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Endoscopic ultrasound-guided fine-needle aspiration biopsy in the gastrointestinal tract

Maurits J Wiersema, MD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Endoscopic ultrasonography (EUS) has evolved from a diagnostic imaging modality to one that can also be used for invasive diagnostic and therapeutic procedures. These advances are largely due to the introduction of linear scanning instruments that can be used to place devices into the ultrasound plane of view, permitting various interventions to be performed. The ability of EUS to guide a biopsy needle into lesions that are too small to be identified by computed tomography or magnetic resonance imaging, or too well encased by surrounding vascular structures to allow percutaneous biopsy, secures its role in a variety of clinical settings.

Indications for EUS-guided fine-needle aspiration (EUS-FNA) include biopsy of mucosal and submucosal lesions in which prior conventional endoscopic biopsies have been nondiagnostic. The procedure is most commonly used to sample peri-intestinal structures such as lymph nodes and masses in the pancreas, liver, adrenal gland, and bile duct. It has also been used to aspirate peritoneal and pleural fluid.

This topic review will summarize experience with EUS-FNA in the gastrointestinal tract. A discussion on EUS-guided trucut biopsy is presented separately. (See "Endoscopic ultrasound-guided trucut biopsy".)


A number of different endoscopic ultrasound (EUS) devices are available. Most are similar to standard endoscopic instruments in that they have biopsy channels and video or fiberoptic endoscopic capability. They differ from normal endoscopes by having sophisticated ultrasound transmission and reception capability at the tip of the instrument.

"Linear" instruments scan in the same plane as the long axis of the endoscope, whereas mechanical "radial" instruments have a rotating mechanical ultrasound probe that scans in a circle at 90 degrees to the long axis of the endoscope. The ultrasound signal is then integrated by a complex processor and transmitted in real time to a video screen. Until recently, electronic (linear) and mechanical (radial) EUS instruments required separate processors, adding significantly to the cost of providing a comprehensive EUS service. However, 360-degree electronic radial echoendoscopes have been developed, allowing for use of a curvilinear array and a radial echoendoscope by a single processor, thus economizing EUS service.

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Literature review current through: Oct 2017. | This topic last updated: Feb 04, 2016.
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  1. Gress FG, Hawes RH, Savides TJ, et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography. Gastrointest Endosc 1997; 45:243.
  2. Iglesias-Garcia J, Poley JW, Larghi A, et al. Feasibility and yield of a new EUS histology needle: results from a multicenter, pooled, cohort study. Gastrointest Endosc 2011; 73:1189.
  3. Wallace MB, Kennedy T, Durkalski V, et al. Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy. Gastrointest Endosc 2001; 54:441.
  4. Chen AM, Thosani NC, Friedland S, et al. 99 Prospective randomized blind controlled trial of capillary EUS-FNA vs. suction EUS-FNA for the diagnosis of solid tumors. Gastrointest Endosc 2014; 79.
  5. LeBlanc JK, Ciaccia D, Al-Assi MT, et al. Optimal number of EUS-guided fine needle passes needed to obtain a correct diagnosis. Gastrointest Endosc 2004; 59:475.
  6. Erickson RA, Sayage-Rabie L, Beissner RS. Factors predicting the number of EUS-guided fine-needle passes for diagnosis of pancreatic malignancies. Gastrointest Endosc 2000; 51:184.
  7. Van Dam J, Brady PG, Freeman M, et al. Guidelines for training in electronic ultrasound: guidelines for clinical application. From the ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1999; 49:829.
  8. Eisen GM, Dominitz JA, Faigel DO, et al. Guidelines for credentialing and granting privileges for endoscopic ultrasound. Gastrointest Endosc 2001; 54:811.
  9. Ardengh JC, de Paulo GA, Ferrari AP. EUS-guided FNA in the diagnosis of pancreatic neuroendocrine tumors before surgery. Gastrointest Endosc 2004; 60:378.
  10. Turner BG, Cizginer S, Agarwal D, et al. Diagnosis of pancreatic neoplasia with EUS and FNA: a report of accuracy. Gastrointest Endosc 2010; 71:91.
  11. Pais SA, Al-Haddad M, Mohamadnejad M, et al. EUS for pancreatic neuroendocrine tumors: a single-center, 11-year experience. Gastrointest Endosc 2010; 71:1185.
  12. Warshaw AL, Compton CC, Lewandrowski K, et al. Cystic tumors of the pancreas. New clinical, radiologic, and pathologic observations in 67 patients. Ann Surg 1990; 212:432.
  13. Ahmad NA, Kochman ML, Lewis JD, Ginsberg GG. Can EUS alone differentiate between malignant and benign cystic lesions of the pancreas? Am J Gastroenterol 2001; 96:3295.
  14. Sedlack R, Affi A, Vazquez-Sequeiros E, et al. Utility of EUS in the evaluation of cystic pancreatic lesions. Gastrointest Endosc 2002; 56:543.
  15. Song MH, Lee SK, Kim MH, et al. EUS in the evaluation of pancreatic cystic lesions. Gastrointest Endosc 2003; 57:891.
  16. Ahmad NA, Kochman ML, Brensinger C, et al. Interobserver agreement among endosonographers for the diagnosis of neoplastic versus non-neoplastic pancreatic cystic lesions. Gastrointest Endosc 2003; 58:59.
  17. Brandwein SL, Farrell JJ, Centeno BA, Brugge WR. Detection and tumor staging of malignancy in cystic, intraductal, and solid tumors of the pancreas by EUS. Gastrointest Endosc 2001; 53:722.
  18. Frossard JL, Amouyal P, Amouyal G, et al. Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions. Am J Gastroenterol 2003; 98:1516.
  19. Hammel P, Levy P, Voitot H, et al. Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas. Gastroenterology 1995; 108:1230.
  20. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004; 126:1330.
  21. Linder JD, Geenen JE, Catalano MF. Cyst fluid analysis obtained by EUS-guided FNA in the evaluation of discrete cystic neoplasms of the pancreas: a prospective single-center experience. Gastrointest Endosc 2006; 64:697.
  22. Hammel PR, Forgue-Lafitte ME, Lévy P, et al. Detection of gastric mucins (M1 antigens) in cyst fluid for the diagnosis of cystic lesions of the pancreas. Int J Cancer 1997; 74:286.
  23. Bartsch D, Bastian D, Barth P, et al. K-ras oncogene mutations indicate malignancy in cystic tumors of the pancreas. Ann Surg 1998; 228:79.
  24. Lumsden A, Bradley EL 3rd. Pseudocyst or cystic neoplasm? Differential diagnosis and initial management of cystic pancreatic lesions. Hepatogastroenterology 1989; 36:462.
  25. Maire F, Couvelard A, Hammel P, et al. Intraductal papillary mucinous tumors of the pancreas: the preoperative value of cytologic and histopathologic diagnosis. Gastrointest Endosc 2003; 58:701.
  26. Chang KJ, Nguyen P, Erickson RA, et al. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointest Endosc 1997; 45:387.
  27. Wiersema MJ, Vilmann P, Giovannini M, et al. Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology 1997; 112:1087.
  28. Bhutani MS, Hawes RH, Hoffman BJ. A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for diagnosis of malignant lymph node invasion. Gastrointest Endosc 1997; 45:474.
  29. Binmoeller KF, Brand B, Thul R, et al. EUS-guided, fine-needle aspiration biopsy using a new mechanical scanning puncture echoendoscope. Gastrointest Endosc 1998; 47:335.
  30. Reed CE, Mishra G, Sahai AV, et al. Esophageal cancer staging: improved accuracy by endoscopic ultrasound of celiac lymph nodes. Ann Thorac Surg 1999; 67:319.
  31. Lewis JD, Faigel DO, Dowdy Y, et al. Hodgkin's disease diagnosed by endoscopic ultrasound-guided fine needle aspiration of a periduodenal lymph node. Am J Gastroenterol 1998; 93:834.
  32. Chen VK, Eloubeidi MA. Endoscopic ultrasound-guided fine needle aspiration is superior to lymph node echofeatures: a prospective evaluation of mediastinal and peri-intestinal lymphadenopathy. Am J Gastroenterol 2004; 99:628.
  33. Ribeiro A, Vazquez-Sequeiros E, Wiersema LM, et al. EUS-guided fine-needle aspiration combined with flow cytometry and immunocytochemistry in the diagnosis of lymphoma. Gastrointest Endosc 2001; 53:485.
  34. Wiersema MJ, Gatzimos K, Nisi R, Wiersema LM. Staging of non-Hodgkin's gastric lymphoma with endosonography-guided fine-needle aspiration biopsy and flow cytometry. Gastrointest Endosc 1996; 44:734.
  35. Pilotti S, Di Palma S, Alasio L, et al. Diagnostic assessment of enlarged superficial lymph nodes by fine needle aspiration. Acta Cytol 1993; 37:853.
  36. Giovannini M, Seitz JF, Monges G, et al. Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients. Endoscopy 1995; 27:171.
  37. Ando N, Goto H, Niwa Y, et al. The diagnosis of GI stromal tumors with EUS-guided fine needle aspiration with immunohistochemical analysis. Gastrointest Endosc 2002; 55:37.
  38. Wieczorek TJ, Faquin WC, Rubin BP, Cibas ES. Cytologic diagnosis of gastrointestinal stromal tumor with emphasis on the differential diagnosis with leiomyosarcoma. Cancer 2001; 93:276.
  39. Fernández-Esparrach G, Sendino O, Solé M, et al. Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study. Endoscopy 2010; 42:292.
  40. Elliott DD, Fanning CV, Caraway NP. The utility of fine-needle aspiration in the diagnosis of gastrointestinal stromal tumors: a cytomorphologic and immunohistochemical analysis with emphasis on malignant tumors. Cancer 2006; 108:49.
  41. Akahoshi K, Sumida Y, Matsui N, et al. Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration. World J Gastroenterol 2007; 13:2077.
  42. Avritscher R, Gupta S. Gastrointestinal stromal tumor: role of interventional radiology in diagnosis and treatment. Hematol Oncol Clin North Am 2009; 23:129.
  43. Watson RR, Binmoeller KF, Hamerski CM, et al. Yield and performance characteristics of endoscopic ultrasound-guided fine needle aspiration for diagnosing upper GI tract stromal tumors. Dig Dis Sci 2011; 56:1757.
  44. Chang KJ, Albers CG, Nguyen P. Endoscopic ultrasound-guided fine needle aspiration of pleural and ascitic fluid. Am J Gastroenterol 1995; 90:148.
  45. Kaushik N, Khalid A, Brody D, McGrath K. EUS-guided paracentesis for the diagnosis of malignant ascites. Gastrointest Endosc 2006; 64:908.
  46. DeWitt J, LeBlanc J, McHenry L, et al. Endoscopic ultrasound-guided fine-needle aspiration of ascites. Clin Gastroenterol Hepatol 2007; 5:609.
  47. Nguyen P, Feng JC, Chang KJ. Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) of liver lesions. Gastrointest Endosc 1999; 50:357.
  48. DeWitt J, LeBlanc J, McHenry L, et al. Endoscopic ultrasound-guided fine needle aspiration cytology of solid liver lesions: a large single-center experience. Am J Gastroenterol 2003; 98:1976.
  49. Singh P, Erickson RA, Mukhopadhyay P, et al. EUS for detection of the hepatocellular carcinoma: results of a prospective study. Gastrointest Endosc 2007; 66:265.
  50. Chang KJ, Erickson RA, Nguyen P. Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration of the left adrenal gland. Gastrointest Endosc 1996; 44:568.
  51. Annema JT, Veseliç M, Rabe KF. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of sarcoidosis. Eur Respir J 2005; 25:405.
  52. DeWitt J, Misra VL, Leblanc JK, et al. EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results. Gastrointest Endosc 2006; 64:325.
  53. Wu LM, Jiang XX, Gu HY, et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy in the evaluation of bile duct strictures and gallbladder masses: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2011; 23:113.
  54. DeWitt J, Jowell P, Leblanc J, et al. EUS-guided FNA of pancreatic metastases: a multicenter experience. Gastrointest Endosc 2005; 61:689.
  55. Williams DB, Sahai AV, Aabakken L, et al. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut 1999; 44:720.
  56. O'Toole D, Palazzo L, Arotçarena R, et al. Assessment of complications of EUS-guided fine-needle aspiration. Gastrointest Endosc 2001; 53:470.
  57. Eloubeidi MA, Tamhane A, Varadarajulu S, Wilcox CM. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006; 63:622.
  58. Mergener K, Jowell PS, Branch MS, Baillie J. Pneumoperitoneum complicating ERCP performed immediately after EUS-guided fine needle aspiration. Gastrointest Endosc 1998; 47:541.
  59. Levy MJ, Abu Dayyeh BK, Fujii LL, et al. Prospective evaluation of adverse events following lower gastrointestinal tract EUS FNA. Am J Gastroenterol 2014; 109:676.
  60. Katanuma A, Maguchi H, Hashigo S, et al. Tumor seeding after endoscopic ultrasound-guided fine-needle aspiration of cancer in the body of the pancreas. Endoscopy 2012; 44 Suppl 2 UCTN:E160.
  61. Shah JN, Fraker D, Guerry D, et al. Melanoma seeding of an EUS-guided fine needle track. Gastrointest Endosc 2004; 59:923.
  62. Paquin SC, Gariépy G, Lepanto L, et al. A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastrointest Endosc 2005; 61:610.
  63. Doi S, Yasuda I, Iwashita T, et al. Needle tract implantation on the esophageal wall after EUS-guided FNA of metastatic mediastinal lymphadenopathy. Gastrointest Endosc 2008; 67:988.
  64. Hirooka Y, Goto H, Itoh A, et al. Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. J Gastroenterol Hepatol 2003; 18:1323.
  65. Chong A, Venugopal K, Segarajasingam D, Lisewski D. Tumor seeding after EUS-guided FNA of pancreatic tail neoplasia. Gastrointest Endosc 2011; 74:933.
  66. Yoon WJ, Daglilar ES, Fernández-del Castillo C, et al. Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: the PIPE Study. Endoscopy 2014; 46:382.
  67. Ngamruengphong S, Xu C, Woodward TA, et al. Risk of gastric or peritoneal recurrence, and long-term outcomes, following pancreatic cancer resection with preoperative endosonographically guided fine needle aspiration. Endoscopy 2013; 45:619.
  68. Eloubeidi MA, Gress FG, Savides TJ, et al. Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States. Gastrointest Endosc 2004; 60:385.
  69. Barawi M, Gottlieb K, Cunha B, et al. A prospective evaluation of the incidence of bacteremia associated with EUS-guided fine-needle aspiration. Gastrointest Endosc 2001; 53:189.
  70. Levy MJ, Norton ID, Wiersema MJ, et al. Prospective risk assessment of bacteremia and other infectious complications in patients undergoing EUS-guided FNA. Gastrointest Endosc 2003; 57:672.
  71. Janssen J, König K, Knop-Hammad V, et al. Frequency of bacteremia after linear EUS of the upper GI tract with and without FNA. Gastrointest Endosc 2004; 59:339.
  72. Levy MJ, Norton ID, Clain JE, et al. Prospective study of bacteremia and complications With EUS FNA of rectal and perirectal lesions. Clin Gastroenterol Hepatol 2007; 5:684.
  73. Lee LS, Saltzman JR, Bounds BC, et al. EUS-guided fine needle aspiration of pancreatic cysts: a retrospective analysis of complications and their predictors. Clin Gastroenterol Hepatol 2005; 3:231.
  74. Eloubeidi MA, Tamhane A. EUS-guided FNA of solid pancreatic masses: a learning curve with 300 consecutive procedures. Gastrointest Endosc 2005; 61:700.
  75. Wallace MB, Hawes RH, Sahai AV, et al. Dilation of malignant esophageal stenosis to allow EUS guided fine-needle aspiration: safety and effect on patient management. Gastrointest Endosc 2000; 51:309.
  76. Schwartz DA, Unni KK, Levy MJ, et al. The rate of false-positive results with EUS-guided fine-needle aspiration. Gastrointest Endosc 2002; 56:868.
  77. Matsumoto K, Yamao K, Ohashi K, et al. Acute portal vein thrombosis after EUS-guided FNA of pancreatic cancer: case report. Gastrointest Endosc 2003; 57:269.