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Background Despite its preference for EUS-guided liver biopsy (EUS-LB), the 19G Franseen-tip core biopsy needle (FNB) faces limitations due to its higher needle cost and post-procedure complications. This study aimed to compare the diagnostic accuracy of a 19G FNB needle to 19G aspiration needle (FNA) for EUS-LB.Methods In this prospective, double-blinded, randomized controlled trial, consecutive patients with suspected liver parenchymal disease were randomized to undergo EUS-LB using either 19G FNA or FNB needle. The primary outcome was specimen adequacy, defined as total specimen length (TSL) > 15 mm and complete portal tracts (CPT) > 6. Secondary outcomes were the number of CPTs, pre- and post-processing TSL, and adverse events.Results Between April 2024 and October 2025, 74 patients (mean age: 34 years (SD); 59.45% males) were randomized to the 19G FNA (n=37) or FNB (n=37) needle arm. Baseline characteristics were similar in both groups. Specimen adequacy was comparable with both FNA and FNB needles [97.29% vs 91.89%, p=0.61]. Both needles were similar in terms of pre-processing TSL [3.8 (2.6-5.0) vs 4.0 (2.6-7.4), p = 0.17], post-processing TSL [3.4 cm (2.4-4.6) vs 3.5 cm (2.3-7.2), p = 0.17], and number of CPTs [16 (12-25) vs 13 (11-24), p = 0.47]. There was a trend towards higher post-procedural pain in the FNB arm (21.6% vs 10.8%, p=0.07). One patient had a post-procedural bleed in the FNB arm, which was managed conservatively.Conclusions 19-G FNA needles for EUS-LB provide similar specimen adequacy with less post-procedural pain compared to 19G FNB needles. Considering lower cost with similar adequacy, 19G FNA needles may be the preferred option for EUS-LB.