Endoscopic ultrasound guided liver biopsy: Recent evidence

Table 1 Advantages and disadvantages of liver biopsy methods

	Percutaneous liver biopsy	Transjugular liver bipsy	Surgery	Endoscopic ultrasound guided liver biopsy
Indication	Mainstay method of liver biopsy for unexplained abnormal LFTs, assessing, staging, diagnosing liver disease	Coagulopathy; ascites; morbid obesity; failure of percutaneous liver biopsy ; thrombocytopenia	Undergoing surgery for another indication	Undergoing endoscopy for another indication
Complications	Pain; hemorrhage; peritonitis; hypotension; infection; gallbladder perforation; pneumothorax; hemothorax	Hemorrhage; pain capsule perforation; arterial aneurysms; arrhythmias	Hemorrhage, abdominal wall injury; intraperitoneal injury; anesthesia related complications	Hemorrhage; abdominal pain; infection
Advantage	Well-known procedure; cost effective; less technical skills required	Decreased risk of complications; more tolerable; useful in patients with comorbidities	Can take LB while performing another procedure	Increased tolerability; decreased recovery time; decreased complications; bi-lobar access; decreased sampling variability; View anatomical/vascular structures
Disadvantage	Increased sampling variability; less tolerable; require more passes; increased risk of complications	Limited view of liver parenchyma and vascular anatomy; increased sample fragmentation	Invasive; requires surgical specialty	Costly, if not performed along with another endoscopic procedure

Table 2 Comprehensive review of studies on endoscopic ultrasound guided liver biopsy

Ref.	Study design	n	Indication	Needle used	No of passes	CPTs	TSL	Insufficient sample	Adverse events
Wiersema et al[70], 2002	Prospective cohort	9	No medical indication	19G Tru-cut	NR	1	4 mm	0	None
Gleeson et al[54], 2008	Retrospective case series	9	Hepatic parenchymal disease	19G Tru-cut	2	7	16.9 mm	0	None
DeWitt et al[71], 2009	Prospective case series	21	Hepatic parenchymal disease	19G Tru-cut	3	2	9 mm	10%	None
Stavropoulos et al[55], 2012	Prospective case series	22	Abnormal LFTs	19G FNA (non-Tru-cut)	2	9	36.9 mm	9%	None
Gor et al[73], 2014	Prospective case series	10	Abnormal LFTs; Suspected cirrhosis	19G FNA (non-Tru-cut)	3	9.2	14.4 mm	0	None
Diehl et al[51], 2015	Retrospective cohort	110	Persistent transaminitis	19G FNA Expect Flexible	1 to 2	14	38 mm	2%	Self-limited bleeding
Lee et al[67], 2015	Prospective cohort	21	Rescue for PCLB	22G FNB, 25G FNB	2	NR	NR	9.50%	None
Pineda et al[66], 2016	Retrospective cohort	110	Abnormal LFTs of Unknown Etiology	19G FNA Expect/Flexible	3	14	38 mm	2%	NR
Sey et al[72], 2016	Prospective Cross-sectional	75	Suspected parenchymal disease	19G FNB ProCore; 19G FNB Tru-Cut	2; 3	5; 2	20 mm; 9 mm	3%; 27%	None; Pain
Schulman et al[79], 2017	Prospective ex-vivo	48	No medical indication	18G1 (percutaneous); 18G2 (percutaneous); 19G FNA Expect; 19G FNB ProCore; 19G FNB SharkCore; 22G FNB SharkCore	1 to 2	2.5; 3.5; 1.9; 1.7; 6.2; 3.8	NR; NR; NR; NR; NR; NR	16.7%; 18.7%; 54%; 81%; 14.6%; 14.6%	None
Mok et al[53], 2017	Prospective cross-over	20	Elevated LFT Unknown Etiology	19G FNB; 22G FNB SharkCore	NR	7.4; 6.1	76.5 mm; 66.9 mm	2.5%; 2.5%	None; Pain
Shah et al[75], 2017	Retrospective chart review	24	Abnormal LFTs, pancreaticobiliary disease	19G FNB SharkCore	2	32.5	65.6 mm	4%	Pain; Subcapsular bleeding
Saab et al[87], 2017	Retrospective chart review	47	Biliary tract disease, abnormal LFTs	19G FNB SharkCore	NR	18	65 mm	0	Self-limited liver; hematomas
Ching-Companioni et al[83], 2018	Prospective randomized	40	Abnormal LFTs	19G FNA Expect Flexible; 19G FNB Acquire	1; 1	38; 16.5	11.8 mm; 16.3 mm	0	Pain
Nieto et al[76], 2018	Prospective observational	165	Unexplained abnormal LFTs, biliary obstruction	19G FNB SharkCore	1	18	60 mm	0	Abdominal pain; Self-limited hematoma
Mok et al[80], 2018	Prospective cross-over	40	Parenchymal liver disease	19G FNA Expect Flexible; 19G FNA Expect Flexible; 19G FNA Expect Flexible	3	4; 4; 7	23.9 mm; 29.7 mm; 49.2 mm	20%; 7%; 2%	Postprocedural bleeding
Rombaoa et al[69], 2018	Retrospective chart review	8	Unexplained abnormal LFTs, hepatitis B staging, cirrhosis	19G FNB Acquire	2	9.4	NR	NR	None
Shuja et al[68], 2019	Retrospective observational cohort	69	NASH fibrosis staging	19G FNA Expect Flexible	3	10.84	45.8 mm	NR	None
Hasan et al[77], 2019	Prospective nonrandomized trial	40	Elevated liver enzymes	22G FNB Acquire	2 L; 1 R	42	55 mm	0	Self-limiting abdominal pain
Bazerbachi et al[78], 2019	Prospective cohort	41	NAFLD diagnosis, staging	22G FNB Fork-tip	2	26	24 mm	0	Postprocedural pain

FNB: Fine needle biopsy; FNA; Fine needle aspiration; TSL; Total Specimen length; CPT: Complete portal tracts; n: Number of study participants; NAFLD: Non-alcoholic fatty liver disease; NASH: Nonalcoholic steatohepatitis.

Table 3 Summary of society guidelines for adequate liver biopsy

Medical society	Total specimen length	Complete portal triads	Needle size
American Association for the Study of Liver Diseases	2-3 cm	≥ 11	16G
European Association for the Study of the Liver	15 mm	-	-
Asian Pacific Association for the Study of the Liver	15 mm	≥ 10	16G