Techniques and application of EUS guided procedures in the pancreas and liver

Endoscopic ultrasound (EUS) has evolved from a diagnostic imaging modality into a therapeutic platform for hepatopancreatobiliary disease, allowing high-resolution assessment and targeted intervention during the same session. In hepatology, EUS-guided liver biopsy offers real-time vascular avoidance, bilobar sampling and high diagnostic adequacy, with a favourable safety profile and reduced post-procedural recovery compared with percutaneous approaches. EUS-guided portal pressure gradient measurement enables direct portal and hepatic venous manometry and may identify pre-sinusoidal portal hypertension that can be underestimated by hepatic venous pressure gradient assessment. EUS-guided vascular therapy, particularly combined coil embolisation and cyanoacrylate injection, permits Doppler-guided targeting of gastric variceal inflow vessels and is associated with high obliteration rates and reduced rebleeding compared with conventional glue injection in selected patients. In pancreatic disease, EUS-guided pancreatic duct drainage provides a minimally invasive salvage option when standard endoscopic retrograde pancreatography fails, using rendezvous or transmural techniques to restore ductal drainage, although adverse events and technical complexity remain important limitations. EUS-guided ablation, most commonly radiofrequency ablation or ethanol-based therapy, is increasingly used for selected pancreatic neuroendocrine tumours, cystic neoplasms and unresectable malignancy, offering symptom control or lesion regression in patients unsuitable for surgery. This review summarises established and emerging EUS-guided interventions in the liver and pancreas, focusing on procedural techniques, clinical outcomes, safety considerations and practical relevance for advanced hepato-pancreato-biliary (HPB) endoscopy services.