Endoscopic ultrasound in chronic liver disease

Figure 1 Endoscopic ultrasound in the diagnosis of obstructive jaundice. An 80-year-old male with a history of non-alcoholic fatty liver disease presented with new onset of painless jaundice, physical examination consistent with Courvoisier’s sign (palpable gallbladder), and laboratory test results suggestive of severe biliary obstruction. A: Distended gallbladder (arrow) seen on computed tomography, sagittal view. B: Distended gallbladder seen on endoscopic ultrasound. C: Double duct sign consisting of a dilated common bile duct (CBD) and dilated pancreatic duct. D: A poorly-marginated, hypoechoic pancreatic mass (asterisk) invading the distal CBD. E: Fine-needle biopsy of the pancreatic mass (asterisk), which led to tissue diagnosis of adenocarcinoma and facilitated subsequent management. GB: Gallbladder; PD: Pancreatic duct; CBD: Common bile duct.

Figure 2 Characteristics of benign and malignant liver masses. A: A distinctly demarcated hyperechoic lesion consistent with a benign hemangioma. B: A liver lesion with both iso/hypoechoic parts peripherally (outlined in orange in inset) and central hyperechoic parts suggestive of malignancy. C: A hypoechoic mass exhibiting post-acoustic enhancement (outlined in orange in inset) as frequently seen in malignancy. D: A hypoechoic, poorly demarcated mass distorting adjacent strictures (orange arrows and brackets in inset) suggestive of malignancy.

Figure 3 Endoscopic ultrasound-guided fine needle biopsy of a hypoechoic hepatic lesion first seen on non-invasive imaging; cytopathology was consistent with metastasis from pancreatic ductal adenocarcinoma (inset).

Figure 4 Endoscopic ultrasound-guided management of gastric varices. A: Gastric varices seen on endoscopy. B: Gastric varices appear anechoic on endoscopic ultrasound (EUS) grey-scale and are highlighted red by Doppler study (inset). C: Injection of embolization coils (orange arrows) into the varices results in near complete resolution of blood flow (blue arrow). D: Fluoroscopic visualization of EUS-guided coil embolization.