Approach to management of bleeding during EUS-guided liver biopsy: salvage therapy using absorbable gelatin sponge.

Background and Aims: EUS-guided liver biopsy (EUS-LB) has emerged as a reliable alternative to interventional radiology-guided biopsy, offering comparable specimen adequacy. Bleeding remains the most common adverse event. We describe a novel use of absorbable gelatin sponge slurry for hemostasis during EUS-LB and propose a stepwise management approach. Methods: Liver biopsy was performed using a dynamic suction technique with a 19-gauge fine-needle biopsy needle. After biopsy, e-Flow Doppler was used to evaluate for bleeding. Since Doppler flow persisted, initial management included leaving the needle in place for 4 minutes and performing a blood patch technique. For bleeding extending beyond the liver capsule, a gelatin sponge slurry was prepared by macerating absorbable gelatin pledgets into a thick gel using the Tessari technique. The slurry was injected into the bleeding tract while withdrawing the needle under EUS guidance. Results: Application of this stepwise approach during EUS-LB successfully achieved hemostasis without the need for surgical or radiologic intervention. The gelatin sponge slurry effectively sealed the bleeding tract, with no significant postprocedural hematoma or ongoing hemorrhage observed. Conclusions: The use of an absorbable gelatin sponge slurry represents a promising salvage technique for managing bleeding during EUS-LB when conventional methods fail.