In this case-series, patients with splenic lesions found on US or CT underwent transgastric EUS/FNA in an attempt to make a diagnosis. Patient with focal splenic lesions in whom US or CT guided puncture were negative or considered difficult due to location (near vessels in hilum or near capsule) or small size were included. Cystic lesions were excluded. Two to four needles passes were performed using 22-gauge needles. Adequate material for cytologic or bacteriologic examination was obtained in 11 of 12 patients. A positive diagnosis was made in 10 of 12 patients, which included tuberculosis, Hodgkin’s lymphoma, presumptive sarcoid, metastatic colon cancer, Staphylococcus aureus abscess, and Serratia abscess. There were no significant complications.

This article reports successful use of EUS/FNA to diagnose focal splenic masses. Percutaneous FNA of splenic lesions has been shown to have a reasonably high sensitivity (90%) and specificity (99%) with a low rate complication (0-2.5%). However, due to size or location of the lesion, percutaneous FNA is not always practical. EUS with FNA will likely be useful in these situations. Four of the 12 patients in the study had infections (abscesses and TB), thus samples for microbiology should be obtained when performing FNA of splenic lesions. This study, although small, suggests that EUS/FNA of focal splenic lesions is safe, and can assist in making a diagnosis.

The authors sought to determine whether on-site cytopathologic interpretation improves the diagnostic yield of EUS-guided FNA. EUS with FNA was performed by one physician at two separate hospitals. Center 1 had an on-site cytopathologist available at the time of EUS/FNA, while center 2 did not. At Center 2, FNA passes were performed until adequate cytologic material was obtained by visual inspection of the slide. Center 1 had more patients with a definitive diagnosis of positive or negative for malignancy (78%) vs. center 2 (52%). Cytology that was suspicious for malignancy was lower at center 1 (3% vs. 20%). Specimens that were considered unsatisfactory for interpretation were lower in center 1 (9% vs. 20%).

This study supports the use of on-site cytopathologic interpretation during EUS-FNA, something many endoscopic ultrasonographers have felt should be the standard of care. Weaknesses of this study include retrospective data collection, and that different cytopathologists were used to interpret the specimens. Although many experts have advocated immediate on-site evaluation of cytologic material during EUS-FNA, there has been little data to support this, until now.

The aim of this study was determine if intraductal ultrasound (IDUS) changes the clinical management of patients undergoing ERCP for suspected choledocholithiasis. Fifty-two patients were enrolled. ERCP with C-arm fluoroscopic guidance was performed in standard fashion. IDUS was only performed in patients with a normal cholangiogram, cholangiogram showing filling defects less than 5mm in diameter, or a cholangiogram with round filling defects less than 10mm in diameter. IDUS was performed in 35 (67%). ERC revealed no stones in 21 patients, of whom IDUS found evidence of stones (n=5) or sludge (n=3) in 8 of these patients (38%). Cholangiogram raised suspicion of stones in 14 patients, of whom IDUS found stones in 9 (67%), but air bubbles/no stones in 5 (36%). In total, IDUS changed clinical management in 13 of 35 (37%) in whom it was performed.

IDUS has been shown to be more accurate than cholangiogram for detection of choledocholithiasis. However, there is little data showing that clinical management changes with the use of IDUS. In this patient population, sphincterotomy was avoided in 5, whereas 8 patients with normal cholangiograms underwent sphincterotomy with stone/sludge removal based on IDUS findings. EUS with a dedicated echoendoscope is quite sensitive and specific for detecting choledocholithiasis, and in contrast to IDUS, does not put the patient at risk for pancreatitis. However, if stones are found on trans-duodenal EUS, a second procedure to remove the stones is needed. The estimated cost per case of using a catheter ultrasound probe was $100, not including the cost of the ultrasound processor. The risks/benefits of different techniques (MRCP, ERCP, EUS, IDUS) for detection of choledocholithiasis, along with the economic implications, need to be further studied. It is possible that in institutions were MRI or EUS is not available; IDUS may improve patient care selecting only patients with definite stones or sludge for sphincterotomies.