AASLD EXPO: Liver biopsy

Background: Liver biopsy is a foundational tool in hepatology, providing direct histologic assessment of hepatic parenchyma. Although noninvasive approaches have substantially reduced the need for biopsy in practice, it continues to play a critical role in diagnosis, staging, and therapeutic decision-making across a broad spectrum of liver disorders. Methods: This Expert Practice Opinion (EXPO) document was created by a writing group of subject matter experts appointed by the AASLD Practice Guidelines Committee. Writing group members performed a targeted literature review and created expert opinion statements that were unanimously agreed upon. Results: Histopathologic evaluation of the liver is utilized for 3 major indications: (1) to establish a diagnosis, (2) to stage the severity of inflammation and/or fibrosis, and (3) to enhance clinical management of liver disease. Liver biopsy can be performed using a percutaneous, transjugular, or endoscopic ultrasound approach. Percutaneous liver biopsy is used in most patients, though transjugular liver biopsy is often performed in those with ascites or coagulopathy and/or when hepatic venous pressure gradient measurement is desired. Endoscopic ultrasound–guided liver biopsy is particularly attractive when endoscopy to evaluate and treat varices or portal pressure gradient measurement is desired. The different biopsy techniques appear to have similar safety profiles and yield adequate tissue when performed by experts. Liver biopsy has limitations, including sampling variability, interobserver differences in interpretation, and procedural complications. Conclusions: Liver biopsy continues to play an essential role in contemporary hepatology practice. Recent advances include the introduction of endoscopic ultrasound liver biopsy. Evolving applications—including the potential for molecular profiling, use of digital pathology, and assessment of therapeutic response—underscore the continued relevance of tissue-based evaluation in precision hepatology.