The Role of EUS Elastography in the Diagnosis of Focal Liver Lesions

Abstract

Sonoelastography is a new ultrasound procedure for the assessment of tissue elasticity, with a very good potential of implementation in the field of endoscopic ultrasogography. The reconstruction of tissue elasticity provides important information about the nature of the disease. The elasticity of the tissue is evaluated qualitatively on the standard B mode with color image in the range from red to blue. The more hard tissues are presenting in blue and easily compressible tissues in red. Giovannini suggest that EUS elastography could be a good diagnostic tool in defining the tissue characteristics of benign and malignant lesions. Case Report: 25-year-old woman presented at our Unit with a two-month history of fever of unknown origin, night sweats and mild abdominal pain. Her previous medical history was unremarkable. On physical examination, only abnormal finding was enlarged liver palpable 3 cm below the right costal margin. Laboratory results showed slightly elevated liver enzymes. Synthetic liver function was normal. Excluded were all potential bacterial and virological causes, hereditary and acquired metabolic liver diseases and autoimmune liver diseases. Chest X-ray was normal. Abdominal ultrasound (US) detected several hipoechogenic lesions, two in left liver lobe (26 and 29 mm) and several smaller in right liver lobe (up to 8 mm in size). This was confirmed with contrast-enhanced multislice computed tomography (MSCT) which showed multiple hypoattenuated lesions on native images which were hypovascular on postcontrast images with no signs of abnormal intrahepatic vascularisation EUS elastography showed diffuse “blue” pattern in the left liver lobe, indicating hard elasticity in the area of focal lessions and in the surrounding tissue. It was therefore concluded that we were dealing with a diffuse liver disease. Liver biopsy of the left liver lobe was performed with US guidance. Tissue cylinder contained the tissue surrounding the focal lesion and part of the focal lesion itself. Histological analysis revealed diffuse granulomatosus infiltration of the liver. Differential diagnosis of hepatic granulomatous disease is very broad, two major causes being sarcoidosis and tuberculosis. . EUS elastography, histology and slightly elevated serum angiotensin converting enzyme (ACE) of 62 U/L (normal up to 52 U/L) pointed toward the diagnosis of liver sarcoidosis. We suggest that EUS elastography is a promising diagnostic method that allows differentiation of the focal liver lesions from the normal liver tissue and detection of diffuse liver disease, with a great diagnostic potential in difficult cases like the one described.