-guided creation of an intrahepatic portosystemic shunt (with video).Gastrointest Endosc. 2009;69:941-947.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 66][Cited by in RCA: 67][Article Influence: 4.2][Reference Citation Analysis (0)]
Northup PG, Garcia-Pagan JC, Garcia-Tsao G, Intagliata NM, Superina RA, Roberts LN, Lisman T, Valla DC. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases.Hepatology. 2021;73:366-413.
[RCA] [PubMed] [DOI] [Full Text][Cited by in Crossref: 171][Cited by in RCA: 381][Article Influence: 95.3][Reference Citation Analysis (1)]
