Endohepatology integrates advanced endoscopic techniques with hepatology to enhance diagnosis and management of liver-related diseases, notably through EUS and ERCP. This review summarizes recent advances across the diagnostic and therapeutic applications of endohepatology, including parenchymal assessment, liver biopsy, portal pressure gradient measurement, and management of the complications of portal hypertension. EUS enables detailed visualization of the hepatic parenchyma, lesions, vasculature, and ascites, and facilitates tissue sampling with EUS-guided liver biopsy (EUS-LBx). Recent advancements, such as shear wave elastography (EUS-SWE), outperform transabdominal methods, particularly in obese patients, with comparable or superior fibrosis detection. EUS also allows for portal pressure gradient assessment (EUS-PPG), showing high correlation with hepatic venous pressure gradient (HVPG), aiding in portal hypertension evaluation. Management approaches focus on gastric varices, where EUS-guided coil and glue injections have demonstrated reduced rebleeding rates and enhanced safety over traditional techniques. Additionally, EUS assists in ascites sampling, differentiation of malignancy, and minimally invasive embolization of spontaneous portosystemic shunts, improving treatment outcomes. The future of endohepatology includes EUS-guided TIPS placement, portal venous sampling for tumor markers, and hepatic malignancy ablation, promising further minimally invasive options. These innovations facilitate comprehensive care, potentially improving patient outcomes through precise diagnosis, monitoring, and targeted therapy. Ongoing research aims to standardize techniques, validate efficacy, and expand applications, positioning endohepatology as a pivotal component in hepatology practice.
Alcohol-related liver disease (ALD) is increasingly recognised as a dynamic condition in which removal of the causal driver may permit hepatic recompensation. This review examines recompensation in ALD and MetALD, focusing on alcohol use disorder (AUD) treatment, phosphatidylethanol (PEth)-based abstinence monitoring, and cardiometabolic risk modification. Using Baveno VII criteria, multicentre studies report recompensation in approximately one-quarter to one-third of patients with decompensated ALD following sustained abstinence, with improved transplant-free survival. Early abstinence preserved hepatic reserve, and the absence of further decompensation predicts recovery. In MetALD and MASLD, weight loss and glycaemic control provide additional benefit, while PEth improves assessment of alcohol exposure and outcomes. Recompensation requires integrated addiction care, objective alcohol monitoring, cardiometabolic optimisation, and continued surveillance for portal hypertension and hepatocellular carcinoma. It represents substantial prognostic improvement but not a cure.
Primary biliary cholangitis (PBC) is a progressive liver disease affecting the small intrahepatic bile ducts, specifically the interlobular and septal bile ducts, associated with an elevated alkaline phosphatase and positive anti-mitochondrial antibody on laboratory testing, which can lead to cirrhosis and the need for liver transplant. The goal of this review paper is to critically evaluate the current treatment algorithms for primary biliary cholangitis and propose future modifications. The first-line treatment option for PBC is ursodeoxycholic acid. FDA-approved second-line therapies are elafibranor and seladelpar. Off-label use of fenofibrate can also be considered. Traditionally, second-line therapies have been added after 12 months of treatment with ursodeoxycholic acid if the alkaline phosphatase and bilirubin levels are above desired goals. Evolving algorithms should consider earlier addition of second-line therapies at 6 months, especially in younger patients with increased liver stiffness, a goal of normalization of the alkaline phosphatase, and assessment of fatigue and pruritus in the decision about treatment options.
This review highlights the global prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD), assesses comparability of the former definition of non-alcoholic fatty liver disease (NAFLD)-era estimates with the 2023 steatotic liver disease (SLD) framework, and identifies emerging regional hotspots. High concordance between NAFLD-era definitions and SLD subclassification supports continuity of established cohorts for trend analyses. Globally, imaging-based steatosis prevalence was 38
This narrative review summarizes recent evidence supporting sarcopenia as a modifiable therapeutic target rather than merely a prognostic marker in hepatocellular carcinoma (HCC). Sarcopenia is one of the most consistent predictors of adverse outcomes across treatment modalities, including resection, locoregional therapy, systemic therapy, and transplantation. Muscle loss in HCC stems from converging mechanisms such as cirrhosis-related hyperammonemia, tumor-associated cachexia, and immune dysfunction linked to myokine depletion. The rise of MASLD-associated HCC has increased the prevalence of myosteatosis and the sarcopenic obesity phenotype. Sarcopenia can be assessed with imaging or bedside markers such as phase angle. After detection, nutritional therapy including branched-chain amino acids, resistance exercise, and selected pharmacological interventions can preserve muscle mass and functional reserve, ideally incorporated into a prehabilitation program. Incorporating sarcopenia assessment into routine care and pairing nutritional therapy and exercise with all HCC treatment modalities, including transplantation, may improve outcomes.
