S5218 Unmasking a Hidden Risk: Delayed Gastric Bleeding Post-EUS Liver Biopsy in a Cirrhotic Kidney Transplant Candidate

Introduction: Liver biopsy is essential for diagnosing many liver diseases. Endoscopic ultrasound liver biopsy (EUS-LB) has emerged as a minimally invasive alternative to the traditional percutaneous or transjugular liver biopsy technique. EUS-LB facilitates access to both the lobes of the liver and allows measurement of portal pressure. Most complications include abdominal pain, subcapsular hematoma, acute pancreatitis, infectious complications, and bile leak. Overall bleeding rates range from 0.13% to 0.9%, with most cases involving mild, self-limited bleeding that rarely requires intervention. Case Description: We present the case of a 37-year-old man with end-stage renal disease secondary to hypertension, who is on hemodialysis. He underwent EUS-guided liver biopsy with fine needle aspiration using a 19-gauge Acquire needle. As part of the kidney transplant eligibility evaluation, samples were obtained from the right and left hepatic lobes by passing through the stomach and duodenal bulb. Patient was discharged stable without complications after procedure. However, 3 days later, he presented to the emergency department with melena, hematemesis, and a hemoglobin level of 5 g/dL. He also reported missing 2 hemodialysis sessions. Two units of packed red blood cells were transfused, and urgent hemodialysis was performed. An emergent esophagogastroduodenoscopy revealed 2 discrete puncture sites with active bleeding, which was unmasked by water irrigation, consistent with previous biopsy sites. Endoclips and PuraStat application achieved hemostasis. Histopathology confirmed hepatocellular cirrhosis. Discussion: EUS-FNB has a relatively low complication rate of 0.03% to 0.15%, with bleeding representing approximately 1.2% of all complications. A near-fatal case of hemorrhagic shock following EUS-FNB was reported in Quebec, Canada. Advanced kidney disease with consequent platelet dysfunction may be a risk factor for such bleeding. This case highlights the importance of remaining vigilant to the potential of delayed gastrointestinal bleeding secondary to platelet impairment in the setting of azotemia.