EUS in pediatric patients

Transcription

1 ORIGINAL ARTICLE: Clinical Endoscopy Tan Attila, MD, Douglas G. Adler, MD, Kristen Hilden, MS, Douglas O. Faigel, MD Portland, Oregon, Salt Lake City, Utah, USA Background: The knowledge of EUS use in children is limited. Objective: We investigated the indications, feasibility, safety, and clinical utility of EUS in the management of pediatric GI, pancreatobiliary, and mediastinal diseases. Design: Retrospective study. Setting: Two tertiary referral university hospitals. Patients: Consecutive children age younger than 18 years referred over a 7-year period for EUS evaluation. Results: Forty EUS scans were performed in 38 children with a mean age of 13.5 years. The indications for pancreatobiliary endosonography were (n Z 10), solid pancreatic mass (n Z 7), cystic pancreatic mass (n Z 1), cyst in the setting of chronic (n Z 1), suspected annular pancreas (n Z 1), celiac plexus block (n Z 1), suspected common bile duct stone (n Z 1), abdominal pain and atrophic pancreas (n Z 1), ampullary adenoma (n Z 1), and abnormal MRCP in a patient with jaundice (n Z 1). The indications for gastric EUS were mucosal lesions (n Z 2) and subepithelial lesions (n Z 4). The indications for mediastinal endosonography were mediastinal masses/lymph nodes (n Z 5). The remaining evaluations were performed for esophageal stricture (n Z 1), unexplained abdominal pain (n Z 1), unexplained abdominal pain with celiac axis block (n Z 1), and perirectal fluid collection (n Z 1). EUS-guided FNA (EUS-FNA) was performed in 12 (30%) cases and established the correct diagnosis in 9 (75%). EUS-guided fine-needle injections for celiac axis block were performed in 2 (5%) cases. The procedure was successful in all patients, and no complications related to sedation, EUS, or EUS-FNA were encountered. Limitation: Retrospective study. Conclusion: EUS and EUS-FNA are feasible and safe and have a significant impact on the management of pediatric GI, pancreatobiliary, and mediastinal diseases. (Gastrointest Endosc 2009;70:892-8.) Since the introduction of EUS, the indications and diagnostic and therapeutic modalities as well as equipment design have been evolving. The role of EUS is well established in adult GI and pancreatobiliary diseases as well as lung cancer diagnosis and staging. 1 Because of the inadequate number of pediatric advanced diagnostic and therapeutic endoscopic procedures such as ERCP Abbreviations: ASA, American Society of Anesthesiologists; EUS-FNA, EUS-guided FNA; EUS-FNI, EUS-guided fine-needle injection; SD, standard deviation. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy /$36.00 doi: /j.gie and EUS to acquire and maintain proficiency for pediatric gastroenterologists, most of the advanced diagnostic and therapeutic procedures in the pediatric patients are performed by adult gastroenterologists. 2 However, the reported experience on its utility in the pediatric patient population is scant. This is because of the relatively low incidence of pancreatobiliary and GI neoplasias, presumptive limitations in the size of EUS equipment and accessories, the need for general anesthesia, and the lack of highly trained and experienced endosonographers in pediatric patients. With the refinement of techniques and advances in endosonographic design, several case reports and studies found successful use of EUS in pediatric patients. 3-8 The aim of this study was to describe clinical and demographic characteristics, indications, feasibility, safety, and impact of EUS in the pediatric patient population from 2 university hospitals. 892 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 5 :

2 Attila et al MATERIALS AND METHODS Patients All EUS procedures performed from September 2001 to September 2008 at 2 tertiary referral centers (Oregon Health & Science University, Portland, Ore, and University of Utah School of Medicine, Salt Lake City, Utah) were reviewed. Patients younger than 18 years of age were identified. The demographics, EUS indications, procedural information (instruments, sedation, American Society of Anesthesiologists [ASA] classifications, duration of the procedures, findings, interventions, outcome, and complications) were retrospectively analyzed. Procedures were performed on both an inpatient and outpatient basis. Capsule summary What is already known on this topic d There are limited studies of with regard to the low incidence of pancreatobiliary and GI neoplasia, limitations in the size of EUS equipment, the need for general anesthesia, and the lack of endosonographers with experience with pediatric patients. What this study adds to our knowledge d In a retrospective study of 38 pediatric patients undergoing EUS for various indications, the procedure was successful in all with no complications related to sedation, EUS, or EUS-FNA. Equipment and procedure All EUS procedures were performed by experienced endosonographers who independently performed more than 1000 EUS procedures in adults. All procedures were performed in facilities specialized in the care of adult patients. All patients had a radial endosonographic evaluation (GF-UM160; Olympus, Melville, NY, or EG- 3630UR; Pentax of America Inc, Montvale, NJ). Curvilinear echoendoscopes were only used after radial endosonographic examination when clinically appropriate to perform EUS-guided FNA (EUS-FNA) or EUS-guided fine-needle injection (EUS-FNI) (GF-UC140P AL5; Olympus or Pentax FG36UX; Pentax of America Inc). A 19- or 22-gauge needle occluded with a stylet (Wilson Cook Inc, Winston-Salem, NC) was used for EUS-FNA and EUS-FNI. Color Doppler examination was performed before EUS-FNA or EUS-FNI to exclude interposed vascular structures. Intravenous antibiotics were only routinely administered in case of cystic lesion sampling or in patients with jaundice. Ciprofloxacin or levofloxacin were the preferred antibiotics. Prophylactic antibiotics were not administered to patients undergoing EUS-FNI. A cytopathologist was present when each EUS-FNA procedure was performed. Three different types of sedation were used: moderate (conscious) sedation, deep sedation, and general anesthesia. Fentanyl, midazolam, promethazine, and propofol were used for sedation. Sedation was administered by the endoscopist in cases of moderate sedation and by pediatric anesthesiologists or pediatric-certified registered nurse anesthetists (n Z 21) and adult anesthesiologists or adult-certified registered nurse anesthetists (n Z 19) in cases of deep sedation or general anesthesia. The type of sedation was chosen based on the patient s age, previous experience with sedation, and comorbidities. Procedures were performed with patients in the left lateral decubitus position or prone position if the procedures were combined with ERCP. RESULTS Patient population Over the 7-year period, 40 (0.6%) of 6724 EUS procedures were performed on 38 patients younger than 18 years of age. Thirty-six patients underwent 1 endosonographic evaluation. Two patients underwent 2 endosonographic evaluations; both of them had endosonographic evaluation of the pancreatobiliary system. There were 22 (57.9%) male and 16 (42.1%) female patients. Patients ages ranged from 3 to 17 years, with a mean (standard deviation [SD]) age of 13.5 (3.6) years. Anesthesia The ASA classification of each patient for every procedure was determined; 19 patients were classified as ASA 1, 15 patients were classified as ASA 2, and 6 patients were classified as ASA 3. The majority of the EUS procedures (27/40 [67.5%]) were performed with the patients under general anesthesia with endotracheal intubation. Nine EUS procedures (22.5%) were performed with the patients under deep sedation with propofol. Four EUS procedures (10%) were performed with the patients under conscious sedation with midazolam, meperidine, and/or fentanyl. Procedure information Thirty-nine upper and 1 lower EUS examinations were performed. Procedure durations were recorded in 33 cases; the average (SD) procedure duration was 40 (18) minutes. The pancreatobiliary system was endosonographically evaluated in 25 cases (62.5%) (Table 1). Indications in these patients were as follows: recurrent/chronic or suspected in 10 (40%) cases, solid pancreatic mass in 7 (17.5%) cases, cystic pancreatic mass in 1 (2.5%) case, a cyst in the setting of in 1 (2.5%) case, suspected annular pancreas in 1 (2.5%) case, celiac plexus blockade in the setting of in 1 (2.5%) case, Volume 70, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY 893

3 Attila et al TABLE 1. Major EUS findings in pediatric patients Sex/age (y) Indication Size (mm) No. of FNA passes Findings Intervention Comorbidities Pancreatobiliary cases M/7 Recurrent M/16 Recurrent M/13 Recurrent M/13 Pancreatitis Periportal LN: 25 M/13 Pancreatitis, pancreatobiliary ductal dilation 4, LN Acute, no ductal dilation h/o mid-pd disruption and PD stenting, s/p distal pancreatectomy UC, s/p colectomy F/17 Recurrent F/16 Abdominal pain, suspected chronic F/17 Abdominal pain, suspected, [ amylase M/14 Suspected chronic F/13 Dilated CBD on CT, acute M/14 Pancreatic head mass LN: 9 5 Focal LN, ( )Cx UC F/16 Pancreatic mass F/11 Pancreatic head mass Pancreatitis M/15 Pancreatic mass F/11 Suspected pancreatic mass at the HOP M/14 Pancreatic mass, jaundice 3 Prominent HOP,, no mass, normal cytology 40 3 B-cell lymphoma ERCP, chemotherapy F/16 Pancreatic cystic mass 12 4 Islet cell tumor Whipple MEN M/5 Pancreatitis, enlarging pseudocyst Cyst: 30, pancreatic pseudocyst F/15 Abdominal pain, suspected annular pancreas h/o TEF, esophageal and duodenal atresia, s/p surgical repair F/17 Celiac plexus block (chronic ) Celiac axis block h/o biliary atresia, s/p OLT F/14 Suspected biliary stones CBD stones ERCP M/8 Abdominal pain, atrophic pancreas Dorsal agenesis of the pancreas (continued on next page) 894 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 5 :

4 Attila et al TABLE 1 (Continued) Sex/age (y) Indication Size (mm) No. of FNA passes Findings Intervention Comorbidities M/17 Ampullary mass 20 Ampullary adenoma ERCP, ampullectomy F/16 Abnormal biliary tree on MRCP, jaundice, PSC M/10 Pancreatic head mass, jaundice Gastric cases Distal CBD narrowing, no mass 41 7 Suspicious for malignancy ERCP Whipple (LPSP) F/17 Gastric mass Gastric ulcer M/16 Prepyloric submucosal mass 20 Subepithelial cyst/mass EMR (reduplication cyst) M/16 Gastric mass 47 4 Subepithelial lesion, negative for malignancy F/15 Gastric mass 11 Subepithelial lesion, pancreatic rest M/16 Gastric polyps 15 Subepithelial lesion, pancreatic rest Surgery (lipoma) Reduplication cysts M/17 Gastric polyps 15 Mucosal polyp Polypectomy, adenocarcinoma CVIS, ring chromosome, mental retardation Mediastinal cases F/15 Mediastinal mass LN: 13 8 LN, ( )Cx M/12 Mediastinal mass LN: 29 8 LN, ( )Cx SGES, dysmorphic M/11 Mediastinal mass LN: 37 6 LN, ( )Cx F/14 Mediastinal mass 60 6 Negative for malignancy M/7 Mediastinal mass 86 9 Burkitt s lymphoma Other cases M/3 Esophageal stricture Tracheobronchial remnant M/17 Abdominal pain Thoracotomy (ganglioneuroma) Chemotherapy s/p kidney transplantation M/15 Idiopathic abdominal pain, celiac plexus block F/12 Perirectal fluid collection Perirectal abscess Pain persists h/o, History of; PD, pancreatic duct; s/p, status post; LN, lymph node; UC, ulcerative colitis; Cx, culture; HOP, head of the pancreas; MEN, multiple endocrine neoplasia; TEF, tracheoesophageal fistula; OLT, orthotrophic liver transplantation; CBD, common bile duct; LPSP, lymphoplasmocytic sclerosing ; CVIS, common variable immunodeficiency syndrome; SGES, Simpson-Golabi-Escobar syndrome. suspected common bile duct stone in 1 (2.5%) case, abdominal pain and atrophic pancreas in 1 (2.5%) case, ampullary adenoma in 1 (2.5%) case, and an abnormal MRCP in a patient with jaundice in 1 (2.5%) case. EUS criteria for chronic described by Catalano et al 9 were used. Ductal criteria include dilation of the main pancreatic duct (O3 mm), tortuous pancreatic duct, intraductal echogenic foci, echogenic ductal wall, Volume 70, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY 895

5 Attila et al TABLE 2. Comparisons of pediatric EUS series Sedation, no. (%) Study No. patients No. EUS Age (y), range (mean) NS CS DS GA Roseau et al, (12) (100) 0 Varadarajulu et al, (13) (100) Cohen et al, (12) 2 (6) 18 (56) 0 12 (38) This study (13.5) 0 4 (10) 9 (22.5) 27 (67.5) NS, No sedation; CS, conscious sedation; DS, deep sedation; GA, general anesthesia; PB, pancreatobiliary. and ectatic side branches. Parenchymal criteria include inhomogeneous echo pattern, foci of reduced echogenicity, foci of increased echogenicity, prominent interlobular septa, lobular outer gland margin, and large echo-free cavities (O5 mm). Among 10 patients who had suspected or chronic/recurrent as indication for EUS, 4 patients fulfilled endosonographic criteria for chronic, 1 patient fulfilled endosonographic criteria for acute, and 4 patients had endosonographically normal appearing pancreas. EUS confirmed the presence of a 30-mm pseudocyst in the setting of chronic. One patient with abdominal pain and increased lipase was found to have an endosonographically normal-appearing pancreas. One patient with a congenital duodenal stricture and recurrent abdominal pain was clinically suspected to have annular pancreas, but CT and magnetic resonance imaging/mrcp of the pancreas were nondiagnostic. EUS confirmed the absence of an annular pancreas. All our pediatric patients with and/ or a pancreatic mass were evaluated by blood work (immunoglobulin G4 and antinuclear antibody) and endosonographic criteria, and none had a diagnosis of autoimmune. Among 7 patients with a solid pancreatic mass on imaging, 1 patient had focal, 2 patients had chronic diffuse, and 1 patient had an endosonographically normal pancreas. One patient with a suspected mass at the head of the pancreas was found to have a prominent pancreatic head in the setting of pancreatic parenchymal changes consistent with ; EUS-FNA of the head of the pancreas did not reveal any malignancy. One patient with a 40-mm lesion was found to have a B-cell lymphoma on EUS-FNA samples, and 1 patient with a 41-mm mass at the head of the pancreas was found to have cells suspicious for malignancy on EUS-FNA samples. The last patient underwent a pancreaticoduodenectomy; histopathologic evaluation of the resected mass revealed lymphoplasmacytic sclerosing. A patient with a 12-mm cystic mass in the pancreatic head was found to have an islet cell tumor on EUS-FNA samples. This patient underwent a Whipple procedure. A patient with a 20-mm endosonographically noninvasive ampullary adenoma underwent a subsequent ampullectomy. One patient with chronic abdominal pain in the setting of chronic underwent EUS-guided celiac blockade; the patient had temporary improvement of pain lasting approximately 8 weeks. In another patient, EUS confirmed the presence of a common bile duct stone; this patient then underwent ERCP for stone retrieval. A patient with abdominal pain underwent EUS, which revealed pancreatic atrophy that was thought to represent dorsal agenesis of the pancreas. EUS confirmed distal CBD narrowing found on MRCP without any endosonographic evidence of an obstructing mass. This patient underwent ERCP; evaluation of brushing samples of the narrowed biliary segment found that they were negative for a malignancy. Evaluation of gastric lesions (masses/polyps) was the indication for EUS in 6 (15%) of 40 patients (Table 1). One of the patients who was referred for an endosonographic evaluation of a gastric mass was found to have a benign gastric ulcer. Four patients were referred for endosonographic evaluation of gastric subepithelial lesions with unremarkable findings on previous mucosal biopsy samples. The maximal diameter of these lesions ranged from 11 mm to 47 mm, with an average (SD) size of (16.25) mm. The endosonographic characteristics of 2 of these lesions were consistent with those of pancreatic rest. EUS-FNA was not performed on these 2 lesions. The endosonographic characteristics of a gastric subepithelial lesion (widest size 47 mm) were suggestive of a possible lipoma. The EUS-FNA (4 passes) of the lesion was negative for a malignancy and did not confirm a lipoma either. Therefore, this patient underwent a surgical resection; histopathological examination of the resected mass confirmed the diagnosis of lipoma. The other subepithelial prepyloric lesion (widest size 20 mm) had cystic and solid components on endosonographic evaluation. The histopathology of the lesion that was removed with the EMR technique showed a reduplication cyst. Given the fact that the base of the EMR site looked suspicious for a possible perforation, this patient was admitted to the hospital for observation. The patient did well and was discharged home in stable condition the day after the procedure. A 17-year-old male patient with common variable immunodeficiency syndrome and mental retardation was referred to us for endosonographic 896 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 5 :

6 Attila et al TABLE 2 (Continued) Indications, no. (%) PB Stomach Mediastinum Esophagus Rectum Other FNA, no. (%) FNI, no. (%) 9 (39) 6 (26) 0 1 (4) 6 (26) 1 (4) (100) (20) 0 19 (59) 2 (6.5) 0 8 (25) 2 (6.5) 1 (3) 7 (22) 0 25 (62.5) 6 (15) 5 (12.5) 1 (2.5) 1 (2.5) 2 (5) 12 (30) 2 (5) evaluation of gastric polyps. Previous biopsy samples showed tubular adenoma with high-grade dysplasia. Endosonographically, the polyps (widest size 20 mm) were confined to the mucosa. The histopathology of the polyps showed adenocarcinoma. This patient underwent a gastrectomy. Mediastinal mass and lymph node evaluation was the indication for EUS in 5 (12.5%) of 40 procedures (Table 1). EUS-FNA was performed on all the mediastinal lesions. The measurement of the maximal diameter of the mediastinal lesions ranged from 13 mm to 86 mm, with an average (SD) size of 45 (28.5) mm. The EUS-FNA samples of 3 lesions showed benign lymph nodes with negative cultures. The maximal diameters of these 3 lesions were 13, 29, and 37 mm. The results of EUS-FNA of a mediastinal mass (widest size 60 mm) were negative for a malignancy. This patient subsequently underwent a thoracotomy, and the diagnosis was a ganglioneuroma. The EUS-FNA of another mediastinal mass (widest size 86 mm) showed Burkitt s lymphoma, for which chemotherapy was subsequently started. The indication of 1 procedure was esophageal stricture in a patient with congenital atresia: EUS revealed a tracheobronchial remnant. One patient who was referred for abdominal pain of unexplained underlying cause had normal findings on an endosonographic evaluation. Another patient with idiopathic abdominal pain had persistence of pain despite an EUS-FNI for celiac axis block. The only patient who had a lower EUS evaluation for perirectal fluid collection had an endosonographically confirmed perirectal abscess (Table 1). EUS-FNA was performed in 12 (30%) patients (Table 1). The diagnosis of Burkitt s lymphoma was established by EUS-FNA of a mediastinal mass, and the diagnosis of islet cell tumor and B-cell lymphoma was established by EUS- FNA of pancreatic masses. The diagnosis of malignancy was excluded in 5 patients by EUS-FNA of lymph nodes. A diagnosis of malignancy was excluded in 1 patient with a prominent pancreatic head by EUS-FNA of the head of the pancreas. In a case of a mediastinal mass and a gastric subepithelial mass, EUS-FNAs produced false-negative results. The diagnoses of ganglioneuroma and lipoma were established by thoracotomy and partial gastric resection, respectively. In a case of lymphoplasmacytic sclerosing, EUS-FNA results were falsely suspicious for a malignancy. The correct diagnosis was established after a Whipple pancreatectomy. EUS-FNA established the correct diagnosis in 9 (75%) of 12 patients and missed the correct diagnosis in 3 (25%) of 12 patients. EUS-FNI for celiac axis block was performed in 2 (5%) cases. No acute or delayed complications occurred relating to the EUS-FNA or FNI. The procedures were technically successful in all patients, and no acute or delayed complications related to sedation, EUS, EUS-FNAs, or FNIs were encountered. Only 1 patient was admitted to the hospital for observation after an endoscopic mucosal resection of a subepithelial partially cystic lesion. DISCUSSION Although the role of EUS is well established in adult GI and pancreatobiliary diseases as well as lung cancer diagnosis and staging (1), there is relatively little in the literature regarding the use of. Although the usefulness of EUS in children has been only recently appreciated, 3-8 published studies remain limited to a few patients and single-center experiences. Table 2 summarizes the comparison of the current study with the previously published series. The current study, however, illustrates the experience of 2 tertiary referral centers with the largest number of cases reported so far and evaluates various pediatric pathologies involving the GI tract, pancreatobiliary system, and mediastinum. Another unique feature of this study was that 30% of pediatric patients underwent EUS- FNA. We found that standard adult EUS equipment and accessories could be used in all patients to successfully perform procedures in children 3 years of age or older. Indications for EUS in children were similar to those for adults, but children have a much lower incidence of neoplastic diseases. Only 6 (15%) of our patients eventually had a diagnosis of a neoplasm. Disorders of the pancreatobiliary system were the primary indication in the majority of our cases (25 cases [62.5%]). This finding is in keeping with the previously published studies (Table 2). EUS supplanted Volume 70, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY 897

7 Attila et al ERCP in 21 (84%) of 25 pancreatobiliary patients. Only 4 (16%) patients subsequently underwent therapeutic ERCP. Similar to adults, diagnostic ERCP may be replaced with less-invasive techniques, including EUS, in children. 4 A common indication for gastric EUS in our patients was subepithelial lesions. Although the incidence of subepithelial lesions in the pediatric population is not known, its incidence in the general population is 0.4% in diagnostic endoscopies. 10 EUS has a unique feature of differentiating gut wall layers, the origin of subepithelial lesions, intramural vascular structures, as well as extraluminal structures. In addition, the ability to obtain a tissue diagnosis from subepithelial tumors through EUS-FNA has placed EUS in a pivotal position in the diagnostic workup of subepithelial lesions. Pediatric mediastinal masses are a heterogeneous group of asymptomatic or potentially life-threatening congenital, infectious, and neoplastic diseases. They represent a diagnostic and therapeutic challenge. Transesophageal EUS with FNA allows assessment and biopsy of posterior and middle mediastinal lesions. To our knowledge, this is the first report of experience with EUS in mediastinal diseases in pediatric patients. In our patients, all the mediastinal lesions were solid masses. EUS-FNA was performed in all the mediastinal lesions without any acute or delayed complications. Three of the solid mediastinal masses were benign lymph nodes. Two other lesions were neoplastic diseases. Although some of the pediatric EUS scans were done with the patients under intravenously administered moderate sedation, the majority of pediatric EUS scans in our series were done with the patients under general anesthesia. This is the major difference in performing EUS in children and adults. The patient s condition (ASA classification), the anticipated level of cooperation from the patient especially during EUS-FNA, the relatively longer duration of EUS procedures, the parents and patient s preference, as well as the endoscopist s personal preference are the major factors that may influence the choice of sedation during pediatric EUS procedures. However, there are no sufficient outcome data to make recommendations about the adequacy, safety, and cost of intravenously administered moderate sedation versus general anesthesia for EUS in the pediatric patient population. In conclusion, EUS and EUS-FNA are safe and have a significant impact on the management of pediatric GI, pancreatobiliary, and mediastinal diseases. EUS allows one to avoid more invasive and higher-risk procedures such as ERCP, laparoscopy, and mediastinoscopy. For the gastroenterologist performing these procedures in adults, knowledge of common congenital abnormalities of the GI and pancreaticobiliary tracts is important. The gastroenterologist endosonographer treating adults should also have close communication with colleagues in pediatric GI and surgery. Although standard-size instruments may be used even in younger children, the need for deeper levels of sedation and maintenance of a patent airway will frequently require the assistance of anesthesia services. REFERENCES 1. LeBlanc JK, DeWitt J, Sherman S. Endoscopic ultrasound: how does it aid the surgeon? Adv Surg 2007;41: Lee KK, Anderson MA, Baron TH, et al. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc 2008;67: Roseau G, Palazzo L, Dumontier I, et al. Endoscopic ultrasonography in the evaluation of pediatric digestive diseases: preliminary results. Endoscopy 1998;30: Varadarajulu S, Wilcox CM, Eloubeidi MA. Impact of EUS in the evaluation of pancreaticobiliary disorders in children. Gastrointest Endosc 2005;62: Cohen S, Kalinin M, Yaron A, et al. Endoscopic ultrasonography in pediatric patients with GI disorders. J Pediatr Gastroenterol Nutr 2008;46: Fox VL, Nurko S, Teitelbaum JE, et al. High-resolution EUS in children with eosinophilic allergic esophagitis. Gastrointest Endosc 2003;57: Nadler EP, Novikov A, Landzberg BR, et al. The use of endoscopic ultrasound in the diagnosis of solid pseudopapillary tumors of the pancreas in children. J Pediatr Surg 2002;37: Usui N, Kamata S, Kawahara H, et al. Usefulness of endoscopic ultrasonography in the diagnosis of congenital esophageal stenosis. J Pediatr Surg 2002;37: Catalano MF, Lahoti S, Geenen JE, et al. Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic. Gastrointest Endosc 1998;48: Hedenbro JL, Ekelund M, Wetterberg P. Endoscopic diagnosis of submucosal gastric lesions. The results after routine endoscopy. Surg Endosc 1991;5:20-3. Received October 17, Accepted April 10, Current affiliations: Division of Gastroenterology and Hepatology (T.A., D.O.F.), Oregon Health & Science University, Portland, Oregon, Division of Gastroenterology and Hepatology (D.G.A., K.H.), University of Utah, Salt Lake City, Utah, USA. Reprint requests: Douglas O. Faigel, MD, Oregon Health & Science University, Physician s Pavilion, Suite 310, 3181 SW Sam Jackson Park Road, Portland, OR GASTROINTESTINAL ENDOSCOPY Volume 70, No. 5 :