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Atlas of Endoscopic Ultrasonography
Atlas of Endoscopic
Ultrasonography
second edition

EDITED BY

Frank Gress, MD
Professor of Medicine
Icahn School of Medicine
Division of Gastroenterology and Hepatology
Mount Sinai Hospital
New York, USA

Thomas Savides, MD
Professor of Clinical Medicine
Division of Gastroenterology
University of California
San Diego, California, USA

Brenna Casey, MD
Assistant Professor of Medicine
Division of Gastroenterology
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts, USA

Everson L. A. Artifon, MD
Associate Professor of Surgery
Department of Surgery
University of São Paulo
São Paulo, Brazil
This edition first published 2022
© 2022 John Wiley & Sons Ltd

Edition History
Blackwell Publishing Ltd (1e, 2012)

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Library of Congress Cataloging‐in‐Publication Data

Names: Gress, Frank G., editor. | Savides, Thomas J., editor. | Casey,
Brenna, editor. | Artifon, Everson L. A., editor.
Title: Atlas of endoscopic ultrasonography / edited by Frank G. Gress,
Thomas John Savides, Brenna Casey, Everson L. A. Artifon.
Description: Second edition. | Hoboken, NJ : Wiley-Blackwell, 2022. |
Includes bibliographical references and index.
Identifiers: LCCN 2021015783 (print) | LCCN 2021015784 (ebook) | ISBN
9781119523000 (hardback) | ISBN 9781119523093 (adobe pdf) | ISBN
9781119523031 (epub)
Subjects: MESH: Endoscopy, Digestive System | Digestive System
Diseases–diagnostic imaging | Digestive System–diagnostic imaging |
Ultrasonography | Atlas
Classification: LCC RC801 (print) | LCC RC801 (ebook) | NLM WI 17 | DDC
616.3/07545–dc23
LC record available at https://lccn.loc.gov/2021015783
LC ebook record available at https://lccn.loc.gov/2021015784

Cover Design: Wiley

Cover Images: Courtesy of Dalton Chaves, Courtesy of Anthony Teoh, Courtesy of Cynthia Behling,
Courtesy of David L. Diehl, MD, Courtesy of Wilson Kwong, Courtesy of Spencer Cheng, Courtesy of
Julio Iglesias Garcia, Courtesy of Toltech

Set in 9/12pt Meridien by Straive, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
 Contents

Contributors, vii 13 Gastric Cancer, 53

Douglas O. Faigel and Sarah A. Rodriguez
Preface, xi
14 Gastric and Esophageal Subepithelial Masses, 58
About the Companion Website, xii
Muhammad Tahir and Andrew J. Bain

15 Anorectal Neoplasia, 67
Part 1 Normal EUS Anatomy, 1 Manoop S. Bhutani and Everson L.A. Artifon

16 Anal Sphincter Disease: Fecal Incontinence

1 Normal Human Anatomy, 3
and Fistulas, 72
John C. Deutsch
Raymond S. Tang and Thomas J. Savides
2 Esophagus: Radial and Linear, 10
17 Endometriosis, 78
James L. Wise and John C. Deutsch
José Celso Ardengh, Juan Pablo Román Serrano,
3 Normal Mediastinal Anatomy by EUS and EBUS, 14 Samuel Galante Romanini, Juliana Silveira Lima de Castro,
Juan Corral, Sebastian Fernandez‐Bussy, and Isabela Trindade Torres
and Michael B. Wallace
18 Vascular Anomalies and Abnormalities, 88
4 Stomach: Radial and Linear, 19 John C. Deutsch
Joo Ha Hwang

5 Bile Duct: Radial and Linear, 22

Kapil Gupta Part 3 Pancreatico-biliary, 93
6 EUS of the Normal Pancreas, 25
19 Duodenal and Ampullary Neoplasia, 95
Richard A. Erickson and James T. Sing, Jr.
Brenna Casey and Kumar Krishnan
7 Liver, Spleen, and Kidneys: Radial and Linear, 30
20 Biliary Tract Pathology, 98
Nalini M. Guda and Marc F. Catalano
Brenna Casey and Kumar Krishnan
8 Anatomy of the Anorectum: Radial and Linear, 33
21 Gallbladder Pathology, 101
Christoph F. Dietrich
Sam Yoselevitz and Ann Marie Joyce

22 Pancreatic Adenocarcinoma, 104

Part 2 Upper and Lower GI EUS, 37 Douglas G. Adler

23 Pancreatic Malignancy (Non‐adenocarcinoma), 108

9 Esophageal Cancer, 39
Larissa Fujii‐Lau, Michael J. Levy, and Suresh T. Chari
Armen Eskandari and Syed M. Abbas Fehmi
24 Autoimmune Pancreatitis, 113
10 EUS for Achalasia, 46
Larissa Fujii‐Lau, Michael J. Levy, and Suresh T. Chari
Michael Chang
25 Pancreatic Cystic Lesions: The Role of EUS, 117
11 Malignant Mediastinal Lesions, 49
William R. Brugge
M. Babitha Reddy, David H. Robbins, and Mohamad A. Eloubeidi
26 Intraductal Papillary Mucinous Neoplasms: The Role
12 Benign Mediastinal Lesions, 51
of EUS, 121
M. Babitha Reddy, David H. Robbins, and Mohamad A. Eloubeidi
William R. Brugge

v
Contents
27 Chronic Pancreatitis, 125
David G. Forcione
28 Liver Pathology, 130
Indraneel Chakrabarty and Ann Marie Joyce
Part 4 How to Section, 135
29 How to Interpret EUS‐FNA Cytology, 137
Cynthia Behling
30 How to do Mediastinal FNA, 146
Sammy Ho
31 How to do Pancreatic Mass FNA, 150
Yunseok Namn and Jonathan M. Buscaglia
32 How to do Pancreatic Cyst FNA, 155
Ahmad Najdat Bazarbashi and Linda S. Lee
33 How to do Pancreatic Pseudocyst Drainage, 160
Shyam Varadarajulu and Vinay Dhir
34 How to do EUS‐guided Pancreatic Cyst
Chemoablation, 165
Matthew T. Moyer and John M. DeWitt
35 How to do Celiac Plexus Block, 173
Sam M. Serouya and Adam J. Goodman
36 How to Place Fiducials for Radiation Therapy, 176
Antonio R. Cheesman, Satish Nagula, and Christopher J.
DiMaio
37 How to Inject Chemotherapeutic Agents, 179
V. Raman Muthusamy and Kenneth J. Chang
38 How to do EUS‐guided Pelvic Abscess Drainage, 182
Shyam Varadarajulu and Sandeep Lakhtakia
39 How to do Doppler Probe EUS for Bleeding, 186
Richard C.K. Wong
40 How to do Endoscopic Ultrasound‐guided Portal
Pressure Gradient Measurement, 194
Rintaro Hashimoto and Kenneth J. Chang
41 How to do Endoscopic Ultrasound‐guided
Liver Biopsy, 197
David L. Diehl
42 How to do EUS‐guided Treatment of Gastric Varices, 202
Dalton Marques Chaves and Filipe Tomishige Chaves
vi
43 How to do EUS‐guided Arterial Embolization, 205
Marc Barthet and Jean‐Michel Gonzalez
44 How to do EUS‐guided Radiofrequency Ablation of
Pancreatic Neuroendocrine Tumors, 209
Marc Barthet, Mohamed Gasmi, and Jean‐Michel
Gonzalez
45 How to do EUS Pancreatic Duct Access
and Drainage, 214
Alberto Larghi, Mihai Rimbas¸, and Mauricio K. Minata
46 How to do EUS Gallbladder Drainage, 220
Shannon Melissa Chan and Anthony Yuen Bun Teoh
47 How to do an EUS‐guided Gastrojejunostomy, 226
Sohini Sameera and Michel Kahaleh
48 How to do EUS Elastography, 229
Julio Iglesias‐Garcia, Jose Lariño‐Noia, Daniel de la
Iglesia‐García, and J. Enrique Dominguez‐Muñoz
49 How to do Contrast‐enhanced EUS, 237
Yasunobu Yamashita and Masayuki Kitano
50 How to do EUS‐guided Ablation of Pancreatic
Neurendocrine Tumors, 248
Sabrina Gloria Giulia Testoni, Gemma Rossi, Livia
Archibugi, and Paolo Giorgio Arcidiacono, 248
51 How to do EUS‐guided Needle Confocal Laser
Endomicroscopy of Pancreatic Cysts, 254
Prashant Bhenswala and Frank G. Gress
52 How to use ex vivo Models in Teaching Therapeutic
Endoscopic Ultrasound, 256
Spencer Cheng, Mauricio K. Minata, Carlos K. Furuya, and
Edson Ide
53 How to do Endoscopic Necrosectomy, 265
Wilson T. Kwong
54 How to Perform Pancreatic Mass Fine Needle
Biopsy, 270
Ahmad Najdat Bazarbashi and Linda S. Lee
55 How to Perform Endoscopic Ultrasound‐directed
Transgastric Endoscopic Retrograde
Cholangiopancreatography (EDGE), 274
M. Phillip Fejleh and Wilson T. Kwong
Index, 278
 Contributors

Douglas G. Adler, MD, FACG, FASGE Ahmad Najdat Bazarbashi, MD Marc F. Catalano, MD
Peak Gastroenterology Associates Division of Gastroenterology, Hepatology and Clinical Associate Professor of Medicine
Colorado Springs, CO, USA Endoscopy Medical College of Wisconsin
Brigham and Women’s Hospital Pancreatobiliary Services
Harvard Medical School St. Luke’s Medical Center
Livia Archibugi, MD
Boston, MA, USA Milwaukee, WI, USA
Pancreas Translational and Clinical Research Center
Division of Pancreato‐Biliary Endoscopy and
Endosonography
Indraneel Chakrabarty, MD, MA
Cynthia Behling, MD, PHD Clinical Associate of Medicine
San Raffaele Scientific Institute IRCCS Pacific Rim Pathology Group Tufts University School of Medicine
Vita‐Salute San Raffaele University Sharp Memorial Hospital Division of Gastroenterology
Milan, Italy San Diego, CA, USA Lahey Clinic Medical Center
Burlington, MA, USA
Paolo Giorgio Arcidiacono, MD,
Prashant Bhenswala, MD, MSCR
FASGE
Department of Medicine
Shannon Melissa Chan, MBCHB,
Pancreas Translational and Clinical Research FRCSEd, FHKAM (SURGERY)
Mount Sinai South Nassau Hospital
Center Department of Surgery
Oceanside, NY, USA
Division of Pancreato‐Biliary Endoscopy and Prince of Wales Hospital
Endosonography The Chinese University of Hong Kong
San Raffaele Scientific Institute IRCCS Manoop S. Bhutani, MD, FASGE, Shatin, Hong Kong
Vita‐Salute San Raffaele University FACG, FACP, AGAF
Milan, Italy Professor of Medicine, Experimental Diagnostic Kenneth J. Chang, MD
Imaging and Biomedical Engineering Professor of Clinical Medicine
José Celso Ardengh, md, phd, Director, Endoscopic Research and Development Division Chief, Gastroenterology
fasge University of Texas MD Anderson Cancer Center University of California
Professor of Surgery and Anatomy Houston, TX, USA Irvine, CA, USA
Ribeirão Preto Medical School
University São Paulo, Ribeirão Preto Michael Chang, MD
Brenna Casey, MD, FASGE Assistant Professor
São Paulo, Brazil
Interventional Gastroenterology Department of Medicine
Head in the Endoscopy Service Hospital 9 de Julho
Director of Interventional Endoscopy University of California San Diego
Sao Paulo, Brazil
Massachusetts General Hospital La Jolla, CA, USA
Harvard Medical School
Everson L.A. Artifon, MD, MBA, Boston, MA, USA Suresh T. Chari, MD
PhD, FASGE MD Anderson Cancer Hospital
Associate Professor of Surgery Houston, TX, USA
Department of Surgery William R. Brugge, MD
Director, Gastrointestinal Endoscopy
University of Sao Paulo Dalton Marques Chaves
Sao Paulo, Brazil Massachusetts General Hospital
Gastrointestinal Endoscopy Unit
Ana Costa Hospital Professor of Medicine
University of Sao Paulo
Santos, Brazil Harvard Medical School
Sao Paulo-Brazil
Boston, MA, USA

Andrew J. Bain, MD Filipe Tomishige Chaves

Roswell Park Comprehensive Cancer Center Jonathan M. Buscaglia, MD Gastrointestinal Endoscopy Unit
Buffalo, NY, USA Director of Advanced Endoscopy University of Sao Paulo
Assistant Professor of Medicine Sao Paulo-Brazil
Stony Brook University Hospital
Marc Barthet, MD, PHD Antonio R. Cheesman, MD
Renaissance School of Medicine at Stony
Head of Gastroenterology Department
Brook University Division of Gastroenterology
Digestive endoscopy and gastroenterology ­department
Stony Brook, NY, USA Icahn School of Medicine at Mount Sinai
North Hospital, Marseille, France
New York, NY, USA

vii
Contributors

Spencer Cheng, MD, PHD Christopher J. DiMaio, MD Mohamed Gasmi, MD

Department of Gastroenterology Director of Therapeutic Endoscopy Digestive endoscopy and gastroenterology
Gastrointestinal Endoscopy Unit Icahn School of Medicine at Mount Sinai ­department
University of São Paulo New York, NY, USA North Hospital, Marseille, France
São Paulo, Brazil
Mohamad A. Eloubeidi, MD, MHS, Jean‐Michel Gonzalez, MD, PHD
Juan Corral, MD FASGE, FACP, FACG, AGAF Head of Endoscopy Unit
Division of Gastroenterology and Hepatology Professor of Medicine Digestive endoscopy and gastroenterology
Mayo Clinic College of Medicine American University of Beirut School of Medicine ­department
Jacksonville, FL, USA Beirut, Lebanon North Hospital, Marseille, France

Juliana Silveira Lima de Castro, MD Richard A. Erickson, MD, FACP,

Adam J. Goodman, MD
Staff of Endoscopy Service FACG, AGAF Associate Professor of Medicine
Hospital Nove de Julho Director, Division of Gastroenterology NYU Langone Health
Sao Paulo, Brazil Scott and White Clinic and Hospital New York, NY, USA
Professor of Medicine
Texas A&M Health Science Center
Daniel de la Iglesia‐García, MD
Temple, TX, USA
Frank G. Gress, MD, MBA
Department of Gastroenterology and Department of Medicine
Hepatology Division of Gastroenterology and Hepatology
Armen Eskandari, MD
Health Research Institute Icahn School of Medicine at Mount
Division of Gastroenterology and Hepatology
University Hospital of Santiago de Compostela Sinai and Mount Sinai South Nassau Hospital
University of California San Diego
Santiago de Compostela, Spain Oceanside, NY, USA
La Jolla, CA, USA

John C. Deutsch, MD Douglas O. Faigel, MD, FACG, FASGE, Nalini M. Guda, MD, FASGE
Essentia Health Care Systems Clinical Associate Professor of Medicine
AGAF
Duluth, MN, USA University of Wisconsin, School of Medicine and
Professor of Medicine
Public Health
Mayo Clinic College of Medicine
Pancreatobiliary Services
John M. DeWitt, MD, FACG, FACP, Scottsdale, AZ, USA
St. Luke’s Medical Center
FASGE
Milwaukee, WI, USA
Associate Professor of Medicine Syed M. Abbas Fehmi, MD
Co‐Director, Endoscopic Ultrasound Clinical Clinical Assistant Professor of Medicine
Program Division of Gastroenterology and Hepatology Kapil Gupta, MD, MPH
University of California San Diego Associate Director, Pancreatic and Biliary Diseases
Division of Gastroenterology and Hepatology
La Jolla, CA, USA Interventional Endoscopy
Indiana University Medical Center
Division of Gastroenterology
Indianapolis, IN, USA
Cedars‐Sinai Medical Center
M. Phillip Fejleh, MD Los Angeles, CA, USA
J. Enrique Dominguez‐Muñoz, Division of Gastroenterology
MD, PHD University of California San Diego Health Sciences
La Jolla, CA, USA Rintaro Hashimoto, MD, PHD
Department of Gastroenterology and Hepatology
Department of Gastroenterology
Health Research Institute
University of California
University Hospital of Santiago de Compostela Sebastian Fernandez‐Bussy, MD
Irvine, CA, USA
Santiago de Compostela, Spain Division of Pulmonary Medicine and Critical Care
Mayo Clinic College of Medicine
Jacksonville, FL, USA Sammy Ho, MD
Vinay Dhir, MD, DNB
Assistant Professor of Medicine
Director Clinical Research and Chief of
David G. Forcione, MD Director of Pancreaticobiliary Services and
Endosonography
Associate Director of Interventional Endoscopy Endoscopic Ultrasound
Institute of Advanced Endoscopy
Massachusetts General Hospital Division of Gastroenterology
Mumbai, India
Harvard Medical School Montefiore Medical Center/AECOM
Boston, MA, USA Bronx, NY, USA
David L. Diehl, MD, FASGE
Professor of Medicine Larissa Fujii‐Lau, MD Joo Ha Hwang, MD, PHD
Geisinger Medical Center and Geisinger University of Hawaii Stanford University
Commonwealth School of Medicine Honolulu, HI, USA Palo Alto, CA, USA
Danville, PA, USA
Carlos K. Furuya JR., PHD, MD Edson Ide, PHD, MD
Christoph F. Dietrich, MD Assistant Professor of Medicine Department of Gastroenterology
Professor, Second Department of Internal Department of Gastroenterology Gastrointestinal Endoscopy Unit
Medicine Gastrointestinal Endoscopy Unit University of São Paulo
Caritas‐Krankenhaus University of São Paulo São Paulo, Brazil
Bad Mergentheim, Germany São Paulo, Brazil

viii
 Contributors

Julio Iglesias‐Garcia, MD, PHD Michael J. Levy, MD Samuel Galante Romanini, MD

Department of Gastroenterology and Hepatology Consultant Staff of Endoscopy Service
Health Research Institute Mayo Clinic Hospital Nove de Julho
University Hospital of Santiago de Compostela Rochester, MN, USA Sao Paulo, Brazil
Santiago de Compostela, Spain
Mauricio K. Minata, MSC, MD Gemma Rossi, MD
Ann Marie Joyce, MD Digestive Endoscopy Unit Pancreas Translational and Clinical Research Center
Assistant Professor of Medicine University of São Paulo Division of Pancreato‐Biliary Endoscopy and
Tufts University School of Medicine SP, Brazil Endosonography
Burlington, MA, USA San Raffaele Scientific Institute IRCCS
Vita‐Salute San Raffaele University
Matthew T. Moyer, MD, MS, FASGE
Milan, Italy
Michel Kahaleh, MD, AGAF, FACG, FASGE Associate Professor of Medicine
Distinguished Professor of Medicine Division of Gastroenterology and Hepatology
Clinical Director of Gastroenterology Penn State Hershey Medical Center Sohini Sameera, MD
Chief of Endoscopy Hershey, PA, USA Rutgers Robert Wood Johnson Medical School
Director Pancreas Program New Brunswick, NJ, USA
Rutgers Robert Wood Johnson Medical School
V. Raman Muthusamy, MD, FACG,
New Brunswick, NJ, USA
FASGE Thomas J. Savides, MD
Director, Gastroenterology Fellowship Program Division of Gastroenterology
Masayuki Kitano, MD, PHD Health Sciences Associate Clinical Professor of University of California San Diego
Second Department of Internal Medicine Medicine La Jolla, CA, USA
Wakayama Medical University Division of Gastroenterology
Wakayama, Japan Department of Medicine Sam M. Serouya, MD
University of California Assistant Professor of Medicine
Kumar Krishnan, MD Irvine, CA, USA NYU Langone Grossman School of Medicine
Interventional Endoscopy New York, NY, USA
Harvard Medical School Satish Nagula, MD
Massachusetts General Hospital Director of Endoscopic Ultrasound Juan Pablo Román Serrano, MD
Boston, MA, USA Icahn School of Medicine at Mount Sinai Staff of Endoscopy Service
New York, NY, USA Hospital Nove de Julho
Wilson T. Kwong, MD, MS Sao Paulo, Brazil
Assistant Professor of Medicine Yunseok Namn, MD
Division of Gastroenterology Stony Brook University Hospital James T. Sing JR., DO, FACG, AGAF
University of California San Diego Health Sciences Renaissance School of Medicine at Stony Brook Assistant Professor of Medicine
La Jolla, CA, USA University Texas A&M University Health Science Center
Stony Brook, NY, USA Director, Endoscopy
Department of Medicine
Sandeep Lakhtakia, MD, MNAMS, DM
Scott and White Clinic and Hospital
Consultant M. Babitha Reddy, DO, MPH
Texas A&M University Health Science Center
Asian Institute of Gastroenterology Gastroenterology Fellow
Temple, TX, USA
Hyderabad, India Lenox Hill Hospital
New York, NY, USA
Alberto Larghi, MD, PHD Muhammad Tahir, MD

Digestive Endoscopy Unit Mihai Rimbaș, MD, PHD Roswell Park Comprehensive Cancer Center
Department of Gastroenterology Buffalo, NY, USA
Fondazione Policlinico A. Gemelli IRCCS
Rome, Italy Colentina Clinical Hospital;
Internal Medicine Department Raymond S. Tang, MD
Carol Davila University of Medicine Clinical Professional Consultant
Jose Lariño‐Noia, MD Bucharest, Romania Institute of Digestive Disease
Department of Gastroenterology and Hepatology The Chinese University of Hong Kong
Health Research Institute David H. Robbins, MD, MSC Prince of Wales Hospital
University Hospital of Santiago de Compostela Associate Director Shatin, New Territories
Santiago de Compostela, Spain Lenox Hill Hospital Hong Kong, China
New York, NY, USA
Linda S. Lee, MD Anthony Yuen Bun Teoh, MBCHB,
Division of Gastroenterology, Hepatology and Sarah A. Rodriguez, MD FRCSED, FHKAM (SURGERY)
Endoscopy Assistant Professor of Medicine Department of Surgery
Brigham and Women’s Hospital Oregon Health and Science University Prince of Wales Hospital
Harvard Medical School Portland, OR, USA The Chinese University of Hong Kong
Boston, MA, USA Shatin, Hong Kong

ix
Contributors

Sabrina Gloria Giulia Testoni, Michael B. Wallace, MD, MPH Yasunobu Yamashita, MD, PHD
MD Division of Gastroenterology and Second Department of Internal Medicine
Pancreato‐Biliary Endoscopy and Endosonography Hepatology Wakayama Medical University
Division Mayo Clinic College of Medicine Wakayama, Japan
Pancreas Translational and Clinical Research Center Jacksonville, FL, USA
San Raffaele Scientific Institute IRCCS Sam Yoselevitz, MD
Vita‐Salute San Raffaele University James L. Wise, MD Clinical Associate of Medicine
Milan, Italy Essentia Health Care Systems Tufts University School of Medicine
Duluth, MN, USA Burlington, MA, USA
Isabela Trindade Torres, MD
Staff of Endoscopy Service Richard C.K. Wong, MD, FASGE,
Hospital Nove de Julho
FACG, AGAF, FACP
Sao Paulo, Brazil
Professor of Medicine
Case Western Reserve University;
Shyam Varadarajulu, MD Medical Director, Digestive Health Institute
Director of Endoscopy Endoscopy Unit
University of Alabama at Birmingham School University Hospitals Case Medical Center
of Medicine Cleveland, OH, USA
Birmingham, AL, USA

x
 Preface
Learning to perform and interpret endoscopic ultrasound
(EUS) requires both didactic learning and repetitive exposure
to images usually accomplished through procedural volume.
We provided detailed aspects of the didactic portion of
learning in the Gress and Savides textbook Endoscopic
Ultrasonography. We then created the Gress, Savides, Bounds
and Deutsch Atlas of Endoscopic Ultrasonography to provide
aspiring endosonographers access to numerous images and
videos to assist them with improving their pattern recogni-
tion of pathologic conditions.
In this second edition of the Atlas, we are grateful that the
renowned Brazilian endoscopist Everson Artifon has joined
our team, along with our previous editor Brenna Casey who
has continued with the Atlas. Our previous editor, John
Deutsch, has retired and fortunately his timeless and superb
chapters related to learning EUS anatomy are retained.
In this edition, we are excited to have expanded our
international panel of world class endosonographers as
contributing authors to provide a variety of styles and
approaches to EUS. Our authors include some of the “first‐
generation” pioneers of endoscopic ultrasound as well as
the next generation of interventional EUS pioneers who
are improving the imaging abilities of new and enhanced
EUS technology and expanding the breadth of interven-
tional techniques. We are especially pleased to offer many
new sections on “How to do” aspects of interventional and
therapeutic EUS procedures.
We hope this Atlas will appeal to a wide spectrum of endo-
sonographers, from those who are beginning their training to
those who are looking to expand their horizons with thera-
peutic techniques.
Finally, we want to thank our families, colleagues, editors,
authors, and especially Jenny Seward from our publisher,
Wiley, for all their support without whom this Atlas could not
be possible.
Frank Gress MD
Thomas Savides MD
xi
 About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/gress/atlas

• Videos showing procedures described in the book.

(All videos are referenced in the text at the end of each chapter.)
• All figures from the book available for downloading

xii
1 Normal EUS Anatomy
 1 Normal Human Anatomy
John C. Deutsch
Essentia Health Care Systems, Duluth, MN, USA
Introduction
The Visible Human Project at the University of Colorado
has generated large volumes of human anatomy data. The
original information is captured by slowly abrading away
frozen human cadavers in a transaxial manner and cap-
turing the anatomy by digital imaging. The digital data is
compiled and then over the years is manipulated by scien-
tists at the University’s Center for Human Simulation to
allow access to identified cross‐sections in any plane as
well as to models which can be lifted from the data set.
Details regarding the Visible Human Project and its appli-
cations to gastroenterology and endosonography have
been previously described.
This atlas is fortunate to be able to use the interactive
anatomy resources developed by Vic Spitzer, Karl Reinig,
David Rubenstein, and others to create movies that help
explain what takes place during endoscopic ultrasound
(EUS) evaluations. Since EUS is a “real‐time” examination,
it seems reasonable to present this section primarily as
“real‐time” videos. The videos can be viewed over and
over, allowing endosonographers to look not only at the
highlighted structures, but also at structures they might
visualize during EUS that are not specifically identified on
the selected video.
This chapter uses the terms “radial array orientation” to
describe planar anatomy which would be found perpen-
dicular to a line going through the digestive tract (as would
be generated by a radial array echoendoscope, Figure 1.1)
and “linear array orientation” for planar anatomy gener-
ated parallel to a line going through the digestive tract (as
would be generated by a linear array echoendoscope,
Figure 1.2).
Atlas of Endoscopic Ultrasonography, Second Edition. Edited by Frank Gress, Thomas Savides, Brenna Casey, and Everson L. A. Artifon.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/gress/atlas
Normal EUS anatomy from the esophagus
Radial array orientation (Video 1.1)
Video 1.1 starts with Visible Human Models of the left atrium
(purple), trachea and bronchi (light blue), aorta and pulmonary
arteries (red), vena cava (dark blue), and the esophagus
(brown). A plane is shown passing through the esophagus.
This plane contains the transaxial cross‐sectional anatomy
images which then follow, starting in the oropharynx and
going caudally. The upper esophageal sphincter (UES) is
identified. As the images proceed distally, the trachea and
esophagus can be followed to a point where the brachioce-
phalic left carotid and left subclavian arteries are evident just
above the aortic arch. Below the aortic arch is the aortopul-
monary window. The azygos arch can be seen exiting the
superior vena cava (SVC). This occurs just above the tracheal
bifurcation. The esophagus (labeled as “E”) is surrounded by
the descending aorta, the vertebrae, and the trachea. The
thoracic duct (not labeled) is visible between the aorta and
vertebrae, inferior to the esophagus. Going distally, the pul-
monary artery becomes prominent. The region between the
right mainstem bronchus (RMB) and left mainstem bron-
chus (LMB) is the subcarinal space. The video progresses to
a level where the left atrium surrounds the superior aspect
of the esophagus and then the video ends as the esophagus
passes the gastroesophageal junction.
An image plane cross‐section taken from a radial array
orientation at the level of the subcarinal space is shown in
Figure 1.3.
Linear array orientation (Video 1.2)
Video 1.2 starts with the same models as above (the left
atrium [purple], trachea and bronchi [light blue], aorta and
3
PA R T 1 Normal EUS Anatomy

Figure 1.1 Visible Human Model of esophagus, stomach, and duode- Figure 1.2 Visible Human Model of esophagus, stomach, and duode-
num. The green circle shows a plane perpendicular to the axis and is num. The red circle shows a plane parallel to the axis and is similar to a
similar to a plane developed during radial array endosonography. plane developed during linear array endosonography.

pulmonary arteries [red], vena cava [dark blue], and the

esophagus [brown]). The plane shows potential ways that
cross‐sectional anatomy can be generated. The video then
shows a sagittal image with the descending aorta inferior to
the esophagus, much as what is done during linear array
EUS. In this orientation the pulmonary artery (PA) and left
atrium are superior. The image plane is rotated to bring the
left atrium and pulmonary artery to the inferior side of the
esophagus. The models are then shown again, and the plane
is moved in the caudal and cephalad directions, much as
during EUS.

Normal EUS anatomy from the stomach

Radial array orientation (Video 1.3)

Endoscopic ultrasound of the stomach differs from EUS at
other sites since the stomach does not constrain the endo-
scope tightly. It is important to follow anatomical structures
(such as in a station approach) to avoid getting lost.
The video shows models of the stomach, esophagus, duo-
denum, gallbladder, pancreas (brown), the aorta, splenic
Figure 1.3 Transaxial cross‐section of digital anatomy taken at the level
of the subcarinal space. Ao, aorta (both ascending, superior in the image,
and descending, inferior in the image, are shown); Az, azygos vein;
PA, pulmonary artery; RMB and LMB, right and left mainstem bronchi;
SVC, superior vena cava.

4

artery, hepatic artery and left gastric artery (red), adrenal
glands (pink), and splenic, superior mesenteric veins (dark
blue) as viewed from behind. A plane is passed that is similar
to the image plane generated during radial array EUS. The
resultant cross‐sectional anatomy starts at the level of the
gastroesophageal junction, with the aorta and inferior vena
cava (IVC) labeled. The aorta (which is collapsed) is fol-
lowed, which brings the pancreas and left adrenal gland into
view. The first artery that comes off the aorta in the abdo-
men is the celiac artery. There is a trifurcation into the
splenic, hepatic, and left gastric arteries (LGA), although the
LGA is generally smaller and difficult to see. It is shown in
the video at the “x” just before the bifurcation into the celiac
and hepatic arteries as identified.
The superior mesenteric artery (SMA) comes off the aorta
just distal to the celiac artery. Various endoscope maneuvers
can be used to bring the portal confluence into view, and
then the splenic vein can be used as a guide to visualize the
pancreas body, left adrenal, kidney, and spleen. The dia-
phragm can be easily imaged between the kidney and the
vertebrae.
Linear array orientation (Video 1.4)
The linear array exam also follows the aorta to the stomach,
but, as shown Video 1.4, the image plane across the pancreas
is generally obtained through a sweeping motion. The first
major gastric landmark is the origin of the celiac artery and
SMA from the aorta (Figure 1.4). The superior mesenteric
vein (SMV), portal vein, and splenic vein can be used as
guides to go back and forth across the pancreas and in the
Figure 1.4 Sagittal cross‐section of digital anatomy at the level of the
gastroesophageal junction, similar to a view seen during linear array
endoscopic ultrasound (EUS). The celiac and superior mesenteric arteries
(SMA) are shown at their insertion into the aorta. The renal vein (RV) is
shown adjacent to the SMA and the splenic vein is shown adjacent to the
pancreas.
CHAPTER 1 Normal Human Anatomy
process, the left adrenal, kidney, and spleen can be seen. The
splenic artery runs roughly parallel to the splenic vein, but is
generally tortuous.
Normal EUS anatomy from the duodenum
Radial array orientation (Video 1.5)
The radial array EUS examination through the duodenum
follows a constrained path, but the endoscope can be rotated
to put various structures into the inferior aspect of the image
plane, as shown in the models of the duodenum, pancreas
(brown), portal and superior mesenteric veins (blue), aorta
(red), and SMA (silver). There are many structures of inter-
est in a rather small area, and most of the images obtained
are from the posterior view, with the liver to the right and
the pancreas to the left of the image screen. After leaving the
pylorus, the pancreas can be oriented with the tail pointed
either to the left or inferiorly, and the splenic vein runs in
the same direction as the pancreas. Going through the duo-
denal bulb, the gastroduodenal artery (GDA) often appears.
Without Doppler, the GDA can be confused with the com-
mon bile duct (CBD) since these structures are nearly paral-
lel in orientation and are very close to each other. As the
apex of the duodenal bulb is reached, the image plane cap-
tures a longitudinal view of the CBD and the portal vein. As
the descending duodenum is reached, the bile duct is seen in
cross‐section and the IVC comes into view. As the third part
of the duodenum is reached, the image plane rotates in such
a way as to give a longitudinal cut through the IVC and then
passes underneath the junction of the SMA with the aorta.
Branches of the SMV can be found and the renal vein is vis-
ible in the “armpit” formed at the insertion of the SMA into
the aorta. A special area is then highlighted in Video 1.5.
Models show how the gastroduodenal artery and the hepatic
artery (in red) relate to the CBD (in orange).
Figure 1.5 shows a model with an image plane and
Figure 1.6 shows the resultant planar anatomy, which forms
the stack sign – a phenomenon in which the portal vein,
CBD, and main pancreatic duct are captured in the same
field.
Linear array orientation (Video 1.6)
The linear array exam of the duodenum is an excellent
way to see the CBD and pancreatic head. The anatomy is
difficult to understand since the endoscope image is tipped
into the C‐sweep of the duodenum, and then the image
plane is swept in various angles, resulting in a cross‐sec-
tioning of the CBD and pancreatic duct (PD). The image
planes employed can be appreciated from observing the
models in the video. The cross‐sections obtained can be
positioned to first give a longitudinal view of the CBD and
both longitudinal views and cross‐sections of the portal
vein and SMV.
5
PA R T 1 Normal EUS Anatomy

Image plane

Portal vein

Pancreatic duct

Probe

Duodenum
CBD
Image plane
that generates
“stack sign”

SMV

Figure 1.7 Visible Human Model with a plane that is in a location similar
Figure 1.5 Visible Human Model of an image plane that is in the location
to what can be generated during linear array endoscopic ultrasound (EUS),
in which radial array endoscopic ultrasound (EUS) generates the “stack
showing the relative position of the gastroduodenal artery, pancreatic duct
sign”, in which the portal vein, common bile duct (CBD), and pancreatic
(PD), hepatic artery, and common bile duct (CBD).
duct are in the same field. A probe in orange is shown going into the
proximal duodenum. The superior mesenteric vein (SMV) is also shown.
As seen in the first part of Video 1.6, if the endoscope is in
the second part of the duodenum, the bile duct goes to the
ampulla away from the transducer and the liver is towards
the transducer. If the endoscope is in the duodenal bulb, as
shown in the second part of the video, the liver is away from
the transducer.
Duodenum The GDA drapes over the portal vein and can be found most
readily using Doppler. Figure 1.7 shows a model and Figure 1.8
the resultant cross‐section where the GDA can be found.

Portal vein CBD

Normal EUS anatomy from the rectum

xx
PD
Radial array orientation, male (Video 1.7)
Video 1.7 shows models of various male pelvic structures,
starting with the rectum and sigmoid colon, the aorta, and
the iliac arteries with internal and external branches. The
SMA is included to show the anterior direction of the models.
The prostate, bladder, coccyx, and sacrum are added sequen-
tially. A second set of models is then shown which contains
Splenic vein the rectum, sigmoid colon, prostate, bladder, coccyx, sacrum,
external iliac arteries (red), veins (blue), as well as three‐
dimensional models of the internal and external anal sphinc-
ters. The sphincters and sigmoid colon are then removed.
Figure 1.6 The cross‐sectional anatomy within the plane shown in Planar anatomy in the radial array orientation from the
Figure 1.3. The common bile duct (CBD), pancreatic duct (PD), and portal male rectum is then shown, starting distally and moving
vein are all in the same field (“stack sign”). proximally. The anal sphincters are labeled, followed by the

6

Figure 1.8 Cross‐sectional anatomy generated within the plane shown in
Figure 1.5. The gastroduodenal artery (GDA) and common bile duct (CBD)
are shown with the pancreatic head. The portal vein (PV) is shown near the
portal confluence.
prostate, urethra, levator ani, and coccyx. The sacrum and
seminal vesicles are then shown, followed by the right inter-
nal iliac artery.
Radial array orientation, female (Video 1.8)
Video 1.8 starts distally at the end of the anal canal. The
internal and external sphincters are shown, and residual
stool is present in the rectum. Moving proximally, the vagina
and urethra are shown, followed by the cervix and bladder.
Linear array orientation, male (Video 1.9)
Video 1.9 starts with a sagittal plane through the pelvis with
the body facing the left. The prostate, rectum, anal canal,
and bladder are identified. The plane is rotated, and the sem-
inal vesicles and internal anal sphincter are labeled. The coc-
cyx and sacrum are apparent at the start and end of the
video but are unlabeled.
Linear array orientation, female (Video 1.10)
Video 1.10 starts with a sagittal plane through the pelvis
with the body facing the left and slightly face down. The anal
canal, rectum, uterus, and bladder are identified. Stool is
present in the rectal vault. The plane is rotated, and towards
the end of the video the internal anal sphincter (IS) and
external anal sphincter (ES) are identified.
Vascular videos
Arterial (Video 1.11)
Video 1.11 shows models of some of the main arteries that are
visualized during endosonography. A close‐up view shows the
celiac artery with its branches (hepatic, splenic, and left gastric
arteries). The gastroduodenal and pancreaticoduodenal arter-
ies are shown coming off the hepatic artery. The internal and
CHAPTER 1 Normal Human Anatomy
external iliac arteries are then identified, followed by identifi-
cation of the arteries associated with the aortic arch (left sub-
clavian, left carotid, brachiocephalic) and the branches of the
brachiocephalic (right subclavian and right carotid). Various
organs are then placed in the model starting with the esopha-
gus, then pancreas, stomach, and duodenum.
Venous (Video 1.12)
Some of the major veins visualized during endosonography
are shown. At first, the vena cava and right atrium are iden-
tified, after which, the renal veins and azygos veins are
added. The portal system with the portal vein, SMV, splenic
vein, and inferior mesenteric vein (not labeled) are placed in
blue. The systemic veins are then colored and removed. The
pancreas is placed on the portal vein and its branches, show-
ing how the head runs parallel to the SMV and the tail runs
parallel to the splenic vein.
Endobronchial ultrasound anatomy (Video 1.13)
Extratracheal anatomy is similar to extraesophageal anat-
omy and many of the structures seen in the extratracheal
spaces are the same as what is seen in the extraesophageal
spaces. The endoluminal views of the trachea are oriented so
that the membranous trachea is inferior and is splayed wider
than the cartilaginous trachea at the level of the carina, put-
ting the right mainstem bronchus (RMB) to the right and the
left mainstem bronchus (LMB) to the left (Figure 1.9). As
one goes right the bronchus immediately branches superi-
orly towards the right upper lobe (RUL), and continues
straight as bronchus intermedius (BI) (Figure 1.10), which
then branches towards the right middle lobe (RML) and
right lower lobe (RLL) of the lung (Figure 1.11).
Going left from the carina, one goes down the relatively long
left mainstem bronchus until it branches towards the left upper
lobe (LUL) and left lower lobe (LLL) of the lung (Figure 1.12).
An overview of the bronchial tree is shown in Figure 1.13.
Video 1.13 starts with the cervical trachea. All images are
in a linear array orientation as endobronchial ultrasound
(EBUS) is exclusively linear. The esophagus is inferior and
the brachiocephalic artery and vein are superior. The video
begins with rotation of the image plane. The superior part of
the plane moves left and the inferior part moves right. This
moves the esophagus out of view and brings the left subcla-
vian artery and left carotid artery into the inferior part of the
image. Eventually, the esophagus is seen in the superior part
of the image and, with continued motion, the esophagus
again appears inferior to the trachea. At this point, the image
plane moves caudally to the carina. The right pulmonary
artery, brachiocephalic artery (BA), and left brachiocephalic
vein (LBV) are labeled. The plane is again rotated to splay
the right (RMB) and left (LMB) mainstem bronchi apart. The
plane is then moved to better visualize the right mainstem
bronchus, showing the branch to the right upper lobe (RUL),
the azygos arch (AzArch), the bronchus intermedius (BI).
7
PA R T 1 Normal EUS Anatomy
Figure 1.9 Endobronchial view of the carina, showing the right (RMB)
and left (LMB) mainstem bronchi.
Figure 1.10 Endobronchial view of the first branch of the right mainstem
bronchus towards the right upper lobe (RUL) and the bronchus intermedius
(BI).
This same plane shows the relation of the aortic arch
(AoArch) and left pulmonary artery to the left mainstem
bronchus (LMB). As the plane goes down the right main-
stem bronchus/bronchus intermedius (RMB) towards its
next bifurcation, the azygos arch (AzAr), right pulmonary
artery (RPA), and right pulmonary vein (RPV) are shown.
8
Figure 1.11 Endobronchial view of the bifurcation of the bronchus
intermedius towards the right middle lobe (RML) and the right lower lobe
(RLL).
Figure 1.12 Endobronchial view of bifurcation of the left mainstem
bronchus towards the left upper lobe (LUL) and left lower lobe (LLL).
The plane is brought back to the carina to visualize the left
mainstem bronchus (LMB), and the azygos arch (AzAr),
aortic arch (AoAr), left pulmonary artery (LPA), and vein
(LPV) are identified. The branching to the left upper lobe
(LUL) and left lower lobe (LLL) are shown, and the aorta
(Ao) and left pulmonary artery are labeled.
 CHAPTER 1 Normal Human Anatomy

Chapter video clips

Video 1.1 Esophageal‐related models and cross‐sectional

anatomy: radial orientation.
Video 1.2 Esophageal‐related models and cross‐sectional
anatomy: linear orientation.
Video 1.3 Gastric‐related models and cross‐sectional anatomy:
radial orientation.
Video 1.4 Gastric‐related models and cross‐sectional anatomy:
linear orientation.
Video 1.5 Duodenal‐related models and cross‐sectional
anatomy: radial orientation.
Video 1.6 Duodenal‐related models and cross‐sectional
anatomy: linear orientation.
Video 1.7 Male rectum‐related models and cross‐sectional
anatomy: radial orientation.
Video 1.8 Male rectum‐related cross‐sectional anatomy: linear
orientation.
Video 1.9 Female rectum‐related cross‐sectional anatomy:
radial orientation.
Video 1.10 Female rectum‐related cross‐sectional anatomy:
linear orientation.
Video 1.11 Arterial models.
Video 1.12 Venous models.
Video 1.13 Bronchial anatomy in a linear orientation.
Figure 1.13 A Visible Human Model of the bronchial tree.

9
 2 Esophagus: Radial and Linear
James L. Wise and John C. Deutsch
Essentia Health Care Systems, Duluth, MN, USA
Layers of the esophageal wall
Staging the depth of involvement of tumors and the layer of
origin of subepithelial masses is an important component of
competency in endoscopic ultrasonography (EUS). An inti-
mate knowledge of the normal layers of the esophageal wall
is critical for this to be done accurately. The wall of the
esophagus has four readily appreciable layers by EUS using
standard operating frequencies (5–12 MHz). The layers are
seen in concentric, alternating rings of hyperechoic and
hypoechoic structures emanating out distally from the tip of
the endoscope. Starting with the layers closest to the scope
tip, they are as follows:
• Interface echo between the superficial mucosa and water
(hyperechoic).
• Deep mucosa (hypoechoic).
• Submucosa plus the acoustic interface between the sub-
mucosa and muscularis propria (hyperechoic).
• Muscularis propria minus the acoustic interface between
the submucosa and muscularis propria (hypoechoic).
If a higher resolution frequency probe is used, greater
number of layers could be visualized as detailed in Chapter 4.
The esophagus lacks an obvious fifth layer as there is no
serosa.
In our opinion, visualization and discernment of the lay-
ers of the esophageal wall is usually best accomplished using
radial compared to linear instruments.
Figure 2.1 shows the esophageal walls using radial and
linear instruments. To help separate the layers, these images
include a muscularis mucosae leiomyoma that was subse-
quently resected. Images show subepithelial hypoechoic
lesion in echolayer II as well as in the other defined layers of
the esophageal wall.
Atlas of Endoscopic Ultrasonography, Second Edition. Edited by Frank Gress, Thomas Savides, Brenna Casey, and Everson L. A. Artifon.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/gress/atlas
10
Normal radial extraesophageal anatomy
(Video 2.1)
Standard examination of the esophagus and mediastinum
begins with advancing the radial instrument to the gastroe-
sophageal (GE) junction at or near the squamocolumnar
junction. At this level the aorta is seen as an anechoic circu-
lar structure in the 5 o’clock position. The descending aorta
is kept in this position as all radial mediastinal imaging will
then correlate quite nicely with cross‐sectional imaging.
Other structures visible at the level of the GE junction are
the inferior vena cava (IVC) seen between 7 and 9 o’clock
and the liver between 6 o’clock and 12 o’clock surrounding
the IVC (Figure 2.2).
As the scope is withdrawn, the vena cava moves clockwise
and superiorly into the right atrium. The spine soon comes
into view adjacent to the descending aorta at 6 o’clock.
Further withdrawal upward to usually around 30–35 cm
reveals the anechoic chamber of the left atrium in the 12
o’clock position (Figure 2.3). With this field, relatively slight
movement of the scope will reveal the mitral valve (Figure 2.4),
aortic root, and the aortic valve (Figure 2.5). In the inferior por-
tion of the field the descending aorta, the spine, the thoracic
duct, and a relatively prominent azygos vein can be seen.
As the scope is withdrawn the bronchi come together at
the carina. At or just proximal to this level the azygos arch
(Figure 2.6) can be identified traveling superiorly and later-
ally into the superior vena cava. This is also the area of the
aortopulmonary (AP) window at approximately 2 o’clock.
The endoscope can be pushed down from here or pulled up
slightly from the position of the left atrium to reach the sub-
carinal space. Of interest in the subcarinal space are the right
and left mainstem bronchi seen emanating out as ribbed‐like
 CHAPTER 2 Esophagus: Radial and Linear

(a) (b)

Figure 2.1 (a) Radial array image of esophageal wall with small echolayer II leiomyoma. (b) Linear array image of esophageal wall with small echolayer II
leiomyoma.

Figure 2.2 Radial array image at gastroesophageal (GE) junction. Figure 2.4 Radial array image at the level of the mitral valve.
IVC, inferior vena cava.

Figure 2.3 Radial array image at the level of the left atrium. PV, pulmo-
nary vein. Figure 2.5 Radial array image at the level of the aortic root.

11
PA R T 1 Normal EUS Anatomy
Tracheal bifurcation
Azygos arch
Aortic arch
Thoracic duct
X
Figure 2.6 Radial array image at the level of the azygos arch.
Tracheal
bifurcation
Aortic arch
Azygos x
vein
Figure 2.7 Radial array image at the mid aortic arch.
air‐filled structures. As many have suggested, these can be
imagined to have the appearance of two headlights.
More proximally from the area at the AP window the
aorta elongates and forms the aortic arch (Figure 2.7). This
usually creates a semicircle on the entire right side of the
image correlating to the left‐sided arch. However, with usual
orientation the aorta should not cross the midline. The left
carotid and left subclavian artery can easily be seen to leave
the aortic arch as small round structures on the right side of
the image (Figure 2.8). The brachiocephalic artery can some-
times be seen as well superior to the carotid on the right. As
the scope is withdrawn the thyroid comes into view. For
example, on the right of Figure 2.9 a prominent thyroid can
be seen with a cystic structure within it.
Normal linear thoracic anatomy
The linear scope is advanced to the GE junction by following
the descending aorta from the level of the arch downward
12
Figure 2.8 Radial array image at the level of the left carotid and
subclavian arteries.
Figure 2.9 Radial array image at the level of the thyroid.
(Figure 2.10). In order to follow this path, the scope is usu-
ally torqued clockwise 90–180 degrees and, as the aorta is
followed down, the scope is gently rotated counterclockwise
to stay on the aorta. As seen in Video 2.2, the thyroid is visu-
alized briefly and the scope is then advanced to the level of
the GE junction.
The origin of the celiac artery (Figure 2.11) is identified
and then the scope can be withdrawn. This is the standard
reference point for the beginning of the exam during with-
drawal. Examination of the extraesophageal and thoracic
structures is more time consuming than the radial approach
as this echoendoscope’s narrow focal point has to be torqued
back a further 180 degrees to cover the same field of exami-
nation. This is done by withdrawing the scope at increments
with constant back and forth torque.
As the scope is withdrawn 3–5 cm back from the GE junc-
tion, the scope will need to be rotated 180 degrees off the
aorta to see the left atrium and cardiac structures. The car-
diac structure can be discerned quite readily using the linear
scope. The mitral valve is just adjacent to the aortic root,
 CHAPTER 2 Esophagus: Radial and Linear

Figure 2.10 Linear array image at the mid aorta. Figure 2.12 Linear array image at the aortic root.

GE junction

Celiac

Aorta

Figure 2.13 Linear array image at the aortopulmonary window (APW).

Figure 2.11 Linear array image at the level of the celiac artery.
PA, pulmonary artery.

which is just at clockwise rotation from the mitral valve. The
aortic valve can be visualized at various angles with appro-
priate endoscopic manipulation given its position relative to
the esophagus (Figure 2.12).
Withdrawing from the level of the left atrium by 1–2 cm
reveals the subcarinal space. This is the area between the
pulmonary artery and the left atrium. The bifurcation of the
trachea by definition occurs at this level as well.
The AP window is just proximal to this area by several
centimeters’ orientation and is slightly clockwise torque
from the subcarinal space. The space between the aortic
arch and the pulmonary artery make up this region. This is
below the level of the aortic arch by a few centimeters.
There is a small node seen on the image which could be
readily sampled via endoscopic ultrasound‐guided fine
needle aspiration (EUS‐FNA) (Figure 2.13).
The azygos arch is also visualized around this area, just at
or slightly below the aortic arch. The azygos vein can be fol-
lowed distally along the spine, as in the accompanying Video
2.2. Occasionally intercostal veins are visible.
Chapter video clips
Video 2.1 Radial array examination of the extraesophageal
spaces.
Video 2.2 Linear array examination of the extraesophageal
spaces.

13
 3 Normal Mediastinal Anatomy by EUS
and EBUS
Juan Corral1, Sebastian Fernandez‐Bussy2, and Michael B. Wallace1
1
Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Jacksonville, FL, USA
2
Division of Pulmonary Medicine and Critical Care, Mayo Clinic College of Medicine, Jacksonville, FL, USA
Introduction
The mediastinum is a common anatomical location for
lymph node (LN) metastases in lung cancer as well as many
other malignant and inflammatory conditions. The pres-
ence and specific location of mediastinal LN metastases in
non‐small cell lung cancer (NSCLC) dictates therapy with
surgery for localized disease, combination therapy when
contralateral LNs are involved, and palliative therapy when
contralateral LNs and metastases are encountered.
Unfortunately, cross‐sectional imaging with computed
tomography (CT), magnetic resonance imaging (MRI), or
positron emission tomography (PET) alone is not adequate
to confirm a diagnosis; thus, a tissue sample is preferred.
Recently, it has been suggested that the use of endoscopic
ultrasound‐guided fine needle aspiration (EUS‐FNA) asso-
ciated with endobronchial ultrasound‐guided transbron-
chial fine needle aspiration (EBUS‐TBNA) can adequately
sample LNs in the mediastinum, avoiding the need for a
futile surgery.
The purpose of this chapter is to provide the basic ana-
tomical information as well as technical maneuvers used to
investigate the mediastinum successfully.
Anatomical definitions
The LNs in the mediastinum were classified in different sta-
tions based on surgical and anatomical landmarks for the
purpose of staging lung cancer but this schema is now widely
used in other chest diseases (Figure 3.1). The LNs with their
respective stations and corresponding anatomical locations
are described in Table 3.1.
EUS‐FNA is usually best suited to sample LNs adjacent to
the esophagus which runs posterior to the trachea. Because
Atlas of Endoscopic Ultrasonography, Second Edition. Edited by Frank Gress, Thomas Savides, Brenna Casey, and Everson L. A. Artifon.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/gress/atlas
14
of ultrasound artifacts created by the air‐filled trachea,
lesions immediately anterior to the trachea are not well
seen. EUS‐accessible stations include 2L, 2R, 4L, 4R, 5, 7, 8,
9, and, sometimes depending on the size, station 6. On the
other hand, EBUS‐TBNA can target LNs either anterior or
lateral to the trachea to the level of the carina, and alongside
the left and right bronchial tree including stations 2L, 2R, 4L,
4R, 7, 10, and 11. Although both procedures overlap in sta-
tions 2 L/R, 4 L/R, and 7, in other stations they are com-
plementary, and in combination allow nearly complete
mediastinal access.
Equipment
Radial and curvilinear array echoendoscopes are available
(Figure 3.2), with scanning radius ranging from 270–360
degrees for radial to 100–180 degrees for the linear echoen-
doscope. These scopes have standard accessory channels
(2.0–2.8 mm) and larger accessory channels (3.7 mm) capa-
ble of delivering needles and other therapeutic devices such
as a 10 French (Fr) plastic stent.
EUS can use several types of needles: 19 gauge (G), 22 G,
and 25 G for FNA, as well as Tru‐cut needles for core biopsy.
The needle is occluded with a stylet during passage through
the gastrointestinal tract wall and bronchial wall to mini-
mize contamination from passage through those structures.
EBUS equipment comprises a curvilinear array echoendo-
scope with an outer diameter of 6.7 mm and a biopsy chan-
nel of 2 mm. The ultrasonic frequency is 7.5 MHz with a
penetration depth of 4–5 cm, making it well suited for FNA of
LNs and lung masses through the trachea and bronchi. A 22
G needle is used to perform TBNA in the same manner as in
EUS. Both systems have integrated oblique‐viewing optics to
guide intubation and limited inspection.
 CHAPTER 3 Normal Mediastinal Anatomy by EUS and EBUS

Table 3.1 Mediastinal lymph node stations with their anatomical

correlations.

Level Anatomical correlation

Superior mediastinal lymph nodes

1 Highest mediastinal
2 Upper paratracheal
3 Prevascular and retrotracheal
4 Lower paratracheal (including azygos nodes)
Aortic lymph nodes
5 Aortopulmonary (AP) window or subaortic
6 Para‐aortic (ascending aorta and phrenic)
Inferior mediastinal lymph nodes
7 Subcarinal
8 Paraesophageal (below carina)
9 Pulmonary ligament
N1 lymph nodes
10 Hilar
11 Interlobar
12 Lobar
13 Segmental
14 Subsegmental

(a) (b) (c)

Figure 3.1 Mediastinal lymph node stations.

Endoscopic ultrasound technique

The initial examination can be performed with either the

radial or linear array echoendoscope; however, the linear
scope is required to perform FNA. Given the obvious efficiencies,
we prefer to use a single linear echoendoscope for both Figure 3.2 Types of echoendoscopes: (a) linear probe; (b) endobronchial
imaging and FNA. probe; (c) radial probe.

Linear scanning
The balloon should be deflated or inflated only slightly to
provide good acoustic coupling with the tissue. The medi-
astinum is imaged by first finding the descending aorta
starting at the cardia. The examination can be performed
by rotating 360 degrees from the cardia, then withdraw-
ing the shaft 4–5 cm and performing another rotation.
Alternatively, one can survey from the cardia to the
cervix, then rotating 90 degrees and repeating the
maneuver until the whole mediastinum is examined. It is
useful to use the following five stations as described
by Deprez (Videos 3.1.1–3.1.3). For radial examination,
see Video 3.2.
Inferior posterior mediastinum
The descending aorta is a large echo‐poor longitudinal struc-
ture on linear array with a bright deep wall due to the air
interface with the left lung. Clockwise rotation will sequen-
tially image left lung, left pleura, left atrium, right lung, right
pleura, azygos vein, and spine. The azygos vein can be local-
ized by rotating approximately 30 degrees counterclockwise
from the descending aorta. It is a thin echo‐poor structure
that can be followed proximally to its union with the supe-
rior vena cava. This is the area of LN stations 8 and 9
(Figure 3.3).

15
PA R T 1 Normal EUS Anatomy
Figure 3.3 Lymph node at station 8 (between calipers).
Figure 3.4 Subcarinal station (station 7).
Subcarinal area
At approximately 30 cm the subcarinal area is easily recog-
nized by finding the left atrium, a large hypoechoic structure
with cardiac motion, and pulling back until it disappears on
the left edge of the screen. Then one should have the pulmo-
nary artery in the right portion of the screen (Figure 3.4).
Slight movements to the right and left have to be performed
to completely interrogate this station. This is the area of LN
station 7 (Videos 3.3 and 3.4).
Aortic arch area
The azygos arch is located at 24–25 cm from the incisors. The
aortopulmonary (AP) window (station 5) is situated between
16
L node
AO
PA_
Figure 3.5 Aortopulmonary window station (stations 4L, 5 and 6). AO,
aorta; L node; lymph node; PA, pulmonary artery.
the aortic arch and the pulmonary artery. The AP window is
found by following the aorta cephalad until its arch, rotating
clockwise approximately 90 degrees, then advancing 1–2 cm
with slight tip up of the echoendoscope. The aorta will be the
echo‐poor structure on the right and the pulmonary artery
will be to the left; the AP window is the space between the
two just outside the AP ligament (which is not seen by EUS).
The 4L region is immediately medial (close to the esophagus
and EUS scope) to the AP window (Figure 3.5). Alternatively,
from the subcarinal area, rotating 90 degrees counterclock-
wise, crossing the left main bronchus and pulling it back
2–3 cm will put you in the same location. Further with-
drawal of the echoendoscope with slight rotation will show
the origin of the left subclavian artery. Occasionally, the left
carotid artery can be seen above the brachiocephalic (innom-
inate) vein.
Cervical area
Between 22 and 24 cm from the incisors, the superior part of
the lungs can be imaged along with the trachea, cricoid
bone, jugular veins, and carotid arteries.
Thyroid gland
At 17–20 cm from the incisors, the inferior thyroid gland can be
imaged as well as cervical LNs, which can be targeted for FNA.
Radial scanning
For radial scanning, one should enter the stomach, inflate the
balloon, and pull back the scope until the GE junction. The
aorta with be visualized as a large round echo‐poor structure.
The aorta should be rotated to the 5 o’clock position, and the
spine will be at 7 o’clock with the azygos vein in the middle.
Then the balloon should be deflated and a slow pull‐back is

performed observing all the mediastinal areas. It is important
to note that, for a complete lung cancer staging with both
radial and linear, the celiac axis, the left adrenal, and the left
lobe of the liver should be surveyed. This is easily accomplished
with a slight tip down on the echoendoscope and and then
pushing it into the stomach; the celiac take‐off can be seen and
the left adrenal can be seen at the 6 to 4 o’clock position with
its usual “seagull” appearance. For the liver, one goes to the
gastric antrum, aspirates all the air, inflating the balloon, and
then tip up with a slow pull‐back.
Endobronchial ultrasound
Just like EUS, EBUS can be performed with conscious
sedation, deep sedation, or general anesthesia. The tip of
the scope is placed under direct visual contact in different
positions, starting from the segmental bronchi to the tra-
chea usually scanning 90–120 degrees every 0.5–1 cm.
The diameter of the EBUS scope (6–7 mm) precludes pas-
sage beyond the second or third airway generation. EBUS‐
TBNA is performed under the same principles as EUS‐FNA.
As mentioned before, this technique is particularly useful
for LN stations 2, 4, 7, 10, and 11 (Figure 3.6). The upper
and middle third of the esophagus can be visualized from
the upper and lower trachea respectively Currently, we
have different sizes of needle available, including 19, 21,
22, and 25 G.
EBUS anatomical landmarks
It is important to note that all right tracheal lymph node sta-
tions are found from the left lateral border of the trachea to
the right aspect of the trachea.
Figure 3.6 Endobronchial ultrasound (EBUS) images of common
mediastinal stations (4L, 7 and 11L). The esophagus and vertebral bodies
can be visualized posteriorly from the upper and lower trachea.
CHAPTER 3 Normal Mediastinal Anatomy by EUS and EBUS
• Right upper paratracheal nodes (station 2R): the upper
border is the apex of the right lung, the lower border is the
intersection of the innominate vein with the trachea. This
station is usually found facing the scope to the right lateral
wall of the trachea, at 3 o’clock, at the level of the fifth tra-
cheal cartilage.
• Left upper paratracheal nodes (station 2L): the upper
border is the apex of the left lung, the lower border is the
superior limit of the aortic arch. This station is usually
found facing the scope to the left lateral wall of the tra-
chea, at 9 o’clock, at the level of the fifth tracheal
cartilage.
• Right lower paratracheal nodes (station 4R): the upper
border is the innominate vein, the lower border is the azygos
vein. This station is usually found just proximal to the main
carina, between 12 and 3 o’clock.
• Left lower paratracheal nodes (station 4L): the upper bor-
der is the superior limit of the aortic arch, the lower border
is superior limit of the left pulmonary artery. This station is
usually found at the level of the main carina, left lateral wall
of the trachea, at 9 o ‘clock. The view of the AP window is
very similar to that seen by the EUS scope with the aortic
arch on the right and pulmonary artery on the left.
• Subcarinal nodes (station 7): the upper border is the
main carina, the inferior border is the superior limit of the
left lower lobe take‐off on the left side, and the inferior limit
of the bronchus intermedius on the right side. This station is
found at the medial wall of the left mainstem bronchus or
the medial wall of the right mainstem bronchus and bron-
chus intermedius.
• Right hilar nodes (station 10R): the upper boder is the
azygos vein, the lower border is the interlobar region. This
station is usually found just proximal to the right upper lobe
take‐off, facing to the anterior and lateral airway wall.
• Left hilar nodes (station 10L): the upper border is the pul-
monary artery, the lower border is the interlobar region.
EBUS scope should be faced just proximal to the left upper
lobe, at 11 o’clock.
• Right interlobar superior nodes (station 11Rs): the
upper limit is the right upper lobe bronchus, the lower
limit is the distal bronchus intermedius. This station
should be found at the lateral wall of the airway, between
2 and 4 o’clock.
• Right interlobar inferior nodes (11Ri): lymph nodes are
between the right middle lobe and the right lower lobe.
EBUS scope should be placed just proximal to the right lower
lobe bronchus, facing laterally.
• Left interlobar nodes (station 11L): the upper limit is the
left upper lobe bronchus, the lower limit is the left lower
lobe bronchus. Place EBUS scope at the left lower lobe take‐
off, facing anterior and lateral.
• Right/left lobar nodes (station 12R/L): any lymph nodes
adjacent to the lobar bronchi.
17
PA R T 1 Normal EUS Anatomy

Complications and safety

EUS‐FNA and EBUS‐TBNA are highly safe procedures in
experienced hands, with a complication rate of 0.8%. A
major safety precaution with FNA is to visualize the entire
length of the needle and to use color Doppler to avoid any
blood vessels in the needle path.
Conclusions
EUS‐FNA and EBUS‐TBNA are complementary procedures
with a high degree of sensitivity and specificity for diagnos-
ing and staging benign and malignant diseases of the chest.
Careful attention to technique must be applied to prevent
the omission of important clinical information.
Chapter video clips
Video 3.1.1 Normal mediastinal anatomy by linear EUS:
vascular anatomy. Source: Hitachi.
Video 3.1.2 Normal mediastinal anatomy by linear EUS: right
and left atrium and AP window. Source: Aloka.
Video 3.1.3 Normal mediastinal anatomy by linear EUS: aorta,
heart and great vessels. Source: Hitachi.
Video 3.2 Normal mediastinal anatomy by radial EUS.
Video 3.3 Paratracheal and subcarinal lymph node evaluation
by EBUS. Source: Hitachi.
Video 3.4 Subcarinal lymph node (station 7) as seen by EBUS
with performance of FNA.

18
 4 Stomach: Radial and Linear
Joo Ha Hwang
Stanford University, Palo Alto, CA, USA
Endoscopic ultrasound (EUS) examination of the stomach is
often performed to evaluate subepithelial lesions, staging of
mucosa‐associated lymphoid tumor (MALT) lymphomas,
staging of gastric cancer, and evaluation of thickened gastric
folds. Examination can be performed using mechanically
scanning or electronic array echoendoscopes, or with ultra-
sound catheter probes.
The basic technique for performing EUS imaging of the gas-
tric wall initially requires clearing the gastric lumen of any
mucus or debris. The lumen should be thoroughly irrigated
with water and suctioned. If there are excessive amounts of
bubbles in the gastric lumen, a small amount of simethicone
can be added to the irrigating water and suctioned. Once the
gastric lumen has been cleared the gastric lumen should be
decompressed and then filled with clean water. Ideally,
degassed water should be used to fill the gastric lumen; how-
ever, this is often not available and clean water typically is
sufficient. However, efforts should be made to minimize the
presence of bubbles within the water as this will degrade the
image quality. It is important to make sure that all air is aspi-
rated from areas where imaging is to be performed. When
filling the gastric lumen with the patient on their left side, the
fundus and body will fill preferentially due to gravity. If the
area of interest is in the antral wall, positioning the patient on
their right side may be necessary to safely fill the gastric lumen
with water for imaging. Filling of the gastric lumen with water
places the patient at risk of aspiration; therefore, precautions
should be taken to protect against an aspiration event.
After aspirating the air out of the lumen and distending
the gastric lumen with water, the gastric wall can be sur-
veyed with a radial scanning echoendoscope by starting the
exam with the ultrasound probe in the antrum and slowly
withdrawing the probe (Figure 4.1). If only a focal area
needs to be examined, the use of a water‐filled balloon can
be used, especially for evaluating non‐mucosal lesions such
as subepithelial tumors. However, the use of a water‐filled
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balloon creates an additional interface echo that impacts the
image quality at the balloon–mucosa interface. Therefore, a
water‐filled balloon should not be used to provide acoustic
coupling to mucosal lesions.
It is also important to perform imaging within the focal
region of the transducer. The mechanical radial scanning
echoendoscopes and catheter probes have a fixed natural
focus where the best image resolution is obtained. The focal
distance can easily be determined by adjusting the distance
of the transducer from the gastric wall. The best resolution
will be seen when the area of interest is at the focus of the
imaging transducer. Electronic array echoendoscopes (radial
and curvilinear) have the ability to electronically adjust the
location of the focal region; therefore, when imaging the
gastric wall, the focal region should be adjusted accordingly.
For imaging superficial lesions, the use of a catheter probe
through a double‐channel endoscope allows for visual guid-
ance of probe placement. The use of a double‐channel endo-
scope allows for one channel to be used for the ultrasound
catheter probe and the other channel to be used for injecting
water into the gastric lumen and suctioning water and air
from the gastric lumen. Ultrasound catheter probes are avail-
able in frequencies of 12, 20, and 30 MHz. The image resolu-
tion increases with increasing frequency; however, penetration
(depth of imaging) decreases as frequency increases.
The stomach has a well‐developed five‐layered wall struc-
ture (Video 4.1). This is easily visualized when water is
placed in the lumen. The second layer is often prominent
because of the relatively thick columnar mucosa and glands
(Figure 4.2). The fourth layer is often thicker in the distal
stomach compared to the proximal stomach. The fifth layer
generally corresponds to surrounding structures and per-
igastric fat as the serosa is too thin to be resolved with endo-
scopic ultrasound. EUS imaging of the gastrointestinal (GI)
tract wall typically exhibits five layers; however, seven or
nine layers can be resolved if imaging is performed at higher
19
PA R T 1 Normal EUS Anatomy
Figure 4.1 Circumferential image of the gastric wall after filling and
distending the gastric lumen with water. Image is taken with an electronic
radial array echoendoscope at 5 MHz.
Figure 4.2 Five‐layer structure of the gastric wall demonstrating a
relatively thick mucosal layer (layers I and II). Image is taken with a 20 MHz
catheter probe.
frequencies depending on the region of the GI tract being
examined. Initial interpretation of the EUS images assumed
direct correspondence of the layers seen on EUS to those
seen on histology. It was presumed that the first echogenic
layer represented the mucosa, the second echolucent layer
the muscularis mucosae, the third echogenic layer the
20
Figure 4.3 Five‐layer structure of the gastric wall obtained with an
electronic radial array echoendoscope at 5 MHz.
s­ ubmucosa, the fourth echolucent layer the muscularis pro-
pria, and the fifth echogenic layer the serosa and subserosal
fat. However, it was later proven that this was an incorrect
interpretation of the EUS images of the GI tract wall. In fact,
it was demonstrated that the five layers seen on EUS imag-
ing correspond to the following (Figures 4.2 and 4.3).
1. Interface echo between the superficial mucosa and water
(hyperechoic).
2. Deep mucosa (hypoechoic).
3. Submucosa plus the acoustic interface between the sub-
mucosa and muscularis propria (hyperechoic).
4. Muscularis propria minus the acoustic interface between
the submucosa and muscularis propria (hypoechoic).
5. Serosa and subserosal fat (hyperechoic).
If a high‐frequency (10 MHz or greater) transducer is used,
seven or nine layers can potentially be identified on EUS imag-
ing. These nine layers correspond to the following (Figure 4.4).
1. Epithelial interface (hyperechoic).
2. Epithelium (hypoechoic).
3. Lamina propria plus the acoustic interface between the lam-
ina propria and the muscularis mucosae (hyperechoic).
4. Muscularis mucosae minus the acoustic interface between
the lamina propria and muscularis mucosae (hypoechoic).
5. Submucosa plus the acoustic interface between the
submucosa and inner muscularis propria (hyperechoic).
6. Inner muscularis propria minus interface between the
submucosa and inner muscularis propria (hypoechoic).
7. Fibrous tissue band separating the inner and outer mus-
cularis propria layers (hyperechoic).
8. Outer muscularis propria (hypoechoic).
9. Serosa and subserosal fat (hyperechoic).
An important aspect of EUS imaging in the stomach is to
maintain orientation of the imaging plane to avoid tangential
 CHAPTER 4 Stomach: Radial and Linear

imaging, especially when evaluating mucosal lesions. Tangential

imaging can result in overstaging of lesions.
In conclusion, the only available in vivo method for examin-
ing the full thickness of the GI wall, beyond the mucosal sur-
face, is EUS. It provides gastroenterologists with a valuable
diagnostic tool to assess pathology in the GI tract to help guide
clinical management of the patient. Selection of the correct
transducer and using good technique are important in obtain-
ing high‐quality images. When imaging the wall of the GI tract,
the method of acoustic coupling is critical. Without good acous-
tic coupling to the mucosal surface, high‐quality images cannot
be obtained. The highest frequency available should be used to
image the wall of the GI tract since deep penetration is not nec-
essary unless imaging a large tumor arising from the wall. Using
a higher frequency transducer will result in better resolution
and allow for better identification of the layers involved. Lower
frequencies may be required to identify the size of a mass and if
there is involvement with any adjacent structures (T‐staging),
and to assess nodal involvement (N‐staging).

Chapter video clip

Figure 4.4 Nine‐layer structure of the gastric wall obtained with a
20 MHz catheter probe. The image is the same as Figure 4.2 except Video 4.1 Layers of the gastric wall. Source: Aloka.
additional layers are identified.

21
 5 Bile Duct: Radial and Linear
Kapil Gupta
Cedars‐Sinai Medical Center, Los Angeles, CA, USA
Normal bile duct anatomy
Endoscopic ultrasound provides excellent imaging of the bil-
iary tree and gallbladder. Using radial and linear echoendo-
scope, visualization of the bile duct is performed from two
main stations: from the duodenal bulb and from the second
portion of the duodenum. The gallbladder is usually seen
from the duodenal bulb or the antrum of the stomach. As
the entire biliary tree can be visualized only using linear ech-
oendoscope, more endosonographers are primarily using
linear echoendoscope for evaluating bile duct anatomy.
Normal anatomy of the bile duct and
gallbladder with radial echoendoscope
The echoendoscope is advanced through the pylorus into
the duodenal bulb. To achieve this, the scope is usually in a
long position along the greater curvature. The big wheel is
then turned downwards and the scope is either turned
slightly clockwise or the small wheel rotated slightly to the
right to deflect the tip of the echoendoscope towards the
apex of the duodenal bulb and impacted there. To achieve a
stable position the balloon can be inflated, which helps in
maintaining the tip of the scope in the bulb.
Here, with slight right and left movement, the liver is ori-
ented at 12 o’clock. In this position the portal vein and the
common bile duct can be visualized as two parallel tubular
structures to the left of the transducer (Figure 5.1). With
slight right rotation the bile duct can be followed towards
the head of the pancreas into the ampulla where a thin pan-
creatic duct can be visualized below the bile duct (Figure 5.2).
With left rotation or slight counterclockwise rotation the bile
duct can be followed upwards into the liver (Video 5.1).
The gallbladder is usually visualized along the under
­surface of the liver (Figure 5.3) and with slight rotation,
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22
withdrawing, and pushing the echoendoscope the entire
gallbladder can be visualized (Video 5.1).
To visualize the bile duct from the second portion of the
duodenum, the transducer is placed along the ampulla and
with slight movement the bile duct and the pancreatic duct
can be visualized as two round anechoic structures
(Figure 5.4) (Video 5.1).
Normal anatomy of the bile duct and
gallbladder with linear echoendoscope
The bile duct is visualized with a linear echoendoscope from
either the duodenal bulb or the second portion of the duode-
num. The transducer of the echoendoscope is advanced
across the pylorus. Once in the bulb the balloon can be filled
slightly with water to maintain a stable position. Initially the
tip of the echoendoscope is impacted at the apex of the bulb;
to achieve this, the big wheel is turned downwards. With
slightly counterclockwise torque and turning the big wheel
down further the bile duct is visualized as a round structure,
right in the center of the field (Figure 5.5). The cut section of
the visualized bile duct is in the region of the common bile
duct or the common hepatic duct. In this view the portal vein
is usually visualized below the bile duct, and also the inferior
vena cava (IVC) can be seen to the right of the field
(Figure 5.5). The common hepatic artery can also be visual-
ized coursing in between the bile duct and the portal vein
towards the left of the bile duct. From this view the inward
impacted position of the tip of the transducer is maintained.
By rotating the transducer in a counterclockwise manner the
bile duct is followed towards the hilum into the liver and the
bifurcation at the porta hepatis can be visualized. Cystic duct
take‐off can also be visualized by tracing the bile duct.
Undoing the counterclockwise rotation, and rotating the
scope to the right, the transducer is rotated to follow the bile
 CHAPTER 5 Bile Duct: Radial and Linear

Liver

Common bile duct

Portal vein

Figure 5.1 Bile duct as visualized from the duodenal bulb (radial Figure 5.4 Bile duct and pancreatic duct from the second portion of the
echoendoscope). duodenum (radial echoendoscope). CBD, common bile duct; PD, pancre-
atic duct.

Cystic duct
Common hepatic duct

Hepatic artery

Portal vein

Figure 5.2 Bile duct followed towards the head of the pancreas from the
duodenal bulb (radial echoendoscope). CBD, common bile duct;
PD, pancreatic duct.
Figure 5.3 Gallbladder from the duodenal bulb (radial echoendoscope).
CBD, common bile duct.
Figure 5.5 Common hepatic duct and cystic duct as visualized from the
duodenal bulb (linear echoendoscope).
duct in the intrapancreatic portion towards the papilla. With
this maneuver the entire bile duct can be followed. In most
of the instances the bile duct can be traced downstream all
the way to the point where it joins the pancreatic duct into
the ampulla. Just below the bile duct, in the intrapancreatic
portion, the pancreatic duct can be visualized (Video 5.1).
For visualizing the gallbladder the transducer is impacted
in the bulb and the big wheel is turned up and the scope
rotated counterclockwise so the transducer now faces the
undersurface of the liver; by turning the small wheel to the
right and left the gallbladder can be seen in the subhepatic
region. Moving the big wheel up and down, and turning the
small wheel right and left, the entire gallbladder can usually
be scanned. Sometimes the scope is slightly withdrawn to
visualize the entire gallbladder (Video 5.1).
Care should be taken when advancing the echoendoscope
into the second portion. By slight inward push, turning the
big wheel down and the small wheel to the right, the scope
tip usually points in the axis of the second portion of the

23
PA R T 1 Normal EUS Anatomy

The transducer is kept in close apposition with the major

papilla. With slight right and left torque while withdrawing
Common bile duct the scope, the bile duct is visualized as a long tubular struc-
ture closer to the duodenal wall, and deep to it lays the pan-
creatic duct (Figure 5.6). The bile duct can then be followed
Ampulla
towards the liver with continued slow withdrawal of the
scope and slight right and left torque. Usually the bile duct
can be followed to the common hepatic duct portion when
Pancreatic duct
the scope tends to slip back into the stomach; to prevent this
scope is again pushed inwards with counterclockwise rota-
tion to gain a position similar to one in the duodenal bulb
(Video 5.1).
Combining views from both the stations, namely the duo-
denal bulb and the second portion of the duodenum, the
Figure 5.6 Bile duct and pancreatic duct from the second portion of the entire biliary tree can be visualized.
duodenum (linear echoendoscope).

duodenum. Carefully moving the big wheel up and down

Chapter video clip
the scope tip falls into the second portion of the duodenum.
At this point the small wheel is kept turned towards the right Video 5.1 Radial and linear array images of the bile duct from
and the scope is reduced to a short position to align the the duodenum.
transducer along the papilla.

24
 6 EUS of the Normal Pancreas
Richard A. Erickson and James T. Sing, Jr.
Scott and White Clinic and Hospital, and Texas A&M Health Science Center, Temple, TX, USA
Radial examination of the pancreas
In radial examination of the pancreas, the organ is usually
first encountered with the instrument in the mid to upper
body of the stomach. On entering the stomach, the abdomi-
nal aorta can be followed a few centimeters distally to the
take‐off of the celiac artery. From there, advancing the scope
just a few centimeters more distally will result in it crossing
the neck/body of the pancreas (Figure 6.1). The confluence
of the portal vein (PV) and splenic vein (SV) should appear
deep to the pancreas neck with some minor manipulations
of the orientation of the echoendoscope tip. The superior
mesenteric artery can be seen in cross‐section deep to the
confluence surrounded by the echogenic fat of the retroperi-
toneum. The portal/splenic vein confluence has been
described as looking like a golf club with the portal vein
being the head of the club, the splenic vein the shaft, and the
superior mesenteric artery the golf ball (Figure 6.2). By con-
tinuing to follow the pancreas and splenic vessels towards
the patient’s left and slightly withdrawing the echoendo-
scope, the tail of the pancreas is imaged (Figure 6.3).
Following the splenic vessels to the left will lead to the hilum
of the spleen, which is an important landmark as it marks
the leftward limit of the tail of the pancreas. It is important
to not forget that the tail of the pancreas may move deep
from the stomach wall nestled between the left kidney and
spleen (Figure 6.4). If this area is not examined carefully,
pancreatic tail lesions can be easily missed. From the conflu-
ence of the portal/splenic vein, gently advancing the tip of
the echoendoscope forward and angulating the tip of the
echoendoscope posterior one can view the pancreatic neck
(Figure 6.5). Again, if this area is not examined carefully,
pancreatic neck lesions may go unnoticed.
On advancing the echoendoscope deep into the duode-
num, the side‐by‐side cross‐sections of the inferior vena
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cava and abdominal aorta come into view. On withdrawing
the echoendoscope from the deep duodenum, the most cau-
dad portion of the ventral pancreas will usually come into
view just to the patient’s left (counterclockwise) of the
abdominal aorta (Figure 6.6). On gentle withdrawal, the
ampulla can usually be located by identifying the first visible
portions of pancreatic duct in the ventral pancreas (VP) and
following the course of the duct by slow withdrawal towards
the duodenal wall and ampulla (Figure 6.7). The triangular‐
shaped ventral pancreas may appear more echolucent than
the dorsal pancreas (DP) in about 75% of normal people and
should not be mistaken for an echolucent tumor (Figure 6.6).
The echolucency of the ventral pancreas can occasionally
even be seen in views of the organ through the stomach.
Further withdrawal reveals more of the pancreatic head
where longitudinal views of the pancreatic duct may occa-
sionally be seen (Figure 6.8). The confluence of the superior
mesenteric vein with the portal vein and splenic vein is seen
deep to the pancreatic head (Figure 6.9). This is an impor-
tant view for examining splanchnic venous involvement by
pancreatic head malignancies. As the echoendoscope comes
around the junction of the second and first portion of the
duodenum, small changes in orientation of the tip will result
in major shifts in views. Sometimes the best views of the
head of the pancreas are obtained when the echoendoscope
first enters into the duodenal bulb with the scope in a long
position. It is this orientation which most commonly pro-
vides a “stack sign” of the common bile duct (CBD) running
parallel to the deeper main pancreatic duct (Figure 6.10). A
stack sign can be demonstrated in more than 80% of patients
with normal pancreatic ductal anatomy. When pancreas
divisum exists (3–7% of normal people), a stack sign can
only be demonstrated in about one‐third of patients. Instead
of the absence of a stack sign in pancreas divisum the more
specific crossed duct sign may be seen. The crossed duct sign
25
PA R T 1 Normal EUS Anatomy

Figure 6.3 Radial EUS: pancreas tail. PD, pancreatic duct; SA, splenic
Figure 6.1 Radial EUS: pancreatic body and portal/splenic vein confluence. artery; SV, splenic vein.
PV, portal vein; SMA, superior mesenteric artery; SV, splenic vein.

Figure 6.4 Radial EUS: pancreas tail.

Figure 6.2 Radial EUS: portal/splenic vein confluence. PV, portal vein;
SMA, superior mesenteric artery; SV, splenic vein.

results from the CBD being seen in cross‐section while the

pancreatic duct, draining to the minor ampulla, is seen in
longitudinal section.

Linear examination of the pancreas

The linear endosonographic examination of the pancreas

through the stomach differs fundamentally from the radial
examination in that complete imaging of the pancreas must
be provided by rotating the shaft of the scope. Since the retro-
peritoneal structures are all posterior to the stomach, clock-
wise (rightward) rotation of the echoendoscope will point the
echoendoscope towards the patient’s left and counterclock- Figure 6.5 Radial EUS: pancreas neck. PD, pancreatic duct; PV, portal
wise (leftward) rotation towards their right side. To find the vein; SV, splenic vein.

26
 CHAPTER 6 EUS of the Normal Pancreas

Figure 6.6 Radial EUS: head of pancreas. DP, dorsal pancreas; VP, ventral
pancreas. Figure 6.9 Radial EUS: head of pancreas, vasculature. CBD, common bile
duct; PD, pancreatic duct; PV, portal vein; SMV, superior mesenteric vein;
SV, splenic vein.

Figure 6.7 Radial EUS: ampulla.

Figure 6.10 Radial EUS: head of pancreas. CBD, common bile duct; PD,
pancreatic duct.

pancreas in the stomach, one starts at the abdominal aorta

Figure 6.8 Radial EUS: head of pancreas. CBD, common bile duct; PD,
pancreatic duct.
near the gastroesophageal junction and follows its course dis-
tally until the take‐off of the celiac artery is visible. Usually,
the more oblique take‐off of the superior mesenteric artery is
apparent just distal to this. Further advancement of the instru-
ment distally will find the pancreas neck/body nestled
between the “V” of the celiac and superior mesenteric artery.
The splenic artery will course tortuously in and out of the
pancreas body/tail, but the splenic vein usually has a straight
course and is the larger, deeper and more ovoid of the two
vessels (Figure 6.11). The pancreas is interrogated sequen-
tially from the neck to the body and tail through the stomach
at this level by rotating the echoendoscope to the right (clock-
wise) with slight withdrawal following the splenic vein and
splenic artery as they run into the hilum of the spleen. The

27
PA R T 1 Normal EUS Anatomy
Figure 6.11 Linear EUS: pancreas body. PD, pancreatic duct; SA, splenic
artery; SV, splenic vein.
Figure 6.12 Linear EUS: pancreas tail. PD, pancreatic duct; SV, splenic
vein.
pancreas neck, body, and tail will appear be the tissue found
between the splenic vein and the posterior gastric wall. The
pancreatic duct is usually seen in cross‐section through the
stomach (Figure 6.12). A normal caliber duct will appear as a
small, sometimes difficult to see, echolucent dot in the middle
of the pancreatic parenchyma. Rotation to the left at the level
of the celiac axis and body of the pancreas brings into view the
pancreatic neck with the portal vein confluence deep to it.
The splenic vein merges into the confluence from the patient’s
left and the superior mesenteric vein runs caudad from the
portal vein confluence. A little further leftward rotation of the
echoendoscope may produce views of the right border of the
pancreatic neck looking down towards the pancreatic head.
Sometimes, longitudinal views of the pancreatic duct can be
obtained from this view.
As with radial endosonography, the linear duodenum
presents the endosonographer with the most variability in
endosonographic relationships of vessels, ducts, and peridu-
28
Figure 6.13 Linear EUS: ampulla.
Figure 6.14 Linear EUS: head of pancreas. CBD, common bile duct; PD,
pancreatic duct.
odenal organs. There is a marked transition in the direction
of the scope tip and therefore anatomic views between
entering the duodenal bulb in a “long position,” where the
scope tip is pointing cephalad and posterior, and a “short
position” when withdrawing from the second portion of the
duodenum, where the scope tip is pointing caudad.
Generally, we try to start by inserting the linear echoendo-
scope deep into the second portion of the duodenum. With
the echoendoscope in a short position in the second portion
of the duodenum, the scope is designed to be facing the
medial wall of the duodenum near the region of the ampulla
(Figure 6.13). On slightly rotating the scope right or left with
very gentle withdrawal, usually the pancreatic duct will be
seen first traveling relatively perpendicularly away from the
transducer. The CBD will be seen to originate from the
ampulla between the duodenal lumen and the pancreatic
duct (Figure 6.14). The pancreatic parenchyma seen at the
level of the ampulla represents primarily the ventral
pancreas. The relative echolucency of the ventral anlage
commonly seen by radial endosonography may be less

apparent by linear endoscopic ultrasound (EUS). At this
level, if vessels are seen deep to the pancreatic head they are
usually the superior mesenteric vein and artery. If one inserts
the echoendoscope deeper into the third portion of the duo-
denum, the uncinate portion of the pancreas nestled among
the vessels of the mesenteric root may be seen. Because this
is a difficult view to get with a radial instrument, this view
using a linear instrument is sometimes the only way in
which deep uncinate tumors may be seen. From the ampul-
lary region, further gradual withdrawal and rotation to the
left (counterclockwise) will follow the course of the tubular
structures of the porta hepatis. The pancreatic head will
appear as the tissue between the superior mesenteric vein/
portal vein and the duodenal wall.
Endosonographic appearance of the normal
pancreatic parenchyma
There is considerable variability in the endosonographic
appearance of the pancreatic parenchyma. Classically it
CHAPTER 6 EUS of the Normal Pancreas
has a homogeneous, fine, “salt and pepper” appearance
with echogenicity similar to the spleen. The ventral anlage
is more echolucent because of its different embryologic
origin and its lesser content of echogenic fat. In the
elderly, the pancreas can get more nodular with courser
echogenicity. In obese patients, the pancreas becomes
infiltrated with fat and can almost disappear into the ret-
roperitoneal fat. Fortunately, any pathologic pancreatic
lesions, such as dilated ducts, cysts, or neoplasms, will be
easily visible in the bright background of retroperitoneal
fat. Thin patients typically offer particularly detailed imag-
ing of the pancreas.
Chapter video clips
Video 6.1 Linear array EUS head of pancreas.
Video 6.2 Linear array EUS of the pancreas neck to tail.
Video 6.3 Radial array EUS head of pancreas.
Video 6.4 Radial array EUS of the pancreatic neck to tail.
29
 7 Liver, Spleen, and Kidneys: Radial
and Linear
Nalini M. Guda1 and Marc F. Catalano2
1
University of Wisconsin, School of Medicine and Public Health, Pancreatobiliary Services, St. Luke’s Medical
Center, Milwaukee, WI, USA
2
Medical College of Wisconsin, Pancreatobiliary Services, St. Luke’s Medical Center, Milwaukee, WI, USA
Introduction
This chapter describes the endosonographic features of the
major organs of the abdomen: the liver, spleen, kidneys, and
adrenal glands. Ultrasound features of the pancreas and bile
duct are described elsewhere.
The liver, spleen, kidneys, and adrenal glands (left side)
are visualized from the stomach (Videos 7.1 and 7.2).
Liver
Radial endosonography
As the radial probe is advanced through the esophagus into
the gastric cardia, the liver is the predominant organ visual-
ized. When positioning the abdominal aorta at the 6 o’clock
position, the left lobe of the liver is seen anteriorly and medi-
ally to the right (Figure 7.1). The aorta, with a dark hypo-
echoic band which is the diaphragmatic crux, is seen
immediately adjacent to the probe. In this position, near the
hiatus, the hepatic veins are seen as anechoic structures,
entering the inferior vena cava (IVC). In this position, possi-
bly with left tip deflection, the spleen can be seen on the right
of the screen. As the aorta is traced distally, maintaining its 6
o’clock position, the liver may still be seen anteriorly. Vascular
structures can be differentiated from ductal structures by a
thicker (echogenic) wall and the presence of flow.
When advancing the echoprobe towards the antrum, the
gallbladder is often visualized as an oval‐shaped anechoic
structure. In this position, the porta hepatis can be seen with
subtle tip deflection upwards.
Linear endosonography
With the probe at the level of the diaphragmatic hiatus, the
longitudinal aorta and celiac artery origin are the most rec-
ognizable reference points (Figure 7.2), demonstrated as
Atlas of Endoscopic Ultrasonography, Second Edition. Edited by Frank Gress, Thomas Savides, Brenna Casey, and Everson L. A. Artifon.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/gress/atlas
30
tubular longitudinal structures. Here, rotation of the probe
counterclockwise will bring into view the liver parenchyma
and its vascular structures (Figure 7.3).
Advancing the probe at the level of the pylorus and duo-
denal bulb, clockwise rotation and superior tip deflection
brings into view the porta hepatis along with several vascu-
lar structures. Use of Doppler can differentiate arterial from
venous structures as well as biliary structures.
The entire liver is not visualized by endoscopic ultrasound
(EUS). Despite this limitation, it is useful to carefully exam-
ine the liver since metastatic processes can be easily identi-
fied and biopsied and could lead to a change in clinical
staging and management of a suspected tumor.
Spleen
The spleen appears as a homogeneous structure seen between
the tail of the pancreas, left kidney, and gastric wall. With a
radial scope it is imaged from the gastric cardia. It is similar to
liver in echogenicity except that it is devoid of any ducts and
vessels (Figure 7.4). It can be easier to follow the splenic vein
after visualizing the pancreas from the gastroesophageal (GE)
junction. The splenic artery, splenic vein, renal vein, and the left
adrenal are usually visualized as well while attempting to scan
the spleen. The splenic vein can be easily traced along the infe-
rior aspect of the body and tail of the pancreas; however, the
splenic artery is tortuous and it is difficult to follow its course to
the celiac trunk. With a linear scope one has to scan inferior to
the left kidney and laterally to visualize the spleen (Figure 7.5).
Kidney
Both the right and left kidneys can be visualized by EUS. The
left kidney is readily identified from the fundus of the stomach.

Figure 7.1 Image of the liver scanned by radial ultrasound.
Figure 7.2 Celiac artery imaging by linear ultrasound.
Figure 7.3 Image of liver by linear ultrasound.
It has a complex echogenicity with hypoechoic parenchyma
and hypertonic areas within representing the calyceal
system.
Radial endosonography
With the echoendoscope in the gastric cardia the left kidney
is readily visualized. One can see the calyceal system and the
renal vessels (Figure 7.6). To visualize the right kidney the
CHAPTER 7 Liver, Spleen, and Kidneys: Radial and Linear
Figure 7.4 Image of spleen by radial ultrasound.
Figure 7.5 Image of spleen by linear ultrasound.
echoscope is placed in the D‐3 position. Visualization of the
IVC and aorta provide easily identifiable landmarks. Upon
slow withdrawal, the image brings into view the right kid-
ney immediately right of the probe along with the right
renal vein and artery. As the kidney is traced proximally,
lateral deflection of the tip may bring into view the right
adrenal gland.
Linear endosonography
With a linear scope one can withdraw the scope in the fun-
dus posteriorly towards the pancreas until the tail is visual-
ized and then push the scope inferiorly to see the left kidney
(Figure 7.7). To view the right kidney, the probe is placed
just below the level of the papilla and counterclockwise rota-
tion brings into view the right kidney and its vascular struc-
tures. Slow withdrawal allows for visualization of the right
adrenal glands.
31
Another random document with
no related content on Scribd:
"Can't stand them. I went to hear Lohengrin once, and came out
before the last act. I leave out Aida now, too. The good old-timers
suit me, old Trovatore and Martha, and some of the new ones aren't
bad, the ones with catchy music."
"You didn't like Aida?" Gwen fairly groaned.
"Bored me to death. Could hardly sit through it. I wouldn't have, only
the ladies I was with appeared to like it, so I stayed on their
account."
Gwen made no comment but opened the book she had brought, a
copy of Kipling. She had considered his masculine taste in making
the selection. "Now I'll read you my favorite 'Bell Buoy' right here
where we can get the sound of one. 'White Horses' is really my
favorite, but it is not in this volume. I'll read first and then you can
pick out something to read to me."
She opened the book and proceeded to read. Her listener sat with
hands behind his head and Gwen hoped he was impressed, for she
read well. "What do you think of it?" she asked as she closed the
book.
"Well, I can't make out exactly what he's driving at. I'm not a great
one for poetry. Once in a while you come across some rattling good
thing like 'Hans Breitmann's Party,' something that makes you laugh.
I don't mind that sort of poetry."
Gwen slipped the book behind her. "What do you like to read, Mr.
Mitchell?"
"Oh, I don't have much time to do more than run through the
newspapers, or a magazine sometimes when I'm on a train."
"But I thought all Bostonians were very intellectual." There was
disappointment in Gwen's tones at discovery of his especial taste in
literature. She had thought he might declare himself for history, at
least.
"Well, I suppose a good many Boston folks are intellectual. I don't
profess to be. Life's too short to spend over books. I enjoy this free
life," he stretched out his arms bared to the shoulders, "and I like
tennis and golf and that sort of thing, for exercise. I enjoy a nice light
opera with a lot of pretty girls in the chorus, or a good play, not too
tragic a one. I'm pretty fond of a horse and a boat. I shall have a
yacht up here next year, I think."
"A yacht would be lovely," said Gwen brightening. "You could go
cruising all around among the islands."
"Yes, and up the coast to Bar Harbor. Yes, a yacht would be jolly
good fun."
"Shall you be glad to get back to the city, or do you feel as if you
would like to stay up here forever living the free life?" queried Gwen.
"Not forever. Nobody would care to do that who'd ever lived in a city,
unless it were some queer freak like Mr. Williams."
"Don't call him a freak." Gwen spoke with some asperity.
"Well, he's an oddity, at least. I can't make him out. To be sure I don't
know him very well, but it strikes me as queer that a man should
want to live on this island. It's all very well for a summer holiday, but
in winter, no, thank you. Yes, I shall be glad to get back, to see the
fellows at the club, and to put on a different sort of rig from this. It
won't be bad to see the inside of a theatre, either, and go to a first-
class dinner, or a German."
Gwen smiled. She did not despise these things herself. "One looks
at life very differently in the city, doesn't one?" she remarked.
"Yes, there's the fun of it. When I do a thing I want to do it thoroughly.
When I'm at home I do as my neighbors do; when I am here I try to
follow the example of those around me."
"Sensible man! So we will not read any more. Come, let's go around
to the other side, and see what it looks like. We'd better not go back
through the woods, for after the sun goes down it gets pretty dark
and spooky in there, so we will go back by the road."
"You're not afraid? Not when I'm with you?" He spoke tenderly, and
more than ever Gwen declared for the road.
"Not afraid," she said, "but it takes longer, and I don't want to miss
my supper, nor do I want you to miss yours."
"A good substantial reason," returned Mr. Mitchell approvingly. "I
hope it will be a pleasant day to-morrow." He looked at the sky. "Are
you a good weather prophet, Miss Whitridge?"
"Not very, though I should say it would be warm. To-day is warmer
than any we have had for a long time. Any special reason to be
curious about the weather, Mr. Mitchell?"
"I promised Miss Fuller I'd row her over to Jagged Island. It's an
engagement of long standing, you know, and the time is getting
short."
"I remember you promised long ago. Shall you go fishing?"
"Perhaps we shall try our hands at it."
"Cap'n Ben says that the steamboats and launches are beginning to
scarcen the mackerel and that they are not so plentiful this year as
usual."
"Scarcen is a good word."
"So I think. I shall adopt it from henceforth. Cap'n 'Lias Hooper's
vessel, the Mary Lizzie, sails to-morrow," remarked Gwen casually,
"so yours will not be the only fishing expedition that goes out."
The sun was setting in a mass of rolling clouds. The air soft and
warm, even as it blew over stretches of water, was of a more
languorous quality than usual. The waves stole in gently, lapping the
stones with a placid murmur. The cove was as smooth as glass,
except where a boat, manned by two rowers, left a brilliant line of
ripples in its wake. The floors of the great chasms indenting the
shores, displayed long ropes of maroon-colored kelp where the tide
had gone out. The main land, beginning at the Neck, stretched its
curving fingers out into the quiet sea as if it would clutch the islands
beyond and draw them into safe keeping against a time when great
breakers should threaten them. Gwen and her companion stood
watching the sky till the sun disappeared behind the piled-up clouds,
which, showing golden edges, drifted off towards the horizon, finally
hiding the distant mountains from view. Retracing their steps the
man and maid went on down hill toward the road, and further to
where they must skirt Little Harbor. Just at this point Gwen gave a
quick glance toward a cottage close to the cove shore, and on the
porch caught sight of a man standing, with folded arms, looking out
upon the water. She gave a gentle sigh as she went through the little
gate on the opposite side of the way.
The next morning was balmy and still, only a slight breeze filled the
sails of Captain Hooker's fishing schooner which passed out of the
cove. Gwen standing on the rocks, watched it slipping slowly by.
Some one on the vessel blew a long blast upon a horn, and
presently, further on, a group of women gathered to watch the vessel
out of sight, and to wave farewell to those on board. In the group
Gwen distinguished Almira Green and Ora. She remembered that
Manny was going out to the Banks that day with the other fishermen.
"Poor little Ora!" said the girl to herself. "And poor Almira, too," she
added. "I am glad to have no lover who must follow the high seas."
She watched the vessel grow smaller and smaller, and presently her
attention was attracted to a smaller craft, a little row-boat moving
steadily toward Jagged Island. "I believe there are Ethel and Mr.
Mitchell!" she exclaimed. "Joy go with you, my dears! I am absolutely
convinced that I could not stand a man who preferred comic operas
to 'Aida,' and who had no soul above newspapers. You are quite
welcome, Ethel dear. I hope you are prepared with plenty of bait, and
will land your beautiful gold fish." She made a deep curtsey and
laughed. "I am sure he is just about as bony and unpalatable as any
other gold fish would be to me," she said to herself.
She turned her eyes from the small boat to another which had just
rounded the point, and was making toward one of the inner islands.
She looked at it attentively for a moment, then sprang over the rocks
toward the cottage, coming out directly with a pair of field glasses. "I
thought so," she murmured. "Everybody is going out to-day, it
appears. I was sure that was Cap'n Ben's boat. I wonder if he is
going off sketching. He is all alone." The "he" could scarcely apply to
Cap'n Ben. "He is sailing off toward Pond Island. He isn't going
there, I know; I suppose to some point further on. That's the third
boat to go out from here this morning. Dear me! I wonder what I shall
do to-day. It seems a wee bit lonely on the island. Bother! there
comes Miss Henrietta, skipping over the rocks like a hart upon the
mountains. I can't pretend not to see her."
Miss Henrietta, the youngest of the Gray sisters, had arrived at that
uncertain period of life when she hesitated to associate with women
older than herself for fear she might be supposed of the same age.
She, therefore, sought the society of those much younger, hoping to
be accredited with a like youthfulness. Gwen usually tried to avoid
her, not because she did not enjoy older companions, but because,
as she said, Miss Henrietta was the kind who took in at one glance
what you had on, and criticized it afterward. She was always very
ready with suggestion. "You would think," said Gwen to her aunt,
"that Miss Henrietta had a copyright on all possible suggestions, she
is so ready to make them and acts as if you had infringed her rights if
ever you present one of your own to her." To each other Ethel and
Gwen always spoke of Miss Henrietta as "Household Hints." So just
now, Gwen, waiting for Miss Henrietta to come up, knew a
suggestion would be ready, and so it was.
"I just thought I'd run over and tell you," said the elder lady, "that I
find tennis shoes injurious, and I suggest that you don't wear them."
"I haven't found them so," returned Gwen.
"But you will," insisted Miss Henrietta.
"I'll wait till I do," said Gwen a little shortly, but with a smile. "Were
you coming to Wits' End, Miss Henrietta?"
"No, I saw you out here and I thought I'd join you. One tires of one's
elders constantly, don't you think?"
"I never tire of Aunt Cam," replied Gwen, "and we see more of one
another at Wits' End than we do in the city."
"Couldn't you find a prettier name for your cottage?" asked Miss
Henrietta. "Why not call it Rock Rest, or something like that?"
"We don't want to be commonplace, and Wits' End just suits us."
"I see your friend Miss Fuller has gone off with our young man," said
Miss Henrietta, ignoring Gwen's reply. "She is quite a handsome girl.
What do you think of her character, Gwen? I wish some one would
tell her that a red jersey is not becoming."
"I think it is becoming." Gwen set aside the question.
"Oh, never, my dear, never. I don't see how you can think so. Then
she has such a fad for mushrooms; she is forever looking for them.
How she can like such things I cannot see.
"Dear me!" Gwen shook her head. "It is sad that one so young
should have such depraved tastes."
Miss Henrietta looked offended. "I see you are bound to disagree
with me," she said tartly. "By the way, why didn't you go to Jagged
Island with your friends?"
"Perhaps because I didn't want to, and perhaps for other reasons,"
returned Gwen noncommittally.
"Do you think it was quite the thing for them to go off alone in that
way? I am afraid your friend isn't very particular about the
proprieties."
"Why didn't you go, Miss Henrietta?"
"I had other things to do," said she bridling.
"For pity's sake go along and do them," rose to Gwen's lips, but she
said only, "I think we all have plenty to do up here, and that reminds
me I must finish a letter before I go for the mail. As Mr. Mitchell is
away to-day, perhaps you would like me to bring yours, too."
"Oh, if you will." The offer was smilingly accepted, and Gwen
returned to the cottage, leaving Miss Henrietta ready to swoop down
upon the Hardy girls who were coming along the rocks.
"What's the matter?" asked Miss Elliott as Gwen threw herself into a
chair. "You look as if some one had been rubbing you the wrong
way."
"Some one has been. I met Miss Henrietta out on the rocks just now.
She is so picky and so ready to condemn fads and fancies in others
when she is full of them herself. She asked me why I wore tennis
shoes; she found fault with Ethel for wearing red, and for liking to
hunt for mushrooms. She asked me what I thought of Ethel's
character, too. What business is it of hers what I think?"
"She was probably trying to find out if Ethel would make a suitable
wife for your millionaire, Gwen," Miss Elliott said laughing.
"My millionaire? I could never marry a man who reads only
newspapers, who can't appreciate good music, and doesn't know a
poor picture from a fine one."
"If those are your only objections, they don't seem very weighty
ones. He probably reads only newspapers because he is too busy a
man for anything else, and as for the other things, it may be only a
lack of opportunity for studying the best. He may be a very fine man
who would make an estimable husband, and yet not be a
connoisseur in art or music."
"Oh, dear, why is it that the men who would make estimable
husbands must so often be unattractive? I am afraid it isn't lack of
opportunity that's the matter with Cephas. It lies deeper than that.
But his deficiencies will never bother Ethel, so she shall have him. I
think they will suit one another admirably. Are you disappointed, Aunt
Cam, that you must forego his nephewly embraces, and that he is
not to call you 'my dear aunt'?"
"Nonsense, Gwen, of course not. I don't care a rap for him in any
capacity."
"But you think he will suit Ethel. You don't exactly approve of Ethel, I
am afraid."
"Not altogether. I like her. She is very agreeable, and even brilliant,
sometimes. She seems to be a person who has many engaging
charms but few sterling qualities. She has not a spiritualizing effect
upon one, and I am afraid her standards are decidedly of a material
order. I can fancy her quite satisfied without the ennobling things of
life."
"She has a sweet disposition, and she has beautiful theories," said
Gwen thoughtfully.
"But does she practise them?"
"Not when it is inconvenient. I am afraid she is rather a brilliant
butterfly, but she is vastly entertaining."
"What has become of your artist friend?" asked Miss Elliott suddenly.
Gwen immediately became very busy rearranging the pillow on the
divan. "Oh, he's around," she said with apparent indifference. "You
know his sister and the children have gone off for some weeks, so of
course I see nothing of them. I saw him yesterday out sketching. To-
day he has gone somewhere in a boat. Everyone has gone off in a
boat. Ethel and Mr. Mitchell are on their way to Jagged Island,
Manny Green is off for the Banks, and Mr. Hilary has gone up along
to some unknown spot. I am quite desolate without my playmates. I
think I shall have to hunt up Daddy Lu."
But Luther Williams had gone to his favorite haunt in Middle Bay,
Gwen discovered, for no one had seen him since morning. So the
girl returned to the house and busied herself with unimportant things
till it was time for the afternoon's mail. "I'll stop in to see Miss
Phosie," she said as she passed out, "so don't expect me right back,
Aunt Cam." She looked across to Jagged Island wondering if the two
who had rowed over that morning had yet returned. She looked
toward the north to see if Cap'n Ben's little boat were on its way
back, but except for a motor boat chugging along and some white
sails far off there were no vessels visible. So she turned toward the
cove and was soon in Miss Phosie's bright kitchen.
 CHAPTER XIV
"THE CLOUDS YE SO MUCH DREAD"
Only Miss Phosie was at home, but she gave a smiling welcome to
her guest. "I see Ora has come back," said Gwen by way of opening
the conversation.
"Yes, she wanted to see Cap'n Hooper's vessel off, I s'pose. Anyway
she wasn't content to stay any longer."
"And Manny has really gone."
Miss Phosie nodded. "I'm happy to say he has. Maybe Ora'll take an
interest in something and somebody else, now. I was hoping she'd
feel inclined to stay at Bangor with her cousins, but here she was
back at the end of a week, and all the difference I can see is, she's
got a bigger lot of hair piled up over her forehead and a gayer hat."
Gwen smiled. She knew Miss Phosie must be more than usually
ruffled to criticize in such a manner. "Perhaps if she were to go away
to school she might forget about the boys here. She is too young to
have her head full of such things." Gwen spoke as one of vast
experience.
"That's what I told her grandpap," returned Miss Phosie, "but he can't
bear to think of her going away for as long as a whole winter. She's
his only grandchild, and he does set such store by her. Won't you
come into the settin'-room, Miss Whitridge, where sister is?"
"If you don't mind my staying here, I'd rather sit with you."
Miss Phosie looked pleased. "Well, that'll be nice," she said. "Two of
our boarders has left, and there ain't quite so much to do. The others
will be going before long, too, and then we can settle down to the old
ways."
"Dear me, when you talk about boarders leaving it makes me feel as
if the summer were nearly over," returned Gwen.
"But you cal'late to stay pretty late, don't you?"
"As late in October as we dare. I must be back by the twentieth."
"Then I hope we shall see more of you," replied Miss Phosie politely.
"Mr. Williams was saying the other day that after the boarders go we
always take more comfort in the cottagers. Them that come and go
just for one season you never feel much acquainted with, but with
them that owns property it's different. They belong here."
"We certainly feel as if we did," Gwen assured her. "I love every inch
of the island."
"That's what Mr. Williams says, and I guess that's why you and him
are such friends. He's real fond of it."
"Where is he to-day?"
"He's gone off in his boat alone. He likes to do that once in a while
and nobody asks him why or wherefore."
"You are very good to him, Miss Phosie. I think it is wonderful that he
should have found such a home here, when he just drifted in,
absolutely unknown, and seems to belong to no one."
"We cal'late he's been long enough in this house to belong to us,"
said Miss Phosie a little defiantly.
"Indeed I am sure he feels so. He has often told me that no sister
could do more than you for him. I know what it must mean to him for
I have very few relatives myself."
"That so?"
"Aunt Cam is my nearest and dearest. I have some distant cousins,
but that is all. I feel almost as if Mr. Williams were a relative. He has
been so kind to us."
"That's his way, though I must say you are the first of the newcomers
that he's taken any fancy to. He don't make much fuss about what he
does, but little things count, Miss Whitridge."
"They surely do. Did he look just as he does now when he first came
here, Miss Phosie?"
"Just about. He always wore his beard that way, close-cropped, and
a short mustache. He must have been considerable over thirty when
he came."
"And he just appeared that way, suddenly?"
Miss Phosie nodded. "Came over on a sailing vessel from the Neck.
There wasn't any steamboat then. Said he'd like a few days' fishing.
Had a grip-sack, but no other baggage. Father took him out, and
liked him from the first, though he was always very quiet and
reserved. Never had any family photographs about or nothing of that
kind, just a little old Bible with his initials on the back. I've looked at
it," Miss Phosie confessed, "but there's nothing on the inside page,
but 'To my little son from Mother.' We've never tried to pry into his
affairs. We didn't feel it would be friendly. He's a nice good man,
father says, and that's all we want to know."
Gwen felt herself properly reproved, and concluded it would be
better to change the subject. "How dark it is getting," she remarked,
"and I do believe that is thunder." She arose and went to the window.
Great masses of heavy clouds were overspreading the sky. The sea
was inky black, though along the horizon shone a line of silver. "Dear
me," exclaimed the girl, "there is a gust coming up, or, I should say, it
has arrived," for, as she spoke, the rain began to fall in big drops,
and a strong wind sent chips and leaves scudding across the grass.
"Land sakes! so it has," returned Miss Phosie, "and Mr. Williams is
out in it. I hope he won't attempt to cross."
"I am afraid Ethel and Mr. Mitchell are out in it, too."
"You don't say! When did they go?"
"They started for Jagged Island this morning. They rowed over.
There are—others out, too. Oh, I do hope they are all safe." A heavy
peal of thunder startled them, and vivid lightning cleaved the dense
clouds overhanging the island.
Ora, pale and frightened, rushed into the kitchen. "Oh, Aunt Phosie,"
she cried, "it's a dreadful storm, and the Mary Lizzie is out in it." She
burst into tears.
"There, child, there," said Miss Phosie soothingly. "Don't you be a
mite afraid about the Mary Lizzie. Her cap'n's weathered more than
one gale. It's the little boats that's in danger, not the big ones. Here's
Miss Whitridge has friends out, and she's not crying. You an island
girl, too."
"There's no one she loves that's in danger," sobbed Ora.
Gwen shuddered, and kept her eyes fixed upon the storm-swept sky.
It was a marvellously grand one. The centre of the storm seemed
directly overhead, where lightnings flashed and thunders rolled from
clouds of intense blackness. These grew in gradation of tone less
and less dense toward the edges where they dropped a wonderful
fringe over the brilliant silver which bordered the visible circle of the
earth. Upon the jagged sides of the dark and forbidding rocks leaped
angry, white-capped waves which rushed in from a sea as black as
the sky, only farther out within the line of dazzling silver shone fair
green islands, brilliant as emeralds upon the gleaming band.
"I must go out, and get a better view of it," said Gwen catching up
her cape.
"But it hasn't stopped raining," Miss Phosie warned her.
"It isn't pouring so hard, and it is such a marvellous sight. I don't care
if I do get wet. Besides, perhaps I can see if my friends are out."
"They'd have a pretty hard time in a little boat, in such weather," said
Miss Phosie, and Ora began to cry again. She turned her wet eyes
upon Gwen.
"May I go with you?" she asked meekly.
"Why, certainly," responded Gwen cordially. And in spite of Miss
Phosie's protestations they fared forth, across the wet grass, and on
to the rocks. The storm was passing over, and more gems of islands
were visible. The bordering band of silver widened. The black fringe
swept further and further across the land, and presently the sun
broke forth, though the angry waves still buffeted the passive rocks.
The two girls said not a word till they stood side by side on the cliff,
then Ora's eyes sought the distant horizon, while Gwen turned her
gaze northward. There was not a sail, not a dot, indicating a boat
upon the ruffled surface of the water.
"I hope, I hope everyone is safe," said Gwen breaking the silence. "It
was such a sudden sharp storm, but it was soon over. It seems to be
passing to the north. I don't believe it has gone out to sea at all, Ora,
and the Mary Lizzie is probably away beyond it."
"It's dreadful to be so frightened," responded Ora faintly. "I was
always afraid of thunder-storms, and when you have friends out you
are more afraid than ever."
"Yes, you are; I realize that." Gwen took Ora's hand and held it in a
warm clasp under the shelter of her cloak.
"They don't understand," said Ora responding to this sympathy.
"Nobody knows what I feel, for I sent him. I wanted him to go so as
to show everybody there was something in him."
Gwen gave the hand a little squeeze. "I can understand, Ora," she
said. "I know just how you feel. It is dreadful to say things that send a
friend away from you. I have done it, and I know."
Ora, in turn, gave the fingers that held hers a little pressure. The
child in her distress felt the need of a confidant. She wanted
sympathy and advice from some one young like herself, but some
one whose experience had given her judgment.
"Do you think," Gwen went on, still looking northward, "that anyone
would be liable to get so far out before the storm came up, that he
couldn't make a harbor?"
"He might," returned Ora doubtfully.
"But even if he were swamped, the boat would float, and the oars; he
could save himself."
"If he could swim, or he might even hold on and float, only there are
these cruel rocks."
"Ah me!" Gwen groaned. "Suppose he—they did start out, and could
not get back. I should never forgive myself."
"For what, Miss Gwen? Did you persuade them to go? Is it Mr.
Mitchell and Miss Fuller you mean?"
"Of course," replied Gwen hastily. "I suppose there is no use
standing here watching, and anyone starting now would be quite
safe, though it would be hard pulling. Ah, there's Mr. Williams! One
at least of our friends is safe. That argues well for the others."
Luther Williams in his sou'wester came up to them. "Miss Phosie told
me I should find you here," he said.
Gwen held out both hands. "I am so glad you are safe," she cried.
"Were you caught in the storm?"
"I was nearly home," he told her, "just coming into the cove, so I put
in there by Jo Thompson's, took shelter in his house, and walked
home from there."
"I hope every one else is as well off. Mr. Mitchell and Miss Fuller
started for Jagged Island this morning. They haven't come back, and
I see no signs of them."
"They're waiting for the sea to smooth down, I suppose. It will after a
while. It was a sharp blow while it lasted, but the wind is back in the
same old quarter, and they'll probably be coming along pretty soon.
Cap'n Ben's boat is out," he added abruptly.
"I know it, oh, I know it," Gwen whispered. "Dear Daddy Lu, can't you
do something?"
He patted her shoulder encouragingly. "I'll go up along, and see what
can be discovered. I shouldn't be surprised if he had put into Water
Cove, if he left Dorr's at all. He was going there sketching to-day,
and thought it would be handier to take his traps in a boat than to lug
them."
Gwen drew a sigh of relief. "It is a good thing to have met you. Have
you seen him lately?"
"Last evening."
"He seemed well?" The question was asked wistfully.
"Yes." It was not like Mr. Williams to do more than give the laconic
reply.
"Ora has been worrying, too," Gwen said in a low voice.
"She has no reason to."
"You are sure the storm went around."
"Yes, though they may get it out at sea later on."
"I will tell her you said there was no cause for worry." She turned to
the girl who stood a little way off. "They are getting the storm over
Bath way, Ora," she said. "We needn't be alarmed."
Ora turned a brighter face toward the girl. "I've been watching it," she
said. "I'm going to see Almira now. She must be lonely to-day." And
without further word she walked away.
Gold green were the islands now, sparkling were the dancing waves,
though over the arm of the mainland there still hung a pall of clouds,
and once in awhile there was a rumble of distant thunder. "It has
been a wonderful storm," Gwen told Mr. Williams, "and if no one is
the worse for it I shall be glad of its having come, for it gave us a
scene I can never forget; those great masses of inky clouds dropping
fringes all along their edges, and those brilliant, sun-touched islands
in a silver rim of sea, beyond the gloomy spaces. It seems almost
like a prophecy, Daddy Lu, as if one might say to one's self, no
matter how dark and terrible the present seems, there is sunlight
beyond, sunlight that will spread and spread till you stand in its glory,
as you and I are doing this minute."
His rare smile lighted up his face. "That is the way to talk," he said.
"Some may be wrecked in the gale, but the same storm brings great
good to others."
"Oh, don't say that. I don't like to think of wrecks, wrecked vessels or
wrecked lives."
"Even wrecked lives may not be lost ones. Sometimes a person may
buffet with the seas for a while and then find a harborage. After the
storm has passed sunlight may reach him, too."
"That's better. I feel more content with that view of it. Are you going
down along, and will you let me know if anything has happened?"
"I will let you know in any event, if you like."
"That's the dear man you always are. I think I'd better go home now
to Aunt Cam. She will be getting anxious about me, and I must find
out if the rain has been leaking in at that south window."
"Very well. As the Spanish say, Hasta luego."
"That's a sort of 'auf wiedersehen,' I suppose."
"About the same."
They parted and Gwen sprang over the soppy ground, reaching
Wits' End to find her aunt and Lizzie busy with cloths mopping up the
floor under a window in the living-room, through which the rain had
leaked. They had placed basins and buckets to catch the drip, but in
spite of all the floor had not escaped a puddle. "The hogshead is full
and we have caught a lot more water in the boiler and the tubs, so
we are well supplied," said Miss Elliott as Gwen entered.
"Good," cried Gwen. The value of rain water was not to be under-
estimated.
"Where have you been?" asked her aunt. "I hope you were under
shelter during that downpour."
"I was in Miss Phosie's kitchen at first," Gwen told her, "but it was so
glorious I had to go down to the rocks to watch it all."
"And in consequence no doubt your feet are sopping wet. I'll have a
fire made in the fireplace at once."
"No, please don't. The sun is shining hot on the back porch. I'll
change my shoes and wet skirt and sit out there."
"You'd better have a fire," persisted Miss Elliott, and had her way, for,
as Gwen said, "When Aunt Cam really determines to do a thing she
manages to carry her point. That is why she was such a success in
China. If she said a patient must swallow a pill he had to do it."
And therefore it was sitting by the open fire that Luther Williams
found the two a little later on. As he stood in the doorway in his
fisherman's garb, flannel shirt, trousers tucked into high boots, Miss
Elliott found no suggestion of that elusive likeness which had
puzzled her more than once. She welcomed him cordially. "Come
right in, Mr. Williams," she said. "What is the news?"
"I've come to report no wrecks so far as discovered," he told her.
"Your niece was afraid the storm might have done some serious
damage about here, but so far as we know all are safe. I looked off
toward Jagged Island just before I started, Miss Gwen, and I think
your friends are on their way. The sea has calmed down and they'll
have no trouble getting in."
"Ethel and Mr. Mitchell, Aunt Cam," Gwen explained. "They
happened to choose this of all days to go over, and I am afraid they
were drenched."
"There's a house over there, you know," volunteered Mr. Williams,
"and it's probable they took shelter there."
"No doubt they are safe then," returned Gwen, "and—and Cap'n
Ben's boat, Mr. Williams?"
"That's in too. The man who had it to-day had started, but he saw the
storm coming, and turned back in time. He waited till the storm was
over before he made a second venture, then he came only so far as
the upper end of the island where he left his boat and some of his
traps and footed it home."
Gwen was grateful for the generalization of the boat's occupant, but
she could not resist asking, "Did you see the storm-tossed mariner,
Mr. Williams?"
"No, but Cap'n Ben did, and he told me, so it's reliable information."
"Thank you, Daddy Lu," said Gwen with a flashing smile which was
answered by as bright a one.
Miss Elliott looked from one to the other. "There!" she exclaimed
suddenly, "I know who Mr. Williams reminds me of, Gwen. It is your
grandfather Whitridge. Do you happen to have any relatives of that
name, Mr. Williams?"
"Yes," he said after a pause, "I have some distant ones. My own
people are all dead, but I believe there were some of the Whitridge
line alive when I last heard."
"And you never told me you had relatives of my name," said Gwen
reproachfully. "Why, we might be kin ourselves."
"Do you chance to have any relatives by the name of Williams?"
asked the man steadily. He turned to Miss Elliott.
"No, not that I know of," she answered. "The connection is not on my
side of the house, you see. It was my sister, Gwen's mother, who
married a Whitridge. Those family likenesses are very puzzling," she
went on. "They crop up in the most surprising manner. You have
what I should call the Whitridge smile, and Gwen has the same."
"I am glad it is anything as pleasant as a smile," returned Mr.
Williams. "You say I resemble your niece's grandfather. Is the
gentleman still living?"
"Now, Daddy Lu, you know I told you I hadn't anyone but Aunt Cam,"
Gwen again spoke reproachfully. "If I had a grandfather I would
surely claim him."
"I beg your pardon," he said. "Sometimes families become
separated. He might be living in some distant place, you know. Did
your father resemble him?"
"Did he?" Gwen turned to her aunt.
"I never saw Gwen's father after he was grown," said Miss Elliott. "I
knew him only by repute, and by a photograph taken when he was
first married."
"He was a noble man," said Gwen proudly. "Wasn't he, Aunt Cam?"
"Yes, very noble," she returned, but she spoke sadly.
"He gave his life for another," Gwen put in eagerly.
Mr. Williams, standing rigidly upon the hearth, did not reply, but
looked fixedly in the fire.
"Don't you think that the noblest thing a man can do?" continued
Gwen.
"There is more than one way of giving a life, too," remarked Miss
Elliott, as if speaking to herself. "Sometimes one lays down his life
and the world does not know it. He does not have to die to do that."
Gwen looked at her in surprise. "What are you saying, Aunt Cam?
One doesn't have to die? What do you mean? But my father did die
for another, Mr. Williams. What do you mean, Aunt Cam?"
"Are there no deaths then but the giving up of one's last breath?"
inquired Miss Elliott. "Haven't you heard the expression, 'dead to the
world'? There was a man out in China who certainly laid down his
life. He is still upon this planet, but he has sacrificed everything,
home, love, all that was dear to him for the sake of others."
Gwen knew who this was. Had she not seen the little picture, her
aunt treasured, of a young ascetic with burning eyes and a firm
mouth? "Oh!" she said and looked satisfied at the explanation, as did
the man who turned his eyes from the fire to the woman and, to
Gwen's surprise, looked an intelligent sympathy.
 CHAPTER XV
ON THE DECK OF THE DOMHEGAN
There was an air of suppressed gaiety and subdued exultation in
Ethel Fuller's manner when she met Gwen that evening at Cottage
Hall where a concert was going on. She was rather splendidly attired
for the occasion, and swept in alone. Mr. Mitchell arrived later with
his mother and two of the Misses Gray. Gwen made a place by her
side for Ethel. The music had not begun, for one of the singers was
rushing around trying to find an accompanist, the one expected
having failed him at the last moment.
"Did you have a dreadful time of it?" asked Gwen sympathetically as
Ethel seated herself. "Weren't you awfully scared when the storm
came up?"
"Not exactly scared," returned Ethel, "though it was rather frightful.
We took refuge in an out-building and didn't get wet at all."
"What would you have done if the storm had continued?"
"I'm sure I don't know. Fortunately that problem didn't have to be
faced."
"It was a gorgeous storm. I fairly revelled in it," said Gwen, "or I
should have if I hadn't been worried."
"About us?"
"Yes, and about all who were out on the water. Didn't you think it was
a splendid sight?"
"I am afraid I didn't think much about that part of it. We couldn't see
very well from where we were."
"Where were you?"
"In a barn, sitting on a sawhorse."
"And you weren't scared?"
Ethel smiled, a sort of retrospective smile which suggested pleasure
rather than fright. "Here comes Jack Lansdale with Flossy Fay," she
said. "I didn't know she had brains enough to grapple with his
accompaniments, but perhaps she is equal to them. Why didn't he
get Miss Caroline Drake?"
"Probably because Flossy was the more available. She looks as
pleased as Punch. Now they're going to begin."
Jack Lansdale had a fresh, unspoiled baritone voice of pleasant
quality. He was quite a shining light among a not inconsiderable
number of musical people. A genial, robust, dark-haired young man
was Jack, who was as much at home in sailing a yacht as in guiding
a dance, and who was as ready to go off for a tramp with a boon
companion as to sit on the rocks in the moonlight and pay
compliments to a pretty girl, consequently, as he was good-looking
as well as athletic he was in much demand. To his credit be it said
that he was most accommodating and seldom refused to sing when
an accompanist could be found, but this was holiday time and even
the most enthusiastic musician could not be expected always to be
ready for a day's sailing, to play accompaniments or dance music,
therefore it was sometimes rather difficult to find one willing to be
pressed into service. Flossy Fay, however, had assiduously charged
herself to learn his accompaniments, and had made such diligent
use of her hour at the piano in the hall that she felt herself equipped
to play the part of understudy when occasion should offer. This
evening it had arrived, and her triumph was complete, for what more
delightfully intimate than to follow a voice dependent upon her skill in
accompanying?
After Jack's first songs, came a violin solo, then there were more
songs. At the last moment, the missing pianist, Tom Belden, rushed
in ready to supersede Flossy at the piano, but she clung to her
rights, and the sturdy Tom retired to the back of the hall, to appear
later to help out with the dances.
One swift glance at a seat near the door showed Gwen that Kenneth
was in the audience, but he had disappeared by the time the chairs
were pushed back and the dancing had begun. As usual Mr. Mitchell
divided himself between Gwen and Ethel, though Gwen remembered
afterward that to her share had fallen fewer dances than usual, and
that Mr. Mitchell and Ethel had sat out more than one dance on the
porch. These little informal affairs always closed early and ten
o'clock saw the lanterns bobbing in various directions as the dancers
wended their way home over uneven paths. Usually a party of them
tarried for awhile at the ice-cream saloon, where delectable ices
were to be had, and where the sweets were highly approved. It was
a cosy little place, the "saloon" proper being divided from the small
shop by portieres of antique make and design, these being nothing
more nor less than hand-woven blue-and-white counterpanes,
heirlooms in the family of Timson. This evening, however, Gwen did
not join the other young people at the favorite resort but jogged
along with the Misses Gray. There was a trip to Portland to be
undertaken the next day, and she must be up and off betimes in
order to get through the day's shopping which had become a
necessity.
It was not an unpleasant duty to seek the tidy bright little city, which
always had the air of being freshly washed and dressed, for one
generally found some pleasant neighbor to chat with on the way, and
even the slow-going steamboat, winding in and out among the
islands of Casco Bay, was not a bad place to rest in after a day's
rushing about from shop to shop. If the weather were good there was
no more charming series of views than those in which fair islands,
rippling water, and distant wooded shores found a place. Sails made
rosy by the setting sun, golden gleams along sandy beaches, sun-
touched rocks, and emerald sea gave such color as delighted most
of those who sought these favored shores, and Gwen's was the
most ardently nature-loving soul among them.
She glanced over the assemblage of those who had congregated
upon the upper deck, but seeing no vacant place upon the side she
preferred, she went down stairs. The little cabin was full of shoppers
with baskets and bundles, women with babies, travellers with bags,
but she had no desire to stay cooped up within, so she stepped out
upon the little narrow deck usually unfrequented by passengers.
There were but three occupying chairs here; one was a stalwart man
surrounded by huge parcels, another was a portly woman who had
settled herself in the midst of a collection of bundles, boxes and
bags. Between these two, and quite aloof, sat Kenneth Hilary. A
vacant stool was between him and the portly woman. Gwen's mind
was quickly made up. She climbed over a huge coil of rope in her
way, circumnavigated, as well as she could, the collection of
bundles, boxes and bags, possessed herself of the vacant stool and
sat down, planting her own bag firmly in front of her. Then turning
around she said demurely, "Good evening, Mr. Hilary."

"GOOD EVENING, MR. HILARY."

He looked around quickly. There was no escape. The ponderous
man had hedged himself in securely at one end, the stout woman's
array of goods formed a barrier at the other, and even supposing he
were to brave the dangers that Gwen had done, he must incommode
the girl herself and show himself distinctly rude. There was nothing
to do but accept the situation. "Good evening," he said and then
silence fell.
Gwen turned her head slightly that her eyes might rest on the man's
goodly length of limb, the shapely hands, the rather rugged but
wholly attractive face under the yachting cap. The brilliant eyes were
turned away. If only she could see into their clear brown depths and
bring again that intense expression she had beheld more than once.
In spite of the discouragement which met her first efforts she felt the
opportunity to be as golden as the light which glorified land and sea,
and she took her courage in both hands. It was now or never. "I
haven't seen you for such a long, long time," she said a little
tremulously. "At least I haven't had a chat with you. Did you get
some good sketches that foggy day when I met you on the road?"
"Fairly good ones," was the none too responsive answer.
"I'd love to see them."
No reply, only a tightening of the lips.
"Dear me," thought Gwen, "it is going to be harder than I imagined. I
shall have to go to greater lengths. I am not to be met half way at all.
It seems perfectly dreadful," she began again, "to think of all the
lovely things you may have been doing, and that I have not seen one
of them."
"You are very good to speak so flatteringly of my poor efforts."
"Ice," thought Gwen, "snow-balls similarly, and all the frozen things
combined. I shall have to take another tack. I saw you at the Hall last
night. Why didn't you stay to the dance?"
"I was tired."
"Nothing doing in that direction," Gwen told herself in girlish
vernacular. "Well, there are two good hours before us. I shall have to
thaw him out in some way. Suppose, just suppose it should be my
last chance in life to meet him undisturbed." She ventured again.
"The summer is almost over. Shall you be sorry to leave the island,
Mr. Hilary?"
"For most reasons, no. I have made pretty good use of its
possibilities for one season."
"A little better. I'll follow this up," Gwen decided, then aloud, "It has
so many possibilities I don't think they can be used up in one
season. Shall you come back next summer?"
"I doubt it, though it's rather too far ahead to make plans."
"But your plans—Fools rush in,"—Gwen quoted to herself—"I am
interested in them. You were to decide something very important.
Have you had any more light on the subject?"
"I have decided to keep on working and studying. Some day I may
be an artist."
"Oh, I am so glad," broke out so spontaneously that the young man's
rigid expression softened a little. "Then," the girl continued, "what
about the holes in the family fortunes? You don't have to—darn
them?" She laughed a little.
Kenneth's face clouded again. The reference brought up too sweet a
memory of those first days of their acquaintance. "Fortunately for
me," he returned coldly, "the fortunes of my family have improved,"
and Gwen felt repulsed.
"I am not asking from idle curiosity," there was a little quiver in her
voice, "but because I am deeply interested." Then impulsively,
"Aren't you ever going to forgive me, Mr. Hilary? I was horrid, I was
vilely cruel that—that evening. I have been sorry ever since that I
was such a beast." Having gone thus far she continued rapidly, "I
have missed you dreadfully. It seemed such a lingering punishment
when day after day I caught glimpses of you out sketching, and knew
you were doing things I was dying to see, little bits that I loved off
there in Sheldon woods, beautiful, mysterious effects on the bay, and
those wonderful opalescent colorings of certain evenings. Don't you
think I have been punished long enough? Can't we be friends
again?" She spoke wistfully, almost as if there were tears in her
eyes.
"Do you really feel that way about it?" asked Kenneth, nervously
twisting the cord which held a small package he carried.
"I feel just that way, and it's been growing worse and worse. You
would pass me by every time. You have taken such pains to avoid
me. You never came to the dances, and refused all invitations to
affairs where you knew you would be liable to meet me. So you see I
had every reason to feel that I had sinned beyond hope of
forgiveness. But, when I saw," she glanced at the barriers at each
end of the deck, "when I saw that you couldn't very well get away
without jumping overboard I made up my mind to risk my life by
climbing over that mountain of shopping," she nodded toward the
portly woman, "in order to tell you that I am sorry for what I said. It
was fairly brutal."
There was no answer, but the nervous twisting of the cord ceased,
and the hands gripped the package as if they would crush it.
"Please, Mr. Painter-man, forgive a meek maiden, and put her out of
her suffering."
He turned suddenly. "Miss Whitridge, do you think I haven't suffered,
too?"
"I am sorry, oh, so sorry. Don't let's suffer any more, please."
"How can I help it when you are going to marry that—"
"Jar-fly? But suppose I have decided that I don't care for jar-flies in
my collection, even when they have gold wings, ruby eyes and are
powdered with diamond dust? Suppose the jar-fly has flown to
another flower and that I saw him go with joyous satisfaction?"
"Is that absolute truth?"
"Absolute. Yesterday the jar-fly and the butterfly, like the owl and the
pussy cat, 'went to sea in a beautiful pea-green boat,' and if they
didn't reach 'the land where the bone-tree grows,' they did get
caught in the storm on Jagged Island. The result I foresee, for if they
are not actually engaged they must be close to it, judging from
certain looks and remarks of last night, while I am ready waiting with
my blessing, which I assure you will be of the heartiest kind." She
turned a smiling face upon her companion. "Please remove the
instruments of torture. I have made my confession."
"Thank you for it. Consider the instruments of torture, as you are
pleased to call them, sunk in the depths of the sea."
"Thanks. I think I notice a volume of steam issuing from the spot
where they sank. Now we are friends, aren't we? And you are going
to tell me about the family fortunes. You are going to let me see all
your sketches, every single one, and you are never going to pass me
on the road without stopping to say some nice friendly thing. You
promise all this?"
"All of it."
"Family fortunes first, for, of course, the other things have to wait.
What has happened?"
"My mother has entered a second time into the matrimonial state.
Her husband has ample means, so the family fortunes don't even
have to be patched. When they get ragged they can be thrown
away."
"How perfectly lovely. That is the last solution we should have
dreamed of, isn't it?"
His heart leaped at that use of the first person plural. "I certainly
didn't expect it," he said.
"And you don't feel sorry? Not a bit?"
"Not at all. I am very glad if my mother is happy. He isn't exactly the
kind of man I should have selected as a veritable parent, but since
my mother is satisfied I have nothing to say."
"What is he?"
"A wealthy brewer, or pork-packer or something of the kind."
"You have met him?"
"Yes. He is large, florid and expansive in manner."
"You didn't go to the wedding?"
"I wasn't asked. They stepped off quietly, were married and sailed for
Europe at once."
Gwen pondered over the information. "Before then what was
happening to you? Had you decided to stick to your palette and
brushes?" she asked presently.
"No. I had decided to do the other thing."
"Absolutely?"
"Absolutely."
"How miserable you must have been with a desk and counting
house ever before your eyes. You were all alone, too, for your sister
and the children were away. You poor boy!" Her voice was tender as
she remembered that she had added to his unhappiness. "It is
perfectly lovely," she went on, "to think that you don't have to
sacrifice yourself."
"I shall be a poor man for a great many years, I am afraid," he said
soberly.
"What of it? You are young, and it is worth everything to be able to
follow the occupation you love best. 'The best use of your best
powers' is how some one defines happiness, so you will be happy.
Perhaps the new papa will send you abroad to study."
"Do you think I would go under such circumstances?" returned the
young man fiercely.
"Proudy! Well, maybe he'll buy all your pictures. You couldn't refuse,
not to one of the family, who isn't a—jar-fly."
Kenneth laughed a little. It was so delightful to respond to her gay
spirits, to be able to feel in sympathy with her sly allusions. They
were back again on the old footing. He laughed again. "No, he isn't
that, but I don't believe he will want to buy my pictures, in spite of
there not being the same reason for refusing to sell as when you—"
"When I acted like a cold-blooded jellyfish." She blushed when she
remembered the exact cause of that refusal to sell, but she was
happy, absurdly so. The blood was coursing wildly through her veins.
She had triumphed and not only did she glory in her victory, but she
felt that the vanquished hugged his chains. "That fatal picture," she
sighed. "Did you paint another like it?"
"Not exactly, though much the same."
"And have you sold it?"
"No."
"Any others?"
"Two or three small ones."
"What are you going to do with that one?" she asked with sudden
audacity.
"Which one?"
"You know. The wave that threatened to wreck our friendship."
He did not answer for a moment, but sat gazing at her, at the joyous
curves of her sweet mouth, the flying tendrils of hair that curled
around her small ears, the tender expression of her clear eyes. "Will
you take it?" he asked suddenly. "I make no conditions—I have no
right. I have my way to make, you know, but if you will have the
picture—"
"As a sign and seal of our eternal friendship? Yes, I will take it gladly,
and thank you a thousand times. You are right. You have your way to
make, and you must not let anything stand in the way of that. No
man has the right to hamper his career in the beginning, and no
woman," she added softly, "would allow him to, if she valued his
success at all. I do value yours, Mr. Hilary."
"I believe it, dear Gwen. Please let me call you that, and say
Kenneth to me."
"I agree, for we are friends, real, true, loyal friends aren't we?"
"We are that. At the very least I am your true friend. At the very most
—I cannot tell you what I am at the most. Some day I hope I may."
"Wait till that some day, and in the meantime you will tell me
everything else; you will see me often and life will be very sweet, I
hope. Are we so near home? Yes, ours is the next landing, and—oh
dear me, I hadn't noticed that our heavily burdened neighbors had
gone ashore. We are the only ones left on this deck. Did you think I
was very forward to make that venturesome journey over all that pile
of stuff in order to speak to you? I did it wilfully because I simply
could not have things going on so wofully."
"I not only forgive you, but I bless you for your heroism. Do you
forgive me for being so stand-offish?"
"You were horrid. I never saw such an iceberg."
"As I pretended to be. It was all pretence. I was a seething volcano
inside when you sat down."
"Oh, you nice boy to confess it. Are you going to walk home with me
and help me carry my bundles? You have such an insignificant little
one compared to mine."
"Only some little tubes of colors I went up on the noon boat to get. I
can put them in my pocket and I'll gladly carry all yours."
"I am willing to take my share of the burdens; I am young," returned
Gwen with a swift look that made the man's heart beat fast, for what
underlying promise was there not in her words, the more
emphasized as the blue eyes drooped softly and she turned shyly
away under his ardent gaze.
At last the steamer stopped at the lower wharf, and the two took the
path along a way odorous with sweet grass and bracken, then over
the long white road they travelled slowly, up the little incline, past
Cap'n Ben's house and through the stile to the pasture, talking
merrily of light things.
Just before reaching Cap'n Ben's they saw Ethel and Mr. Mitchell
coming home from the rocks. Gwen waved her umbrella and called
out to them; they answered cheerily and both went toward Almira