Eus guided liver biopsy; two is better than one

Introduction

Live biopsy remains the gold standard once less invasive methods in the diagnostic pathway of liver disease are non-diagnostic. EUS guided liver biopsy (EUS-LB) is increasingly seen as a viable alternative to percutaneous or trans-jugular biopsies. We sought to assess the suitability for histological diagnosis and identify factors associated with non-diagnostic samples.

Methods

A prospective database of consecutive patients who underwent EUS guided liver biopsy from September 2020 to December 2022 was retrospectively analysed.

Results

Twelve patients (7 female; 5 male) were identified. Median age was 52 years (range 23- 81). Indication for EUS-LB was deranged liver function tests (LFT) (n=11, 92%) or biliary pain with normal LFT in the context of positive autoantibodies (n=1, 8%). In addition to raised liver enzymes; 7 (58%) had biliary pain and 3 (25%) had biliary dilatation. Five (42%) patients had positive autoantibodies; smooth muscle antibodies in 3 (25%), anti-mitochondrial antibody in 1 (8%) and anti-LC1 in 1 (8%). Two (16%) had a radiological diagnosis of cirrhosis. There was one (8%) patient with a previous liver transplant. The preprocedural median bilirubin was 23 μmol/L (range 5–80 μmol/L), alanine aminotransferase 157 IU/L (range 13–642 IU/L) and alkaline phosphatase 141 IU/L (range 57–306 IU/L). A 19-gauge Franseen needle (Acquire, Boston Scientific Corp, Natick, Massachusetts, United States) was used in all cases. Two passes were taken from the right and 2 from the left lobe of the liver in 10 cases (83%). Median number of portal tracts was 30 (range 8- 103). The median specimen length was 20mm (range 15–31mm). Adequate specimen for a definitive histological diagnosis was available for 11 (92%) patients. The patient without sufficient tissue for histological diagnosis had 2 passes into the left liver lobe alone, 8 portal tracts were retrieved. Three (25%) patients were found to have no evidence of parenchymal liver disease. Three (25%) had minor changes of uncertain significance. One patient had non-specific cholestatic changes and was found to have a common bile duct stone on further investigation. One patient each had drug induced liver injury, non-alcoholic steatohepatitis, chronic ductopenia and cystic fibrosis associated changes. One (8%) patient developed periprocedural pain which recovered with simple analgesia. There were no other complications.

Conclusions

EUS guided liver biopsy is a safe and effective method of tissue acquisition. Two passes of both lobes of the liver should be taken. A full PB examination should be undertaken prior to performing liver biopsy to rule out other causes of deranged LFTs including biliary stones.