Technical considerations in endoscopic ultrasound-guided liver biopsy: A comprehensive review

Liver biopsy continues to serve as a cornerstone in the evaluation of diffuse and unexplained liver disease, yet the percutaneous and trans-jugular routes are limited by safety concerns, patient acceptability and sampling variability. Endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as a safe and effective alternative, offering real-time access to both lobes and the opportunity to combine tissue acquisition with other endoscopic interventions. This review summarizes current evidence on EUS-LB, with focus on technical considerations including needle design, gauge, number of passes and actuations, suction techniques and specimen handling. Reported diagnostic adequacy consistently meets or exceeds established histologic benchmarks, while adverse event rates are comparable to percutaneous and trans-jugular biopsy. Bleeding is the most notable complication, though it is uncommon and usually self-limiting. Beyond tissue acquisition, the concept of EUS as a "one-stop" platform-integrating biopsy, portal pressure gradient measurement, elastography and therapeutic interventions is gaining importance. With ongoing refinements and accumulating supportive data, EUS-LB is increasingly recognized as a versatile, minimally invasive and comprehensive tool in hepatology.