2 Methods
The European Society of Gastrointestinal Endoscopy (ESGE) commissioned this Guideline
(Guideline Committee chair, J.v.H.) and appointed a guideline leader (R.P.) who invited
the listed authors to participate in the project development. After the project group
had been assembled, task forces were formed to define the key questions and PICOs
(population, intervention, comparator, outcome) in the upper gastrointestinal, lower
gastrointestinal, and HPB domains (Table 1 s , see online-only Supplementary material). Literature searches and reviews of the
relevant articles were performed between March and September 2020. The available evidence
was graded according to the Grading of Recommendations Assessment, Development and
Evaluation (GRADE) system [1 ]. Based on the available evidence, recommendations and suggestions were drafted and
discussed with the project group during online meetings. Further details on the methodology
of ESGE guideline development have been reported elsewhere [2 ].
In February 2021, a draft prepared by the leaders and coordinating team was sent to
all group members. The manuscript was also reviewed by two independent reviewers and
sent for further comments to the ESGE National Societies and individual members. After
agreement on a final version, including the agreed recommendations (a summary of the
upper gastrointestinal tract recommendations is given in [Table 1 ]), the manuscript was submitted to the journal Endoscopy for publication. All authors agreed on the final revised manuscript.
Table 1
Summarized recommendations for tissue sampling in the upper gastrointestinal tract.
Suspected diagnosis or indication
Number and location of biopsies
Remarks
Eosinophilic esophagitis: initial diagnosis or evaluation of therapy response
At least six biopsies, two to four biopsies from the distal esophagus and two to four
biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities
Place biopsies from the distal and proximal esophagus into separate containers
Gastroesophageal reflux disease
Biopsies not indicated for diagnosis
Infectious esophagitis
Given the high positive predictive value of white plaque-like lesions for candida,
biopsies are only indicated if the results would have therapeutic consequences
Mycologic analysis only indicated for treatment resistance
Six biopsies, including from the base and the edge of esophageal ulcers
Barrett’s esophagus
In cases with endoscopic evidence of Barrett’s esophagus > 1 cm, biopsies should be
taken from all visible abnormalities; in addition, random four-quadrant biopsies should
be collected every 2 cm within the Barrett’s segment, starting from the upper end
of the gastric folds
Place biopsies from any abnormalities and from each level into separate containers
Esophageal cancer and early neoplasia
At least six biopsies in cases of suspected advanced cancer
Dyspepsia and gastritis
Two biopsies from the antrum and two from the corpus in patients where H. pylori is suspected
Place biopsies from antrum and corpus in separate containers
Gastric polyps
Standard biopsies are not required
Biopsy (or resect) if size is > 10 mm
Biopsy or, if endoscopically resectable, resect
Gastric cancer and early neoplasia
At least six biopsies in cases of suspected advanced cancer
Celiac disease
At least six biopsies from different locations in the duodenum, including two samples
from the bulb
Biopsies can be collected in one container
OLGA, operative link for gastritis assessment; OLGIM, operative link on intestinal
metaplasia assessment.
This Guideline was issued in 2021 and will be considered for review and update in
2026, or sooner if new and relevant evidence becomes available. Any updates to the
Guideline in the interim will be noted on the ESGE website: http://www.esge.com/esge-guidelines.html .
3 Upper gastrointestinal tract
3.1 Eosinophilic esophagitis
ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least
six biopsies should be taken, two to four biopsies from the distal esophagus and two
to four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal
abnormalities. Distal and proximal biopsies should be placed in separate containers.
Strong recommendation, low quality of evidence.
Biopsies should be obtained in patients in whom eosinophilic esophagitis is a clinical
possibility, even when normal mucosa is visualized. Inflammatory alterations in eosinophilic
esophagitis are frequently patchy, therefore it is recommended that at least six biopsies
should be obtained from at least two different locations in the esophagus, typically
two to four biopsies from both the distal and proximal esophagus, depending on where
most endoscopic abnormalities are visualized. The diagnostic sensitivity increases
with the number of biopsies and is maximized with at least six biopsies. Esophageal
biopsies should be targeted to areas of endoscopic abnormality, mainly white stipples,
exudates, and longitudinal furrows, which are associated with higher eosinophil counts.
In patients with symptoms, biopsies should also be taken even if the endoscopic appearance
is normal, as this has been reported in up to 10 % of adult patients [3 ]
[4 ]
[5 ]
[6 ]
[7 ].
ESGE suggests, in histologically confirmed eosinophilic esophagitis, obtaining biopsies
after a 6- to 12-week initial treatment course, with at least two to four biopsies
from the distal esophagus and two to four biopsies from the proximal esophagus, focusing
on areas with endoscopic mucosal abnormalities.
Weak recommendation, very low quality of evidence.
ESGE suggests against endoscopy and histologic assessment on an annual basis for patients
who have responded to therapy and are maintained on these treatments.
Weak recommendation, very low quality of evidence.
For patients who are treated with a proton pump inhibitor (PPI), elimination diet,
or steroids, the response to therapy can be assessed by means of a follow-up endoscopy
after a 6- to 12-week initial course, obtaining at least six biopsies from at least
two different locations in the esophagus, typically two to four biopsies from both
the distal and proximal portions of the esophagus. However, there is little evidence
to support this in patients who respond to therapy. For patients who respond to a
PPI, elimination diet, or steroids and are maintained on these treatments, current
data do not support follow-up with endoscopic and histologic assessment [3 ]
[4 ]
[5 ]
[6 ]
[7 ].
3.2 Gastroesophageal reflux disease
ESGE recommends against obtaining biopsies for the diagnosis of gastroesophageal reflux
disease (GERD) in patients with normal endoscopic findings.
Strong recommendation, low quality of evidence.
In patients with complaints of gastroesophageal reflux, with or without PPI use, and
with or without endoscopic signs of erosive esophagitis, biopsies are not recommended
to confirm gastroesophageal reflux disease (GERD). For this indication, the sensitivity
and specificity of the histologic findings have insufficient diagnostic accuracy and
alternative diagnostic methods with higher sensitivity and specificity are available
(e. g. reflux monitoring). Biopsies can be considered to exclude alternative diagnoses,
if these are suspected based on the patient’s symptoms [8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ].
3.3 Infectious esophagitis
ESGE suggests only obtaining biopsies in cases of suspected candida esophagitis if
results are expected to have therapeutic consequences. Esophageal biopsies targeted
at white plaque-like lesions should be sent for histologic and mycologic analysis
when there is treatment resistance.
Weak recommendation, very low quality of evidence.
ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal
ulcers, for histologic analysis in patients with suspected viral esophagitis.
Strong recommendation, low quality of evidence.
The most frequent cause of infectious esophagitis is fungal infection by Candida species. When associated with oropharyngeal thrush, upfront empiric antifungal treatment
can be considered, as the positive predictive value of oral thrush for candida esophagitis
in a patient with dysphagia reaches 77 % [17 ]
[18 ]. If treatment fails or there is an absence of oropharyngeal lesions, endoscopic
inspection and possible sampling of the esophageal mucosa is needed. An endoscopic
diagnosis of candida esophagitis may be made by the observation of white or yellowish,
plaque-like lesions (so called “cottage-cheese” plaques), and exudates on the esophageal
mucosa, which are usually easily removable. White plaque-like lesions on the esophageal
mucosa have a positive predictive value for candida esophagitis of 88 %–90 % [19 ]. The sensitivity of endoscopic biopsies with histologic assessment ranges from 54 %
to 95 % [20 ]
[21 ]
[22 ]. Endoscopic biopsies with fungal culture may be needed in treatment-resistant cases.
In patients with esophageal ulcers, viral esophagitis should be suspected, most commonly
caused by herpes simplex virus (HSV 1 or 2) and cytomegalovirus (CMV) [23 ]. In human immunodeficiency virus (HIV)-infected patients, idiopathic esophageal
ulcers must also be considered in the differential diagnosis, as this has therapeutic
consequences because these idiopathic esophageal ulcers are best treated with corticosteroids.
Whereas HSV typically presents with ulcers in immunocompromised patients, in elderly
patients it may present with vesicles and “volcano-shaped” mucosal structures. Conflicting
data on the recommended number of endoscopic biopsies is possibly explained by the
need to perform biopsies on the ulcer edge to observe the cytopathogenic effect of
HSV and on the ulcer base for CMV [24 ]. Biopsies have a sensitivity of 68 %–100 % for HSV and 90 %–100 % for CMV [24 ]
[25 ]
[26 ]
[27 ]
[28 ]
[29 ]
[30 ]
[31 ]
[32 ]
[33 ].
Viral culture, although highly specific [24 ], is not available in most centers [34 ]. The only prospective study in the field did not observe an added diagnostic value
of viral culture over routine histologic evaluation with immunohistochemical staining
for CMV and HSV antigens [24 ]. Furthermore, the use of immunohistochemistry has not been consistently shown to
improve detection of HSV and CMV [35 ]. Finally, routine hematoxylin and eosin staining is accurate for the diagnosis of
most cases of viral esophagitis; immunohistochemical staining can be of help in selected
cases.
Besides candida, HSV, and CMV esophagitis, other rare causes of infectious diagnoses
should be kept in mind in the presence of esophageal ulceration, such as Epstein–Barr
virus, Leishmania , and tuberculous esophagitis.
3.4 Barrett’s esophagus
ESGE recommends that, in patients with endoscopic evidence of Barrett’s esophagus
of > 1 cm, biopsy samples should be taken from all visible mucosal abnormalities.
In addition, random four-quadrant biopsies should be collected every 2 cm within the
Barrett’s segment, starting from the upper end of the gastric folds. Biopsies from
each level should be collected in and presented to the pathologist in a separate container.
Strong recommendation, high quality of evidence.
For evidence, please refer to the existing ESGE position statement [36 ]. No new evidence is available on this statement.
3.5 Esophageal cancer and early neoplasia
ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal
cancer.
Strong recommendation, moderate quality of evidence.
ESGE recommends taking only one to two targeted biopsies for lesions that are potentially
amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm
the diagnosis and not compromise subsequent endoscopic resection.
Strong recommendation, low quality of evidence.
High definition white-light upper gastrointestinal endoscopy using standard or virtual
chromoendoscopy with biopsy is the recommended diagnostic modality for all suspected
cases of esophageal cancer. Any lesion suspicious for cancer should be sampled and
sent to pathology in a separate container. In cases with potentially malignant esophageal
stenosis, an ultrathin endoscope should be used to complete the esophagogastroduodenoscopy
and obtain tissue samples from inside the stenosis. The sensitivity of endoscopic
forceps biopsies for esophageal cancer ranges from 92 % for a single biopsy to 100 %
for six biopsies [37 ]
[38 ]
[39 ]. There is no role for cytology [40 ].
Early esophageal neoplasia is best staged and treated by endoscopic resection. Furthermore,
extensive biopsy sampling can jeopardize subsequent endoscopic resection by inducing
submucosal fibrosis. Therefore, where there is a suspected neoplastic esophageal lesion
that is potentially amenable to endoscopic resection (Paris type 0-I or 0-II), one
to two endoscopic biopsies, targeted on the most suspicious parts of the lesion, should
be taken to document the presence of dysplasia or neoplasia.
Conversely, where a lesion is not amenable to endoscopic resection (esophageal stenosis,
Paris type ≥ 0-III), at least six endoscopic biopsies should be obtained [41 ]. [Fig. 1 ] illustrates examples of early and advanced esophageal neoplasia.
Fig. 1 Endoscopic images of esophageal neoplasia showing: a, b early Paris type 0-IIb squamous cell cancer from the 4–10 o’clock position on: a white-light endoscopy (WLE); b narrow-band imaging (NBI); c, d early Paris type 0-IIa-IIb adenocarcinoma from the 12–4 o’clock position in a short
segment Barrett’s esophagus on: c WLE; d NBI; e, f advanced esophageal squamous cell cancer on: e WLE; f NBI; g, h advanced distal esophageal adenocarcinoma on: g antegrade view; h retroflexed view.
3.6 Dyspepsia and gastritis
ESGE recommends obtaining two biopsies from the antrum and two from the corpus in
patients with suspected Helicobacter pylori infection and for gastritis staging.
Strong recommendation, low quality of evidence.
ESGE recommends placing biopsies from the antrum and corpus into separate containers.
Strong recommendation, high quality of evidence.
Helicobacter pylori is a potentially curable cause of dyspepsia, peptic ulcer disease, and gastric adenocarcinoma
or mucosa-associated lymphoid tissue (MALT) lymphoma. The management of H. pylori infection was consecutively summarized in the Maastricht/Florence Consensus Report
[42 ]. The indications for endoscopy-based diagnosis vary according to the a priori chance
of malignancy or previous treatments, and are beyond the scope of this guideline.
During such procedures, biopsies should be performed in the antrum and corpus. The
need to assess both compartments is drawn from indirect evidence of the patchy distribution
in the corpus in surgical specimens and that, with age and expansion of pyloric glands,
a distal to proximal gastric spread of H. pylori occurs [43 ]
[44 ]
[45 ]. Moreover, according to the management of precancerous conditions and lesions in
the stomach (MAPS) guidelines, biopsies should be taken with the purpose of staging
atrophy/intestinal metaplasia as this will affect the allocation to different surveillance
strategies [46 ]. Different containers should be used for specimens from the antrum and the corpus.
A single container may be enough according to local expertise, both of the pathologists
and the endoscopists, after proper training and if the endoscopic risk of extensive
intestinal metaplasia is diminutive or during surveillance of individuals with known
atrophic status [47 ]. If staging systems are to be used in patients with atrophy or intestinal metaplasia
(e. g. OLGA, OLGIM), a biopsy in the angle should also be performed as described extensively
in the ESGE MAPS-II guideline.
This evidence refers to the existing ESGE guideline [46 ]. No new evidence is available on this statement.
3.7 Gastric polyps
Gastric polyps are commonly encountered lesions during routine endoscopy. They are
usually asymptomatic and non-neoplastic, and may be found sporadically or in association
with polyposis syndromes. Some gastric polyps may have malignant potential. Gastric
polyps can be mainly distinguished as fundic gland polyps (FGPs), hyperplastic polyps,
and adenomatous polyps and can mostly be classified endoscopically based on their
typical endoscopic appearance ([Fig. 2 ]). Biopsies for classification are therefore superfluous but may be considered if
in doubt and if the outcome has clinical relevance. For an endoscopically resectable
polyp with the need for a histologic diagnosis, resection is preferred over biopsies,
because biopsies may underestimate the neoplastic progression risk owing to sampling
error.
Fig. 2 Endoscopic images of the various types of gastric polyps: a fundic gland polyp; b hyperplastic polyp; c gastric adenoma (source for Fig. 2c: Dr. S. Mühldorfer).
3.7.1 Fundic gland polyps
ESGE does not recommend standard biopsies of fundic gland polyps.
Strong recommendation, low quality of evidence.
FGPs are the most frequently encountered gastric polyps. They are usually found in
patients with chronic PPI use or in association with polyposis syndromes. A diagnosis
of FGPs is often made based on the endoscopic appearance. FGPs are usually present
in the fundus and gastric body. They are characterized by their small size (< 10 mm)
and luminous, glossy appearance ([Fig. 2a ]).
Neoplastic features are rarely found in FGPs, with the exception of FGPs on the background
of a polyposis syndrome. Case series of FGPs reveal low grade dysplasia (LGD) in < 1 %
of FPGs [48 ]
[49 ]. There have been limited case reports published on the occurrence of high grade
dysplasia (HGD) and gastric carcinoma in FGPs [50 ]
[51 ]
[52 ]. Large (> 10 mm) FGPs seem to have a slightly higher risk for the presence of dysplasia
or focal cancer compared with small (< 10 mm) FGPs [53 ]. The risk of malignant progression of sporadic or PPI-associated FGPs is very low.
In cases where FGPs have atypical features, size of > 1 cm, antral location, ulceration,
or unusual appearance, biopsies of the FGP can be considered.
3.7.2 Hyperplastic polyps
ESGE recommends taking biopsies from (or resection of) hyperplastic polyps of > 10 mm.
Strong recommendation, low quality of evidence.
Gastric hyperplastic (hyperplasiogenic) polyps are a result of chronic inflammation
of the gastric mucosa, mainly due to H. pylori infection or autoimmune gastritis. They appear as solitary, sessile or pedunculated
lesions with an eroded surface and are mainly located in the antrum ([Fig. 2b ]). Multiple hyperplastic polyps can also be present, usually in association with
a hereditary disorder [54 ].
In the literature, large variations in neoplastic progression rates of gastric hyperplastic
polyps are documented. Focal carcinoma can be present in 0 %–8 % of hyperplastic polyps
[55 ]
[56 ]
[57 ]
[58 ]
[59 ]. The presence of a hyperplastic polyp appears to be associated with an increased
risk, up to 8.5 %, of gastric cancer development in the surrounding gastric mucosa
[53 ]
[60 ].
Large (> 10 mm) hyperplastic polyps are more at risk of harboring dysplastic foci
compared with small (< 10 mm) hyperplastic polyps [59 ]
[61 ]. Recurrence rates after the resection of large hyperplastic polyps are high, up
to 55 % has been described [61 ]
[62 ].
3.7.3 Adenomas
ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric
adenomas.
Strong recommendation, moderate quality of evidence.
Gastric adenomas can be found sporadically or in association with familial polyposis
syndrome. They appear as solitary, delineated lesions that are often eroded ([Fig. 2c ]). Adenomas can be distinguished as tubular, villous, or tubulovillous adenomas.
Histologically, their differentiation can be intestinal or gastric. Gastric differentiation
includes pyloric gland adenomas, rare foveolar adenomas, and even more rare oxyntic
gland adenomas. They may occur anywhere in the stomach, although they are frequently
encountered in the antrum.
Adenomas are associated with atrophic gastritis and gastric cancer development in
the surrounding gastric mucosa [63 ]
[64 ]
[65 ]. According to the literature, foci of carcinoma are present in up to 38 % of adenomas
[65 ]
[66 ]
[67 ]. Gastric adenomas are precancerous lesions with a risk of neoplastic progression.
3.8 Gastric cancer
ESGE recommends at least six biopsies in cases of suspected advanced gastric cancer.
Strong recommendation, moderate quality of evidence.
ESGE recommends taking only one to two targeted biopsies for lesions that are potentially
amenable to endoscopic resection (Paris classification 0-II) to confirm the diagnosis
and allow subsequent endoscopic resection.
Strong recommendation, low quality of evidence.
High definition upper gastrointestinal endoscopy with biopsy is the recommended diagnostic
modality for all suspected cases of gastric neoplasia. Any lesion suspicious of neoplasia
should be sampled and sent to pathology in a separate container.
Early gastric neoplasia is best staged and treated by endoscopic resection. Furthermore,
extensive biopsy sampling can jeopardize subsequent endoscopic resection by inducing
scarring and submucosal fibrosis. Therefore, for suspected neoplastic gastric lesions
that are potentially amenable to endoscopic resection, the number of endoscopic biopsies
should be limited. One large retrospective study showed that two endoscopic biopsies
yielded a 92.5 % diagnostic accuracy for early gastric neoplasia [68 ]. Therefore, two biopsies targeted on the most suspicious parts of the lesion should
be taken to document the presence of dysplasia or neoplasia. Conversely, for lesions
not amenable to endoscopic resection (Paris classification 0-I or 0-III, ulcerated
lesions > 3 cm) where surgery or oncologic treatments will be requested, although
three endoscopic biopsies will yield a 98.3 % sensitivity, at least six endoscopic
biopsies should be obtained, in order to assess the expression of potential biomarkers,
such as Her2neu [41 ]
[69 ]. [Fig. 3 ] illustrates examples of early and advanced gastric neoplasia.
Fig. 3 Endoscopic images of gastric neoplasia showing: a, b early Paris type 0-IIb mucosal gastric cancer on: a white-light endoscopy (WLE); b narrow-band imaging (NBI); c, d early Paris type 0-IIa submucosal gastric cancer on: c WLE; d near focus with NBI; e advanced ulcerative gastric cancer (Borrmann type III); f linitis plastica (Borrmann type IV).
ESGE suggests obtaining at least 10 bite-on-bite biopsies in cases of suspected gastric
linitis plastica, targeting mucosal abnormalities.
Weak recommendation, low quality of evidence.
ESGE suggests that, where there are negative biopsies and a persisting suspicion of
gastric linitis plastica, endoscopy with more extensive biopsies can be repeated.
Endoscopic ultrasound (EUS) may be used to target biopsies or fine-needle aspiration/biopsy
(FNA/B) of the most affected part of the stomach.
Weak recommendation, low quality of evidence.
Obtaining a histologic diagnosis of gastric linitis plastica (diffuse gastric cancer)
can be challenging because tumor cells are diffusely spread in the gastric submucosa
and stroma, and the mucosa is often normal. Where there is a radiologic or endoscopic
suspicion of linitis plastica (presence of large folds, gastric stenosis, circumferential
thickening of at least one segment, lack of stomach distensibility, or thickening
of the third hyperechogenic layer on endoscopic ultrasound [EUS]) [70 ], it is advisable to obtain at least 10 bite-on-bite biopsies of the areas that appear
most abnormal [71 ]
[72 ]. If biopsies are negative, these can be repeated to obtain more tissue. As for CDH1 patients, the Cambridge protocol could be used [71 ]
[72 ].
In addition, EUS can be used to identify the most affected area of the stomach and
to guide target biopsies or fine-needle aspiration/biopsy (FNA/B). FNA of the gastric
wall or suspicious lymph nodes has been reported to be helpful in some cases, although
data are scarce [73 ]
[74 ]
[75 ]. Other possibilities for obtaining tissue samples from the submucosa, such as submucosal
tunneling or prior endoscopic resection of overlying normal mucosa, have been described
but evidence on the efficacy and safety of these techniques is very limited [76 ].
3.9 Celiac disease
ESGE recommends at least six biopsies from different locations in the duodenum, including
two samples from the duodenal bulb, in patients with a suspicion of celiac disease.
Biopsies can be collected in the same container.
Strong recommendation, high quality of evidence.
Celiac disease is characterized by typical histologic changes. Mucosal changes appear
mostly in the proximal part of the small intestine and may be patchy. Therefore, mucosal
changes may be missed if insufficient biopsies are obtained. Studies have demonstrated
that in patients with ultrashort celiac disease, pathology may be confined to the
duodenal bulb [77 ]. Including biopsies from the bulb increases the diagnostic yield of endoscopic biopsies
for the diagnosis of celiac disease. ESGE adheres to the advice from the World Gastroenterology
Organisation and American College of Gastroenterology, namely to obtain at least six
biopsies from different sites in the small bowel, including two biopsies from the
duodenal bulb, in patients with a suspicion of celiac disease based on endoscopy or
serology [78 ]
[79 ]
[80 ]
[81 ]
[82 ]
[83 ].
This represents agreement between merged guidelines [78 ]
[79 ]. No new evidence is available on this statement.
4 Hepatopancreatobiliary tract
4.1 Liver
Tissue sampling is often required for solid liver lesions or parenchymal liver disease.
For both indications, the method of choice is a percutaneous approach, which has been
well established and provides core samples for histologic diagnosis. EUS-guided biopsy
may be considered in specific situations, such as anatomical issues, failure of percutaneous
biopsy, or concomitant indications for EUS. For example, EUS-guided liver biopsy has
recently been increasingly used for patients in whom diagnostic EUS is being performed
to exclude extrahepatic biliary obstruction [84 ], evaluate esophageal varices, or perform portal pressure gradient measurement.
4.1.1 Liver tumors
ESGE suggests performing EUS-guided sampling of solid liver masses suspicious for
malignancy, if the pathologic result will affect patient management and (i) the lesion
is poorly accessible/not detected at percutaneous imaging, or (ii) a sample obtained
via the percutaneous route has repeatedly yielded an inconclusive result.
Weak recommendation, low quality of evidence.
For solid liver masses that are suspicious for malignancy or metastases, histologic
tissue sampling can be necessary to decide on further patient management. Generally,
tissue sampling of these lesions is performed percutaneously. However, recently, there
have been reports on the use of EUS-FNA to sample solid liver masses suspicious for
malignancy, with high specimen adequacy and diagnostic accuracy [85 ]. Although this indication for EUS-FNA is relatively new and not yet clearly defined,
one may consider it in cases where lesions are poorly accessible or not detected by
percutaneous imaging, or if percutaneous sampling has repeatedly yielded an inconclusive
result.
4.1.2 Parenchymal liver disease
ESGE suggests, where EUS-guided sampling is indicated, the use of larger caliber needles
(19G FNA or FNB needles) in cases of suspected parenchymal liver disease.
Weak recommendation, low quality evidence.
EUS-guided liver biopsy has been increasingly used, especially in patients in whom
diagnostic EUS is being performed to exclude extrahepatic biliary obstruction. Newer
indications may include patients with unknown liver disease undergoing endoscopic
evaluation of esophageal varices or portal pressure gradient measurement. Generally,
liver biopsy requires histologic evaluation of a specimen of a minimum size and number
of portal tracts, making proper needle selection important. A number of studies have
evaluated and compared the use of differently sized FNA needles and FNB. Samples adequate
for histopathologic evaluation were acquired more often with 19 G FNA needles or FNB,
compared with smaller sized needles. Factors such as the technique of biopsy may contribute
to the tissue yield rather than the needle itself [86 ]
[87 ]
[88 ]
[89 ]
[90 ]
[91 ]
[92 ]
[93 ]
[94 ]
[95 ]
[96 ].
4.2 Pancreatic solid masses
ESGE recommends FNA and FNB needles equally for sampling of solid pancreatic masses.
Strong recommendation, high quality evidence.
ESGE suggests using newer generation FNB needles (with forward-facing bevels, fork
tip, or crown tip) when the aim is to obtain core tissue (e. g. neuroendocrine neoplasia,
need for tumor genotype profiling) and when rapid onsite evaluation (ROSE) is not
available.
Weak recommendation, moderate quality evidence.
Since the 2017 ESGE guideline on EUS-guided sampling [97 ], a number of randomized trials and six meta-analyses comparing FNA and FNB sampling
in pancreatic masses have been published. These publications support the recommendation
from 2017 that FNA and FNB are recommended equally for the sampling of pancreatic
masses [98 ]
[99 ]
[100 ]
[101 ]
[102 ]
[103 ]
[104 ]
[105 ]
[106 ]
[107 ]
[108 ]
[109 ]
[110 ]
[111 ]
[112 ]
[113 ]
[114 ]. Overall, the diagnostic yield does not differ between FNA and FNB needles [110 ]
[113 ], but some studies indicate that the sample adequacy for histologic evaluation is
higher when using FNB compared with FNA needles [99 ]
[100 ]
[111 ]
[112 ]. There is some evidence suggesting that the use of FNB results in more tissue and
higher diagnostic accuracy with fewer needle passes than FNA [98 ]
[99 ]
[100 ]
[101 ]
[104 ]
[105 ]
[106 ]
[109 ]
[111 ]
[114 ], which may be relevant in cases where core tissue is required for diagnosis or genetic
profiling, or when rapid onsite evaluation (ROSE) is not available. The handling of
specimens is addressed below. Technical aspects of EUS-guided tissue sampling are
described in the 2017 ESGE clinical guideline [97 ].
4.3 Bile ducts
The majority of biliary strictures are malignant (70 %–80 %), with a limited number
of causes (i. e. cholangiocarcinoma, pancreatic cancer, gall bladder carcinoma, metastatic
disease, or lymphoma). A benign etiology may also be found in 20 %–30 %, with a much
broader differential diagnosis (e. g. IgG4 disease, primary sclerosing cholangitis,
infection, post-trauma or post-surgery, and vasculitis, among others) [115 ]. Early diagnosis of biliary strictures is important for achieving optimal patient
outcomes and avoiding unnecessary surgical procedures. The etiology of most biliary
strictures can be diagnosed after a basic work-up including transabdominal imaging,
endoscopic retrograde cholangiopancreatography (ERCP) with standard transpapillary
tissue sampling, or EUS-FNA/B in cases of suspected pancreatic malignancy. Those cases
in which this basic work-up is non-diagnostic are referred to as indeterminate biliary
strictures.
4.3.1 Indeterminate biliary strictures
ESGE suggests performing peroral cholangioscopy (POC) and/or EUS-guided tissue acquisition
in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is
preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred,
with POC where this is not diagnostic.
Weak recommendation, low quality evidence.
ESGE suggests that performing POC with visually guided biopsies provides the highest
chance of confirming malignancy.
Weak recommendation, moderate quality evidence.
Studies have demonstrated a high sensitivity (75 %–94 %) and diagnostic accuracy (79 %–94 %)
for EUS-guided sampling in indeterminate strictures, which is much higher than the
sensitivity (49 %–60 %) and diagnostic accuracy (60 %–61 %) for ERCP-guided brush
cytology [116 ]
[117 ]
[118 ].
For peroral cholangioscopy (POC), meta-analyses have reported a sensitivity of 72 %–94 %
and a specificity of 87 %–99 % for cholangioscopy-guided biopsies in indeterminate
strictures [119 ]
[120 ]
[121 ]
[122 ]
[123 ]. The sensitivity and accuracy of POC were proved to be higher than those of ERCP
in indeterminate strictures in a randomized study [124 ]. It suggested that POC may be preferable for proximal and intrinsic strictures,
whereas EUS-guided tissue sampling may be preferable for distal and extrinsic strictures
[124 ]
[125 ].
5 Miscellaneous
5.1 Biopsy handling, technical aspects
ESGE suggests that mucosal biopsy specimens are released into labelled containers
containing adequate amounts of tissue fixation fluid (10 % buffered formalin).
Weak recommendation, low quality of evidence.
ESGE recommends obtaining biopsies for microbial testing or fresh biopsy material
first, before the biopsy forceps has come into contact with any tissue fixation fluid.
Strong recommendation, low quality of evidence.
ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected
malignant lesions to prevent intraluminal spread of malignant disease.
Weak recommendation, low quality of evidence.
Proper biopsy handling is of paramount importance in maximizing clinical return and
maintaining endoscopy quality standards. Mucosal biopsy specimens should be gently
released into labelled biopsy containers containing adequate amounts of tissue fixation
fluid. Fixation stops cellular autolysis and prepares tissues for embedding and sectioning.
Although a range of fixatives are available for specific downstream purposes (for
example glutaraldehyde for electron microscopy studies in cases of pediatric failure
to thrive), in general 10 % buffered formalin is the fixative of choice for mucosal
biopsies. This is compatible with point-of-care molecular (panel) sequencing tests
and the global standard for antigen retrieval in immunohistochemical studies. Comparative
studies examining other fixatives in standard endoscopy practice are not available.
If tissue material for microbial testing is required, this should be secured first.
If fresh biopsy material is required, for example for molecular testing or enzymatic
studies, this should not be obtained with biopsy forceps that have come into contact
with any tissue fixation fluid. Studies have suggested that, in some cases, biopsy
instrumentation may facilitate intraluminal spread of malignant disease, indicating
that, where possible, non-neoplastic biopsies should be secured before any suspected
malignant lesions are sampled.
Direct communication with histopathology staff is encouraged to improve quality standards
and ensure that specimens are handled in line with institutional practices. For example,
work-up of endoluminal resection specimens and essential pathology requisition details
are best discussed within the context of multidisciplinary team meetings and benefit
greatly from alignment between endoscopy and histopathology staff [126 ]
[127 ].
5.2 Type of biopsy forceps
ESGE suggests the use of a standard cold biopsy forceps, because there is too little
benefit in terms of histopathologic outcome to recommend the use of a jumbo biopsy
forceps.
Weak recommendation, moderate quality of evidence.
Various studies have examined the impact of biopsy forceps design on tissue adequacy
in a pathologist-blinded fashion. Different types of biopsy forceps are available,
with serrated jaws, oval beaks, different jaw sizes, and with a spike to be able to
contain two biopsies within the cups of the forceps. Jumbo biopsy forceps sample about
three times the surface area compared with standard cold biopsy forceps, but importantly
do not consistently provide deeper specimens. Despite variations in the designs of
different biopsy forceps and their claimed benefits, studies agree that there are
no reproducible differences in tissue adequacy or clinically relevant histopathologic
outcome [128 ]
[129 ]
[130 ]
[131 ].
5.3 Preparation of EUS-FNA material
ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based
cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending
on local experience.
Weak recommendation, low quality evidence.
Adequate preparation of FNA samples and dedicated training of cytotechnologists and
pathologists are the prerequisites for achieving optimal results. Cytologic tissue
can be evaluated using smears or liquid‑based cytology (LBC), or both. LBC material
can be further processed as thin preparations and/or cell blocks.
Depending on the practical experience of the involved pathology personnel, EUS‑FNA
material could be divided into smears (two per pass) and a cell block for additional
evaluation. Alternatively, the whole of the EUS-FNA material can be processed as LBC,
with a thin preparation as the first step and a cell block as the second step ([Fig. 4 ]) [132 ]
[133 ]
[134 ]
[135 ]
[136 ]
[137 ]
[138 ].
Fig. 4 Diagram of the preparation of tissue specimens obtained by endoscopic ultrasound-guided
fine-needle aspiration (EUS-FNA) into smears and a cell block, or alternatively into
liquid-based cytology with a thin preparation as the first step and a cell block as
the second step.
