Is endoscopic ultrasound a promising technique in the diagnosis and treatment of liver diseases?

Abstract

Percutaneous ultrasound has been a longstanding method in the diagnostics and interventional procedures of liver diseases. In some countries, its use is restricted to radiologists, limiting access for other clinicians, such as gastroenterologists. Endoscopic ultrasound, as a novel technique, plays a crucial role in diagnosis and treatment of digestive diseases. However, its use is sometimes recommended for conditions where no clear advantage over percutaneous ultrasound exists, leaving the impression that clinicians sometimes resort to an endoscopic approach due to the unavailability of percutaneous options.

Key Words: Endoscopic ultrasound, Percutaneous ultrasound, Liver biopsy, Fine needle aspiration, Focal liver lesion, Liver abscess drainage

Core Tip: Endoscopic ultrasound is crucial in managing digestive diseases. Yet, its application is occasionally advised in scenarios where it lacks superiority over percutaneous ultrasound. This editorial reviews the paper published in the World Journal of Gastroenterology in 2024, to discuss its findings and implications.

TO THE EDITOR

Upon reading the article by Gadour et al[1], a comment emerged. The article thoroughly reviews and summarizes the current evidence on the roles of endoscopic ultrasound (EUS) in accurately diagnosing liver disease as well as its therapeutic accuracy and efficacy[1]. They concluded that EUS is a promising technique with potential to be a first-line option for diagnosis and treatment in a subset of liver diseases. This comprehensive review effectively highlights EUS as a safe and effective method in various interventions performed for the diagnosis and/or treatment of liver diseases[1].

The results of this systematic review suggest that EUS may be the method of first choice for the diagnosis and treatment of liver disease and that it has advantages over percutaneous ultrasound (US) in certain diagnostic and interventional procedures. However, direct comparisons between EUS and percutaneous US in the diagnosis and treatment of liver disease are scarce[2-4], and, according to our best knowledge, the only randomized clinical trial directly comparing the two techniques demonstrates the advantage of percutaneous US[5]. Albeit we recognize the robust design and execution, this study[1], also, primarily encompasses retrospective and prospective.

We are certain in EUS’ importance in managing digestive diseases[6-8]. However, its application is occasionally advised in scenarios where it lacks superiority over percutaneous US. Having extensive experience in liver disease management[9], we believe that EUS does not surpass conventional percutaneous US in efficacy for liver-related diagnostic and therapeutic procedures and that it can rather rarely be considered as a first-line option during those interventions. Our stance is based on the following considerations:

The liver’s location in the abdomen generally allows for better visualization and interventional access via percutaneous US compared to EUS, particularly for most of its segments except for possibly segments I, II, and VI. Moreover, segments VII and VIII are positioned such that visualization and the feasibility of conducting interventional procedures using EUS are notably challenging.

For liver lesions, it is preferable to drain pathological contents externally rather than into the gastrointestinal tract, especially if the content is infectious or potentially malignant. The sole exception is bile drainage in cases of obstructive jaundice[9].

Monitoring and catheter manipulation in patients with infectious complications or other drainage issues, irrigating liver abscess collections through a catheter with antiseptic or normal saline, and the cytological, microbiological, and biochemical analysis of the obtained content are considerably challenging or impractical with an endoscopic approach, unlike with percutaneous US procedures[9].

Percutaneous US involves much simpler training compared to EUS, which necessitates proficiency in both endoscopic and US techniques. It is a technically straightforward and cost-effective method, considerably easier to master than EUS which requires comprehensive training in both US and endoscopy[9].

Finally, we would like to highlight that, while EUS is effective, we believe that percutaneous US has more advantages, suggesting it as the first choice in the diagnostic and therapeutic procedures in liver diseases, except for obstructive jaundice cases. EUS is recommended only in rare occasions when percutaneous US is not an option. Future studies, especially randomized clinical trials comparing both techniques, are encouraged to clarify their roles in managing liver diseases more definitively.