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LETTER TO EDITOR
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 69-70

Contrast-enhanced EUS in the evaluation of peritoneum and omentum in undiagnosed ascites


1 Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission27-Jul-2019
Date of Acceptance24-Dec-2019
Date of Web Publication12-Feb-2020

Correspondence Address:
Dr. Surinder Singh Rana
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_78_19

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How to cite this article:
Rana SS, Sharma R, Srinivasan R, Rohilla M, Gupta R. Contrast-enhanced EUS in the evaluation of peritoneum and omentum in undiagnosed ascites. Endosc Ultrasound 2020;9:69-70

How to cite this URL:
Rana SS, Sharma R, Srinivasan R, Rohilla M, Gupta R. Contrast-enhanced EUS in the evaluation of peritoneum and omentum in undiagnosed ascites. Endosc Ultrasound [serial online] 2020 [cited 2020 Feb 25];9:69-70. Available from: http://www.eusjournal.com/text.asp?2020/9/1/69/278200



Dear Editor,

Advent of EUS has improved our diagnostic capability in patients with undiagnosed ascites.[1] EUS, by providing high-resolution images, can directly visualize as well as sample peritoneal and omental deposits/thickening. EUS-FNA can help in identifying the etiology of peritoneal/omental deposits.[2] Occasionally, FNA may be noncontributory and the patient may need repeat sampling. Contrast-enhanced EUS (CEUS) by providing information on enhancement pattern can help in the differential diagnosis of benign and malignant lesions.[3],[4] We retrospectively assessed CEUS features of malignant peritoneal and omental deposits/thickening in six patients with malignant ascites and compared them with tubercular peritoneal and omental deposits/thickening in seven patients with tubercular ascites. CEUS was performed by a linear scanning echoendoscope from the stomach and duodenum under conscious sedation using intravenous midazolam. On EUS, the thickened omentum is visualized as a sheet-like hypoechoic or echogenic structure adjacent to the gastric wall, and peritoneal nodules are seen as heteroechoic nodules hanging from the peritoneum into the anechoic ascites. After visualizing the lesion, 2.4-mL bolus of the US contrast agent Sonovue (Bracco, Milan, Italy) was injected followed by flushing with 10 mL of saline. The contrast enhancement of the lesion was classified as enhancing, hypoenhancing, or no enhancement. Thereafter, the peritoneal deposits or thickened omentum or both were sampled using a 22-G needle.

EUS revealed a thickened omentum in seven patients, peritoneal nodules in six patients, and both thickened omentum and peritoneal nodules in two patients. The peritoneal nodules were larger and well-defined in malignant ascites as compared to tubercular ascites (5.2 ± 1.0 mm vs. 2.2 ± 0.3 mm, respectively; P = 0.002). On CEUS, the peritoneal deposits [Figure 1] as well as thickened omentum were enhancing in all the six patients with malignant ascites, whereas the thickened omentum as well as peritoneal nodules [Figure 2] were hypoenhancing in all patients with tubercular ascites. There were no complications of the procedure. Cytological examination of EUS-FNA samples from peritoneal deposits revealed metastatic adenocarcinoma in four patients, poorly differentiated carcinoma in one patient, granulomatous inflammation in two patients, and nonspecific inflammation in one patient. Cytological examination of EUS-FNA samples from thickened omentum revealed metastatic adenocarcinoma in two patients and granulomatous inflammation in five patients.
Figure 1: EUS in a patient with malignant ascites: Peritoneal nodule is seen as enhancing lesion on contrast-enhanced EUS (arrow)

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Figure 2: Hypoenhancing ill-defined peritoneal nodule (arrows) in tubercular ascites (arrows)

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To the best of our literature search, CEUS features of these deposits have not been evaluated previously. Que et al. used contrast-enhanced transabdominal ultrasound to study the enhancement pattern of metastatic peritoneal nodules in 25 patients with confirmed peritoneal metastases after ultrasound-guided biopsies of peritoneum.[5] Similar to our results, they also reported that metastatic peritoneal nodules showed fast radial enhancement. We have for the first time demonstrated the CEUS findings in malignant as well as tubercular omental as well as peritoneal nodules. CEUS, by demonstrating the enhancement pattern of peritoneal nodules as well as thickened omentum, appears to be a good diagnostic modality for differentiating tubercular from malignant ascites. However, prospective studies with a large sample size are needed to confirm these interesting initial results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma V, Rana SS, Ahmed SU, et al. Endoscopic ultrasound-guided fine-needle aspiration from ascites and peritoneal nodules: A scoping review. Endosc Ultrasound 2017;6:382-8.  Back to cited text no. 1
    
2.
Rana SS, Bhasin DK, Srinivasan R, et al. Endoscopic ultrasound-guided fine needle aspiration of peritoneal nodules in patients with ascites of unknown cause. Endoscopy 2011;43:1010-3.  Back to cited text no. 2
    
3.
Fusaroli P, Spada A, Mancino MG, et al. Contrast harmonic echo-endoscopic ultrasound improves accuracy in diagnosis of solid pancreatic masses. Clin Gastroenterol Hepatol 2010;8:629-34.e1-2.  Back to cited text no. 3
    
4.
Zhong L, Chai N, Linghu E, et al. A prospective study on contrast-enhanced endoscopic ultrasound for differential diagnosis of pancreatic cystic neoplasms. Dig Dis Sci 2019;64:3616-22.  Back to cited text no. 4
    
5.
Que Y, Wang X, Tao C, et al. Peritoneal metastases: Evaluation with contrast-enhanced ultrasound. Abdom Imaging 2011;36:327-32.  Back to cited text no. 5
    


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  [Figure 1], [Figure 2]



 

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