Endo-Hepatology: Advanced Endoscopy in the Management of Liver Disease
January 30, 2023
This article was written by Harkirat Singh, MD, clinical assistant professor and Medical Director of GI Endoscopy at UPMC Mercy.
Esophago-gastro-duodenoscopy (EGD) has long been used in patients with liver disease to assess and treat esophageal varices and gastric antral vascular ectasias. New techniques guided by endoscopic ultrasound (EUS) have broadened the scope of care that endoscopists can provide for patients with liver disease. EUS allows evaluation of the liver parenchyma and hepatic vessels from a close proximity, which has led to development of advanced interventions, aptly termed endo-hepatology. We’ll discuss how this subspecialty of advanced endoscopy can essentially offer comprehensive evaluation during a single procedure when multiple assessments are deemed necessary for patients with suspected or established chronic liver disease.
EUS-guided liver biopsy (EUS-LB) is technically easy due to the location of the left liver lobe adjacent to the stomach and excellent visualization of any intervening blood vessels, which minimizes bleeding complications. Although liver biopsies have been traditionally done via a percutaneous or transjugular route, published data shows that the samples obtained using EUS-LB meet or exceed the criteria set by the American Association for the Study of Liver Diseases for an adequate liver biopsy specimen in >95% of biopsies. Anecdotally, we have achieved adequate sampling in almost 100% of EUS-guided liver biopsies at our center. EUS-LB has several advantages as compared with percutaneous or transjugular biopsy. Because no skin is punctured, there is less postprocedural pain. With the ability to perform both right and left lobe biopsies, sampling error due to patchy distribution of liver disease is minimized. The recovery time is shorter. The sedation used for EUS makes EUS-LB the preferred approach in highly anxious patients and patients with a poor prior experience. EUS-LB is most cost effective when combined with an EGD or EUS examination for another indication. EUS-LB can be done simultaneously in a patient with any indication for EGD (e.g., dyspepsia, surveillance for Barrett’s esophagus, portal hypertension screening) or EUS (e.g., pancreatic cysts, evaluating biliary obstruction).1,2
Liver elastography has been widely utilized as a noninvasive method for staging liver fibrosis. Commonly used techniques include transient elastography (FibroScan®), MR elastography, and transabdominal ultrasound-guided shear wave elastography (SWE). We can now perform EUS-guided SWE in both the right and left lobes that correlates well with histologic findings on liver biopsy and with similar diagnostic accuracy as the transabdominal approaches.3 EUS-SWE is advantageous because it is not affected by obesity or the presence of ascites, which both affect the accuracy of transabdominal techniques.1
Portal hypertension is the major determinant of the clinical course of patients with liver disease. Traditionally, the hepatic venous pressure gradient (HVPG) has been measured by interventional radiologists using a transjugular approach. Now, the HVPG can be directly measured in a minimally invasive manner using EUS. The left or middle hepatic vein and left portal vein are easily identified during EUS, and a fine needle is inserted into the target veins to measure the venous pressure directly.
EUS-guided HVPG measurement is very safe and accurate, and the results are correlated with those obtained using the transjugular approach. EUS-HVPG is more accurate in evaluating pre and postsinusoidal portal hypertension as compared with the transjugular approach.1
Portal hypertension causes bleeding from gastric and esophageal varices, which is associated with significant morbidity and mortality. The usual standard-of-care for treating bleeding gastric varices is single or combination therapy with placement of a transjugular intrahepatic portosystemic shunt (TIPS) or a retrograde transvenous obliteration procedure using a balloon-occluded, coil-assisted, or plug-assisted approach. These modalities have contraindications and associated complications and cannot always be applied to critically ill patients with cirrhosis. EUS-guided therapies for obliterating gastric varices have gained a lot of traction. Good outcomes data have been reported with EUS-guided deployment of coils alone or deployment of coils plus glue embolization or coils plus gel-foam embolization in management of gastric varices.1,4,5 We will soon bring these into our armamentarium to manage complicated portal hypertension patients at UPMC.
A significant proportion of patients with cirrhosis and portal hypertension are considered high-risk surgical candidates for any major surgery due to decompensation of their liver disease that can lead to high postoperative morbidity and mortality. Cholecystitis is a common surgical issue that becomesvery challenging in patients with cirrhosis. In high-risk surgical candidates, cholecystitis is traditionally managed with percutaneous drainage of the gallbladder, but percutaneous drains have poor outcomes in patients with cirrhosis, especially when ascites are present. These drains become dislodged, leak, and result in recurrent hospitalizations.
Moreover, it affects patient quality of life. EUS-guided gallbladder drainage, accomplished by placing a lumen-apposing metal stent into the gallbladder via the duodenum or stomach, has developed into an attractive technique for managing cholecystitis in these patients. EUSguided gallbladder drainage has a technical and clinical success rate of>90%. A randomized controlled trial demonstrated that when compared with percutaneous drainage, EUS-guided gallbladder drainage resulted in significantly fewer adverse events 30 days and one-year postprocedure, a reduced reintervention rate, fewer unplanned admissions, and better pain control.6 We are happy to provide this option to our patients here at UPMC. Substantial advancements have been made in evaluating and managing liver disease through the use of endohepatology.
In the end, the success of everything we do depends on careful patient selection and close collaboration with our colleagues, including hepatologists, interventional radiologists, and surgeons, in a multidisciplinary manner.
Advanced Endoscopy in Action
A 58-year-old male presented with recurrent ascites. Evaluation at an outside institution showed no cirrhosis on imaging or liver biopsies and no portal hypertension on transjugular HVPG measurement. After evaluation, our hepatology team was still concerned about portal hypertension, and EGD and EUS exams were performed. EGD showed portal hypertensive gastropathy and small esophageal varices. The EUS-HVPG was 15 mm Hg, consistent with clinically significant portal hypertension. Liver biopsy showed obliterative portal venopathy without cirrhosis. So, a diagnosis of noncirrhotic portal hypertension was made to explain the etiology of the patient’s recurrent ascites. He underwent a TIPS procedure for management of his condition. This efficient “one-stop-shop” comprehensive assessment using advanced endoscopy yielded an actionable diagnosis, which truly benefited this patient.
References/Recommended Reading
1. Jearth V, Sundaram S, Rana SS. Diagnostic and interventional EUS in hepatology: An updated review. Endosc Ultrasound. 2022;11:355-370.
2. Mohan BP, Shakhatreh M, Garg R, Ponnada S, Adler DG. Efficacy and safety of EUS-guided liver biopsy: A systematic review and meta-analysis. Gastrointest Endosc.
2019;89:238-246 e233.
3. Kohli DR, Mettman D, Andraws N, Haer E, Porter J, Ulusurac O, et al. Comparative accuracy of endosonographic shear wave elastography and transcutaneous liver stiffness measurement: A pilot study. Gastrointest Endosc. 2022.ePub ahead of print.
4. Bazarbashi AN, Wang TJ, Jirapinyo P, Thompson CC, Ryou M. Endoscopic ultrasound-guided coil embolization with absorbable gelatin sponge appears superior to traditional cyanoacrylate injection for the treatment of gastric varices. Clin Transl Gastroenterol. 2020;11:e00175.
5. Fugazza A, Khalaf K, Colombo M, Carrara S,Spadaccini M, Koleth G, et al. Role of endoscopic ultrasound in vascular interventions: Where are we now? World J Gastrointest Endosc. 2022;14:354-36.
6. Teoh AYB, Kitano M, Itoi T, Pérez-Miranda M,Ogura T, Chan SM, et al. Endosonographyguided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: An international randomised multicentre controlled superiority trial. (DRAC) Gut. 2020;69:1085-1091.
1). Gut. 2020;69:1085-1091.
