28 - Endo-hepatology

Abstract

Endo-Hepatology is broadly defined as the integration of endoscopic procedures within the practice of hepatology. While the GI endoscopist has had endoscopic control of imaging, tissue acquisition, and intervention as pancreatico-biliary specialist, the same has not been the case in the liver where endoscopy has been limited to the diagnosis and treatment of varices. Over the past few years however, there has been a groundswell of endoscopic ultrasound (EUS) procedures and technological advancements with diagnostic, prognostic, and therapeutic applications to the liver. The endosonographer can assess the liver surface (nodular vs smooth), liver edge (blunted vs sharp), liver parenchyma (heterogeneity), and even liver stiffness by “palpating” the liver. A recent advancement has been the incorporation of shear-wave elastography (SWE) to the newest EUS processors—enabling quantitative measurements of both liver lobes as well as the spleen. For focal lesion assessment, EUS with contrast enhancement (CE) is now available in most countries including the United States. Moreover, EUS-guided liver biopsy (EUS-bx) has come of age, and EUS-guided portosystemic pressure gradient (PPG) measurement has emerged as a powerful prognostic tool. Taken together, the practice of Endo-Hepatology offers liver patients a true “one-stop-shop” evaluation consisting of a combination of the following: endoscopic and EUS assessment of portal hypertensive gastropathy and esophageal/gastric varices, EUS-SWE of liver and spleen, EUS-bx of one or both lobes, CE-EUS, and EUS-PPG. This chapter will focus on these Endo-Hepatology EUS modalities.