Ultrasound-Guided Endoscopies Can Replace More Invasive Procedures for Liver Disease

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Physician researchers at the University of Miami Miller School of Medicine have summarized existing data that show that endoscopic ultrasound– nonsurgical procedures often used to view the digestive tract – can provide a minimally invasive alternative for liver disease patients. Published in the journal Gastroenterology & Hepatology, the review titled “The Evolving Role of Advanced Endoscopic Techniques in Hepatology” showed endoscopies could provide more patient-friendly alternatives for liver biopsies, portal pressure measurements, and gastric varices treatments.

“We wanted to see if we could provide a one-stop approach for patients,” said Mahmoud Mahfouz, M.D., gastroenterology fellow and first author, who collaborated with Sunil Amin, M.D., assistant professor of clinical medicine, and Andres Carrion, M.D., associate professor of clinical medicine, on the paper. “If we’re doing an upper endoscopy, we can also conduct a liver biopsy and measure the portal pressure gradient, instead of bringing the patient back three or four times for different procedures.”

Illustration from Boston Scientific

These approaches offer incredible benefits for liver disease patients, who often need continuous monitoring. In portal hypertension, for example, blood pressure increases in the portal vein, which carries blood from the digestive organs to the liver, boosting the risk of internal bleeds.

“Advanced endoscopic interventions are increasingly being used for diagnosis and treatment of multiple problems in patients with liver diseases,” said Dr. Carrion, who is also the director of the Transplant Hepatology Program at the University of Miami Health System. “This particular population benefits significantly from minimally invasive interventions, which oftentimes reduce the need for surgery, but expertise is required to improve outcomes and minimize complications.”

Traditionally, clinicians have estimated portal pressure by snaking a device through the jugular vein. Unfortunately, this approach cannot actually gauge the portal pressure directly, measuring the nearby hepatic vein as a surrogate. The endoscopic approach offers the dual advantages of being less invasive and providing greater access to the portal vein.

“Endoscopic hepatology is an exciting new frontier in gastroenterology,” said Dr. Amin, who is also the director of endoscopy at The Lennar Foundation Medical Center and Jackson Memorial Hospital. “We are proud to be on the cutting edge by offering all of these procedures to our patients here at the University of Miami Health System.”

For biopsies, clinicians have used a transjugular method or inserted a needle through the skin. Again, the endoscopic approach is easier on patients and may produce better results, improving access to both hepatic lobes. In addition, these procedures are well tolerated. One study showed that 92% of patients were pain-free one hour after receiving an endoscopic liver biopsy.

“We're coming in from the stomach or the duodenum, and looking directly at the liver,” said Dr. Mahfouz. “It gives us an excellent approach to gather tissue.”

Perhaps the most important finding was that patients could easily tolerate multiple endoscopic procedures at once, alleviating the need for repeat visits.

These approaches also represent an important change in how endoscopic ultrasound procedures are deployed. Previously, they were used almost exclusively for diagnoses. If a patient was experiencing bleeding, or another acute problem, the gastroenterologist would have to send them to surgery or interventional radiology. Now, with the advances in endoscopic ultrasound, they can intervene on the spot.

“The main purpose is to be less invasive with patients,” said Dr. Mahfouz. “It’s also probably more cost-effective, since we don't want to bring patients back for multiple procedures. We can do everything in one sitting.”