Ameya A. Deshmukh, BA1, Ahmed M. Elmeligui, MBBCh, MD2, Javier Tejedor-Tejada, MD3, Enad Dawod, MD4, Jose Nieto, DO, FACG5; 1Midwestern University - CCOM, Downers Grove, IL; 2Kasr Alainy Hospital / Cairo University, Cairo, Al Jizah, Egypt; 3Hospital Universitario Rio Hortega, Valladolid, Castilla y Leon, Spain; 4New York-Presbyterian/Weill Cornell Medical Center, New York City, NY; 5Borland Groover Clinic, Jacksonville, FL
Introduction: Liver biopsy is currently the benchmark in the assessment of hepatic disease, particularly in visualizing the histologic degree of fibrosis. However, the invasive nature of traditional sampling methods can pose danger to the patient. The emergence of EUS-guided liver biopsy (EUS-LB) provides the endoscopist the option to offer a treatment modality with advantages such as reduced pain, increased safety due to continuous ultrasound guidance, the ability to take multiple samples with a widened view of the organ, and can be performed in the outpatient setting.
Methods: A 56-year old female with multiple co-morbidities such as obesity, hypertension and diabetes mellitus type 2 presented with right upper abdominal discomfort and worsening fatigue. She denies alcohol use. Physical examination displayed mild hepatomegaly with some tenderness to palpation. AST and ALT levels were moderately elevated. In conjunction with the patient presentation, elevated LFT’s and radiographic findings, nonalcoholic fatty liver disease (NAFLD) was suspected. EUS-guided liver biopsy was selected for this patient. A linear EUS endoscope is advanced into the duodenum at the location of the duodenal bulb. In this position, the left hepatic lobe is located from the proximal stomach or right hepatic lobe. First, open the 19-gauge needle and remove the stylit. After, flush the needle with normal saline. Then, a needle trajectory of approximately 5 cm is chosen, avoiding large vessels. The needle travels through the duodenal wall and into the liver and one pass is made through liver tissue. Withdraw the needle as saline is placed into the syringe at 20cc suction. Suction is stopped once the sample is obtained. Once the specimen has been collected, it is directly placed into formalin from the needle. Discussion: We have shown the efficacy of EUS-MLB. It has been shown to accurately predict fibrosis in patients with fatty liver disease and several studies cite a range of diagnostic yields ranging from 91-100%. However, some potential pitfalls include the similar visual nature of the liver and spleen on EUS, a misidentified spleen can result in an adverse bleeding complication. Additionally, tissue sample yield can be dependent on the endoscopist’s technical skill with this complex procedure.
EUS displaying increased areas of hepatic echogenicity suggestive of NAFLD.
19-gauge needle advancing through the liver using one pass to obtain optimal viable tissue sample.
Live view of parenchymal tissue obtained via EUS.
Disclosures: Ameya Deshmukh indicated no relevant financial relationships. Ahmed Elmeligui indicated no relevant financial relationships. Javier Tejedor-Tejada indicated no relevant financial relationships. Enad Dawod indicated no relevant financial relationships. Jose Nieto: Boston Scientific – Consultant. ERBE – Consultant.