Impact and safety of endoscopic ultrasound guided fine needle aspiration on patients with cirrhosis and pyrexia of unknown origin in India

Background and aims: Etiologic diagnosis of pyrexia of unknown origin is important in patients with cirrhosis for optimal management and to prevent flare up of infectious disease after liver transplantation. However, there is very limited literature available on this subject. The present study aimed to examine the safety and impact of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with cirrhosis.

Methods: The study was conducted between January 2014 and January 2016 at a tertiary care center. A total of 50 (47 lymph nodes, 3 adrenal) EUS guided FNAs were performed in 46 patients. Data are presented as median (25 – 75 IQR).

Results: The study included 46 patients (40 males) whose mean age was 47.9 ± 11.1 (SD) years; mean Child-Turcotte-Pugh (CTP) score and mean MELD (Model for End-Stage Liver Disease) score were 10 (8 – 11) and 18 (12 – 20), respectively. The Child Pugh class was A in 4, B in 14, and C in 28 (including three patients with adrenal FNAs). Indications for FNA were pyrexia of unknown origin and lymphadenopathy on CT imaging. The cytopathological diagnoses were metastatic disease in 1 (adrenal), granulomatous change in 10 (6 positive with acid fast bacilli stain), histoplasmosis in three (two adrenals, one lymph node), 32 lymph nodes were reactive and four lymph node FNAs showed inadequate cellularity. The pathologic nodes had significantly lower long-to-short axis ratio [1.25 (1.09 – 1.28) versus 1.46 (1.22 – 1.87), P = 0.020]; a higher proportion of hypoechoic echotexture (5 versus 3, P = 0.017), and sharply defined borders (4 versus 2, P = 0.029). Complications included mild hepatic encephalopathy related to sedation in two patients with Child’s C status.

Conclusion: EUS guided FNA is safe in patients with cirrhosis and modified the management in 14/46 (30.4 %) patients.

• References

• 1 Ergönül O, Willke A, Azap A et al. Revised definition of ‘fever of unknown origin’: limitations and opportunities. J Infect 2005; 50: 1-5
• 2 Cunha BA. Fever of unknown origin. New York, NY: Informa Healthcare; 2007
• 3 Fever of unknown origin. In: Longo D, Fauci A, Kasper D, (eds.) Principles of internal medicine. 18th edn. McGraw Hill; 2012: 158-164
• 4 Sharma P, Tyagi P, Singla V et al. Clinical and biochemical profile of tuberculosis in patients with liver cirrhosis. J Clin Exp Hepatol 2015; 5: 8-13
• 5 Dhiman RK, Saraswat VA, Rajekar H et al. A guide to the management of tuberculosis in patients with chronic liver disease. J Clin Exp Hepatol 2012; 2: 260-270
• 6 Duseja A, Chawla YK, Dhiman RK et al. Non-hepatic insults are common acute precipitants in patients with acute on chronic liver failure (ACLF). Dig Dis Sci 2010; 55: 3188-3192
• 7 Duseja A, Choudhary NS, Gupta S et al. APACHE II score is superior to SOFA, CTP and MELD in predicting the short-term mortality in patients with acute-on-chronic liver failure (ACLF). J Dig Dis 2013; 14: 484-490
• 8 Bhangui P, Laurent A, Amathieu R et al. Assessment of risk for non-hepatic surgery in cirrhotic patients. J Hepatol 2012; 57: 874-884
• 9 Choudhary NS, Puri R, Kotecha H et al. An uncommon etiology of adrenal enlargement and fever in a patient of cirrhosis diagnosed with EUS guided FNAC. Trop Gastroenterol 2014; 35: 258-260
• 10 Thulstrup AM, Molle I, Svendsen N et al. Incidence and prognosis of tuberculosis in patients with cirrhosis of the liver. A Danish nationwide population based study. Epidemiol Infect 2000; 124: 221-225
• 11 Baijal R, Praveenkumar HR, Amarapurkar DN et al. Prevalence of tuberculosis in patients with cirrhosis of liver in western India. Trop Doct 2010; 40: 163-164
• 12 American Thoracic Society; CDC; Infectious Diseases Society of America. Treatment of tuberculosis. MMWR Recomm Rep 2003; 52: 1-77
• 13 Self TH, Chrisman CR, Baciewicz AM et al. Isoniazid drug and food interactions. Am J Med Sci 1999; 317: 304-311
• 14 Senousy BE, Belal SI, Draganov PV. Hepatotoxic effects of therapies for tuberculosis. Nat Rev Gastroenterol Hepatol 2010; 7: 543-556
• 15 Bonnel AR, Bunchorntavakul C, Reddy KR. Immune dysfunction and infections in patients with cirrhosis. Clin Gastroenterol Hepatol 2011; 9: 727-738
• 16 Puri R, Thandassery RB, Choudhary NS et al. Endoscopic ultrasound-guided fine-needle aspiration of the adrenal glands: analysis of 21 patients. Clin Endosc 2015; 48: 165-170
• 17 Tsai H-C, Lin Y-C, Ko C-L et al. Propofol versus midazolam for upper gastrointestinal endoscopy in cirrhotic patients: a meta-analysis of randomized controlled trials. PLoS ONE 2015; 10: 1-13