Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

Table 5 Technique of endoscopic ultrasound guided liver biopsy[50,51]

Pre-biopsy: The following workup is needed in all cases of liver biopsy

(1) Coagulation work up including platelet count, PT/INR and BT/CT; (2) Prior to the biopsy, the medications should be stopped as follows: anti-platelet medications 7 d, warfarin 5 d, heparin and related products discontinued 12-24 h prior to biopsy; and (3) Use of conscious sedation such as midazolam and nalbuphine or propofol as per operator’s preference or patient comfort

Procedural details of EUS-LB

(1) A linear array echoendoscope (Olympus GF-UCT180, Center Valley, United States) is generally used for the procedure; (2) Prior to the procedure, Doppler imaging is done to ensure that no vascular structures are present along the expected trajectory of the needle; (3) The EUS-LB can be performed using a 19 G EUS-FNA/FNB needle; (4) The left lobe is identified first, as that liver parenchyma which is a few centimeters below the gastro-esophageal junction with the scope torqued clockwise. The right lobe if needed to be biopsied, is accessed from the duodenal bulb. Two site biopsy can be undertaken at the discretion of the endosonographer; (5) A preferably long vessel free trajectory allowing free passage of the needle to a depth of at least 3 cm or more is usually selected; (6) For wet heparin suction, the stylet is removed and the needle is primed with a heparin flush and the suction syringe is reattached to the needle hub; (7) The needle is then introduced into the echoendoscope channel; (8) Once liver parenchymal penetration is achieved with the needle (around 1-2 cm), full suction is applied with the 20 mL vacuum syringe with fluid column; (9) One pass consists of a total of 4-5 to-and-fro needle motions using the fanning technique under direct EUS guided visualization of the tip of the needle. Two such passes are usually taken (maximum 10 actuations); and (10) The specimen is pushed from the needle directly into the formalin solution using the stylet or saline flush

Post-liver biopsy: The following instructions are to be followed in all cases post liver biopsy

(1) The patient post biopsy, irrespective of the type of procedure, is transferred to the post procedure recovery room and monitored as per the AASLD protocol[69]; (2) The minimum observation period is 2-4 h; (3) Post-procedure pain and need for analgesics to be noted and provided; and (4) Patient is asked to report adverse events at specific time intervals (as per institute policy)

EUS: Endoscopic ultrasound; PT Prothrombin time; INR International normalized ratio; BT: Bleeding time; CT: Clotting time; EUS-LB: Endoscopic ultrasound guided liver biopsy; FNA: Fine needle aspiration; FNB: Fine needle biopsy; AASLD: American Association for the Study of Liver Diseases.