Endoscopic ultrasound in hepatology: A European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

Endoscopic ultrasound (EUS)-guided techniques are increasingly applied in hepatology, including for tissue acquisition, vascular access, pressure measurement, and selected therapeutic interventions. However, adoption remains heterogeneous because of variability in technical approaches, devices, outcome definitions, operator expertise, and the quality of available evidence. This European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review summarizes the current evidence on selected EUS-guided techniques in liver disease and portal hypertension, including liver stiffness assessment, focal liver lesion characterization and sampling, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, therapy for gastric varices, and portal vein sampling for liquid biopsy applications. Evidence was identified through a structured literature search up to April 2026, and recommendation statements were graded using the GRADE framework. Eight ESGE statements were developed. The available evidence supports selected use of EUS-guided shear wave elastography and contrast-enhanced EUS as adjunctive techniques; EUS-guided liver biopsy and EUS-guided portal pressure gradient measurement as complementary approaches in selected patients and expert centers; and EUS-guided treatment of gastric varices as a valid alternative to direct endoscopic injection where appropriate expertise is available. Portal vein sampling remains investigational. Across the indications, the evidence base is limited by small studies, heterogeneous techniques, variable outcome definitions, and limited prospective comparative data. This review provides an evidence-based framework for the selective use of EUS-guided techniques in hepatology and portal hypertension. Wider adoption will require standardized techniques, structured training, consistent outcome definitions, and prospective comparative studies.