Clinical Outcome of Endoscopic Ultrasound-Guided Liver Abscess Drainage Using Self-Expandable Covered Metallic Stent (with Video)

Endoscopic ultrasound-guided infectious liver cyst drainage associated with autosomal dominant polycystic kidney disease in which percutaneous approach is impossible

A man in his 70s on maintenance dialysis for autosomal dominant polycystic kidney disease was admitted with epigastralgia and a fever lasting for 1 week. Computed tomography showed a thickened liver cyst measuring 121 mm in the caudate lobe, suggesting infection. Percutaneous drainage was impossible because multiple liver cysts and ascites entered the puncture route. Endoscopic ultrasound (EUS) revealed a huge liver cyst with debris-like echoes. Transgastric EUS-guided drainage was performed, and internal and external drainage was performed without adverse events. After the procedure, the symptoms quickly improved, and the external drain was removed after 12 days. The internal drainage stent remained in place, and the patient was discharged from the hospital 53 days after the EUS-guided drainage. EUS-guided drainage is an effective alternative treatment for infected liver cysts where a percutaneous approach is impossible.

Comparison of endoscopic ultrasound-guided drainage and percutaneous drainage combined with minocycline sclerotherapy for symptomatic hepatic cysts: A retrospective study

Simple hepatic cysts (SHC) are generally asymptomatic and incidentally diagnosed using imaging studies. Asymptomatic SHC does not require treatment, but symptomatic SHC warrants treatment using different modalities, including intravenous antibiotic therapy, ultrasound-guided percutaneous catheter drainage (PCD) with sclerotherapy, and surgery. The dissemination of endoscopic ultrasonography (EUS) intervention techniques has enabled the performance of puncture and drainage via the transgastrointestinal route for intra-abdominal abscesses. Despite the development of an EUS-guided drainage method for treating symptomatic SHC, only a few case reports using this method have been reported. This study retrospectively analyzed the safety and feasibility of EUS-guided drainage of symptomatic SHC as well as its clinical outcomes and compared it with combined therapy using PCD and minocycline sclerotherapy. The records of 10 consecutive patients with 11 symptomatic SHCs treated with either EUS-guided drainage or PCD combined with minocycline sclerotherapy at the Musashino Tokushukai Hospital from August 2019 to January 2024 were retrospectively examined. All cases in both groups achieved technical and clinical success, with no reported adverse events. The median reduction rates of the major cyst diameters in the EUS-guided drainage and PCD with sclerotherapy groups were 100% (interquartile range [IQR]: 94%-100%) and 67% (IQR: 48.5%-85%). The length of hospital stay was 7 and 22.5 days in the EUS-guided and PCD with sclerotherapy groups (P = .01). EUS-guided drainage of symptomatic SHC is a safe and effective therapeutic alternative to percutaneous drainage with sclerotherapy and surgery for treating symptomatic SHC.

Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis

BACKGROUND

In hepatology, the clinical use of endoscopic ultrasound (EUS) has experienced a notable increase in recent times. These applications range from the diagnosis to the treatment of various liver diseases. Therefore, this systematic review summarizes the evidence for the diagnostic and therapeutic roles of EUS in liver diseases.

AIM

To examine and summarize the current available evidence of the possible roles of the EUS in making a suitable diagnosis in liver diseases as well as the therapeutic accuracy and efficacy.

METHODS

PubMed, Medline, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched until October 2023. The methodological quality of the eligible articles was assessed using the Newcastle-Ottawa scale or Cochrane Risk of Bias tool. In addition, statistical analyses were performed using the Comprehensive Meta-Analysis software.

RESULTS

Overall, 45 articles on EUS were included (28 on diagnostic role and 17 on therapeutic role). Pooled analysis demonstrated that EUS diagnostic tests had an accuracy of 92.4% for focal liver lesions (FLL) and 96.6% for parenchymal liver diseases. EUS-guided liver biopsies with either fine needle aspiration or fine needle biopsy had low complication rates when sampling FLL and parenchymal liver diseases (3.1% and 8.7%, respectively). Analysis of data from four studies showed that EUS-guided liver abscess had high clinical (90.7%) and technical success (90.7%) without significant complications. Similarly, EUS-guided interventions for the treatment of gastric varices (GV) have high technical success (98%) and GV obliteration rate (84%) with few complications (15%) and rebleeding events (17%).

CONCLUSION

EUS in liver diseases is a promising technique with the potential to be considered a first-line therapeutic and diagnostic option in selected cases.

Endohepatology: The endoscopic armamentarium in the hand of the hepatologist

ABSTRACT

Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.

Endoscopic Ultrasound (EUS)-guided Drainage of Caudate Lobe Abscess: A Single Center Experience

BACKGROUND

Liver abscess is usually treated with medical therapy. Few patients require drainage of the collection due to large size, certain high-risk location or rupture of the collection. Percutaneous drainage is most commonly used modality for the drainage of such collection. However, caudate lobe poses a unique difficulty in percutaneous drainage due to its deep location.

METHODS

We did a retrospective analysis of all patients with caudate lobe abscess who underwent endoscopic ultrasound (EUS)-guided drainage at our center. We reviewed their indications, technical and clinical success rates of the procedure from 2020 to 2023. We also performed systemic review of published literature till June 12, 2023 showing use of EUS-guided drainage of caudate lobe abscess.

RESULTS

Total of 8 patients (age: 37.33 ± 12.8 y; Males 62.5%) underwent EUS-guided drainage of caudate lobe collection at our center. Six patients underwent drainage using plastic stents, 1 patient underwent using metal stent, and 1 patient had aspiration of the abscess. Technical success was achieved in all patients. One patient succumbed to background illness and clinical success could be achieved in rest of the patients. In systemic review of literature on EUS-guided drainage of caudate lobe, a total of 10 studies (17 patients) were included. All patients achieved technical success. Majority studies reported use of plastic stents or naso-cystic drains whereas only 1 case reported use of metal stents. One procedure related complication (localized para-esophageal abscess) was reported requiring endoscopic intervention for management.

CONCLUSION

EUS-guided drainage of caudate lobe abscess is safe and effective. It should be used as a first-line intervention after a failed medical management.

Interventional Endoscopic Ultrasound: Current Status and Future Frontiers

Interventional endoscopic ultrasound has fueled remarkable advancements in the field of therapeutic procedures, revolutionizing minimally invasive interventions for a diverse range of conditions. This review highlights the latest breakthroughs and advancements in therapeutic endoscopic ultrasound, showcasing its potential to transform patient care.

EUS-guided drainage of a segment VI liver abscess using a lumen-apposing metal stent

Video 1EUS-guided FNA and lumen-apposing metallic stent deployment.

Efficacy of endoscopic ultrasound-guided abscess drainage for non-pancreatic abscesses: A retrospective study

Background and Aim

Percutaneous drainage of intra-abdominal abscesses is often uncomfortable for the patient and may result in prolonged hospital stays. Recent studies have shown that endoscopic ultrasound-guided abscess drainage (EUS-AD) could effectively treat various abscesses and fluid collections. However, no indications or procedures have been established for EUS-AD treatments, and studies on its usefulness and safety are insufficient. The present study aimed to evaluate the efficacy and safety of EUS-AD for treating non-pancreatic abscesses.

Methods

This retrospective study included 20 patients, aged ≥20 years, who underwent EUS-AD for an abscess or fluid accumulation in the abdomen or mediastinum, but not the pancreas. Patients were treated at the Kawasaki University General Medical Center between March 2013 and June 2021. All EUS-AD procedures were performed prior to a percutaneous drainage or surgical drainage.

Results

Among the 20 patients who underwent an EUS-AD for abscess, 8 (40%) had liver abscesses, 6 (30%) had intraperitoneal abscesses, 3 had (15%) splenic abscesses, 1 (5%) had a mediastinal abscess, 1 (5%) had an iliopsoas abscess (n = 1, 5%), and 1 (5%) had an abdominal wall abscess. The technical success rate was 95% (n = 19/20). We inserted nasobiliary catheters in 4/20 patients (20%). The clinical success rate was 90% (n = 18/20). Two clinical failures required reintervention, and both were treated with percutaneous drainage. Adverse events were observed in 2/20 patients (10%). One patient experienced fever after the procedure, and the other experienced localized peritonitis.

Conclusion

EUS-AD was effective and safe for abscess removal, particularly when approached from the upper gastrointestinal tract.

Giant Klebsiella pneumoniae pyogenic liver abscess in the left liver lobe presenting with dyspepsia and vaginal discharge

Pyogenic liver abscess (PLA) commonly occurs in the right liver lobe, causing the typical symptoms of fever and right upper quadrant pain. Less than one-third of cases occur in the left lobe. We describe an unusual presentation of a giant left-sided PLA that was compressing the stomach and surrounding venous vasculature, causing the respective symptoms of gastro-oesophageal reflux and vaginal discharge from secondary pelvic congestion syndrome. CT revealed a solitary 14 cm×10 cm×10 cm multiloculated lesion, replacing most of the left liver lobe. It was successfully treated with intravenous antibiotics and percutaneous drainage, resulting in complete resolution at 1-year follow-up. This case explores the predisposing risk factor of diabetes in PLA and its association with Klebsiella pneumoniae, which was the offending pathogen in our patient. We also discuss the phenomenon of secondary pelvic venous congestion syndrome and compare similar cases of left-sided PLA, highlighting the different modes of presentation and treatment options.

The Role of Endoscopic Ultrasound in Hepatology

Endoscopic ultrasound (EUS) has been an indispensable and widely used diagnostic tool in several medical fields, including gastroenterology, cardiology, and urology, due to its diverse therapeutic and diagnostic applications. Many studies show that it is effective and safe in patients with liver conditions where conventional endoscopy or cross-sectional imaging are inefficient or when surgical interventions pose high risks. In this article, we present a review of the current literature for the different diagnostic and therapeutic applications of EUS in liver diseases and their complications and discuss the potential future application of artificial intelligence analysis of EUS.

Diagnostic and interventional EUS in hepatology: An updated review

EUS has become an increasingly used diagnostic and therapeutic modality in the armamentarium of endoscopists. With ever-expanding indications, EUS is being used in patients with liver disease, for both diagnosis and therapy. EUS is playing an important role in providing additional important information to that provided by cross-sectional imaging modalities such as computerized tomography and magnetic resonance imaging. Domains of therapy that were largely restricted to interventional radiologists have become accessible to endosonologists. From liver biopsy and sampling of liver lesions to ablative therapy for liver lesions and vascular interventions for varices, there is increased use of EUS in patients with liver disease. In this review, we discuss the various diagnostic and therapeutic applications of EUS in patients with various liver diseases.

Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie

Biliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten Verfahren.

Endosonography-Guided Caudate Lobe Liver Abscess Drainage: A Case and Review of Methods

There are only 11 cases of caudate lobe liver abscess drainage described in the published literature. We present a case of liver abscess drainage done by endosonography (EUS) and review of various EUS-guided liver abscess drainage techniques and endoprostheses. Here we have aimed at reviewing the data for paving the way for the development of a consensus for liver abscess drainage.

Liver cyst with biliary communication treated with endoscopic ultrasound-guided drainage: A case report

RATIONALE

Simple liver cysts are common, and usually benign and asymptomatic, requiring little to no treatment. Liver cysts with biliary communication, however, are rare and require effective treatment to avoid recurrence.

PATIENT CONCERNS

A 70-year-old woman with breast cancer visited our hospital for treatment. Physical examination revealed abdominal distension and bilateral lower leg edema.

DIAGNOSIS

Abdominal contrast-enhanced computed tomography revealed a giant liver cyst, inducing inferior vena cava compression that was causing her edema.

INTERVENTIONS

Percutaneous transhepatic cyst drainage was performed. Since the bilirubin level in the drained fluid was high, the patient was diagnosed with a liver cyst with biliary communication. After the procedure, her symptoms improved and the cyst decreased in size. However, the drainage volume did not decrease after approximately 2 weeks. Sclerotherapy with minocycline was ineffective. Thus, endoscopic retrograde cholangiopancreatography was performed, and an endoscopic nasobiliary drainage tube was inserted. The percutaneous drainage tube was clamped, and the cyst showed increase in size. Therefore, endoscopic ultrasound-guided cyst drainage, which is less invasive than surgery, was performed.

OUTCOMES

The cyst tended to decrease in size even after the percutaneous drainage tube had been removed. At 3years follow-up, the cyst has almost disappeared.

LESSONS

Endoscopic ultrasound-guided drainage can treat liver cyst with biliary communication.

Endoscopic ultrasound-guided drainage to abdominal abscess: A systematic review and meta-analysis

Background:

Ultrasound (US)- or computed tomography-guided drainage for abdominal abscess is currently the first-line options for drainage, but both options have disadvantages. Patients without adequate windows for drainage mostly undergo surgical drainage. However, surgical drainage is invasive and expensive. Endoscopic US (EUS)-guided drainage is a minimally invasive alternative for abdominal abscess, but there is less consensus on its efficacy, safety and complications. This meta-analysis aims to evaluate EUS-guided drainage for abdominal abscess.

Materials and Methods:

We retrieved relevant papers on EUS-guided drainage for abdominal abscess from the PubMed, Cochrane Library, Web of Science and EMBASE databases. Each paper was reviewed, and data were extracted. We used R software version 3.6.3 to perform the meta-analysis. Fixed effects models were used for merging data.

Results:

A total of 11 papers met the inclusion criteria, with a total sample population of 264 patients. The meta-analysis showed that the pooled clinical success rate was 90% (95% confidence interval [CI], 0.85–0.95), the technical success rate was 99% (95% CI, 0.97–1.00) and the recurrence rate was 1% (95% CI, 0.00–0.03). Three studies reported the complications, including perforation, bleeding and stent migration; none of the other eight studies reported complications. There were no significant differences between subgroups. There was no publication bias in either the clinical or the technical success rates.

Conclusions:

This meta-analysis showed that EUS-guided drainage for abdominal abscess was effective and safe, with an excellent technical success rate. In addition, EUS-guided drainage could be used for abscesses with complex anatomy. Nevertheless, complications and stent type should be considered.

A state-of-the-art comprehensive review summarizing the emerging data on endoscopic ultrasound-guided liver diseases management

Liver diseases are among the most common diseases worldwide accounting for substantial morbidity and mortality. Most liver diseases necessitate radiological evaluation or accurate diagnosis and recently for management as well. In the last decade, the application of therapeutic endoscopic ultrasound (EUS) procedure has been increasingly utilized for the management of various liver diseases. In this comprehensive narrative review article, we provide systematic overview on EUS-guided therapeutic interventions in various liver diseases summarizing most updated data regarding technical success, outcomes and safety profiles. Overall, 35 articles have reported on the use of EUS in the treatment of liver diseases with excellent technical success, favorable radiological response and high safety profiles for EUS-guided treatment of solid and cystic liver lesion and for EUS-guided angiotherapy for gastric varices, except for EUS-guided cyanoacrylate glue injection which was associated with life-threatening fatal systemic embolization adverse events. This suggests that EUS-guided intervention is a new promising therapeutic intervention for the treatment of various liver diseases with durable effect and a limited potential for adverse events.

Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

The role of endoscopic ultrasound (EUS) as a diagnostic and therapeutic modality for the management of various gastrointestinal diseases has been expanding. The imaging or intervention for various liver diseases has primarily been the domain of radiologists. With the advances in EUS, the domain of endosonologists is rapidly expanding in the field of hepatology. The ability to combine endoscopy and sonography in one hybrid device is a unique property of EUS, together with the ability to bring its probe/transducer near the liver, the area of interest. Its excellent spatial resolution and ability to provide real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS, have facilitated the growth of EUS. The concept of “Endo-hepatology” encompasses the wide range of diagnostic and therapeutic procedures that are now gradually becoming feasible for managing various liver diseases. Diagnostic advancements can enable a wide array of techniques from elastography and liver biopsy for liver parenchymal diseases, to CE-EUS for focal liver lesions to portal pressure measurements for managing various liver conditions. Similarly, therapeutic advancements range from EUS-guided eradication of varices, drainage of bilomas and abscesses to various EUS-guided modalities of liver tumor management. We provide a comprehensive review of all the different diagnostic and therapeutic EUS modalities available for the management of various liver diseases. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.

The Role of Interventional Endoscopic Ultrasound in Liver Diseases: What Have We Learnt?

Chronic liver disease (CLD) is still a major problem, where the disease progression will lead to liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Portal hypertension (PH) management and loco-regional therapy for HCC have become the cornerstones in advanced liver disease management. Recently, there are studies looking at the potential role of interventional endoscopic ultrasound (EUS) in liver diseases. EUS may be useful in vascular changes of the digestive wall evaluation, performing dynamic assessment of hemodynamic changes, predicting variceal bleeding and rebleeding risk, and assessing the pharmacological effects. In PH management, EUS-guided vascular therapy-which revolves around glue injection, endovascular coil placement/embolization, and combination of both-has shown promising results. As a diagnostic modality for liver cancer, the implementation of EUS in liver diseases is currently not only limited to liver biopsy (EUS-LB) but also in shear-wave elastography (SWE) and portal pressure gradient measurement, as well as portal vein sampling. The application of EUS-guided radiofrequency ablation (EUS-RFA) and tumor injection can also overcome the limitations shown by both modalities without EUS. Nevertheless, establishing EUS as a firm diagnostic and therapeutic modality is still challenging since the performance of interventional EUS requires high expertise and adequate facilities.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Endoscopic ultrasound-guided drainage of a fungal liver abscess using a lumen-apposing metal stent: case report and literature review

Liver abscesses are rare entities for which percutaneous drainage is traditionally employed. The technique is simple, but associated with a significant rate of side effects and patient discomfort. We herein report a case of fungal left liver lobe abscess that was successfully treated by using EUS-guided drainage, with insertion of a large caliber lumen-apposing metal stent. The literature review we performed on the topic seems to favor, at least for abscess in the left and/or caudate liver lobes, EUS as compared to percutaneous drainage.

Endoscopic ultrasound-guided transgastric drainage of radiologically inaccessible left lobe liver abscess involving segment 4, caudate lobe, and left lateral segments using a modified technique

Liver abscess requiring drainage is conventionally managed by interventional radiology-guided percutaneous drainage (PCD). Radiologically inaccessible abscesses are managed with laparoscopic or open surgery, which carries high rates of morbidity and mortality. EUS-guided transluminal liver abscess drainage is minimally invasive and can be an alternative approach for caudate lobe, segment 4, and left lateral segment abscesses. We report on three consecutive patients with radiologically inaccessible left lobe liver abscess involving the caudate lobe, segment 4, and lateral segment in whom EUS-guided transluminal drainage using a modified technique was successful.

Endoscopic ultrasound guided hepatic interventions

Intervention for liver disease has predominantly been performed through the percutaneous approach. However, as endoscopic ultrasound (EUS) applications have expanded, there have emerged various EUS-guided interventions for liver disease, a space we call "Endo-Hepatology". EUS-guided liver biopsy can be considered the "forerunner" of Endo-Hepatology and has become a clinical option for patients requiring histologic diagnosis and staging of their liver disease. EUS also enables direct access to the portal vein. Subsequently, many procedures are being explored, such as angiography, measurement of the portosystemic pressure gradient, portal vein sampling to detect cancer cell or DNA, and EUS-guided transhepatic intrahepatic portosystemic shunt creation. Since the transducer is close to the liver, especially the left and caudate lobes, EUS can be used as a rescue when the percutaneous approach is not favorable and EUS-guided treatments of liver tumor, cyst and abscess have been reported. This review summarizes the available studies of EUS-guided intervention in the liver.

Endoscopic ultrasound in chronic liver disease

Endoscopic ultrasound (EUS) is a minimally invasive diagnostic and therapeutic modality with a number of established as well as evolving uses in patients with chronic liver disease. Compared to other diagnostic tools such as cross-sectional imaging or conventional endoscopy, EUS has been shown to increase diagnostic sensitivity and therapeutic success for many clinical scenarios and applications with a low rate of adverse events. In this review, we discuss and focus on the current and growing role of EUS in the evaluation and/or treatment of hepatobiliary masses, hepatic parenchymal disease, portal hypertension, esophageal and other varices, and indeterminate biliary strictures.

Endoscopic ultrasound-guided drainage of difficult-to-access liver abscesses

OBJECTIVES

Antibiotic therapy and percutaneous drainage have been the first-line treatments for liver abscesses. However, percutaneous drainage of abscesses may be challenging in difficult-to-access locations such as the caudate lobe. The aim of this review was to determine the indications, technical feasibility and efficacy of endoscopic ultrasound-guided drainage of difficult-to-access liver abscesses.

METHODS

A literature review of original articles, abstracts, case series and case reports describing endoscopic ultrasound-guided liver abscess drainage was performed. The indications, techniques and complications associated with endoscopic ultrasound-guided drainage were reviewed.

RESULTS

A total of 15 studies were identified. The main indications were failed antibiotic therapy and difficulty in gaining percutaneous access. The technique involved identification and puncturing of an abscess under endoscopic ultrasound guidance followed by placement of a prosthesis via a guide wire. The technique was 97.5% successful with no major complications reported.

CONCLUSION

Endoscopic ultrasound-guided drainage was feasible and safe and allowed complete drainage of liver abscesses not accessible by percutaneous drainage.

The role of EUS in diagnosis and treatment of liver disorders

Background and aim  Transabdominal ultrasound (US), computed tomographic scanning (CT) and magnetic resonance imaging (MRI) are established diagnostic tools for liver diseases. Percutaneous transhepatic cholangiography is used to perform hepatic interventional procedures including biopsy, biliary drainage procedures, and radiofrequency ablation. Despite their widespread use, these techniques have limitations. Endoscopic ultrasound (EUS), a tool that has proven useful for evaluating the mediastinum, esophagus, stomach, pancreas, and biliary tract, has an expanding role in the field of hepatology complementing the traditional investigational modalities. This review aimed to assess the current scientific evidence regarding diagnostic and therapeutic applications of EUS for hepatic diseases.

Endoscopic Ultrasound-Guided Hepaticogastrostomy With Lumen-Apposing Metal Stent for Management of Pyogenic Liver Abscess

A 45-year-old man presented with abdominal pain, fever with chills, nonproductive cough, mild pleurisy, and anorexia. Computed tomography scan showed a heterogeneously enhancing mass in the left hepatic lobe with leukocytosis and elevated C-reactive protein. Interval growth of the lesion was noted on magnetic resonance imaging obtained several days after admission. Given the clinical suspicion for pyogenic liver abscess and favorable location in the left hepatic lobe, endoscopic ultrasound-guided drainage was pursued. The patient underwent endoscopic ultrasound-guided hepaticogastrostomy with a lumen-apposing metal stent. His symptoms gradually abated after procedure. Radiographic resolution of the abscess was noted 1 week after stent placement, and the stent was subsequently removed. He had no clinical or radiographic evidence of recurrence at 1-month follow-up.

Retrospective cohort study comparing endoscopic ultrasound-guided and percutaneous drainage of upper abdominal abscesses

BACKGROUND AND AIM

Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) has become the standard treatment for peripancreatic fluid collections. Its use in other intra-abdominal abscesses has been reported, although there is limited evidence.

METHODS

We carried out a single-center retrospective cohort study comparing percutaneous drainage (PCD) and EUS-D of upper abdominal abscesses between January 2012 and June 2017. Pancreatic fluid collections and liver transplant recipients were excluded. Primary endpoints were technical and clinical success rates.

RESULTS

We included 18 EUS-D (nine hepatic and nine intraperitoneal abscesses) and 62 PCD. There were no differences regarding age, gender and etiology. Size was larger in the PCD group (80 vs 65.5 mm, P = 0.04) and perivesicular location was more frequent in the PCD group (24.2% vs 11.1%, P = 0.003). In the EUS-D group, metal stents were deployed in 16 (88.9%) subjects (eight lumen-apposing metal stents and eight self-expandable metal stents), coaxial double-pigtail plastic stents in six (33.3%) and lavage/debridement was carried out in five (27.8%). There were no significant differences in technical success (EUS-D: 88.9%, PCD: 96.8%, P = 0.22) or clinical success (EUS-D: 88.9%, PCD: 82.3%, P = 0.50), with no relapses in the EUS-D group and 10 (16.1%) in the PCD group (P = 0.11). There were four (22.2%) adverse events in the EUS-D group, none of them severe, and 13 (21%) in the PCD group (P = 0.91).

CONCLUSIONS

EUS-D is an alternative to PCD in the treatment of upper abdominal abscesses, reaching similar success, relapse and adverse events rates.

Endoscopic ultrasound-guided transduodenal drainage of idiopathic retroperitoneal abscess in an immunocompromised patient: A case report

RATIONALE

Idiopathic retroperitoneal abscesses are insidious, occult illnesses with high mortality if inadequately drained. Endoscopic ultrasound-guided drainage is an alternative to percutaneous or surgical drainage, it is not widely performed for retroperitoneal abscesses other than peripancreatic fluid collection.

PATIENT CONCERNS

We present a 76-year-old Japanese woman with abdominal pain, high fever, and a history of rheumatism on treatment with immunosuppressants.

DIAGNOSES

The patient was diagnosed with idiopathic retroperitoneal abscess based on results obtained from her clinical course and findings on computed tomography.

INTERVENTIONS

We performed Endoscopic ultrasound-guided drainage. After we performed needle puncture via the descending portion of the duodenum, the fistula was expanded using a dilator, and a double-pigtail stent and endoscopic nasobiliary drainage tube were inserted.

OUTCOMES

The patient was kept nil by mouth, together with intravenous antibiotic therapy, and repeated washing of the abscess cavity with saline was performed. After that, we confirmed disappearance of the cavity, and, after removing the tubes, commenced oral feeding. We were able to avoid surgery in this immunosuppressed patient.

LESSONS

Endoscopic ultrasound (EUS)-guided abscess drainage can be overall considered a safe and useful procedure. We also propose the double-stent method, with both internal and external stents, for the treatment of idiopathic retroperitoneal abscesses.

Role of endoscopic ultrasound in liver disease: Where do we stand in 2017?

Endoscopic ultrasound (EUS) was first introduced into medical practice in 1980s as a diagnostic imaging modality for pancreatic pathology. EUS has the unique advantage of combining ultrasound and endoscopy to obtain detailed information of the gastrointestinal tract. Over the past decade, the use of EUS in liver diseases has been increasing. EUS, which was initially used as a diagnostic tool, is now having increasing therapeutic role as well. We provide a review of the application of EUS in the diagnostic and therapeutic aspects of liver disease. We also look at the evolving future research on the role of EUS in liver diseases.

Prospective clinical study of endoscopic ultrasound-guided biliary drainage using novel balloon catheter (with video)

BACKGROUND AND AIM

On endoscopic ultrasound (EUS)-guided biliary drainage, fistula dilation may be accompanied by leakage of bile juice, potentially along with bacteria or air, so this procedure should be kept as simple and short as possible. To date, various techniques to dilate the fistula have been reported. This prospective, single-center, single-arm study evaluated the technical feasibility and safety of EUS-guided biliary drainage using novel balloon catheters.

METHODS

Tip of novel balloon catheters is only 3 Fr and tapered, and the catheters also show favorable push ability. First, biliary tract was punctured using 19-G fine needle aspiration needle. Next, we immediately inserted the novel balloon catheter, and the biliary tract and intestinal wall were dilated. Then, we performed metallic stent placement without any dilation fistula.

RESULTS

A total of 20 patients were prospectively enrolled in this study. Technical success rate was 100%. Eleven patients underwent EUS-guided choledochoduodenostomy, and nine patients underwent EUS-guided hepaticogastrostomy. Median procedure time was only 11 min (range, 8-16 min) for EUS-guided choledochoduodenostomy and 14 min (range, 11-18 min) for EUS-guided hepaticogastrostomy. Adverse events were seen in 15% (3/20; self-limited abdominal pain n = 2, peritonitis n = 1).

CONCLUSIONS

Although additional cases and a randomized controlled comparison with another dilation technique such as the graded dilation or cystotome dilation technique are needed, our technique may be helpful for EUS-guided biliary drainage.

A retrospective study of pyogenic liver abscess focusing on Klebsiella pneumoniae as a primary pathogen in China from 1994 to 2015

Pyogenic liver abscess (PLA) is a common intra-abdominal infection in adults. In this study, we aim to explore demographic and clinical characteristics of PLA focusing on Klebsiella pneumoniae (K. pneumoniae) induced PLA (KP-PLA) in mainland China. A retrospective review of medical records from all patients with KP-PLA admitted to a tertiary teaching hospital over a 21-year period (1994–2015) was performed. Among 296 PLA cases with confirmed culture-positive data, K. pneumoniae was revealed as the predominant pathogen (n = 189, 63.9%), followed by Escherichia coli (n = 39, 13.2%). Strikingly, KP-PLA patients had a higher incidence of metabolic disorders, such as diabetes mellitus (49.7% vs. 36.4%, P = 0.027; odds ratio (OR): 1.725; 95% confidence interval (CI): 1.061–2.805), hypertension (38.1% vs. 19.6%, P = 0.001; OR: 2.520; 95% CI: 1.439–4.413), and fatty liver (32.3% vs. 14.0%, P = 0.001; OR: 2.923; 95% CI: 1.564–5.462) than those with non-K. pneumoniae induced PLA (non-KP-PLA). Moreover, patients with KP-PLA had higher susceptibility to septic metastatic infection at distant sites compared to those with non-KP-PLA (10.6% vs. 3.7%, p = 0.038). Our results indicate that K. pneumoniae is the predominant pathogen of PLA in mainland China. KP-PLA is frequently diagnosed in patients with metabolic diseases and has a higher risk for septic metastatic infection.

Endoscopic ultrasonography-guided drainage of infected intracystic papillary adenocarcinoma of the liver

We describe a case of effective use of endoscopic ultrasonography (EUS)-guided drainage of an infected intracystic papillary adenocarcinoma (ICPA) of the liver. The patient was an 84-year-old woman who was admitted with complaints of continuous epigastric pain and a slight fever. Laboratory data revealed severe inflammation. Computed tomography scanning showed a 110-mm cystic lesion with enhanced papillary tumors in the medial segment of the liver associated with a cyst in the right lobe and subcapsular cyst of the liver. Streptococcus species were detected in the culture of cystic fluid, and a diagnosis of infected ICPA was suspected. Although the patient was medicated by antibiotics, the fever did not resolve. EUS-guided transgastric drainage was performed for the abscess of the medial segment of the liver. Fourteen days after the endoscopic procedure, the plastic drainage tube was replaced with a metal stent. Inserting an endoscope into the liver cyst through the metal stent permitted observation and biopsy of an intracystic tumor, and the diagnosis of ICPA was confirmed. The patient was discharged with the internal metal stent still in place.