EUS-guided Liver Biopsy Research Articles

S3996 EUS-Guided Liver Biopsy in Pediatric Cholestasis: A Case Report of PSC/AIH Overlap Syndrome

S3996 EUS-Guided Liver Biopsy in Pediatric Cholestasis: A Case Report of PSC/AIH Overlap Syndrome

Endoscopic ultrasound-guided tissue acquisition for the diagnosis of focal liver lesion.

In patients with liver tumors, the histopathology examination can assist in diagnosis, staging, prognosis, and therapeutic management strategy. Endoscopic ultrasound (EUS)-guided tissue acquisition using fine needle aspiration (FNA) or more newly fine needle biopsy (FNB) is a well-developed technique in order to evaluate and differentiate the liver masses. The goal of the EUS-FNA or EUS-FNB is to provide an accurate sample for a histopathology examination. Therefore, malignant tumors such as hepatocarcinoma, cholangiocarcinoma and liver metastasis or benign tumors such as liver adenoma, focal hyperplastic nodular tumors and cystic lesions can be accurately diagnosed using EUS-guided tissue acquisition. EUS-FNB using 19 or 22 Ga needle provide longer samples and a higher diagnostic accuracy in patients with liver masses when compared with EUS-FNA. Few data are available on the diagnostic accuracy of EUS-FNB when compared with percutaneously, ultrasound, computer tomography or transjugulary-guided liver biopsies. This review will discuss the EUS-guided tissue acquisition options in patients with liver tumors and its efficacy and safety in providing accurate samples. The results of the last studies comparing EUS-guided liver biopsy with other conventional techniques are presented. The EUS-guided tissue acquisition using FNB can be a suitable technique in suspected liver lesions in order to provide an accurate histopathology diagnosis, especially for those who require endoscopy.

Dynamic suction: a novel technique to optimize EUS-guided liver biopsy

Dynamic suction: a novel technique to optimize EUS-guided liver biopsy

Endoscopic Ultrasonography In Diagnostic Endohepatology: The Hepatologist's Swiss Army Knife.

In recent years, significant advances have been made in endoscopic ultrasonography (EUS) processors, transducers, and the instruments used. In parallel with these developments, the importance of EUS in the diagnosis, treatment, and management of chronic liver diseases has increased considerably. One of the most important advantages of EUS is that the ultrasound probe can examine the liver area under examination from a very close distance. Additionally, EUS provides the ability to provide excellent spatial files and realtime images; Doppler, elastography, and contrast methods are also widely used to increase diagnostic accuracy in EUS evaluations. Endoscopic ultrasound-guided procedures are an alternative method used when percutaneous approaches are not feasible. Endoscopic ultrasound-based advanced applications such as EUSguided liver biopsy (LB), EUS-guided ascites assessment, the use of EUS in the evaluation of focal lesions of the liver, and EUS portal pressure gradient (EUS-PPG) measurements are becoming increasingly common and important. As a result of the developments in EUS devices and instruments, it is possible to perform all diagnostic procedures in hepatology with EUS. In other words, EUS can provide all the imaging and interventional procedures that a hepatologist would require for diagnosis in a single session, without the need for any other expertise other than the gastroenterologist (such as a radiologist, interventional radiologist, or surgeon). This is called the single-procedure diagnostic approach, or "all in one" in hepatology. From a hepatologist's perspective, EUS can be thought of as the "hepatologist's Swiss army knife."

Comparing a 19-gauge fine-needle biopsy needle with a 22-gauge fine-needle biopsy needle for EUS-guided liver biopsy sampling: a prospective randomized study

EUS-guided liver biopsy (EUS-LB) sampling is being increasingly used. We performed a prospective randomized trial to compare specimen adequacy of a 19-gauge fine-needle biopsy (FNB) needle with a 22-gauge FNB Franseen tip needle for EUS-LB sampling. Forty-two consecutive patients referred for EUS-LB sampling were prospectively randomized to a 19-gauge or 22-gauge FNB needle. When the specimen with the 22-gauge needle was macroscopically inadequate, an additional pass with the 19-gauge needle was done. Bilobar EUS-LB sampling was performed with heparinized wet suction using 1 pass and 3 actuations per lobe. Descriptive statistics were computed for all variables. Biopsy sampling was performed for abnormal liver enzymes in 95.5% of patients (57% women; average age, 51 years). Five patients undergoing sampling with the 22-gauge FNB needle had macroscopically inadequate specimens and required additional biopsy sampling with the 19-gauge FNB needle. Mean preprocessing length of the longest tissue core was 21.5 ± 6.3mm with a 19-gauge FNB needle compared with 9.4 ± 5.5mm with the 22-gauge FNB needle (P< .001). Postprocessing specimens were significantly longer with 19-gauge than with 22-gauge FNB needles (17.4mm vs 6.8, P< .001). There were no adverse events, and postprocedure pain and discomfort was similar in both groups (14% for 19-gauge vs 10% for 22-gauge, P= .99). Liver core biopsy sampling using the 19-gauge FNB needle is superior to the 22-gauge FNB needle in terms of length of longest core and aggregate specimen length. Considerably more fragmentation of the 22-gauge cores occurs during tissue processing. No increased postprocedure pain or AEs were found with the 19-gauge needle. A 19-gauge FNB needle is preferred to the 22-gauge FNB needle for EUS-LB. (Clinical trial registration number: NCT04806607.).

Endohepatology in clinical practice: EUS-guided portal pressure measurement combined with EUS-guided liver biopsy and variceal screening and treatment in outpatients.

EUS-guided portal pressure gradient (PPG) is a novel technique that permits a true, direct measure of portal vein pressure and hepatic vein pressure. This article details our experience and lessons learned from 20 consecutive outpatient EUS-PPG procedures performed at a single center, along with simultaneous EUS-guided liver biopsy, variceal screening, and variceal banding. Data on the first 20 patients who underwent EUS-PPG at a single center were retrospectively viewed and analyzed. The effects of various liver diseases or other patient-related factors on the clinical and technical success of EUS-PPG measurements, as well as EUS-guided liver biopsy (EUS-LB), were evaluated. During the procedure, if esophageal varices were encountered, they were assessed, and if felt to be clinically indicated, endoscopic variceal ligation was performed. The 20 patients included 10 male and 10 female patients. All procedures were technically successful. In all patients, the portal vein and hepatic veins could be easily identified. One adverse event of bleeding occurred during the EUS-PPG measuring procedure. All 20 EUS-LBs were technically successful and yielded adequate samples for histological evaluations, with an average of 25 complete portal tracts per sample. Among patients with esophageal varices, 40% of patients underwent banding. The mean EUS-PPG among 5 patients with esophageal varices was 11.6 mm Hg, compared with 3.2 mm Hg among 15 patients without esophageal varices. This study demonstrates that EUS-PPG is a novel, safe, reproducible, and effective technique. Also, the fact that EUS-PPG, EUS-LB, variceal screening, and variceal banding could be performed in 1 session and on an outpatient basis speaks to the growing relevance and impact of the nascent field of endohepatology.

The safety and efficacy of endoscopic ultrasound-guided portal pressure gradient measurement with concomitant endoscopic ultrasound-guided liver biopsy: a systematic review

IntroductionPortal hypertension (PH) is a complication of advanced liver disease. Traditionally, PH has been quantified using hepatic venous pressure gradient (HVPG) through an indirect transjugular approach requiring ionizing radiation exposure. Endoscopic ultrasound-guided porto-systemic pressure gradient (EUS-PPG) measurement is an emerging alternative, minimally invasive technique that provides direct portal pressure measurement. The aim of this systematic review is to evaluate the safety and efficacy of EUS-PPG measurement and concomitant EUS-guided liver biopsy (EUS-LB) in patients with chronic liver disease.MethodsThe preferred reporting items for systematic reviews and meta-analyses method was used. A PubMed, Medline, Web of Science, Google Scholar, and CINAHL search for terms “endoscopic ultrasound,” “EUS,” and “portal pressure gradient” was used to identify qualifying studies. Eligible studies included those which were published before 2022, reporting outcomes of EUS-PPG measurement, simultaneous EUS-LB if applicable, and adverse events rate. Risk of bias was assessed by Egger’s test. Results were synthesized using I2 to test heterogeneity.ResultsFour published studies including 147 patients met inclusion criteria, with mean age 59.6 years, 59% male. Indications for EUS-PPG measurement were history of chronic liver disease or suspected cirrhosis, viral hepatitis, alcohol associated liver disease, hepatic sinusoidal obstruction or Budd Chiari syndrome. The pooled technical success rate of EUS-PPG measurements was 98.61% with 95% confidence interval of 95.20% - 99.82%. A 25-gauge needle was used in 92% (135/147) of patients. EUS-PPG measurement was performed through a transgastric approach in all 147 (100%) patients using a compact manometer with pressure transducer and non-compressible tubing. The mean PPG was 10.07 (range 6.44 – 13.70) mmHg. Ninety-five patients underwent simultaneous EUS-LB using 19G needle with wet suction technique. Technical success rate of EUS-LB was 100% and specimen was adequate in 99% (94/95) patients to establish histological diagnosis. There were no major life-threatening complications of the EUS-PPG procedure. Predominant adverse events were abdominal pain 6.1% (9/147) and sore throat 5.4% (8/147).ConclusionEUS-PPG measurement is safe and useful in providing an assessment of portal pressure in patients with chronic liver disease. Future studies are needed to evaluate whether there is consistent correlation between EUS-PPG measurements and histologic fibrosis stage by liver biopsy.

Distinct ways to perform a liver biopsy: The core technique setups and updated understanding of these modalities.

There is dramatically increased incidence of several liver diseases worldwide; thus, an unmet need to diagnose and stage these pathological entities heralds the wide application of liver biopsy (LB) techniques. The ways of LB are versatile, including percutaneous LB, transjugular LB, and more recently an approach of minimal invasiveness, that is, EUS-guided LB (EUS-LB). In this review article, we come to the conclusion that EUS-LB may serve as a feasible, reliable, and safe alternative to percutaneous LB and transjugular LB in terms of improved diagnostic yield, excellent sampling performance, and controlled adverse events among patients with focal, infiltrative, and parenchymal liver diseases. Furthermore, extensive efforts have been made to optimize and refine several technical pillars within EUS-LB modality such as the selection of needle size/type, priming manner of biopsy needle, and choice of pass/actuation technique, all of which aim at obtaining better specimen quantity and quality. Another advantageous aspect and unique property pertinent to EUS-guided modality indicate that multiple screening, surveillance, and intervention procedures can be combined into one single endoscopic session. Accordingly, some pilot studies have clarified the clinical usefulness by integrating EUS-LB with simultaneous measurement of portal pressure gradient or examination of liver stiffness. However, more studies, in particular, randomized controlled trials or real-world evidence, are practically warranted to elucidate the validity and safety of EUS-LB as a regular/routine part of managing liver diseases.

S1303 The Efficacy and Safety of EUS-Guided Portal Pressure Gradient with Concomitant EUS-Guided Liver Biopsy in Patients with Chronic Liver Disease

S1303 The Efficacy and Safety of EUS-Guided Portal Pressure Gradient with Concomitant EUS-Guided Liver Biopsy in Patients with Chronic Liver Disease

Liver Biopsy and Pressure Hemodynamics: GI Perspective

AbstractEndoscopic ultrasound (EUS) has come a long way from mere diagnostic modality to performing interventional procedures like fine needle aspiration, gastric varices glue and coiling, and management of pancreatic fluid collection along with necrosectomy. Recently, EUS-guided biopsy of the liver has gained traction. This coupled with the ability to access the portal vein and measure portal pressure has made comprehensive liver evaluation possible using endoscopic route. In this review, we will discuss evolution and techniques of performing EUS-guided liver biopsy and portal pressure gradient. We will also compare the merits and demerits as compared with the other conventional techniques.

“Two for one”: histologic diagnosis of Helicobacter pylori during EUS-guided liver biopsy

“Two for one”: histologic diagnosis of Helicobacter pylori during EUS-guided liver biopsy

EUS-guided versus percutaneous liver biopsy: A prospective randomized clinical trial.

Prospective studies comparing EUS-guided liver biopsy (EUS-LB) to percutaneous LB (PC-LB) are scarce. We compared the efficacy and safety of EUS-LB with those of PC-LB in a prospective randomized clinical trial. Between 2020 and 2021, patients were enrolled and randomized (1:1 ratio). The primary outcome was defined as the proportion of patients with ≥11 complete portal tracts (CPTs). The sample size (n = 80) was calculated based on the assumption that 60% of those in the EUS-LB and 90% of those in the PC-LB group will have LB with ≥11 CPTs. The secondary outcomes included proportion of patients in whom a diagnosis was established, number of CPTs, pain severity (Numeric Rating Scale-Pain Intensity), duration of hospital stay, and adverse events. Eighty patients were enrolled (median age, 53 years); 67.5% were female. Sixty percent of those in the EUS-LB and 75.0% of those in the PC-LB group met the primary outcome (P = 0.232). The median number of CPTs was higher in the PC-LB (17 vs 13; P = 0.031). The proportion of patients in whom a diagnosis was established was similar between the groups (92.5% [EUS-LB] vs 95.0% [PC-LB]; P = 1.0). Patients in the EUS-LB group had less pain severity (median Numeric Rating Scale-Pain Intensity, 2.0 vs 3.0; P = 0.003) and shorter hospital stay (2.0 vs 4.0 hours; P < 0.0001) compared with the PC-LB group. No patient experienced a serious adverse event. EUS-guided liver biopsy was safe, effective, better tolerated, and associated with a shorter hospital stay.

EUS-guided liver biopsy using a novel hydrostatic stylet technique

Video 1Hydrostatic stylet technique for the performance of EUS-guided liver biopsy.

EUS guided liver biopsy in patients with suspected cACLD and cirrhosis: a real-life observational study

EUS guided liver biopsy in patients with suspected cACLD and cirrhosis: a real-life observational study

Diagnostic efficacy of endoscopic ultrasound-guided liver biopsy for diffuse liver diseases and its predictors - a multicentric retrospective analysis.

Endoscopic ultrasound (EUS)-guided liver biopsy (LB) has become an increasingly popular method of tissue acquisition for evaluating liver diseases. Despite its advantages, EUS-LB has not been widely adopted in clinical practice due to concerns regarding efficacy and safety. Present data on EUS-LB from India are scarce. We aimed to study the diagnostic outcome and safety of EUS-guided liver biopsy. This is a retrospective analysis of prospectively maintained data from January 2021 to October 2022 of consecutive patients undergoing EUS-LB at four tertiary care centers in India. The primary outcome was sample adequacy, while secondary outcomes were rate of successful pathological diagnoses and incidence of adverse events (AE). A total of 74 patients (median age: 44.5 years, 50.0% males) were included. The majority of the patients underwent left-lobe biopsy (62/74, 83.7%), and a 19-G Franseen FNB needle was most commonly used (61/74, 82.4%). Wet heparin suction was used in most cases (60/74, 81.1%). There were five mild AEs observed (one case of self-limited bleeding and four cases of post-procedural pain). Adequate and optimal samples were obtained in 71 (95.9%) and 49 (66.2%) cases, with a conclusive diagnosis being made in 97.3% (72/74) of the patients. On multivariate analysis, the presence of ascites was a negative predictor of optimal sample (odds ratio [OR] = 0.128, 95% CI: 0.017-0.96). EUS-LB is a safe and viable alternative to percutaneous liver biopsy, achieving diagnosis in > 95% of cases. EUS-LB can be performed safely even in patients with mild ascites, although ascites reduces the chances of getting an optimal sample.

Evolution of interventional endoscopic ultrasound.

Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.

EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes.

EUS-guided liver biopsy (EUS-LB) has gained momentum in recent years, especially with availability of newer needle designs. Given the emerging comparative data on EUS-LB with second-generation needles and percutaneous LB (PC-LB), we conducted a systematic review and meta-analysis to compare the safety and efficacy of the two techniques. We searched multiple databases from inception through November 2021 to identify studies comparing outcomes of EUS-LB and PC-LB. Pooled estimates were calculated using a random-effects model, and the results were expressed in terms of pooled proportions and odds ratio (OR) along with relevant 95% confidence intervals (CIs). Five studies with 748 patients were included in the final analysis. EUS-LB was performed in 276 patients and PC-LB in 472 patients. Across all studies, PC-LB had an overall higher diagnostic accuracy than EUS-LB, 98.6% confidence interval (CI: 94.7-99.7) versus 88.3% (49.6-98.3), OR: 1.65, P = 0.04. On assessing data from randomized controlled trials, there was no difference between the two. While pooled diagnostic adequacy and overall adverse events were not significantly different between PC-LB and EUS-LB, the former was superior in terms of the mean number of complete portal tracts (CPT) and total specimen length. PC-LB and EUS-LB produce similar results. PC-LB allows obtaining longer samples and more CPT. Further studies are needed to see if these trends hold up as more providers begin to perform EUS-LB.

S1308 Utility of Endo-Hepatology in Assessing Liver Fibrosis in Patients With Chronic Liver Disease: Data From University Hospital in WV

Introduction: The clinical utility of EUS and the field of Endo-Hepatology (EH) are expanding. While CT-guided liver biopsy (LB) was once considered the gold standard other modalities such as Transient elastography (TE), EUS-shear wave elastography (EUS-E), and EUS guided liver biopsy (EUS-LB) are becoming more prevalent due to multitude of benefits from cost to patient tolerability and comparable accuracy. We look to add to this growing body of evidence. Our study investigated the accuracy and diagnostic yield of EUS-LB. We then compared LB to TE and EUS-E. Our results add to the clinical utility and strengths of EH. Methods: In this IRB approved retrospective analysis, 53 patients with chronic liver disease (CLD) were diagnosed with severe fibrosis on TE and underwent EUS guided analysis. EGD indicated for distinct reasons was coupled with EUS-LB to further stage the fibrosis of these high-risk patients. The study evaluated patients between October 2021 – June 2022. Demographic characteristics were collected in each patient. Liver biopsies were reviewed for adequacy. A cutoff of 10 and 14 kPa on TE/EUS-E was used to assess accuracy in predicting fibrosis when compared to EUS-LB. Correction coefficient was used to assess the association between these methods. Results: Our Appalachian population was unique, as it was predominantly Caucasian, held a BMI >30, and multiple comorbidities equally present in both genders. Our study found a correlation between the EUS-E and TE in KPa (r=0.549, p=0.1) as well as EUS-E KPa and LB fibrosis stage (r=0.6627, p=0.007) as showed in Fig 2. Additionally, a significant correlation was found between the TE and LB in terms of fibrosis stage (r=0.6 p=0.003) and steatosis stage (r=0.5249, p=0.01) in diagnosis of cirrhosis (Table A). This was more consistent in ALD (r=0.5847) in comparison to NAFLD (r=0.4). Interestingly, this correlation seems more consistent in higher fibrosis stages as shown in Table B. Conclusion: 53 patients underwent EH based procedures without any complications. EUS-LB had adequacy rate of 92.2% and held > 14 portal triads on avg. Our study indicated that various modalities via EH are reliable in identifying severe fibrosis when compared to the previous gold standard and TE. Our study adds to the large body of evidence regarding reliability of TE in detecting severe fibrosis present in various etiologies of CLD.Figure 1.: Statistical Analysis: Figures and Tables Table 1. - Demographics Result of This Study Population Total number of cases, n 53 Age, mean ± SD 55.6 ± 12.9 Male, n (%) 26 (49.1%) Female, n (%) 27 (50.9%) Race White, n (%) 52 (98.1%) Black, n (%) 1 (1.9%) BMI, mean ± SD 33.3 ± 9.2 Etiology of Liver Disease Non-alcoholic fatty liver disease (NAFLD), n (%) 14 (26.4%) Viral Hepatitis, n (%) 8 (15.1%) Alcohol, n (%) 34 (62.2%) Other (AIH, DILI, PBC), n (%) 10 (18.9%) Clinical Cirrhosis, n (%) 20 (37.7%) EV/GV on EGD, n (%) 15 (28.3%) Fibroscan, Mean ± SD in kPa 23.9 ± 19.2 EUS-SWE, Mean ± SD in kPa 24.3 ± 8.1 Fibrosis stage ³ 3 on biopsy, n (%) 25 (54.3%) Portal Triad on biopsy, mean ± SD 14 ± 5.6

S1228 EUS-Guided Shear Wave Elastography Appears to Be More Accurate Than Transient Elastography in Predicting Liver Fibrosis Staging in Patients With Obesity

Introduction: Transient elastography (TE) is a non-invasive clinical tool used to assess liver stiffness measurement (LSM) and can be correlated to liver fibrosis staging. Obesity can make elastography challenging to perform due to increased abdominal wall thickness, with high failure rates for TE. Fibroscan XL probes have lower failure rates, though it is unclear if readings are reliable or correlate well with liver biopsies. EUS guided shear wave elastography (EUS-SWE) can potentially circumvent this limitation, as liver parenchyma via EUS can be visualized under a thin subcentimeter gastric or duodenal wall, which does not change appreciably with body habitus. We aim to determine whether TE or EUS-SWE correlate better with liver biopsy fibrosis staging for patients with obesity. Methods: A retrospective chart review was performed for patients with obesity at a single tertiary hospital from Dec 2021 to May 2022. Patients with obesity (BMI≥30) with LSM concerning for advanced fibrosis (F3 or F4) were referred for EUS-SWE and EUS guided liver biopsy, both of which performed in the left liver lobe. LSM (reported in kPa) were correlated with fibrosis staging on liver biopsy and were considered accurate if they fell within cutoff ranges: kPa ≤7 = F0-1, kPa 7-8 = F2, kPa 8-12 = F3, and kPa >12 = F4. No established cutoffs exist for EUS-SWE, so stiffness values were compared to that for TE on which were closer to TE cutoff ranges. Results: 12 consecutive patients with obesity underwent TE, EUS-SWE, and EUS guided liver biopsy. The mean age was 55.3 [range 18-69], 9 (75%) were females, and mean BMI was 44.9 [range 30.2-67.8]. LSM ranged from 9.1 to 41.9 kPa. Only 2 (17%) patients’ TE results correlated accurately with liver fibrosis staging on biopsy; see Table. Assuming similar fibrosis staging cutoff ranges for TE, EUS-SWE accurately downgraded 8 (67%) patients and demonstrated no change for 4 (33%) patients. EUS-SWE was closer to biopsy LSM cutoffs for 9 (75%) patients, while TE was more accurate in only 1 (8%) patient. Conclusion: In this small cohort of patients with obesity with possible advanced fibrosis, TE appeared to overdiagnose fibrosis stage, while EUS-SWE appeared to downgrade LSM appropriately for patients who were overdiagnosed. Larger cohort studies are ongoing to allow proper interpretation of EUS-SWE stiffness values and compare its utility and accuracy to TE. Table 1. - Individual patient data with basic demographics, transient elastography data, EUS shear wave elastography data, and data comparison and analysis Patient # Age Gender BMI TE LSM Value (kPa) Fibrosis Staging Based on TE Cutoff Fibrosis Stage on Biopsy (TE cutoffs) TE LSM as Compared to Fibrosis Staging on Biopsy EUS-SWE Stiffness (kPa) Closer to Biopsy Cutoffs? TE vs EUS-SWE How Did EUS-SWE Compare to TE via Fibrosis Staging ? 1 58 Female 62.4 9.1 F3 F0 (kPa≤7mmHg) Overstaged 5 EUS-SWE Downgraded 2 68 Female 39 9.9 F3 F0 (≤7) Overstaged 4.9 EUS-SWE Downgraded 3 59 Female 32.6 9.4 F3 F0 (≤7) Overstaged 6.3 EUS-SWE Downgraded 4 63 Female 32.8 15.7 F4 F0 (≤7) Overstaged 7.3 EUS-SWE Downgraded 5 48 Male 67.8 41.9 F4 F0 (≤7) Overstaged 7.3 EUS-SWE Downgraded 6 63 Female 38 9.4 F3 F0 (≤7) Overstaged 2 EUS-SWE Downgraded 7 56 Male 43.6 9.6 F3 F3 (8-12) Appropriate Stage 10.5 EUS-SWE No Change 8 18 Female 61.1 34.6 F4 F2 (7-8) Overstaged 19.6 EUS-SWE Downgraded 9 53 Female 32.6 20.5 F4 F4 (≥12) Appropriate Stage 21.7 Same No change 10 55 Male 34.9 12.2 F4 F2 (7-8) Overstaged 12.2 Same No Change 11 53 Female 30.2 14 F4 F3 (8-12) Overstaged 15.2 TE No Change 12 69 Female 64.1 14.7 F4 F2 (7-8) Overstaged 10.2 EUS-SWE Downgraded

S2943 Budd-Chiari Syndrome Diagnosis Achieved With High Clinical Suspicion Raised by EUS-Guided Portal Pressures and Liver Biopsy

Introduction: Budd Chiari syndrome (BCS) is a rare syndrome due to hepatic venous obstruction in the absence of cardiac cause, mostly secondary to thrombosis. As high as 80%of patients present with ascites. The diagnosis should be suspected in patient with acute or chronic liver disease without identified cause. Venous obstruction can be seen on Doppler ultrasound, CT, or MRI of the hepatic veins and inferior vena cava. In some cases, hepatic venogram is needed for its diagnostic and therapeutic advantages. We report a 50-year-old woman with BCS who underwent successful wire recanalization, angioplasty and thrombolysis of the right hepatic vein. Case Description/Methods: 50-year-old woman with no significant past medical history presented with abdominal distension and bilateral lower extremity swelling of two weeks duration. On exam, abdomen was distended with positive signs of fluid collection with +3 bilateral lower extremity edema. Labs revealed total bilirubin 3.3 direct bilirubin 1.4, ALP 477, ALT 38, AST 96, PT 14.4, INR 1.35. Ultrasound showed Heterogeneous appearance of liver and large volume ascites. Doppler study showed normal hepatic and portal venous flow. Abdominal MRI showed hepatic steatosis and caudate lobe hypertrophy. Large volume paracentesis was done with analysis showing SAAG of 3.1, WBC 364, Neutrophils 8. EGD revealed large esophageal varices. Viral hepatitis panel, ceruloplasmin, alpha-1antitripsin, ASMA, AMA antibodies were negative. EUS guided liver biopsy and portal pressure measurement was done showing venous pressure gradient of 13 consistent with portal hypertension. Liver biopsy showed grade 2 fibrosis and zone 3 congestion. Hepatic venogram showed chronically occluded right hepatic vein on which successful wire recanalization was done. Pt was worked up for hypercoagulable state and was found to have JAK 2 mutation and Protein C deficiency. Apixaban, Beta blocker and diuretics were started. Patient showed significant improvement with ascites and MELD score. Discussion: First line investigation for diagnosis of BCS is doppler ultrasound. Doppler US and MRI venography didn’t reveal the hepatic venous thrombosis in our patient. However, high index of suspicion, finding of elevated IVC pressure on EUS, and caudate lobe hypertrophy found on imaging as well as congestion liver biopsy findings led us to further investigate with hepatic venogram which confirmed the diagnosis and provided therapeutic advantages. Table 1. - Prothrombotic risk factors for BCS ACG Clinical Guideline A. Acquired thrombophilia B. Inherited thrombophilia C. Systemic factors D. Hormonal factors Myeloproliferative disorderPolycythemia veraEssential thrombocytosisIdiopathic myelofibrosisJAK 2 mutationPNH Hyperhomocysteinemia Factor V LeidenProthrombin gene G20210A mutationMTHFR C677T mutationThalassemiaPC deficiencyProtein C deficiencyAntithrombin deficiency SarcoidosisVasculitisBehcet’s diseaseConnective tissue diseaseInflammatory bowel diseases OCP usePregnancy Disorders of the Hepatic and Mesenteric Circulation Simonetto, Douglas A.; Singal, Ashwani K.; Garcia-Tsao, Guadalupe; Caldwell, Stephen H.; Ahn, Joseph; Kamath, Patrick S. Official journal of the American College of Gastroenterology | ACG115(1):18-40, January 2020. doi: 10.14309/ajg.0000000000000486