An Innovative Approach to Liver Biopsies

Avik Sarkar, M.D. Avik Sarkar, M.D.
Assistant Professor of Medicine
Director, Bariatric Endoscopy Program
Robert Wood Johnson University Hospital
New Brunswick, NJ
Vinod Rustgi, M.D. Vinod K Rustgi, M.D., MBA
Professor of Medicine
Clinical Director of Hepatology
Robert Wood Johnson University Hospital
New Brunswick, NJ

Patient History

A 27-year-old woman with a past medical history significant for obesity, OSA on CPAP, pre-DM presented for initial evaluation of elevated liver enzymes. On routine labs, the patient was noted to have AST 118 U/L and ALT 140 U/L. She was not on any medications known to cause hepatotoxicity, and work-up for other causes of elevated transaminases was negative. The patient underwent right upper quadrant ultrasound which revealed hyperechoic hepatic parenchyma consistent with hepatic steatosis. FibroScan™ revealed E (kPa) Value 17.8 Fibrosis Score: F4 which raised concerns for cirrhosis. The patient was to undergo EGD for variceal screening and same session EUS-guided liver biopsy to confirm the FibroScan findings. EGD was normal without evidence of portal hypertension.  


A 7.5 MHz Linear Echoendoscope was used to locate the right and left lobes of the liver. There was diffuse mild abnormal echotexture in the both lobes characterized by a mildly hyperechoic appearance. Fine needle biopsy (FNB) was performed from both lobes. Color Doppler imaging was utilized prior to needle puncture to confirm a lack of significant vascular structures within the needle path. One pass with four actuations was made with a 19ga Acquire™ FNB Needle using a transgastric approach for the left lobe and the same was done using a transduodenal approach for the right lobe. This was all done using the wet-heparin suction technique. Two visible samples of tissue were obtained.  

Specimen Preparation

Once the needle was removed from the scope, the specimen was expelled using 500 USP units/5ml of Heparin Lock Flush Solution. As the specimen was being expelled, the needle was held over a pathology filter and five layers of 4x4 gauze to separate the blood from the tissue specimen (Figure 1).  A large amount of white core tissue was left in the filter and transferred into a formalin bottle for histology. The same specimen preparation was repeated for the right lobe biopsy. (Figures 2 & 3)
Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3



The patient tolerated the procedure well without difficulty and there were no adverse events. Pathology revealed liver tissue with steatosis (involving 35% of liver parenchyma) and steatohepatitis (NAFLD Activity Score 4/8), portal and perisinusoidal fibrosis with focal bridging, stage 3 out of 4. Findings were similar from both lobes. Noninvasive tests are becoming more widely used as a surrogate for liver biopsy.  Elastography may be used to detect degree of steatosis or to determine the extent of scarring of the liver. This patient had findings on elastography concerning for cirrhosis, although her imaging, labs and physical exam were not diagnostic of cirrhosis. When noninvasive testing suggests advanced fibrosis, patient management is altered with  recommendations of increased follow-up, labs, and screening.  When there is discordance between noninvasive tests and labs, exam and imaging, the diagnosis may be confirmed with liver biopsy. This case is one demonstration that liver biopsy obtained during EUS can be safe, efficient and comfortable for the patient.

Hepatologist Perspective

In the correct contexts, liver biopsies are very useful in planning clinical management. Patients often have trepidation about undergoing the procedure due to the perception of pain. Tissue obtained during EUS has the advantages of being done while the patient is sedated and additionally, tissue can be obtained from both lobes of the liver which may allow for more representative tissue sampling than the older technique of percutanous sampling of the right lobe of the liver only. We anticipate this technique will offer an innovative method of obtaining liver biopsies and increase in the future.

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