title: Exploration under the dome: Esophageal ultrasound with the ultrasound bronchoscope is indispensible.
abstract: BACKGROUND
  Effective use of the convex curvilinear ultrasound bronchoscope in the esophagus (EUS-B) for fine needle aspiration biopsy of mediastinal structures is now well described. In contrast, there is little to no reporting, depending on the site of EUS-B for access to sub-diaphragmatic structures. Our practice has been accessing sub-diaphragmatic sites for years. This review documents our experience with EUS-B to biopsy liver, left adrenal glands, and coeliac lymph nodes.
  
  
  METHODS
  After Institutional Review Board's approval, all endosonographic procedures performed by interventional pulmonary between July 2013 and June 2015 were reviewed. Those including biopsy of sub-diaphragmatic sites were then selected for analysis.
  
  
  RESULTS
  Over the study interval, 45 sub-diaphragmatic biopsy procedures (25 left adrenal glands, 7 liver, and 13 celiac node) were performed with EUS-B. In all cases, cellular adequacy was present, and samples were large enough for immunohistochemistry and any relevant ancillary studies. Metastatic malignancy was documented in 58% of cases, 16% of cases contained benign diagnostic findings, and in 27% of cases, normal organ tissue was documented. There were no complications.
  
  
  CONCLUSIONS
  Operators comfortable with the endobronchial ultrasound scope in both the airway and the esophagus can actively seek and successfully perform biopsy of sub-diaphragmatic abnormalities when present and can thereby add to the diagnostic value of the procedure.
authors: Department of Medicine, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, AR, USA.
authors: Nikhil
authors: N
authors: Meena
authors: Department of Internal Medicine, CHI St. Vincent Infirmary, Little Rock, AR, USA.
authors: Cidney
authors: C
authors: Hulett
authors: Department of Internal Medicine, St. Louis University, St. Louis, MO, USA.
authors: Setu
authors: S
authors: Patolia
authors: Department of Medicine, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, AR, USA.
authors: Thaddeus
authors: T
authors: Bartter