title: Impact and safety of endoscopic ultrasound guided fine needle aspiration on patients with cirrhosis and pyrexia of unknown origin in India.
abstract: OBJECTIVE
  Etiologic diagnosis of pyrexia of unknown origin is important in patients with cirrhosis for optimal management and to prevent flare up of infectious disease after liver transplantation. However, there is very limited literature available on this subject. The present study aimed to examine the safety and impact of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with cirrhosis.
  
  
  METHODS
  The study was conducted between January 2014 and January 2016 at a tertiary care center. A total of 50 (47 lymph nodes, 3 adrenal) EUS guided FNAs were performed in 46 patients. Data are presented as median (25 - 75 IQR).
  
  
  RESULTS
  The study included 46 patients (40 males) whose mean age was 47.9 ± 11.1 (SD) years; mean Child-Turcotte-Pugh (CTP) score and mean MELD (Model for End-Stage Liver Disease) score were 10 (8 - 11) and 18 (12 - 20), respectively. The Child Pugh class was A in 4, B in 14, and C in 28 (including three patients with adrenal FNAs). Indications for FNA were pyrexia of unknown origin and lymphadenopathy on CT imaging. The cytopathological diagnoses were metastatic disease in 1 (adrenal), granulomatous change in 10 (6 positive with acid fast bacilli stain), histoplasmosis in three (two adrenals, one lymph node), 32 lymph nodes were reactive and four lymph node FNAs showed inadequate cellularity. The pathologic nodes had significantly lower long-to-short axis ratio [1.25 (1.09 - 1.28) versus 1.46 (1.22 - 1.87), P = 0.020]; a higher proportion of hypoechoic echotexture (5 versus 3, P = 0.017), and sharply defined borders (4 versus 2, P = 0.029). Complications included mild hepatic encephalopathy related to sedation in two patients with Child's C status.
  
  
  CONCLUSIONS
  EUS guided FNA is safe in patients with cirrhosis and modified the management in 14/46 (30.4 %) patients.
authors.affiliation: Medanta, The Medicity - Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India.
authors.forename: Narendra
authors.initials: N
authors.lastname: Choudhary
authors.affiliation: Medanta, The Medicity - Institute of Digestive and Hepatobiliary Sciences, Gurgaon, Haryana, India.
authors.forename: Rinkesh Kumar
authors.initials: RK
authors.lastname: Bansal
authors.affiliation: Medanta, The Medicity - Institute of Digestive and Hepatobiliary Sciences, Gurgaon, Haryana, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Puri
authors.affiliation: Medanta, The Medicity - Institute of Digestive and Hepatobiliary Sciences, Gurgaon, Haryana, India.
authors.forename: Rajiv Ranjan
authors.initials: RR
authors.lastname: Singh
authors.affiliation: Medanta, The Medicity - Institute of Digestive and Hepatobiliary Sciences, Gurgaon, Haryana, India.
authors.forename: Mukesh
authors.initials: M
authors.lastname: Nasa
authors.affiliation: Medanta, The Medicity - Institute of Digestive and Hepatobiliary Sciences, Gurgaon, Haryana, India.
authors.forename: Vinit
authors.initials: V
authors.lastname: Shah
authors.affiliation: Medanta, The Medicity - Cytopathology, Gurgaon, Haryana, India.
authors.forename: Haimanti
authors.initials: H
authors.lastname: Sarin
authors.affiliation: Medanta, The Medicity - Cytopathology, Gurgaon, Haryana, India.
authors.forename: Mridula
authors.initials: M
authors.lastname: Guleria
authors.affiliation: Medanta, The Medicity - Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India.
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Saigal
authors.affiliation: Medanta, The Medicity - Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India.
authors.forename: Neeraj
authors.initials: N
authors.lastname: Saraf
authors.affiliation: Medanta, The Medicity - Institute of Digestive and Hepatobiliary Sciences, Gurgaon, Haryana, India.
authors.forename: Randhir
authors.initials: R
authors.lastname: Sud
authors.affiliation: Medanta, The Medicity - Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, Haryana, India.
authors.forename: Arvinder S
authors.initials: AS
authors.lastname: Soin