EUS:The basics
Jayapal Ramesh
Advanced Endoscopist
Royal Liverpool and Broadgreen University Hospitals NHS Trust
Honorary Senior Lecturer, University of Liverpool
Aims
Introduction
Equipment
Indications
Procedure
Some cases
Introduction 1
Sivak MV, Gut 2006;55:1061–1064.
Introduction 2
Combined Endoscope and
Ultrasound
Small ultrasonic
transducer on the tip of
endoscope
Provide excellent
resolution:
lesions as small as 2 –
3 mm
depth of 4 – 6 cm
Equipment 1
Diagnostic Scope
Electronic radial scanning
Frequency: 5, 6, 7.5 and 10MHz
13.8mm distal end outer diameter
11.8mm insertion tube outer diameter
1250mm working length
2.2mm channel diameter
Doppler facility
Electrical curved linear array scanning.
5, 6, 7.5 & 10MHz operating frequencies
14.6mm distal end diameter.
12.6mm insertion tube diameter.
3.7mm channel.
100O field of view
1250mm working length.
130O/90O up/down, 90O/90O
left/right angulation.
Colour doppler.
Equipment 2
Therapeutic Scope
Equipment 3
Probes High Frequency catheter Probe
Blind Probe
IDUS
EBUS
Rectal probes
Procedure
Endoscopy Unit
Standard Preparation as for EGD
Off Warfarin and Clopidogrel for FNA/ therapy
Left lateral position
Conscious sedation with fentanyl and midazolam
Oxygen and observations
Procedure time can vary from 10 mins to 60 mins
Post procedure – standard for diagnostic
Post procedure for therapy-
Endoscopist
Assistant
USS processor +monitor
Video processor
Nurse
Assistant
Monitors
Indications
Diagnostic
Cancer Staging
Oesophago-gastric cancer
Ampullary cancer
Pancreatic cancer
Lung cancer
Rectal cancer
Other Upper GI tumours (Benign and Malignant)
Gastric Lymphoma
Submucosal tumours (GIST, Leiomyoma, Lipoma)
Endocrine tumours
Pancreatic cystic disease
Benign Pancreato-biliary diseases
Chronic Pancreatitis
Gallstones
Obstructive Jaundice
TherapeuticPseudocyst drainageCoeliac Plexus NeurolysisFNA
Lymph nodesPancreatic massesCystic lesions of pancreasAlcohol injection into cystsTatooing
Others
Oesophageal Cancer
‘M’ staging by CT
‘T’ & ‘N’ staging by EUS
EUS In Locally Advanced Disease
Aorta
Azygos
Vein
Muscularis Propria
AortaInvasion
<Tumor
Pancreatic Cancer
Issues
• Early diagnosis
• Accurate staging
• Tissue procurement
• Palliation
ERCP Brushings Vs EUS-FNA
INSULINOMA
GASTRINOMA
OGD: Probing with cold biopsy forceps
EUS: Mural or extra-mural
Layer of origin
Margins and echogenecity
Size
Tissue diagnosis: FNA/FNB
SUBMUCOSAL LESIONS
SUBMUCOSAL LESION
EUS
EXTRA MURAL
GALLBLADDER
VASCULAR IMPRESSION
TUMORS
INTRAMURALL
SUBMUCOSA
HYPERECHOICLIPOMA
HYPOECHOIC
CARCINOID
PANCREATIC REST
GRANULAR CELL TUMOR
GIST
ANECHOIC
CYST
MUSCULARIS PROPRIA
GIST
LEIOMYOMA
LEIOMYOBLASTOMA
LEIOMYOSARCOMA
Polyp
Gastric Lipoma
Duodenal Lipoma
Carcinoid
Prominent Fold: Varices
Prominent Fold: Gastrinoma
Prominent Fold: Linitis Plastica
MALT Lymphoma
Cardia ‘Bump”
Stomach GIST
Antral Bulge: Courvoisier’s GB
Peri-rectal Cyst
Peri-rectal Metastasis
SMT
“Lumps and Bumps” are common at
endoscopy
EUS “narrows” diagnosis and “directs” Rx
FNA provides tissue confirmation
GIST “must” be investigated further
EUS Features of Chronic Pancreatitis
Ductal
dilatation
echogenic walls
irregular contour
side branch dilation
calcifications
Parenchymal
echogenic foci
small cysts
lobular outer contour
echogenic strands
inhomogeneity
Lees W.R., Scand J Gastro 1986;21:123-29
ERCP versus EUS
Common Bile Duct Stones
EUS or MRCP or ERCP
Bile duct stone
Microlithiasis
CBDS > 6 mm : MRCP = ERCP = EUSCBDS < 6 mm : EUS > MRCP/ERCP
EUS-FNA
Indications pancreatic mass/cyst
mediastinal lymph nodes (metastasis from esophageal and lung cancer)
celiac lymph node
intra-abdominal lymph nodes in association with a known (or suspicion of) cancer
peri-rectal lymph node/mass
posterior mediastinal mass of unknown etiology
intrapleural/intra-abdominal fluid.
peri-pancreatic masses
submucosal masses
liver lesions
adrenal masses
suspected recurrent cancers in and adjacent to surgical anastomosis
Retroperitoneal masses
Any mass accessible from the GI tract
Patient preparation
Ensure correct indication
Patient leaflet and information
4- 6hr fast
Precaution for diabetics
Rule out any bleeding diathesis in history
If there is history of low platelets
Stopping anticoagulants
Stop clopidogrel 7 days before (liaise with cardiology)
Antibiotics in case of cyst puncture
Review previous cross sectional imaging
Why use EUS for therapy
Evaluates beyond gut wall. Punctures under direct vision
Intervening vessels can be identified.
Small puncture ( 19 gauze) good enough to pass a guidewire
Internal with no skin incision
Does not need an external bulge on gut wall
Tissue diagnosis, tumor staging and drainage can be done in a single sitting
Equipment Scopes
Needles- size
Syringe with suction for negative pressure
Slides – label, hospital no
Staining material
Cellblock tube/flow cytometry tube
Call cytopathologist
Stylet
Specimen cup for cysts
Biochem form for cysts
Therapeutic EUS Head end
Sedation
aspiration risk
Anticipation
Accessories
Scope
19G needle
Guidewires
Cannula
Balloons
Plastic/metals tents
Nagi/Hot axios
Clips
Injection needles
Adrenaline
Bearclaw
Fiducials
Alcohol
Bupivacaine
Triamcinolone
Procedural steps
EUS-guided Drainage
EUS-guided Fiducial Placement
for insulinoma
Ramesh J, UCTN Endoscopy 2012
Celiac Plexus Interventions
Neurolysis for Cancer
• CPN or 19-G needle
• 10 ml of 0.25% Bupivacaine
• 20 ml of dehydrated (98%)
alcohol
• 5 ml of Normal Saline
Block for Chronic
Pancreatitis
• CPN or 19G needle
• 10 ml of 0.25% Bupivacaine
• 80mg of Triamcinolone in 2 mls
• 5 ml of Normal Saline
CPN
One-side CPN Two-side CPN
Ganglia CPN
Gunaratnam: pain relief 78% LeBlanc: 65% vs. 59%
Levy: pain relief 94%
Doi 73.5 % vs 45.5 %; P = 0.026).
SMA
Sakamoto: pain relief
79% vs. 19%
EUS-guided alcohol ablation of pancreatic
cyst neoplasm
Brugge W: Techniques in GI Endoscopy 2007
Recovery and follow up
Observe with standard obs
Antibiotics
Advise similar to any therapeutic ERCP
Clinic, endo or image follow up
Thank You