ESGE and EFSUMB guidelines recommend multimodal imaging, including contrast-enhanced CT/MR (CE-CT/MR) and contrast-harmonic EUS (CH-EUS), for evaluation of solid pancreatic lesions. However, integration of these modalities into the workflow of a mixed emergency–endoscopy unit remains challenging. This study evaluated the diagnostic performance of CE-CT/MR, CH-EUS, and EUS-FNA/FNB against the final reference diagnosis, and assessed adherence to ESGE performance indicators for EUS tissue acquisition (EUS-TA).

We retrospectively analyzed 124 consecutive patients with solid pancreatic lesions evaluated over 36 months. Final diagnosis was determined by histopathology and/or 6-month follow-up, yielding 104 cases with definitive malignant or benign outcomes (malignant 91.3%). CH-EUS, CE-CT/MR, and EUS-FNA/FNB results were compared with the reference standard using standard diagnostic metrics. ESGE quality indicators (EUS-TA rate, diagnostic adequacy, and adverse events) were calculated from procedural data. Clinical and technical determinants of sampling performance were explored. 

For ADK-only diagnosis, CH-EUS achieved a sensitivity of 97.5% and a specificity of 72.5%. CE-CT/MR yielded a sensitivity of 81.0% and a specificity of 50.0%. EUS-FNA/FNB demonstrated a sensitivity of 89.9% and a specificity of 75.0%. ESGE performance benchmarks were fulfilled, with EUS-TA performed in 95.2% of lesions, a diagnostic adequacy rate of 90.3%, and no recorded adverse events. Correct EUS-FNA/FNB diagnosis correlated with elevated CA19-9 and the presence of cholestasis, whereas needle type and number of passes did not significantly influence adequacy.

These data are very consistent with the concept that CH-EUS is the best “rule-out” tool (do not miss malignancy), while EUS-FNA/FNB is the best “rule-in” tool (confirm malignancy and the specific type of malignancy when cytology/histology is positive). CT/MR remains important for staging and initial triage, but not for fine discrimination of benign vs malignant solid lesions.

In an emergency hospital environment, CH-EUS provides high diagnostic accuracy for solid pancreatic lesions compared with CT/MR, while EUS-FNA/FNB maintain full compliance with ESGE quality benchmarks for EUS-TA. Integrating CH-EUS early in the diagnostic pathway enhances real-world performance and supports the feasibility of guideline-concordant care even in busy emergency hospitals.