Recent Development of Endo-hepatology

Endo-hepatology is a rapidly evolving field encompassing endoscopic diagnosis and treatment of hepatobiliary diseases, primarily using endoscopic ultrasound (EUS). Since its conceptualization in 2012, the field has expanded dramatically alongside advances in interventional EUS. A landmark 2024 review broadened the concept to include endoscopic management of hepatobiliary diseases using interventional EUS/endoscopic retrograde cholangiopancreatography and advanced imaging technologies. In portal hypertension (PH), diagnostic applications include EUS-based variceal hemodynamic assessment, EUS-guided shear wave elastography, EUS-guided porto-systemic pressure gradient measurement (EUS-PPGM), EUS-guided liver biopsy (EUS-LB), and portal vein sampling. Therapeutic applications include EUS-guided vascular embolization for gastric, esophageal, and ectopic varices; portosystemic shunt obliteration for refractory hepatic encephalopathy; radiofrequency ablation of hepatocellular carcinoma; and emerging procedures such as intrahepatic portosystemic shunt creation and portal vein stenting. EUS-PPGM enables direct, minimally invasive portal pressure measurement and correlates strongly with the hepatic venous pressure gradient (HVPG). It may offer particular advantages in pre-sinusoidal PH, such as porto-sinusoidal vascular disorder, and in conditions with mixed sinusoidal and presinusoidal components, including metabolic dysfunction-associated steatotic liver disease, where HVPG may underestimate portal pressure. The "one-stop" concept integrates portal pressure measurement, LB, liver stiffness assessment, and variceal evaluation and treatment within a single endoscopic session. EUS-guided coil plus cyanoacrylate injection has demonstrated favorable efficacy and safety for gastric varices, while EUS-LB provides diagnostic accuracy comparable to percutaneous biopsy with less post-procedure pain. By integrating diagnostic and therapeutic procedures, endo-hepatology bridges endoscopy and hepatology and may provide comprehensive, minimally invasive, and personalized management of PH and chronic liver disease.