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Kim-Romo received funding to conduct this study from the PhRMA Foundation Pre-Doctoral Fellowship in Health Outcomes. Rascati, Richards, Ford, Wilson, and Beretvas declare no conflict of interest in relation to this manuscript. Kim-Romo and Rascati collaborated on the study design, data analysis, study interpretation, and writing of this manuscript. Richards, Ford, Wilson, and Beretvas provided critical evaluation of the study design, analysis, and interpretation, as well as edited this manuscript.

Introduction: Endoscopic ultrasoundguided liver biopsy (EUS-LB) is a well-established technique for liver biopsy in adult patients due to direct visualization and real-time guidance, feasibility in obese patients, patient tolerance and comfort, and decreased recovery time. The applicability in pediatric patients is still underreported. Methods: This is a single center retrospective review to assess the safety and utility of EUS-LB in the evaluation of pediatric NAFLD at Community Regional Medical Center in California's Central Valley. An analysis of the biopsy sample including quality, features, and interpretability was performed. To fully critique the utility of EUS-LB in assessing liver steatosis and fibrosis, we compared other forms of hepatic assessment including laboratory values and imaging. Results: A total of 15 pediatric patients (7 female) ages ranging from 7 -18 years old (median age 16 years) were included in the review. Twelve patients underwent only transgastric fine needle biopsy (FNB), with an average of 1.92 (range 1-3) passes. Two patients only underwent transduodenal FNB passes with an average of 1.33 (range 1-2) passes. One patient underwent both transgastric and transduodenal FNB passes. The shortest specimen length was 0.7 cm and the longest was 2 cm in length with a median of 1.3 cm. All biopsies performed were technically successful. All biopsy specimen was adequate for histopathologic evaluation and diagnostic yield was 100%. By diagnostic criteria for NAFLD, 86.67% (46.15% female, 92% Hispanic) were diagnosed with NAFLD and of those, 61.54% of patients found to have NASH. No major or minor post-procedural complications were identified or reported. Conclusion: Noninvasive investigation such as labs and imaging may be useful for screening and identifying patients with likely diagnosis of NAFLD, however noninvasive methods have limitations. Accurate staging, histologic review, and prognostication for NAFLD are best characterized by liver biopsy. EUS-LB is a efficacious and safe procedure that should be considered to be the primary method when pursuing liver biopsy in pediatric patients. We recognize limitations of the study, including small sample size and largely homogenous patient population.

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