GIT J Club EUS-Liver biopsy.

1. Kurdistan Board GEH/GIT Surgery J Club 2022
Supervised by Professor Dr. Mohamed Alshekhani.

2. Introduction:
 EUS-guided liver biopsy has moved to the fore, becoming more widespread
, replacing liver biopsy performed via transabd or transjugular routes.
 With the introduction of EUS-guided portal pressure measurement
procedures (most include a liver biopsy as well), this trend is likely to
increase with time.
 EUS-guided liver biopsy is not as simple or as straightforward as it may
seem at first glance.

3. Practical steps:1
 1. Talk to your hepatologists & other referring physicians to inform them
that you are doing EUS-guided liver biopsy (EUS-LB).
 We found that our gastroenterology&hepatology colleagues who were not
doing percutaneous liver biopsies any more were agreeable with
transferring the liver biopsy workload to the EUS team.
 Be sure to inform the hepatologists that portal pressure gradient
measurements can be made during the same EUS session, avoiding the
more invasive transjugular technique.
 Talk to your pediatric gastroenterologists as well, to let them know that
this procedure is available, inasmuch as it is likely to be less anxiety
provoking for the younger patient to have a sedated procedure.

4. Advantages:
 A. Clinical care remains in the gastroenterology/ hepatology department.
 B. Real-time US needle guidance appears to be safer than other
approaches to liver biopsy.
 C. The sedated procedure decreases patient anxiety&can result in
increased patient satisfaction.
 D. Bilobar biopsy is easily accomplished, decreasing the potential for
sampling error.
 E. Additional endoscopic procedures, including EGD,EUS, or colonoscopy
can be done during the same endoscopic session, resulting in time, effort,&
money savings for the patient, physician&healthcare system.

5. Practical steps:2
 2. Talk to pathologists that you will be doing EUS-guided liver biopsies.
 EUSLB specimens meet accepted benchmarks for adequacy in terms of
specimen length& complete portal triad count,comparable with or even
better than specimens obtained by PC or transjugular liver biopsy.
 Pathologists independently noted an improvement in sample quality using
EUS-LB, particularly when using the core needle.
 The core needle provide excellent long cores, even if cirrhosis.

6. Practical steps:3
 3. Check procedure indication& need for additional procedures during it.
 It is common for a patient undergoing a liver biopsy to have an indication
for another endoscopic evaluation,as EGD to rule out varices,investigate
dyspepsia, or rule out Barrett’s& others.
 A colonoscopy may be required for screening or surveillance reasons.
 There may be a need for EUS for pancreatic abns seen on imaging,
evaluation of biliary disease as bile duct dilatation, to rule out gallbladder
stones/sludge, or suspected biliary pain, or portal pressure measurement.

7. Practical steps:4
 4. Check procedure contraindications.
 In general, we require an INR of <1.5& a platelet count of 50,000 before
liver biopsy.
 The patient should not be taking anticoagulation or antiplatelet agents for
an appropriate length of time before the procedure. If that is not possible,
a transjugular approach may be required.
 Large-volume ascites is thought to be a contraindication to liver biopsy.
 Previous gastric surgery (eg, Rouxen- Y gastric bypass) is not a
contraindication because a left lobe liver biopsy can be readily done even
in patients with partial gastric resection.
 Known liver cirrhosis is not strictly a contraindication, but it is uncommon
for a patient with cirrhosis to need a liver biopsy.

8. Practical steps:5
 5. Select the biopsy needle.
 Usually, 19-gauge EUS needles are used for EUS-LB; 22-gauge needles
produce specimens that are subject to fragmentation during specimen
processing&not preferred.
 A 19-gauge “core needle” (fine-needle biopsy) is preferred over a 19-gauge
FNA needle, with better LB specimens.
 If a 19-gauge FNB needle is not available, a 19-gauge FNA needle should
be adequate, although it works best if used with the “wet suction” method.

9. Practical steps:6
 6. Prepare the biopsy needle.
 We have found that “wet suction” provides higher tissue yields compared
with dry suction.
 For wet suction, the needle stylet is removed.
 The needle is then flushed with a small amount of a standard heparin
flush.
 The suction syringe is filled with 1 to 2 mL of water, the stopcock is turned
to off& then the suction syringe is set at a full suction setting,this is then
mounted on the primed needle.
 A stylet slow-pull technique is preferred by some endosonographers, but it
is still advantageous to flush the needle with heparin first (and then
reinsert the stylet) to prevent blood clotting in the needle

10. Practical steps:7
 7. Assess the biopsy target in the liver& avoid inadvertent splenic biopsy.
 Be certain to distinguish the left lobe of the liver from the spleen, which is
in a similar location in the proximal stomach, can be enlarged in chronic
liver disease& may have a similar US echotexture to that of the liver.
 The left lobe can be positively identified by known landmarks (hepatic
veins, portal venous structures),although portal structures may be
obscured in livers with significant fat.
 Inadvertent splenic puncture can result in possible bleeding adverse effect,
particularly if splenic hilar vessels are in the path of needle insertion.
 The right hepatic lobe target is easily found with the echoendoscope tip
placed in the duodenal bulb& torqued counterclockwise

11. Practical steps:8
 8. Use an optimal& safe needle biopsy technique.
 Find a trajectory for needle travel into the liver that avoids sizable vessels.
 This may be 2-3 cm, or in some cases could be longer than 3.5 cm.
 It is important to realize that in some cases a very long needle throw will
not be possible.
 Both endoscope knobs are locked&elevator is used to deflect the needle.
 It may be advantageous add to some endoscope, pull the big wheel back &
assistant hold the endoscope at the bite block to prevent recoiling with
initial needle puncture.
 The needle is introduced 1 cm into parenchyma with short rapid move.
 The initial needle stroke needs to be “high velocity” to get the needle
through the gastric (or duodenal) wall, but the initial stroke should not be
too deep. The gastric wall can be a little hard to puncture on occasion& the
echoendoscope adjustments described above allow the needle to enter the
liver in as nearly a perpendicular approach as possible.

12. Practical steps:8
 Once the needle is in the liver, the suction is applied by turning the
stopcock to “open,”& the needle is advanced with slow& steady
movements to& fro 3-4 times in the liver. A 3-cm course of needle travel is
excellent& sufficient; but it can be longer if no vessels are seen beyond this
point.
 After the biopsy& before the needle is removed from the liver, the suction
is turned off. The needle is removed from the echoendoscope in
preparation for sample collection.
 We usually do bilobar liver biopsy,advantageous in biopsies done for
nonalcoholic steatohepatitis.
 Unilobar biopsy may be sufficient for other indications for liver biopsy.
 If the sample that is obtained appears inadequate in terms of specimen
length or excessive fragmentation, a second trial done.

13. Practical steps:9
 9. Retrieve specimen without introducing fragmentation&assess adequacy
of biopsy.
 Excessive handling of the specimen should be avoided.
 It is common that the specimen will be admixed with blood.
 If the needle was primed with heparin, then the blood is less likely to form
a “noodle-like” clot.
 A collection sieve allows blood to be washed from the specimen&rapid
adequacy review is possible.
 A purpose made device has been developed for liver biopsy sample
collection kit has a peel-off mesh that catches the liver cores& can be
transferred directly to formalin&immediate review of the amount of tissue
obtained is possible.
 Alternatively, the contents of the needle can be expressed straight into the
jar of formalin.
 Assessment of the adequacy of the specimen may be more difficult because
admixed blood can obscure the view of the liver ores in the jar.

14. Practical steps:10
 10. Assess the patient after biopsy.
 1 hr of recovery is sufficient for EUS-LB, even if bilobar biopsy is done.
 About 30-40% of patients experience abdominal pain after EUS-LB, most
from local peritoneal irritation by a small amount of blood that may be
coming from the puncture sites,typically self limited, although some
patients require a single dose of opiates,typically use 1 mg hydromorphone
hydrochloride, although 50-75 mg of fentanyl is also effective.
 Patients are typically discharged after 1 hr of observation& return to a
normal diet.
 Pain that is persistent is first managed with a second dose of opiate
analgesia,if not effective, we usually perform contrast-enhanced liver CT
to determine whether a bleeding adverse event has occurred&even if there
is evidence of bleeding or intrahepatic hematoma, it is usually self limited&
does not usually require interventional radiologic management by vascular
embolization, although we do admit the patients for at least overnight.