Successful endoscopic ultrasound-guided drainage using contrast-enhanced harmonic imaging

Contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) has been reported to be useful in the diagnosis of pancreatobiliary disease. CH-EUS facilitates the differentiation of the cystic component from the parenchymal component by assessing the presence of blood flow [1] [2]. Herein, we report a case of successful EUS-guided transluminal drainage (EUS-TD) for infected pancreatic fluid collection using CH-EUS.

A 56-year-old man who had undergone distal pancreatectomy for pancreatic cancer two months ago was admitted to our hospital because of fever. Contrast-enhanced computed tomography revealed a postoperative pancreatic fistula (POPF) with fluid collection around the pancreas ([Fig. 1]) and EUS-TD was attempted. Initially, we scanned the lesion with fundamental B-mode ultrasound, but the POPF was not well-recognized ([Fig. 2] a). Consequently, CH-EUS was performed to identify the spread of the POPF cavity and its margins. The initially targeted location was recognized as only minimal avascular areas ([Fig. 2] b). However, as a large avascular area was identified at another location ([Fig. 3]), EUS-TD was successfully performed ([Fig. 4], [Fig. 5]; [Video 1]). After the procedure, the patient’s symptoms resolved, and he was discharged five days later without any adverse events.

Fig. 1 Contrast-enhanced computed tomography showed large post-operative pancreatic fluid collection (yellow arrowheads).

Fig. 2 Endoscopic ultrasound images. a The initially targeted region. Despite the absence of an anechoic lesion, a mixed hypo- and hyperechoic area around the pancreas was observed under fundamental B-mode. b The initially targeted region was recognized as only minimal avascular areas (yellow arrowheads) on a contrast-enhanced harmonic image.

Fig. 3 Another location with a large avascular area (yellow arrowheads) was identified.

Fig. 4 Endoscopy image showing 7-Fr double pigtail plastic stent.

Fig. 5 Computed tomography showed a successfully deployed 7-Fr double pigtail plastic stent.

Successful endoscopic ultrasound-guided drainage for infected pancreatic fluid collection using contrast-enhanced harmonic imaging.Video 1

A POPF is usually well recognized in fundamental B-mode because of its predominantly liquid component. However, when it is composed mostly of solid components, such as necrosis, and has only a small liquid component, the boundary with the surrounding tissue is difficult to identify. In the present case, using CH-EUS the POPF cavity exhibited no enhancement owing to the absence of vascularity, whereas the surrounding tissue was enhanced. The application of CH-EUS may be useful in demarcating the boundary between the POPF cavity and its surrounding tissue in EUS-TD.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Minaga K, Kitano M, Yoshikawa T. et al. Hepaticogastrostomy guided by real-time contrast-enhanced harmonic endoscopic ultrasonography: A novel technique. Endoscopy 2016; 48: E228-E229
• 2 Minaga K, Takenaka M, Omoto S. et al. A case of successful transluminal drainage of walled-off necrosis under contrast-enhanced harmonic endoscopic ultrasonography guidance. J Med Ultrason (2001) 2018; 45: 161-165

Publication History

Article published online:
22 November 2024