At the Focal Point
EUS elastography in the diagnosis of focal liver lesions
A 25-year-old woman was admitted with a history of fever of unknown origin, hepatomegaly, and elevated liver biochemical tests. Multislice CT (MSCT) showed multiple focal liver lesions (A). EUS elastography showed a diffuse blue pattern in the focal lesions and in the tissue surrounding focal lesions (B). US-guided biopsy of the left liver lobe was performed. Samples were taken from the focal lesion and surrounding tissue. Histology revealed diffuse granulomatous infiltration (C, hematoxylin, orig. mag. 400), which together with elevated angiotensin levels was highly suggestive of sarcoidosis involving the liver. EUS elastography is another method with unique potential for investigation of diffuse liver disease presenting as focal liver lesions. EUS elastography allows assessment of tissue elasticity, thereby providing important information about the nature
of the disease. Tissue infiltration (inflammation or cancer) changes the tissue’s consistency. ‘‘Harder’’ tissue presents itself as blue colored on elastogram, while easly compressible ‘‘soft’’ tissue presents as a color ranging from yellow to red, giving value to elastography for defining benign and malignant lesions. Malignant lesions usually present themselves as infiltrated ‘‘hard’’ tissue surrounded with the normal ‘‘soft’’ tissue, as evident in another patient with metastatic stomach cancer (D).
Volume 66, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 823
DISCLOSURE None of the authors have any disclosures to make.
At the Focal Point
Rustemovic Nadan, MD, PhD, Hrstic Irena, MD, MSc, Opacic Milorad, MD, PhD, Ostojic Rajko, MD, PhD, Division of Gastroenterology; Jakic-Razumovic Jasminka, MD, PhD, Department of Pathology; Kvarantan Marino, MD, Pulanic Roland, MD, PhD, Vucelic Boris, MD, PhD, Divi-
sion of Gastroenterology, University Hospital Zagreb, Zagreb, Croatia
Commentary Elastography is a method in which ‘‘stiffness’’ images of soft tissue are used to detect and classify disease, usually tumors. Precompression images are correlated to postcompression images and mathematical derivatives are applied to obtain stiffness values. Cancers are stiffer than benign tumors and up to 100 times stiffer than the normal soft tissue; when mechanical compression or vibration is applied, cancer deforms less than benign tumors and benign tumors deform less than the normal surrounding tissue. Ultrasonic imaging is the most common medical imaging technique for producing elastograms; however, MRI and CT are also being evaluated. Elastography has been used to measure the stiffness of the liver in vivo and is a noninvasive alternative to liver biopsy for determining a fibrosis score. How successful elastography will be in the evaluation and differentiation of inflammatory/infectious disorders, however, must await the test of time. Albert Schweitzer said, ‘‘.it sometimes happens that light and frivolous spirits recover their elasticity. sooner than those of a loftier character.’’ Perhaps inflamed tissues may regain their elasticity, but once a tumor, always a tumor. Lawrence J. Brandt, MD Associate Editor for Focal Points
Ampulla of Vater as seen on capsule endoscopy (with video)
A 42-year-old woman was referred for chronic right upper quadrant abdominal pain and intermittently loose stools. Physical examination revealed right upper quadrant pain only with deep palpation. Serum liver enzymes, amylase and lipase, and complete blood count were normal. A US study of the right upper quadrant showed normal results except for a 1-cm diameter common bile duct. End-viewing upper endoscopy and colonoscopy showed normal results. A capsule endoscopy was performed to rule out occult inflammatory small-bowel disease. At 5 minutes and 19 seconds, the image shown in A was captured with the capsule endoscope (Video 1, available online at www. giejournal.org); first thought to be a duodenal polyp or
mass, it was subsequently correctly interpreted as the papilla of Vater. The remainder of the capsule endoscopic study also showed normal results.
824 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 4 : 2007
DISCLOSURES The authors have no disclosures. Brian Feyen, DO, William B. Silverman, MD, Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA doi:10.1016/j.gie.2007.06.011