Abstract
Endoscopic ultrasound (EUS) can directly visualize as well as sample peritoneal deposits/thickening. Contrast enhanced EUS (CEUS) is an image enhancement technique that provides high resolution images of the microcirculation of the target lesions. The peritoneal deposits/thickening have not been previously evaluated with CEUS. To assess the CEUS features of malignant peritoneal deposits/thickening in patients with undiagnosed ascites and compared them with the CEUS features of tubercular deposits. Records of 12 patients (10 males; mean age: 54.0 ±11.1 years) with undiagnosed ascites who underwent EUS and CEUS followed by EUS guided fine needle aspiration (FNA) were retrospectively retrieved from our data base and analysed. The peritoneal nodules were seen as heteroechoic nodules hanging from the peritoneum into the anechoic ascites. CEUS was performed done at low output power (MI = 0.2) after injecting a 2.4-mL bolus of the US contrast agent Sonovue (Bracco, Milan, Italy) followed by flushing with 10 mL of normal saline. The contrast enhancement of nodules was classified as enhancing, hypo-enhancing, or no enhancement. All the included 12 patients had exudative ascites with low serum ascitic albumin gradient (SAAG). CT revealed omental thickening in 2 patients and only ascites in remaining 10 patients. The final diagnosis was: tuberculosis in 4 patients and malignant ascites in 8 patients. EUS revealed peritoneal nodules only in 10 patients and both thickened omentum as well as peritoneal nodules in two patients. The peritoneal deposits were noted as echogenic rounded lesions hanging out clearly in the presence of anechoic ascites (Fig 1). The peritoneal nodules were larger and well defined in malignant ascites as compared to tubercular ascites (4.6 ± 1.2 mm vs. 2.1 ± 0.5 mm respectively; p=0.003). On CEUS, the peritoneal deposits were enhancing in all 8 patients with malignant ascites whereas they were enhancing in only 1 patient with tubercular ascites (p=0.01). There were no complications of the procedure. CEUS, by demonstrating the enhancement pattern of peritoneal nodules, appears to be a good diagnostic modality for accurately differentiating tubercular from malignant ascites.
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