Scandinavian Journal of Gastroenterology.

2014; 49: 473480

ORIGINAL ARTICLE

Endoscopic ultrasound in patients with normal liver blood tests and

unexplained dilatation of common bile duct and or pancreatic duct

KOFI W. OPPONG1,2, VIKRAMJIT MITRA1,2, JOHN SCOTT3, KIRSTY ANDERSON3,

RICHARD M. CHARNLEY1,4, STUART BONNINGTON2, BRYON JAQUES1,4,
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STEVEN WHITE1,4, JEREMY J. FRENCH1,4, DEREK M. MANAS1,4, GOURAB SEN1,4 &

MANU K. NAYAR1,2
1
Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK, 2Department of Gastroenterology,
Freeman Hospital, Newcastle upon Tyne, UK, 3Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK,
and 4Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK

Abstract
Objective. To determine the yield of endoscopic ultrasound (EUS) in the investigation of patients with normal liver function
For personal use only.

tests (LFTs) and unexplained dilatation of common bile duct (CBD) and/or pancreatic duct (PD), following CT and/or
magnetic resonance cholangiopancreatography. Materials and methods. Consecutive patients undergoing linear EUS
between January 2007 and August 2011 for the indication of dilated CBD and/or PD, normal LFT, and nondiagnostic cross-
sectional imaging formed the study group. The study was performed as a retrospective analysis of prospectively collected data.
Results. During the study period, 83 patients (CBD and PD dilatation n = 38, PD dilatation n = 5, CBD dilatation n = 40) met
the inclusion criteria and underwent EUS. Five (13.1%) of the CBD and PD groups had a new nding, which in one (2.6%)
case was causal. In this group, men were signicantly more likely to have a new nding (p = 0.012). Eight (20%) of the CBD
group had a new nding, which in seven (17.5%) cases was causal. In the CBD group, cholecystectomy was signicantly
(p = 0.005) more common in those without a nding. Three (60%) of the PD group had a nding on EUS, all of which were
causal, including a case of pancreatic malignancy. Conclusion. There is a signicant yield from EUS in individuals with
isolated PD dilatation and isolated CBD dilatation. Previous cholecystectomy is signicantly associated with a negative EUS in
the group with isolated CBD dilatation. The yield in those with CBD and PD dilatation was low and a nding was more likely
in males.

Key Words: dilated bile duct, dilated pancreatic duct, endoscopic ultrasound, normal ALT

Introduction chronic pancreatitis, but one-third had malignancy

A dilated common bile duct (CBD), pancreatic duct
(PD), or both (double duct sign), in association with
abnormal liver function tests (LFTs), is strongly
indicative of disease. A double duct sign is highly
suggestive of a pancreatico-biliary malignancy [13].
Indeed, even isolated PD dilatation has been reported
as having a very high risk for pancreatic malignancy
[4]. For example, a recent CT study found that the
majority of patients with isolated PD dilatation had
[5]. Bile duct size may vary slightly dependent on the
imaging modality used [6]. The upper limit of normal
on ultrasound is generally accepted as 7 mm [68].
For the PD, a diameter greater than 3 mm in the head
or 2 mm in the body or tail on CT is generally
regarded as dilated [5]. Increasing age and prior
cholecystectomy have been suggested as causes of
an increase in bile duct diameter [6,9].
The nding of dilated ducts on abdominal cross-
sectional imaging in patients with normal LFT is an

Correspondence: Ko W. Oppong, Consultant HPB Physician, Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK.
E-mail: Ko.oppong@nuth.nhs.uk

(Received 22 October 2013; revised 10 December 2013; accepted 1 January 2014)

ISSN 0036-5521 print/ISSN 1502-7708 online  2014 Informa Healthcare
DOI: 10.3109/00365521.2014.881547
 474 K. W. Oppong et al.
increasingly common clinical scenario due to the use
of high-resolution cross-sectional imaging to investi-
gate a range of abdominal symptoms. When no cause
is identied following CT and/or magnetic resonance
cholangiopancreatography (MRCP), concerns about
possible occult biliary or pancreatic pathology may
lead to such individuals being referred for endoscopic
ultrasound (EUS). EUS is more sensitive than CT for
the detection of small pancreatic tumors [10,11], and
while EUS and MRCP have similar diagnostic
performance for choledocholithiasis [12], MRCP
performs less well for small stones, while EUS
remains highly sensitive [10,13]. There is very little
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literature, however, on the yield of EUS in the setting
of incidentally found dilated ducts with normal LFTs.
Aim
The aim was to evaluate the yield of EUS in patients
with normal LFT and a dilated CBD and/or PD and
to identify any factors predicting a positive nding.
Methods
For personal use only.
This study was performed using routinely collected
clinical data, and in accordance with UK National
Research Ethics Service guidelines, it did not require
formal ethical review. After informed consent was
obtained, the EUS procedures were undertaken by
two experienced endosonographers (K.W.O and M.
K.N), who were not blinded to the results of previous
investigations. Hitachi EUB-7500 or Preirus US
workstations (Hitachi Medical Systems, Wellingbor-
ough, UK) and Pentax linear echoendoscopes
(Pentax, Slough, UK) were used.
A retrospective review of our prospectively main-
tained EUS database was carried out for a 56-month
period, between January 2007 and August 2011, to
identify all patients with dilated duct(s) as the indi-
cation for EUS. Patients identied from the EUS
database were cross-referenced with the prospectively
maintained HPB database. Case notes were reviewed
to collect data for patient demographics, symptoms,
serum liver enzymes values, cross-sectional imaging
studies before EUS, EUS ndings, and follow-up.
Patients were excluded from the study if any of the
bilirubin, alanine transaminase or alkaline phosphate
was elevated or if a mass, stricture, or ductal lling
defect was reported on pre-EUS imaging. In addition,
cases where there was a plausible cause for dilatation
in the clinical history such as symptoms suggestive of
sphincter of Oddi dysfunction or chronic pancreatitis
were excluded. All patients were followed up for a
period of at least 18 months. Regarding pre-EUS
imaging, the maximum recorded duct diameter was
used if the patient had undergone both CT and
MRCP. The majority of cases were referred from
outside our institution and the imaging was not rou-
tinely re-evaluated by a pancreaticobiliary radiologist,
prior to EUS. On EUS the main PD was considered
dilated if it was larger than 3 mm in the head or 2 mm
in the body or 1 mm in the tail [14,15].
Statistical analysis
Continuous variables are presented as median (range)
and bivariate analysis was performed using the Mann
Whitney test. Categorical variables were compared
using the chi-square test and Fishers exact test. Data
were analyzed on the basis of all new ndings on EUS
and separately for ndings that were specically attrib-
uted as the cause of ductal dilatation. A double-sided
p Value of less than 0.05 was considered statistically
signicant. Data were analyzed using MedCalc
12.7 (MedCalc Software, Ostend, Belgium).
Results
A total of 2767 pancreatico-biliary EUS procedures
were carried out during this period, of which
323 (11.7%) for the indication of dilated duct(s).
Out of 323 patients, 240 did not fulll the inclusion
criteria and were excluded (see Figure 1). Two hun-
dred and nine had abnormal LFT and 25 were
excluded because of diagnostic radiology; nine had
chronic pancreatitis, four a possible stone in the CBD,
three an ampullary polyp, three with a pancreatic
mass, three a possible CBD stricture, two a distal
CBD mass, and one had extrinsic compression due to
lymph nodes. Six patients were excluded due to
suggestive clinical history, four gallstone pancreatitis,
one suspected sphincter of Oddi dysfunction, and one
chronic abdominal pain treated with opiates;
83 patients (3% of all EUS procedures done during
this period) were included for nal analysis. The
median age of the study group was 66.7 years (range
3087). There was a female preponderance (73%,
p < 0.0001). The baseline characteristics of these
patients are shown in Table I. In terms of prior
imaging, 26 (36%) patients had undergone a CT
scan only, 17 (24%) an MRI only, and 29 (40%)
had undergone both.
Forty individuals were referred with an isolated
dilatation of the CBD of these, 33 had a recorded
measurement of duct diameter [median 12.0 mm
(range 7 25 mm)]. Five individuals were referred
with an isolated PD dilatation of these, four had a
documented duct diameter [median 5 mm (range 3
5 mm)]. In the cohort with both ducts dilated (n = 38),
the CBD diameter was documented in 33 [median of
 EUS in unexplained duct dilatation and normal LFT 475

Patients referred for EUS with duct

dilatation as the indication [n = 323]

Patients with abnormal LFTs and

dilated duct(s) [n = 209]

Patients with normal LFTs and dilated duct(s) [n = 114]

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Patients with diagnostic radiology

and dilated duct(s) [n = 25]

Patients with suggestive clinical

history and dilated duct(s) [n = 6]

Patients with normal LFTs, non-diagnostic

For personal use only.

CT/MRI and dilated duct(s) [n = 83]

PD dilatation [n = 5] CBD & PD dilatation [n = 38] CBD dilatation [n = 40]

Figure 1. Flow chart of study patients.

13.0 mm (range 840 mm)] and the PD diameter in
27 patients [median 5.0 mm (range 39 mm)]. Over-
all, EUS was in discordance with prior imaging in
23 patients (28%) (comprising partial agreement in
18, nondilated ducts in 3, and a different duct dilated
in 2).
Sixteen (19%) patients had a new nding on EUS
that was not reported by prior cross-sectional imaging
(Table II). Of these 16, 11 (13%) were considered to
explain the ductal dilatation, 7 (17.5%) causing iso-
lated CBD dilatation, 3 (60%) isolated PD dilatation,
and 1 (2.5%) causing both ducts to be dilated. One
patient was diagnosed with pancreatic malignancy.
Dilated CBD
Table III (patients with dilated CBD only) compares
the baseline characteristics in patients with or without
a new nding on EUS. On bivariate analysis, there
was no signicant difference in age, sex, or propor-
tions with symptoms between the two groups. Prior
cholecystectomy was signicantly more common in
the group without a new nding (p = 0.005). Patients
with prior cholecystectomy had no new nding on
EUS. Of the eight (20%) cases with a new nding on
EUS, seven were deemed to be the cause of the
dilatation, while one (microlithiasis) was assessed as
a secondary phenomenon. Of the seven, four went on
to have ERCP (Table IV) two with an EUS diag-
nosis of a polyp and two with an EUS diagnosis of
stones. Both cases of presumed stones had a stone or
sludge cleared from the duct. One case with an EUS
diagnosis of polyp had a stone, and in the other there
was no polyp or stone seen at ERCP.
In the group with no new nding, there was no
correlation between duct diameter and age. There
was also no signicant difference in CBD diameter
between patients who had and had not undergone
 476 K. W. Oppong et al.

Table I. Baseline characteristics for all patients (n = 83). case was found not to have a dilated PD on EUS. The
Baseline characteristics Value diagnostic yield, therefore, in cases with proven duct
dilatation was 3/4 (75%). Two patients with a new
Median age (range) 67 (3087)
diagnosis of chronic pancreatitis were recommended
Median bilirubin (range) (normal value: 7.0 (317)
<20 mmol/L) pancreatic enzyme replacement therapy. The patient
Median alanine transaminase (range) 18.0 (539) with PDAC underwent a pancreaticoduodenctomy
(normal value: <40 IU/L) (Table IV).
Median alkaline phosphatase (range) 78 (32125)
(normal value: <130 IU/L)
Females 61 (73%) Dilated CBD and PD
Symptomatic 63 (76%)
Abdominal pain 48 (58%)
Weight loss 6 (7.2%)
Table V compares the baseline characteristics of
Diarrhea 1 (1.2%) patients with and without a new nding on EUS.
Abdominal pain and weight loss 5 (6%) On bivariate analysis, there was no signicant differ-
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Diarrhea and abdominal pain 1 (1.2%) ence in age, proportions with symptoms, or prior
Abdominal pain, weight loss, 2 (2.4%) cholecystectomy between the two groups. There
and diarrhea
Patients with prior cholecystectomy 30 (36%) was a female preponderance in the group with no
Patients who underwent CT 32 (38.5%) new nding and a male preponderance in the group
only prior to EUS with a nding this difference was statistically
Patients who underwent MR 17 (20.5%) signicant (p = 0.012).
only prior to EUS
Patients who underwent both 34 (41%) Of the 38 patients with dilated CBD and PD, 5 had a
CT and MR prior to EUS new nding on EUS. However, in four of these (three
Patients with dilated CBD only 40 (48%) with microlithiasis and one with early chronic pancre-
on imaging prior to EUS
atitis), the ndings were not assessed as being causative.
Patients with dilated PD only 5 (6%)
For personal use only.

on imaging prior to EUS Microlithiasis in the absence of a stricture or mass was

Patients with dilated CBD and PD
on imaging prior to EUS
cholecystectomy. Periampullary diverticula have been
suggested as a possible cause of otherwise unex-
plained CBD dilatation. In our study, one patient
who had a prior cholecystectomy was also found to
have a periampullary diverticulum.
Dilated PD
38 (46%) deemed to be suggestive of benign ampullary stenosis.
Four individuals (one suspected ampullary adenoma,
three microlithiasis) were recommended to undergo
ERCP the patient with suspected ampullary adenoma
declined. The three cases with microlithiasis under-
went ERCP and sphincterotomy and one case had
stones removed (Table IV). In the group with no
new nding, there was no correlation between either
CBD diameter (n = 29) and age [correlation coefcient
0.25 (95% CI, 0.13 to 0.56), p = 0.19] or PD diameter,
correlation coefcient [r = 0.27 (95% CI, 0.16 to
0.61), p = 0.21].

Of the ve patients with a dilated PD, three (60%) Discussion

patients had a new nding on EUS, all of which were
deemed to be causal; two had chronic pancreatitis and Diagnostic EUS has a very low complication rate [16],
one pancreatic ductal adenocarcinoma (PDAC). One and is a much safer procedure than ERCP [17], which

Table II. Signicant ndings on EUS indicating whether causal or not.

Diagnosis (percentage of overall n = 83) Dilated CBD and PD n = 38 Dilated PD n = 5 Dilated CBD n = 40
(number of patients) (number of patients) (number of patients)

CBD polyps (3.6%) 0 0 *3

CBD stones (3.6%) 0 0 *3
Microlithiasis (4.8%) 3 0 1
Ampullary adenoma (1.2%) *1 0 0
Chronic pancreatitis (3.6%) 1 *2 0
Pancreatic adenocarcinoma (1.2%) 0 *1 0
Portal vein compressing CBD (1.2%) 0 0 *1
Proportion with a new nding on EUS (%) 5/38 (13.1%) 3/5 (60%) 8/40 (20%)
Proportion with a cause identied on EUS (%) 1/38 (2.6%) 3/5 (60%) 7/40 (17.5%)

*Identied as the cause of duct dilatation.

 EUS in unexplained duct dilatation and normal LFT 477

Table III. Dilated CBD:Comparison of baseline characteristics in patients with or without a new nding on endoscopic ultrasound.
Baseline characteristics No new nding on EUS New nding on EUS Statistical signicance
(n = 32) (n = 8) (p Value)

Median age in years (range) 66.5 (3187) 74.5 (5982) 0.09

Sex n (%)
Female n (%) 26 (81.25) 5 (62.5) 0.35
Male n (%) 6 (18.75) 3 (37.5)
Symptoms n (%) 23 (71.9) 8 (100) 0.16
Abdominal pain n (%) 21 (65.6) 8 (100) 0.08
Prior cholecystectomy n (%) 18 (56.2) 0 0.005
Median CBD diameter in mm (95% CI) 12.0 (10.114.4) [25] 14.5 (11.820.4) [8] 0.05
(number of cases)
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has a very limited role as a diagnostic modality [18].
A number of studies have previously investigated the
yield of EUS in patients with nondiagnostic cross-
sectional imaging and a dilated CBD [1921] and
double duct sign [20].
The present study is the rst to examine the yield of
EUS in patients with dilated CBDs and/or PDs,
focusing on individuals with completely normal
LFTs, combined with nondiagnostic cross-sectional
imaging. The yield on EUS in our study in patients

Table IV. Final outcome of all the patients with a new nding on the EUS on long-term follow-up.
Duct dilated EUS diagnosis EUS explanation Advice following EUS Outcome on follow-up
For personal use only.

of duct dilatation

CBD and PD Distal CBD mass Yes ERCP, sphincterotomy and biopsy Patient declined procedure and
probable bile died after 4 years following EUS
duct adenoma
CBD and PD Microlithiasis No ERCP No stone or sludge seen during
ERCP. Sphincterotomy made in
view of EUS ndings. Patient
well on follow-up
CBD and PD Chronic pancreatitis No GB with stones Cholecystectomy
cholecystectomy recommended Well on follow-up
CBD and PD Microlithiasis No ERCP No stone or sludge seen during
ERCP. Sphincterotomy made in
view of EUS ndings. Well on
follow-up.
CBD and PD Microlithiasis No ERCP Stones removed during ERCP.
Well on follow-up
Dilated CBD CBD polyp Yes ERCP, sphincterotomy, Stone removed, no polyp seen
and biopsy during ERCP. Well on follow-up
Dilated CBD CBD stone Yes ERCP Stone removed during ERCP.
Well on follow-up
Dilated CBD CBD polyp Yes ERCP No polyp or stone seen during
ERCP
Dilated CBD CBD stone Yes ERCP Sludge removed during ERCP.
Well on follow-up
Dilated CBD Microlithiasis Yes No further intervention as patient Well on follow-up
asymptomatic. Advised to proceed to
ERCP only if symptomatic as patient
was very frail
Dilated CBD CBD polyp Yes ERCP, sphincterotomy, and biopsy. Patient declined. Well on
follow-up
Dilated CBD Portal vein compressing Yes No intervention indicated Well on follow-up
mid-CBD
Dilated CBD CBD stone Yes ERCP, stones removed Well on follow-up
Dilated PD Chronic pancreatitis Yes Commence on Creon Well on follow-up
Dilated PD Chronic pancreatitis Yes Advised treatment with Creon Patient did not attend clinic and
was referred back locally to
referring hospital
Dilated PD PDAC Yes Whipples procedure Well on follow-up
 478 K. W. Oppong et al.
Table V. Dilated CBD and PD: comparison of baseline characteristics in patients with or without a new nding on endoscopic ultrasound.
Baseline characteristics No new nding on
EUS (n = 33)
Median age in years (range) 70 (3085)
Sex n (%)
Female n (%) 27 (81.8)
Male n (%) 6 (18.2)
Symptoms n (%) 24 (72.7)
Abdominal pain n (%) 20 (60.6)
Prior cholecystectomy n (%) 10 (30.3)
Median CBD diameter in 13.0 (840.0) (29)
mm (95% CI) (number of cases)
Median PD diameter in 4.0 (3.09.0) (23)
mm (95% CI) (number of cases)
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with dilated CBD and normal LFT was signicant
(20%) and supports the use of EUS in this group of
patients, particularly in those without cholecystec-
tomy. Age and post-cholecystectomy adaptation
have been described as causes of CBD enlargement.
Recent studies have provided evidence that previous
cholecystectomy causes CBD dilatation [9,2225].
Our nding of a greater proportion of cholecystec-
For personal use only.
tomy in the cohort without a new nding is consistent
with this. On the other hand, the median age was
lower in those without a new nding on EUS and age
did not correlate with duct size in this group.
A study by Malik et al. [19] compared the yield of
EUS in patients with dilated CBD and nondiagnostic
imaging in two groups normal LFT and abnormal
LFT. They reported a causative diagnosis of 6% (2/
32) in the normal LFT group, comprising 1 case of
choledocholithiasis and 1 periampullary diverticu-
lum. In the study by Carriere et al. [20], there was
an EUS yield of 29.8% in 94 patients with unex-
plained isolated CBD dilatation; however, not all
underwent prior cross-sectional imaging (CT and
or MRCP) and a signicant proportion had abnor-
mal LFT. Our ndings are similar to that of a recent
study by Bruno et al. [21] that investigated the yield
of EUS in 57 individuals with normal LFT and
inconclusive prior imaging. Abnormal EUS ndings
were made in 12 (21%). Clinically signicant nd-
ings included one pancreatic malignancy, two
chronic pancreatitis, two ampullary adenoma, and
one CBD stone. Neither age nor prior cholecystec-
tomy was found to be a predictor of an abnormal
EUS nding in this study.
In our study, three of ve patients with an isolated
dilated PD had a diagnosis made on EUS. This
nding suggests that such cases should be further
investigated with EUS. The case of pancreatic ade-
nocarcinoma highlights the importance of the
re-evaluation of nondiagnostic imaging by a specialist
New nding on Statistical signicance
EUS (n = 5) (p Value)
74 (5678) 0.93
1 (20) 0.012
4 (80)
4 (80) 1.0
4 (80) 0.08
2 (40) 0.58
14.0 (13.023.0) (4) 0.24
5.5 (5.08.0) (4) 0.13
radiologist, as following the EUS diagnosis of pan-
creatic malignancy, review of the original CT by a
pancreatic radiologist identied the tumor.
The double duct sign originated as a term to
describe the nding at ERCP of contiguous strictures
in both the PD and CBD [1,26].The term has been
adopted for use in cross-sectional imaging. In the
setting of jaundice, it is strongly predictive of pancre-
atic malignancy [27,28]. In our study, the yield (in
patients with both ducts dilated) was low, with only
one individual (2.6%) having a causal nding.
A recent EUS study by Krishna et al. [27] found
that only 5.9% of patients with double duct sign
without jaundice had a nal diagnosis of malignancy.
This study did not exclude patients with diagnostic
cross-sectional imaging, and it is not clear what pro-
portion of the patients in the non-jaundiced cohort
had completely normal LFT. In the study by
Bruno et al. [21], there were a small number of
patients with both ducts dilated; although numerically
more prevalent in the group with an abnormal EUS
(33.3% vs. 11.1% in the normal EUS group) this was
not statistically signicant.
On rst sight, it appears counterintuitive that there
was such a low yield in our study. A possible expla-
nation is that biliary obstruction and hence abnormal
LFT and/or jaundice is an integral part of the double
duct sign due to malignancy or chronic pancreatitis.
A small tumor causing isolated PD dilatation could
conceivably be missed on cross-sectional imaging, not
cause abnormality of LFT, and be subsequently diag-
nosed by EUS, as in this study. However, while a
small tumor causing double duct dilatation might not
be detected on cross-sectional imaging, it would likely
cause cholestatic LFT at an early stage. In our series,
there was a signicant female preponderance. Our
data suggest that in those with normal LFT and a
double duct sign, but no mass lesion on cross-
sectional imaging, a malignant cause is unlikely,
 EUS in unexplained duct dilatation and normal LFT
and that in females, the yield from further investiga-
tion is probably low. These cases may be due to
benign papillary stenosis. There may be a role for
ERCP with sphincterotomy and biopsy from the cut
surface in selected cases, such as those with symptoms
or evidence of functional holdup, e.g. microlithiasis
on EUS.
There are several strengths to our study. This is the
rst study to examine the yield of EUS in all types of
dilated duct(s) (CBD, PD, or both) with normal LFT
and nondiagnostic cross-sectional imaging. The
number of patients in our study is the largest to
date. The exclusion criteria used were strict. None
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of the patients in our study underwent ERCP prior to
EUS evaluation. All patients had a minimum period
of 18 months follow-up. Data collection was robust.
The main limitation of our study is its retrospective
nature. In addition, the pre-EUS evaluation was not
standardized most patients were referred from
peripheral hospitals and a signicant proportion of
the CT were not to pancreatic protocol. Standard
cutoffs for duct sizes were not used in the reporting of
the pre-EUS imaging; it is, therefore, possible that
different radiologists used differing criteria. How-
For personal use only.
ever, this reects the reality of everyday clinical
practice. In addition, based on the diameters
recorded, all cases referred exceeded the generally
accepted upper limit of normal for the CBD and PD.
Some patients with similar indication (dilated ducts
and normal imaging) may not have been referred to
our tertiary center and may have undergone ERCP
directly, resulting in a selection bias. Longer-term
follow-up data would be useful in the group with no
apparent diagnosis to explain the duct dilatation.
In conclusion, we think that EUS has a role in the
investigation of selected patients with normal LFT,
nondiagnostic cross-sectional imaging, and dilated
ducts. Individuals with unexplained PD dilatation
are likely to have a nding on EUS including the
possibility of malignancy and should undergo EUS
promptly. EUS is worthwhile in those with isolated
dilated CBD, the yield was signicant, primarily small
stones, and a nding was less likely in those who had
undergone a prior cholecystectomy. The EUS yield in
those with normal LFT and both a dilated CBD and
PD was low. Large prospective studies with long-term
follow-up are required to investigate this further. EUS
should ideally follow review of original cross-sectional
imaging by a specialist radiologist.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.
479
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