Should Interventional Radiology (IR) or Gastroenterology (GI) perform a biopsy?

Who Should Perform Biopsies: Interventional Radiology (IR) or Gastroenterology (GI)?

Interventional Radiology (IR) should perform most biopsies, particularly for liver and focal GI tract lesions, as they have the expertise and equipment for image-guided procedures that optimize safety and diagnostic yield.

Evidence-Based Rationale

Current Practice Patterns

• According to the British Society of Gastroenterology guidelines, liver biopsies are predominantly performed by radiologists (76% consultant radiologists, 19% trainee radiologists) compared to only 4% by gastroenterologists 1
• Image-guided biopsies have become the standard of care, replacing "blind" biopsies due to improved safety profiles and diagnostic accuracy

Specific Biopsy Types and Recommended Performers

Liver Biopsies

• Percutaneous liver biopsies should be performed by radiologists using ultrasound guidance to minimize complications 1
• For high-risk patients (obesity, coagulopathy, ascites), transjugular liver biopsy performed by IR is recommended 1
• Ultrasound-guided percutaneous liver biopsy performed by experienced pediatric interventional radiologists is as safe and effective as biopsy performed by pediatric gastroenterologists 2

GI Tract Lesions

• For gastric tumors, fine needle aspirate or core needle biopsy under endoscopic ultrasound (EUS) guidance is most common 1
• CT or ultrasound-guided biopsy may be considered for very large (>10 cm) tumors 1
• Percutaneous biopsy of GI tract lesions performed by IR is a safe and sensitive procedure (84% accuracy) that should be considered for:
  • Small bowel lesions where endoscopy is not feasible
  • Submucosal lesions
  • Patients with previously negative endoscopic biopsies 3

Gastrointestinal Stromal Tumors (GISTs)

• For suspected GISTs, EUS-guided biopsy is preferable to minimize peritoneal contamination
• However, transcutaneous biopsy by IR appears safe when targeting solid components of tumors 1

Decision Algorithm for Biopsy Route Selection

1. For Upper GI Tract Lesions:

   • If accessible by endoscope → GI performs EUS-guided biopsy
   • If large (>10cm) or not accessible by endoscope → IR performs CT/US-guided biopsy

2. For Liver Lesions:

   • Standard approach: IR performs US-guided percutaneous biopsy
   • High-risk patients: IR performs transjugular liver biopsy

3. For Small Bowel Lesions:

   • If accessible by enteroscopy → GI performs biopsy
   • If not accessible by endoscopy → IR performs percutaneous biopsy

4. For Suspected GIST:

   • First choice: EUS-guided biopsy by GI
   • If not feasible: Image-guided percutaneous biopsy by IR

Clinical Considerations and Caveats

• Pre-operative diagnosis is preferable even in easily resectable tumors to exclude differential diagnoses that may require different treatment strategies 1
• For cystic masses, EUS biopsy is preferable to minimize peritoneal contamination, but transcutaneous biopsy by IR is safe when targeting solid components 1
• In patients with metastatic disease, biopsy of an easily accessible metastatic focus should be performed rather than the primary tumor 1

Multidisciplinary Approach

While IR performs most biopsies, the ideal approach is collaborative rather than competitive:

• Complex cases benefit from discussion between IR and GI specialists to determine the optimal approach 4
• The future of digestive intervention will continue to move toward therapeutic modalities requiring gastroenterologists to become "micro-surgeons of the gastrointestinal tract working in multispecialty teams along with their colleagues: surgeons and radiologists" 5

By following this evidence-based approach, patient safety and diagnostic accuracy can be optimized while utilizing the specific expertise of each specialty.