A 48-year-old man presented with dysphagia, lower retrosternal pain
following food ingestion, and significant weight loss. Clinical examination
found epigastric pain during palpation, while laboratory workup revealed only
an elevated erythrocyte sedimentation rate.
Upper endoscopy visualized an intraluminal mass in the lower
esophagus ([Fig. 1]), which was shown by biopsy to
be a poorly differentiated squamous cell carcinoma ([Fig. 2]). Computed tomography (CT) scan and
endoscopic ultrasound (EUS) were performed and indicated a T3N1 esophageal
malignancy. EUS also visualized conglomerated lymph nodes in the vicinity of
the celiac trunk and adjacent to the left liver lobe. EUS-guided fine-needle
aspiration (EUS-FNA) was performed with a 25-G needle without immediate
complications ([Fig. 3]). Cytology smears showed
clumps of squamous cells with nuclear atypia, in a background of leukocytes
([Fig. 4]).
Fig. 1 Upper gastrointestinal
endoscopy showed an ulcerated, exophytic tumor in the lower esophagus.
Fig. 2 Poorly differentiated
squamous cell carcinoma (hematoxylin and eosin × 100).
Fig. 3 Endoscopic
ultrasound-guided fine-needle aspiration of the hypoechoic, inhomogeneous mass
of 5 cm diameter localized in the vicinity of the pancreatic head.
Fig. 4 Positive cytology smear
showing clumps of atypical epithelial cells (May-Grünwald-Giemsa
× 200).
Four days later, the patient developed fever, severe diffuse
abdominal pain with tenderness, and high white blood cell count. The patient
was referred for surgery where laparoscopic intervention revealed necrosis of
the celiac lymph nodes with generalized peritonitis. Excision of the abdominal
lymph nodes was performed with peritoneal lavage and multiple drainage, with an
improvement in the patient's general and local status.
EUS can accurately assess local tumor infiltration (T stage) and
detect regional or distant lymph nodes metastases (N and M stage). Moreover,
EUS-FNA significantly improves the specificity by enabling cytological
diagnosis [1]. To the best of our knowledge this is the
first reported case of peritonitis after EUS-FNA of a large metastatic celiac
lymph node, although there are several reported cases of mediastinitis
following EUS-FNA of mediastinal masses [2]
[3]. Antibiotic prophylaxis is not required for EUS-FNA of
lymph nodes or solid lesions, being generally considered a safe, minimally
invasive procedure with a low risk for bacteremia [4].
However, the presented case should make endosonographers more aware of the
potential serious complications of EUS-FNA.
Endoscopy_UCTN_Code_CPL_1AL_2AF
