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Mistakes in endoscopic ultrasonography and how to avoid them

Rodica Gincul, Andrada Seicean

Summary

AI Generated

This material discusses the most frequent mistakes made in pancreatobiliary and digestive endoscopic ultrasonography imaging.

  • Understanding anatomical variations and postoperative modifications is vital when undertaking EUS.
  • Choosing the correct linear echoendoscope for the structures being examined is important, with different scopes suited to different regions such as the hilum of the liver versus the tail of the pancreas.
  • Difficulties with tissue acquisition can arise related to tumour location and internal structures, and there are situations when sampling is contraindicated.
  • Consideration needs to be given to the use of contrast with special settings and to difficulties in differential diagnosis of pancreatic solid lesions, indeterminate biliary strictures, and gastric neuroendocrine tumours.
  • The role of EUS assessment after neoadjuvant therapy should be considered.
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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

References

Mistakes
References
Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10
1.
Ghorashi B and Rector WR. Gray scale sonographic anatomy of the pancreas. J Clin Ultrasound 1977; 5: 25–29. [Link]
2.
Marks WM, Filly RA and Callen PW. Ultrasonic evaluation of normal pancreatic echogenicity and its relationship to fat deposition. Radiology 1980; 137: 475–479. [Link]
3.
Choi CW, et al. Associated factors for a hyperechogenic pancreas on endoscopic ultrasound. World J Gastroenterol 2010; 16: 4329–4334. [Link]
4.
Catalano MF, et al. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification. Gastrointest Endosc 2009; 69: 1251–1261. [Link]
5.
Savides TJ, et al. Detection of embryologic ventral pancreatic parenchyma with endoscopic ultrasound. Gastrointest Endosc 1996; 43: 14–19. [Link]
6.
Gong TT, DM Hu and Zhu Q. Contrast-enhanced EUS for differential diagnosis of pancreatic mass lesions: a meta-analysis. Gastrointest Endosc 2012; 76: 301–309. [Link]
7.
Palazzo L, et al. Endoscopic ultrasonography in the diagnosis and staging of pancreatic adenocarcinoma. Results of a prospective study with comparison to ultrasonography and CT scan. Endoscopy 1993; 25: 143–150. [Link]
8.
Bhutani MS, et al. The no endosonographic detection of tumor (NEST) study: a case series of pancreatic cancers missed on endoscopic ultrasonography. Endoscopy 2004; 36: 385–389. [Link]
9.
Munigala S, et al. New diagnosis of chronic pancreatitis: risk of missing an underlying pancreatic cancer. Am J Gastroenterol 2014; 109: 1824–1830. [Link]
10.
Gincul R, et al. Contrast-harmonic endoscopic ultrasound for the diagnosis of pancreatic adenocarcinoma: a prospective multicenter trial. Endoscopy 2014; 46: 373–379. [Link]
11.
Larghi A, et al. Management of hilar biliary strictures. Am J Gastroenterol 2008 103: 458–473. [Link]
12.
Fritscher-Ravens A, et al. EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. Am J Gastroenterol 2004; 99: 45–51. [Link]
13.
Nayar MK, et al. Role of EUS/EUS-guided FNA in the management of proximal biliary strictures. Hepatogastroenterology 2011; 58: 1862–1865. [Link]
14.
Navaneethan U, et al. Endoscopic ultrasound in the diagnosis of cholangiocarcinoma as the etiology of biliary strictures: a systematic review and meta-analysis. Gastroenterol Rep (Oxf) 2015; 3: 209–215. [Link]
15.
Kaneko M, et al. Prospective, randomized, comparative study of delineation capability of radial scanning and curved linear array endoscopic ultrasound for the pancreaticobiliary region. Endosc Int Open 2014; 2: E160–E170. [Link]
16.
Sharma M, et al. Endoscopic ultrasound of the hepatoduodenal ligament and liver hilum. Endosc Ultrasound 2018; 7: 168–174. [Link]
17.
Glover JR, PJ Shorvon, and WR Lees. Endoscopic ultrasound for localisation of islet cell tumours. Gut 1992; 33: 108–110. [Link]
18.
Schumacher B, et al. Prospective study on the detection of insulinomas by endoscopic ultrasonography. Endoscopy 1996; 28: 273–276. [Link]
19.
Sotoudehmanesh R, et al. Endoscopic ultrasonography (EUS) in the localization of insulinoma. Endocrine 2007; 31: 238–241. [Link]
20.
Tanaka K, et al. Endoscopic ultrasound-guided fine needle aspiration for diagnosing pancreatic mass in patients with surgically altered upper gastrointestinal anatomy. Dig Endosc 2020; 32: 967–973. [Link]
21.
Wilson JA, et al. EUS in patients with surgically altered upper GI anatomy. Gastrointest Endosc 2010; 72: 947–953. [Link]
22.
Fusaroli P, et al. Performance of the forward-view echoendoscope for pancreaticobiliary examination in patients with status post-upper gastrointestinal surgery. Endosc Ultrasound 2015; 4: 336–341. [Link]
23.
Jacobson BC, et al. Through-the-scope balloon dilation for endoscopic ultrasound staging of stenosing esophageal cancer. Dig Dis Sci 2007; 52: 817–822. [Link]
24.
Jenssen C, et al. Diagnostic endoscopic ultrasonography: assessment of safety and prevention of complications. World J Gastroenterol 2012; 18: 4659–4676. [Link]
25.
Varadarajulu S, Tamhane A and Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc 2005; 62: 728–736. [Link]
26.
Fritscher-Ravens A, et al. Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis. Am J Gastroenterol 2002; 97: 2768–2775. [Link]
27.
Kurita Y, et al. Features of chronic pancreatitis by endoscopic ultrasound influence the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration of small pancreatic lesions. Dig Endosc 2020; 32: 399–408. [Link]
28.
Yamashita Y, et al. Value of contrast-enhanced harmonic endoscopic ultrasonography with enhancement pattern for diagnosis of pancreatic cancer: A meta-analysis. Dig Endosc 2019; 31: 125–133. [Link]
29.
Seicean A, et al. Harmonic contrast-enhanced endoscopic ultrasonography for the guidance of fine-needle aspiration in solid pancreatic masses. Ultraschall Med 2017; 38: 174–182. [Link]
30.
Antonini F, et al. Biliary plastic stent does not influence the accuracy of endoscopic ultrasound-guided sampling of pancreatic head masses performed with core biopsy needles. Dig Liver Dis 2017; 49: 898–902. [Link]
31.
Bekkali NLH, et al. Impact of metal and plastic stents on endoscopic ultrasound-guided aspiration cytology and core histology of head of pancreas masses. Endoscopy 2019; 51: 1044–1050. [Link]
32.
Kim JJ,et al. Lower yield of endoscopic ultrasound-guided fine-needle aspiration in patients with pancreatic head mass with a biliary stent. Dig Dis Sci 2015; 60: 543–549. [Link]
33.
Siddiqui AA, et al. Comparison of the influence of plastic and fully covered metal biliary stents on the accuracy of EUS-FNA for the diagnosis of pancreatic cancer. Dig Dis Sci 2012; 57: 2438–2445. [Link]
34.
Ranney N, et al. Impact of biliary stents on EUS-guided FNA of pancreatic mass lesions. Gastrointest Endosc 2012; 76: 76–83. [Link]
35.
Fisher JM, Gordon SR and Gardner TB. The impact of prior biliary stenting on the accuracy and complication rate of endoscopic ultrasound fine-needle aspiration for diagnosing pancreatic adenocarcinoma. Pancreas 2011; 40: 21–24. [Link]
36.
Kamata K, et al. Impact of avascular areas, as measured by contrast-enhanced harmonic EUS, on the accuracy of FNA for pancreatic adenocarcinoma. Gastrointest Endosc 2018; 87: 158–163. [Link]
37.
Liu S, et al. Can endorectal ultrasound, MRI, and mucosa integrity accurately predict the complete response for mid-low rectal cancer after preoperative chemoradiation? a prospective observational study from a single medical center. Dis Colon Rectum 2018; 61: 903–910. [Link]
38.
Wang KX, et al. Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review. Gastrointest Endosc 2011; 73: 283–290. [Link]
39.
Gress F, et al. EUS-guided fine-needle aspiration of the pancreas: evaluation of pancreatitis as a complication. Gastrointest Endosc 2002; 56: 864–867. [Link]
40.
Varadarajulu S and Eloubeidi MA. Frequency and significance of acute intracystic hemorrhage during EUS-FNA of cystic lesions of the pancreas. Gastrointest Endosc 2004; 60: 631.–635. [Link]
41.
Tarantino I, et al. Complications of endoscopic ultrasound fine needle aspiration on pancreatic cystic lesions: final results from a large prospective multicenter study. Dig Liver Dis 2014; 46: 41–44. [Link]
42.
Zhu H, et al. Assessment of morbidity and mortality associated with endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: A systematic review and meta-analysis. Dig Endosc 2017; 29: 667–675. [Link]
43.
Kawakubo K, et al. A Prospective Multicenter Study Evaluating Bleeding Risk after Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients Prescribed Antithrombotic Agents. Gut Liver 2018; 12: 353–359. [Link]
44.
Veitch AM, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy 2016; 48: C1. [Link]
45.
Polkowski M, et al. Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline. Endoscopy 2012; 44: 190–206. [Link]
46.
Annema JT, et al. Mediastinitis caused by EUS-FNA of a bronchogenic cyst. Endoscopy 2003; 35: 791–793. [Link]
47.
Valli PV, Gubler C and Bauerfeind P. Severe infectious complications after endoscopic ultrasound-guided fine needle aspiration of suspected mediastinal duplication cysts: a case series. Inflamm Intest Dis 2017; 1: 165–171. [Link]
48.
Han C, et al. A case report of esophageal bronchogenic cyst and review of the literature with an emphasis on endoscopic ultrasonography appearance. Medicine (Baltimore) 2016; 95: E3111. [Link]
49.
Grandjean JP, et al. Vestigial retrorectal cystic tumors in adults: a review of 30 cases. Gastroenterol Clin Biol 2008; 32: 769–778. [Link]
50.
Krishnan K, et al. Enhanced EUS imaging (with videos). Gastrointest Endosc 2021; 93: 323–333. [Link]
51.
Fusaroli P, et al. Contrast harmonic echo-endoscopic ultrasound improves accuracy in diagnosis of solid pancreatic masses. Clin Gastroenterol Hepatol, 2010; 8: 629–634.e1–2. [Link]
52.
Kitano M, et al. Characterization of small solid tumors in the pancreas: the value of contrast-enhanced harmonic endoscopic ultrasonography. Am J Gastroenterol 2012; 107: 303–310. [Link]
53.
Pancreas ESGoCTot. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67: 789–804. [Link]
54.
Kamata K, et al. Value of additional endoscopic ultrasonography for surveillance after surgical removal of intraductal papillary mucinous neoplasms. Dig Endosc 2018; 30: 659–666. [Link]
55.
Oyama H, et al. Long-term Risk of Malignancy in Branch-Duct Intraductal Papillary Mucinous Neoplasms. Gastroenterology 2020; 158: 226–237.e5. [Link]
56.
Tang JY, et al. Value of contrast-enhanced harmonic endoscopic ultrasonography in differentiating between gastrointestinal stromal tumors: A meta-analysis. J Dig Dis 2019; 20: 127–134. [Link]
57.
Lisotti A and Fusaroli P. Contrast-enhanced EUS for the differential diagnosis of lymphadenopathy: technical improvement with defined indications. Gastrointest Endosc 2019; 90: 995–996. [Link]
58.
Yoshida K, et al. Efficacy of contrast-enhanced EUS for lymphadenopathy: a prospective multicenter pilot study (with videos). Gastrointest Endosc 2019; 90: 242–250. [Link]
59.
Iglesias-Garcia J, et al. Quantitative endoscopic ultrasound elastography: an accurate method for the differentiation of solid pancreatic masses. Gastroenterology 2010; 139: 1172–1180. [Link]
60.
Van Gulik TM, et al. Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic head cancer. Gastrointest Endosc 1997; 46: 417–423. [Link]
61.
Chari ST, et al. Histopathologic and clinical subtypes of autoimmune pancreatitis: the Honolulu consensus document. Pancreas 2010; 39: 549–554. [Link]
62.
Shimosegawa T, et al. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas 2011; 40: 352–358. [Link]
63.
Löhr JM, et al. European Guideline on IgG4-related digestive disease — UEG and SGF evidence-based recommendations. United European Gastroenterol J, 2020; 8: 637–666. [Link]
64.
Kamisawa T, et al. Clinical difficulties in the differentiation of autoimmune pancreatitis and pancreatic carcinoma. Am J Gastroenterol 2003; 98: 2694–2699. [Link]
65.
Taniguchi T, et al. Autoimmune pancreatitis detected as a mass in the head of the pancreas without hypergammaglobulinemia, which relapsed after surgery: case report and review of the literature. Dig Dis Sci 2003; 48: 1465–1471. [Link]
66.
Fujii-Lau LL and Levy MJ. The role of endoscopic ultrasound in the diagnosis of autoimmune pancreatitis. Gastrointest Endosc Clin N Am 2017; 27: 643–655. [Link]
67.
Farrell JJ, et al. EUS findings in patients with autoimmune pancreatitis. Gastrointest Endosc 2004; 60: 927–936. [Link]
68.
Buscarini E, et al. Endoscopic ultrasonography findings in autoimmune pancreatitis. World J Gastroenterol 2011; 17: 2080–2085. [Link]
69.
Kamisawa T, et al. Role of endoscopy in the diagnosis of autoimmune pancreatitis and immunoglobulin G4-related sclerosing cholangitis. Dig Endosc 2014; 26: 627–635. [Link]
70.
Koyama R, et al. Ultrasonographic imaging of bile duct lesions in autoimmune pancreatitis. Pancreas 2008; 37: 259–264. [Link]
71.
De Lisi S, et al. Endoscopic ultrasonography findings in autoimmune pancreatitis: be aware of the ambiguous features and look for the pivotal ones. JOP 2010; 11: 78–84. [Link]
72.
Kitano M, et al. A novel perfusion imaging technique of the pancreas: contrast-enhanced harmonic EUS (with video). Gastrointest Endosc 2008; 67: 141–150. [Link]
73.
Piscaglia F, et al. The EFSUMB Guidelines and recommendations on the clinical practice of contrast enhanced ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med 2012; 33: 33–59. [Link]
74.
Dietrich CF, et al. EUS elastography: how to do it? Endosc Ultrasound 2018; 7: 20–28. [Link]
75.
Cosgrove D, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications. Ultraschall Med 2013; 34: 238–253. [Link]
76.
Ohno E, et al. Feasibility and usefulness of endoscopic ultrasonography-guided shear-wave measurement for assessment of autoimmune pancreatitis activity: a prospective exploratory study. J Med Ultrason (2001) 2019; 46: 425–433. [Link]
77.
Learn PA, et al. Pitfalls in avoiding operation for autoimmune pancreatitis. Surgery 2011; 150: 968–974. [Link]
78.
Holmes BJ, et al. Fine needle aspirate of autoimmune pancreatitis (lymphoplasmacytic sclerosing pancreatitis): cytomorphologic characteristics and clinical correlates. Acta Cytol 2012; 56: 228–232. [Link]
79.
Iwashita T, et al. Use of samples from endoscopic ultrasound-guided 19-gauge fine-needle aspiration in diagnosis of autoimmune pancreatitis. Clin Gastroenterol Hepatol 2012; 10: 316–322. [Link]
80.
Kerdsirichairat T, et al. Autoimmune pancreatitis diagnosed with core biopsy obtained from a novel fork-tip EUS Needle. ACG Case Rep J 2017; 4: E7. [Link]
81.
Detlefsen S, Joergensen MT and Mortensen MB. Microscopic findings in EUS-guided fine needle (sharkcore) biopsies with type 1 and type 2 autoimmune pancreatitis. Pathol Int 2017; 67: 514–520. [Link]
82.
Kurita A, et al. Comparison of a 22-gauge Franseen-tip needle with a 20-gauge forward-bevel needle for the diagnosis of type 1 autoimmune pancreatitis: a prospective, randomized, controlled, multicenter study (COMPAS study). Gastrointest Endosc 2020; 91: 373–381.e2. [Link]
83.
Ishikawa T, et al. Usefulness of endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of autoimmune pancreatitis using a 22-gauge Franseen needle: a prospective multicenter study. Endoscopy 2020; 52: 978–985. [Link]
84.
Sun B, et al. Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures. Aliment Pharmacol Ther 2018; 48: 138–151. [Link]
85.
Chiang A, et al. The incremental benefit of EUS for the identification of malignancy in indeterminate extrahepatic biliary strictures: A systematic review and meta-analysis. Endosc Ultrasound 2019; 8: 310–317. [Link]
86.
Jo JH, et al. Same-session endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography-based tissue sampling in suspected malignant biliary obstruction: A multicenter experience. J Gastroenterol Hepatol 2019; 34: 799–805. [Link]
87.
De Moura DTH, et al. Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis. Endosc Ultrasound 2018; 7: 10–19. [Link]
88.
Heimbach JK, et al. Trans-peritoneal fine needle aspiration biopsy of hilar cholangiocarcinoma is associated with disease dissemination. HPB (Oxford), 2011; 13: 356–360. [Link]
89.
Faulx AL, et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85: 1117–1132. [Link]
90.
Cho JW and KES Group. Current guidelines in the management of upper gastrointestinal subepithelial tumors. Clin Endosc 2016; 49: 235–240. [Link]
91.
Noordman BJ, et al. Detection of residual disease after neoadjuvant chemoradiotherapy for oesophageal cancer (preSANO): a prospective multicentre, diagnostic cohort study. Lancet Oncol 2018; 19: 965–974. [Link]
92.
Beseth BD, et al. Endoscopic ultrasound does not accurately assess pathologic stage of esophageal cancer after neoadjuvant chemoradiotherapy. Am Surg 2000; 66: 827–831. [Link]
93.
Bowrey DJ, et al. Serial endoscopic ultrasound in the assessment of response to chemoradiotherapy for carcinoma of the esophagus. J Gastrointest Surg 1999; 3: 462–467. [Link]
94.
Sun F, et al. Staging accuracy of endoscopic ultrasound for esophageal cancer after neoadjuvant chemotherapy: a meta-analysis and systematic review. Dis Esophagus 2015; 28: 757–771. [Link]
95.
Willis J, et al. Correlation of EUS measurement with pathologic assessment of neoadjuvant therapy response in esophageal carcinoma. Gastrointest Endosc 2002; 55: 655–661. [Link]
96.
Catalano MF, et al. Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc 1994; 40: 442–446. [Link]
97.
van der Bogt RD, et al. Endoscopic ultrasound and fine-needle aspiration for the detection of residual nodal disease after neoadjuvant chemoradiotherapy for esophageal cancer. Endoscopy 2020; 52: 186–192. [Link]
98.
Martin-Romano P, et al. Neoadjuvant therapy for locally advanced gastric cancer patients. A population pharmacodynamic modeling. Plos One 2019; 14: E0215970. [Link]
99.
Vanagunas A, Lin DE and Stryker SJ. Accuracy of endoscopic ultrasound for restaging rectal cancer following neoadjuvant chemoradiation therapy. Am J Gastroenterol 2004; 99: 109–112. [Link]
100.
Ehrlich D, et al. The utility of EUS-FNA to determine surgical candidacy in patients with pancreatic cancer after neoadjuvant therapy. J Gastrointest Surg 2020; 24: 2807–2813. [Link]

Abstract

Examination of the pancreas and biliary and digestive structures by endoscopic ultrasonography (EUS) can be tricky and using it to make a diagnosis can be challenging. Understanding anatomical variations and postoperative modifications is vital when undertaking EUS, as is choosing the correct linear echoendoscope for the structures being examined (e.g. the hilum of the liver versus the tail of the pancreas). There can also be difficulties with tissue acquisition related to tumour location and internal structures, and there are situations when sampling is contraindicated. Consideration also needs to be given to the use of contrast with special settings and difficulties in differential diagnosis (pancreatic solid lesions, indeterminate biliary strictures, gastric neuroendocrine tumours). The role of EUS assessment after neoadjuvant therapy should also be considered. Here we discuss the most frequent mistakes that are made in pancreatobiliary and digestive EUS imaging. 


Topics

Endoscopy Radiology & Imaging

Citation

Seicean A and Gincul R. Mistakes in endoscopic ultrasonography and how to avoid them. UEG Education 2021; 21: 1–9. 

Published

2021

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Mistakes in the management of hepatocellular carcinoma and how to avoid them

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References

Mistakes
References
Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10
1.
Ghorashi B and Rector WR. Gray scale sonographic anatomy of the pancreas. J Clin Ultrasound 1977; 5: 25–29. [Link]
2.
Marks WM, Filly RA and Callen PW. Ultrasonic evaluation of normal pancreatic echogenicity and its relationship to fat deposition. Radiology 1980; 137: 475–479. [Link]
3.
Choi CW, et al. Associated factors for a hyperechogenic pancreas on endoscopic ultrasound. World J Gastroenterol 2010; 16: 4329–4334. [Link]
4.
Catalano MF, et al. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification. Gastrointest Endosc 2009; 69: 1251–1261. [Link]
5.
Savides TJ, et al. Detection of embryologic ventral pancreatic parenchyma with endoscopic ultrasound. Gastrointest Endosc 1996; 43: 14–19. [Link]
6.
Gong TT, DM Hu and Zhu Q. Contrast-enhanced EUS for differential diagnosis of pancreatic mass lesions: a meta-analysis. Gastrointest Endosc 2012; 76: 301–309. [Link]
7.
Palazzo L, et al. Endoscopic ultrasonography in the diagnosis and staging of pancreatic adenocarcinoma. Results of a prospective study with comparison to ultrasonography and CT scan. Endoscopy 1993; 25: 143–150. [Link]
8.
Bhutani MS, et al. The no endosonographic detection of tumor (NEST) study: a case series of pancreatic cancers missed on endoscopic ultrasonography. Endoscopy 2004; 36: 385–389. [Link]
9.
Munigala S, et al. New diagnosis of chronic pancreatitis: risk of missing an underlying pancreatic cancer. Am J Gastroenterol 2014; 109: 1824–1830. [Link]
10.
Gincul R, et al. Contrast-harmonic endoscopic ultrasound for the diagnosis of pancreatic adenocarcinoma: a prospective multicenter trial. Endoscopy 2014; 46: 373–379. [Link]
11.
Larghi A, et al. Management of hilar biliary strictures. Am J Gastroenterol 2008 103: 458–473. [Link]
12.
Fritscher-Ravens A, et al. EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. Am J Gastroenterol 2004; 99: 45–51. [Link]
13.
Nayar MK, et al. Role of EUS/EUS-guided FNA in the management of proximal biliary strictures. Hepatogastroenterology 2011; 58: 1862–1865. [Link]
14.
Navaneethan U, et al. Endoscopic ultrasound in the diagnosis of cholangiocarcinoma as the etiology of biliary strictures: a systematic review and meta-analysis. Gastroenterol Rep (Oxf) 2015; 3: 209–215. [Link]
15.
Kaneko M, et al. Prospective, randomized, comparative study of delineation capability of radial scanning and curved linear array endoscopic ultrasound for the pancreaticobiliary region. Endosc Int Open 2014; 2: E160–E170. [Link]
16.
Sharma M, et al. Endoscopic ultrasound of the hepatoduodenal ligament and liver hilum. Endosc Ultrasound 2018; 7: 168–174. [Link]
17.
Glover JR, PJ Shorvon, and WR Lees. Endoscopic ultrasound for localisation of islet cell tumours. Gut 1992; 33: 108–110. [Link]
18.
Schumacher B, et al. Prospective study on the detection of insulinomas by endoscopic ultrasonography. Endoscopy 1996; 28: 273–276. [Link]
19.
Sotoudehmanesh R, et al. Endoscopic ultrasonography (EUS) in the localization of insulinoma. Endocrine 2007; 31: 238–241. [Link]
20.
Tanaka K, et al. Endoscopic ultrasound-guided fine needle aspiration for diagnosing pancreatic mass in patients with surgically altered upper gastrointestinal anatomy. Dig Endosc 2020; 32: 967–973. [Link]
21.
Wilson JA, et al. EUS in patients with surgically altered upper GI anatomy. Gastrointest Endosc 2010; 72: 947–953. [Link]
22.
Fusaroli P, et al. Performance of the forward-view echoendoscope for pancreaticobiliary examination in patients with status post-upper gastrointestinal surgery. Endosc Ultrasound 2015; 4: 336–341. [Link]
23.
Jacobson BC, et al. Through-the-scope balloon dilation for endoscopic ultrasound staging of stenosing esophageal cancer. Dig Dis Sci 2007; 52: 817–822. [Link]
24.
Jenssen C, et al. Diagnostic endoscopic ultrasonography: assessment of safety and prevention of complications. World J Gastroenterol 2012; 18: 4659–4676. [Link]
25.
Varadarajulu S, Tamhane A and Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc 2005; 62: 728–736. [Link]
26.
Fritscher-Ravens A, et al. Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis. Am J Gastroenterol 2002; 97: 2768–2775. [Link]
27.
Kurita Y, et al. Features of chronic pancreatitis by endoscopic ultrasound influence the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration of small pancreatic lesions. Dig Endosc 2020; 32: 399–408. [Link]
28.
Yamashita Y, et al. Value of contrast-enhanced harmonic endoscopic ultrasonography with enhancement pattern for diagnosis of pancreatic cancer: A meta-analysis. Dig Endosc 2019; 31: 125–133. [Link]
29.
Seicean A, et al. Harmonic contrast-enhanced endoscopic ultrasonography for the guidance of fine-needle aspiration in solid pancreatic masses. Ultraschall Med 2017; 38: 174–182. [Link]
30.
Antonini F, et al. Biliary plastic stent does not influence the accuracy of endoscopic ultrasound-guided sampling of pancreatic head masses performed with core biopsy needles. Dig Liver Dis 2017; 49: 898–902. [Link]
31.
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32.
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33.
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34.
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35.
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36.
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37.
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38.
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39.
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40.
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41.
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42.
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43.
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44.
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45.
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46.
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47.
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48.
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49.
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50.
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51.
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52.
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53.
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Abstract

Liver cancer is the sixth most common cancer and the third leading cause of cancer-related death. Hepatocellular carcinoma (HCC) accounts for about 90% of cases and mostly arises in chronic liver disease, especially cirrhosis. Viral hepatitis remains a leading cause, but alcohol-related disease and MASLD are rising. With immune checkpoint inhibitors transforming HCC management, it is timely to highlight common mistakes across screening, staging, diagnosis and treatment.

Topics

Digestive Oncology Hepatobiliary

Published

2026

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Mistakes in transjugular intrahepatic portosystemic shunt (TIPS) in cirrhosis and how to avoid them

Kymentie Ferdinande, Alberto Zanetto, Virginia Hernández-Gea, Marco Senzolo

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References

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47.
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49.
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50.
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51.
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52.
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53.
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54.
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55.
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56.
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57.
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58.
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59.
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60.
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61.
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62.
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63.
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65.
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Abstract

TIPS success is rarely about the procedure alone. It depends on decisions made across the entire clinical pathway.

New in the UEG "Mistakes in…" series: Ferdinande et al., present 10 common mistakes in TIPS for cirrhosis, from referral to long-term follow-up.

Key themes:
• Screen the heart first: cardiac decompensation follows TIPS in up to 20% of patients.
• Refer early: delay costs survival in refractory ascites and high-risk variceal bleeding.
• Prevent encephalopathy by design: careful selection, nutrition, rifaximin, and controlled underdilation.
• Individualise haemodynamic targets and follow up structurally.

Topics

Hepatobiliary Surgery

Published

2026

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European Interdisciplinary Guidelines on Pain Management in Acute Pancreatitis: UEG, EPC, EDS, ESDO, EAGEN, ESPGHAN, ESGAR, and ESPCG Evidence-Based Recommendations

Sanjay Pandanaboyana

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Guideline

ABSTRACT

Pain is often the presenting symptom of acute pancreatitis (AP) and has a prognostic significance, with poorly treated pain affecting patient outcomes. Despite this, there are currently no international recommendations for pain management in patients admitted with AP. This current guideline was developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. Nine working groups were formed to develop statements on pain management in AP from admission to discharge. After systematic literature reviews, the evidence was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted using three rounds of Delphi method. The guidelines concluded that acute postoperative pain management guidelines are applicable for treating acute pain due to AP. The numerical rating scale is preferred for pain assessment because of better compliance. Opioids currently form the cornerstone of severe pain management. Potent opioids such as buprenorphine and pentazocine provide superior pain relief over non-opioid medications and decrease the need for rescue analgesia. Current evidence does not consistently demonstrate harm from opioids in AP. In patients with severe pain, safety concerns should not delay the timely use of opioids to ensure adequate pain management. Specific recommendations concerning the use of epidural analgesia, acupuncture and management of pain in the paediatric population and during pregnancy are provided based on evidence and expert opinions. Finally, the unmet needs for future research were discussed and proposed.

Guideline

Clinical Practice Guideline

Topics

Pancreas

Citation

United European Gastroenterology Journal, 2026

Published

2026

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Oesophageal cancer with Massimiliano di Pietro (Part 2)

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Abstract

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2025

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References

Mistakes
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Ohno E, et al. Feasibility and usefulness of endoscopic ultrasonography-guided shear-wave measurement for assessment of autoimmune pancreatitis activity: a prospective exploratory study. J Med Ultrason (2001) 2019; 46: 425–433. [Link]
77.
Learn PA, et al. Pitfalls in avoiding operation for autoimmune pancreatitis. Surgery 2011; 150: 968–974. [Link]
78.
Holmes BJ, et al. Fine needle aspirate of autoimmune pancreatitis (lymphoplasmacytic sclerosing pancreatitis): cytomorphologic characteristics and clinical correlates. Acta Cytol 2012; 56: 228–232. [Link]
79.
Iwashita T, et al. Use of samples from endoscopic ultrasound-guided 19-gauge fine-needle aspiration in diagnosis of autoimmune pancreatitis. Clin Gastroenterol Hepatol 2012; 10: 316–322. [Link]
80.
Kerdsirichairat T, et al. Autoimmune pancreatitis diagnosed with core biopsy obtained from a novel fork-tip EUS Needle. ACG Case Rep J 2017; 4: E7. [Link]
81.
Detlefsen S, Joergensen MT and Mortensen MB. Microscopic findings in EUS-guided fine needle (sharkcore) biopsies with type 1 and type 2 autoimmune pancreatitis. Pathol Int 2017; 67: 514–520. [Link]
82.
Kurita A, et al. Comparison of a 22-gauge Franseen-tip needle with a 20-gauge forward-bevel needle for the diagnosis of type 1 autoimmune pancreatitis: a prospective, randomized, controlled, multicenter study (COMPAS study). Gastrointest Endosc 2020; 91: 373–381.e2. [Link]
83.
Ishikawa T, et al. Usefulness of endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of autoimmune pancreatitis using a 22-gauge Franseen needle: a prospective multicenter study. Endoscopy 2020; 52: 978–985. [Link]
84.
Sun B, et al. Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures. Aliment Pharmacol Ther 2018; 48: 138–151. [Link]
85.
Chiang A, et al. The incremental benefit of EUS for the identification of malignancy in indeterminate extrahepatic biliary strictures: A systematic review and meta-analysis. Endosc Ultrasound 2019; 8: 310–317. [Link]
86.
Jo JH, et al. Same-session endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography-based tissue sampling in suspected malignant biliary obstruction: A multicenter experience. J Gastroenterol Hepatol 2019; 34: 799–805. [Link]
87.
De Moura DTH, et al. Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis. Endosc Ultrasound 2018; 7: 10–19. [Link]
88.
Heimbach JK, et al. Trans-peritoneal fine needle aspiration biopsy of hilar cholangiocarcinoma is associated with disease dissemination. HPB (Oxford), 2011; 13: 356–360. [Link]
89.
Faulx AL, et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85: 1117–1132. [Link]
90.
Cho JW and KES Group. Current guidelines in the management of upper gastrointestinal subepithelial tumors. Clin Endosc 2016; 49: 235–240. [Link]
91.
Noordman BJ, et al. Detection of residual disease after neoadjuvant chemoradiotherapy for oesophageal cancer (preSANO): a prospective multicentre, diagnostic cohort study. Lancet Oncol 2018; 19: 965–974. [Link]
92.
Beseth BD, et al. Endoscopic ultrasound does not accurately assess pathologic stage of esophageal cancer after neoadjuvant chemoradiotherapy. Am Surg 2000; 66: 827–831. [Link]
93.
Bowrey DJ, et al. Serial endoscopic ultrasound in the assessment of response to chemoradiotherapy for carcinoma of the esophagus. J Gastrointest Surg 1999; 3: 462–467. [Link]
94.
Sun F, et al. Staging accuracy of endoscopic ultrasound for esophageal cancer after neoadjuvant chemotherapy: a meta-analysis and systematic review. Dis Esophagus 2015; 28: 757–771. [Link]
95.
Willis J, et al. Correlation of EUS measurement with pathologic assessment of neoadjuvant therapy response in esophageal carcinoma. Gastrointest Endosc 2002; 55: 655–661. [Link]
96.
Catalano MF, et al. Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc 1994; 40: 442–446. [Link]
97.
van der Bogt RD, et al. Endoscopic ultrasound and fine-needle aspiration for the detection of residual nodal disease after neoadjuvant chemoradiotherapy for esophageal cancer. Endoscopy 2020; 52: 186–192. [Link]
98.
Martin-Romano P, et al. Neoadjuvant therapy for locally advanced gastric cancer patients. A population pharmacodynamic modeling. Plos One 2019; 14: E0215970. [Link]
99.
Vanagunas A, Lin DE and Stryker SJ. Accuracy of endoscopic ultrasound for restaging rectal cancer following neoadjuvant chemoradiation therapy. Am J Gastroenterol 2004; 99: 109–112. [Link]
100.
Ehrlich D, et al. The utility of EUS-FNA to determine surgical candidacy in patients with pancreatic cancer after neoadjuvant therapy. J Gastrointest Surg 2020; 24: 2807–2813. [Link]

Abstract

Cholangioscopy is a minimally invasive, endoscopic technique that allows direct visualisation of the bile ducts, facilitating both diagnostic and therapeutic interventions. It is a useful tool in managing biliary diseases, allowing characterisation and tissue acquisition for strictures of undetermined aetiology, facilitating extension assessment for biliary cancer and providing intraductal lithotripsy for complex biliary stones.

Published

2025

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Mistakes in pancreatic cystic neoplasms and how to avoid them

Marco Del Chiaro, Juan Enrique Dominguez-Munoz, Giovanni Marchegiani

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References

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76.
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77.
Learn PA, et al. Pitfalls in avoiding operation for autoimmune pancreatitis. Surgery 2011; 150: 968–974. [Link]
78.
Holmes BJ, et al. Fine needle aspirate of autoimmune pancreatitis (lymphoplasmacytic sclerosing pancreatitis): cytomorphologic characteristics and clinical correlates. Acta Cytol 2012; 56: 228–232. [Link]
79.
Iwashita T, et al. Use of samples from endoscopic ultrasound-guided 19-gauge fine-needle aspiration in diagnosis of autoimmune pancreatitis. Clin Gastroenterol Hepatol 2012; 10: 316–322. [Link]
80.
Kerdsirichairat T, et al. Autoimmune pancreatitis diagnosed with core biopsy obtained from a novel fork-tip EUS Needle. ACG Case Rep J 2017; 4: E7. [Link]
81.
Detlefsen S, Joergensen MT and Mortensen MB. Microscopic findings in EUS-guided fine needle (sharkcore) biopsies with type 1 and type 2 autoimmune pancreatitis. Pathol Int 2017; 67: 514–520. [Link]
82.
Kurita A, et al. Comparison of a 22-gauge Franseen-tip needle with a 20-gauge forward-bevel needle for the diagnosis of type 1 autoimmune pancreatitis: a prospective, randomized, controlled, multicenter study (COMPAS study). Gastrointest Endosc 2020; 91: 373–381.e2. [Link]
83.
Ishikawa T, et al. Usefulness of endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of autoimmune pancreatitis using a 22-gauge Franseen needle: a prospective multicenter study. Endoscopy 2020; 52: 978–985. [Link]
84.
Sun B, et al. Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures. Aliment Pharmacol Ther 2018; 48: 138–151. [Link]
85.
Chiang A, et al. The incremental benefit of EUS for the identification of malignancy in indeterminate extrahepatic biliary strictures: A systematic review and meta-analysis. Endosc Ultrasound 2019; 8: 310–317. [Link]
86.
Jo JH, et al. Same-session endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography-based tissue sampling in suspected malignant biliary obstruction: A multicenter experience. J Gastroenterol Hepatol 2019; 34: 799–805. [Link]
87.
De Moura DTH, et al. Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis. Endosc Ultrasound 2018; 7: 10–19. [Link]
88.
Heimbach JK, et al. Trans-peritoneal fine needle aspiration biopsy of hilar cholangiocarcinoma is associated with disease dissemination. HPB (Oxford), 2011; 13: 356–360. [Link]
89.
Faulx AL, et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017; 85: 1117–1132. [Link]
90.
Cho JW and KES Group. Current guidelines in the management of upper gastrointestinal subepithelial tumors. Clin Endosc 2016; 49: 235–240. [Link]
91.
Noordman BJ, et al. Detection of residual disease after neoadjuvant chemoradiotherapy for oesophageal cancer (preSANO): a prospective multicentre, diagnostic cohort study. Lancet Oncol 2018; 19: 965–974. [Link]
92.
Beseth BD, et al. Endoscopic ultrasound does not accurately assess pathologic stage of esophageal cancer after neoadjuvant chemoradiotherapy. Am Surg 2000; 66: 827–831. [Link]
93.
Bowrey DJ, et al. Serial endoscopic ultrasound in the assessment of response to chemoradiotherapy for carcinoma of the esophagus. J Gastrointest Surg 1999; 3: 462–467. [Link]
94.
Sun F, et al. Staging accuracy of endoscopic ultrasound for esophageal cancer after neoadjuvant chemotherapy: a meta-analysis and systematic review. Dis Esophagus 2015; 28: 757–771. [Link]
95.
Willis J, et al. Correlation of EUS measurement with pathologic assessment of neoadjuvant therapy response in esophageal carcinoma. Gastrointest Endosc 2002; 55: 655–661. [Link]
96.
Catalano MF, et al. Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc 1994; 40: 442–446. [Link]
97.
van der Bogt RD, et al. Endoscopic ultrasound and fine-needle aspiration for the detection of residual nodal disease after neoadjuvant chemoradiotherapy for esophageal cancer. Endoscopy 2020; 52: 186–192. [Link]
98.
Martin-Romano P, et al. Neoadjuvant therapy for locally advanced gastric cancer patients. A population pharmacodynamic modeling. Plos One 2019; 14: E0215970. [Link]
99.
Vanagunas A, Lin DE and Stryker SJ. Accuracy of endoscopic ultrasound for restaging rectal cancer following neoadjuvant chemoradiation therapy. Am J Gastroenterol 2004; 99: 109–112. [Link]
100.
Ehrlich D, et al. The utility of EUS-FNA to determine surgical candidacy in patients with pancreatic cancer after neoadjuvant therapy. J Gastrointest Surg 2020; 24: 2807–2813. [Link]

Abstract

Pancreatic cystic neoplasms (PCN) are a frequent and clinically challenging condition. PCN prevalence increases with age and reports estimate that they may be present in 2–45% of the general population. In addition, the biological behaviour of the various types of PCN differs (ranging from benign to malignant [table 1]), requiring different surveillance and therapeutic approaches. Correct management of PCN is, therefore, critical for avoiding progression to cancer, but at the same time avoiding unneeded close and long-term follow-up, unnecessary invasive diagnostic procedures and overtreatment.

Topics

Digestive Oncology Pancreas

Citation

  Domínguez-Muñoz J.E. and Del Chiaro M. Mistakes in pancreatic cystic neoplasms and how to avoid them. UEG Education 2018; 18: 35–37.

Published

2024

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