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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