CASES OF THE WEEK – “Abdominal Lymph nodes (peripancreatic and periportal) Tuberculosis diagnosed by Endoscopic Ultrasound (EUS) - FNA with ROSE (Rapid-on-site evaluation)” by Dr Piyush Somani, Specialist Gastroenterology

Abdominal Lymph nodes (peripancreatic and periportal) Tuberculosis diagnosed by Endoscopic Ultrasound (EUS) - FNA with ROSE (Rapid-on-site evaluation)

A 34 years old male, presented with intermittent upper abdominal pain since two months with no fever/weight loss. He underwent CT abdomen with contrast suggestive of multiple peripancreatic/periportal lymph nodes. In view of close proximity to blood vessels, USG or CT guided biopsy was not possible. Patient was referred for Endoscopic Ultrasound (EUS) - Fine Needle Aspiration (FNA) to make the final diagnosis.

Patient underwent EUS as day case procedure.

The EUS revealed multiple, rounded, well defined lymph nodes; heterogeneous echotexture predominantly hypoechoic with anechoic necrotic areas of different sizes (largest 22 mm x 15 mm) in the peripancreatic/periportal region. Using 22 gauge needle, multiple passes were taken and the material was sent for FNAC/biopsy/TB PCR/TB culture/AFB stain.

ROSE (Rapid-on-site evaluation) of the FNA sample was performed inside the OT by Dr. Ehsan Ahmed (Specialist Anatomical pathologist) which revealed caseation necrosis with granuloma suggestive of Tuberculosis. Patient underwent treatment for tuberculosis with improvement in his abdominal pain.

During routine ultrasound abdomen, enlarged abdominal lymph nodes are routinely encountered. However, some regions (peripancreatic/periportal/aortocaval/precaval and celiac) lymph nodes and large size of the lymph nodes (more than 1 cm) can be pathological which requires biopsy/FNAC. CT or USG guided biopsy in such difficult locations can be associated with complications and are not always feasible.

EUS from stomach or duodenum can easily sample tissue from abdominal lymph nodes without any major complications and with ROSE, the diagnosis can be achieved in 15-20 minutes.

In summary, EUS with ROSE helps in making diagnosis in difficult locations of abdominal lymph nodes near blood vessels.

This facility is available only in few hospitals in UAE.