principles and practice of gi endoscopy

A SEMINAR ON A SEMINAR ON PRINCIPLES AND PRINCIPLES AND PRACTICE OF GI PRACTICE OF GI ENDOSCOPYENDOSCOPY

Guide; Dr. M.Singh (M.S.)Guide; Dr. M.Singh (M.S.) Associate professorAssociate professor Dept of SurgeryDept of Surgery

Presented byPresented by Dr.K.RaviDr.K.Ravi

History of EndoscopyHistory of Endoscopy

Kussmaul in 1869 introduced silver tube successfully Kussmaul in 1869 introduced silver tube successfully into the stomach of the sword-swallower and became into the stomach of the sword-swallower and became the first person in medical history to visualize the the first person in medical history to visualize the stomach. stomach.

In 1957 first prototype fiber optic endoscope was In 1957 first prototype fiber optic endoscope was introducedintroduced

In 1968 ERCP was introducedIn 1968 ERCP was introduced In 1974 Endoscopic sphincterotomyIn 1974 Endoscopic sphincterotomy In 1979 PEGIn 1979 PEG In 1980 Endoscopic injection sclerotherapyIn 1980 Endoscopic injection sclerotherapy In 1980 Endoscopic ultrasonographyIn 1980 Endoscopic ultrasonography In 1983 Electronic (charge coupled device) endoscopeIn 1983 Electronic (charge coupled device) endoscope

ENDOSCOPYENDOSCOPYTwo typesTwo types a. Rigid endoscope a. Rigid endoscope

b. Flexible endoscope b. Flexible endoscope

Now a days rigid type is virtually obsolete though Now a days rigid type is virtually obsolete though some surgeons still use this traditional instrument some surgeons still use this traditional instrument

It needs skill to introduce though there is It needs skill to introduce though there is significant risk of perforationsignificant risk of perforation

Probably better for examination of the lower Probably better for examination of the lower pharynx and cricopharyngeal areapharynx and cricopharyngeal area

1 Function buttons, e.g., video recorder remote control2 Freeze button3 Suction button4 Air/water button5 Instrument channel6 Locking device7 Angling wheel (right/left)8 Angling wheel (up/down)

Video processor (above) and light source (below)

Tip of Endoscope

Handling the EndoscopeHandling the Endoscope

The control head of the endoscope is held in the left hand.

The index and middle fingers activate the suction and air/water valves.

Many examiners operate the angulation control wheels with the right hand, but an endoscopist with large hands can also manage these controls with the left hand.

This leaves the right hand free to manipulate the insertion tube, which is advantageous in some situations.

PRINCIPLES OF ENDOSCOPYOF ENDOSCOPY

InIn all flexible endoscopic system light is all flexible endoscopic system light is transmitted down the endoscope shaft to transmitted down the endoscope shaft to illuminate the surface to be examined.illuminate the surface to be examined.

The reflected image is conveyed back to the The reflected image is conveyed back to the endoscopist via one of two different endoscopist via one of two different modalitiesmodalities

A. Fiber opticsA. Fiber optics

B. ElectronicsB. Electronics

Fiber optic EndoscopyFiber optic Endoscopy

In the fiber optics, a fixed lens at the end of In the fiber optics, a fixed lens at the end of the instrument shaft focuses the image on the instrument shaft focuses the image on internal fiber optic bundle.internal fiber optic bundle.

The fiber optic bundle is 2-3mm wide &is The fiber optic bundle is 2-3mm wide &is composed of 20,000-40,000 individual fine composed of 20,000-40,000 individual fine glass fibers, each approximately 10mm in glass fibers, each approximately 10mm in diameter.diameter.

The image undergoes a series of internal The image undergoes a series of internal reflection with in each fiber as it is reflection with in each fiber as it is transmitted up the bundle.transmitted up the bundle.

Electronic EndoscopyElectronic Endoscopy

Most endoscopes currently produced are electronic.Most endoscopes currently produced are electronic. In these system the image is reflected onto a charge In these system the image is reflected onto a charge

coupled device [CCD] chip mounted on the end of coupled device [CCD] chip mounted on the end of instrument shaft. instrument shaft.

These chips contain thousands of light sensitive points These chips contain thousands of light sensitive points [ “Pixels”]. [ “Pixels”].

The greater the number of pixels, the better the The greater the number of pixels, the better the resolution.resolution.

Current chips contain 100,000 to 300,000 pixels.Current chips contain 100,000 to 300,000 pixels. The image is then transmitted through wires instead The image is then transmitted through wires instead

of light bundles to additional electronics in the of light bundles to additional electronics in the instrument head.instrument head.

Advantages of video endoscopeAdvantages of video endoscope

The endoscopist can stand erect and watch the The endoscopist can stand erect and watch the television monitor without any interruptiontelevision monitor without any interruption

The intraluminal view and the lesions present within The intraluminal view and the lesions present within can be seen with more clarity by more than one can be seen with more clarity by more than one person in the endoscopy roomperson in the endoscopy room

Therapeutic procedures are easier with a video Therapeutic procedures are easier with a video endoscopeendoscope

The video endoscopes are water tight instruments and The video endoscopes are water tight instruments and can be immersed in cleaning solutionscan be immersed in cleaning solutions

Endoscopic pictures can be made readily available Endoscopic pictures can be made readily available with the help of printerwith the help of printer

In video endoscope the images of tumors, ulcers & In video endoscope the images of tumors, ulcers & polyps can be faithfully transferred to the television polyps can be faithfully transferred to the television monitor in their natural colors.monitor in their natural colors.

Gastrointestinal EndoscopyGastrointestinal Endoscopy

Types of Gastrointestinal EndoscopyTypes of Gastrointestinal Endoscopy

Esophagogastroduodenoscopy (Upper GI Esophagogastroduodenoscopy (Upper GI Endoscopy)Endoscopy)

Small Bowel Enteroscopy (Jejunoscopy)Small Bowel Enteroscopy (Jejunoscopy) Colonoscopy (Lower GI Endoscopy)Colonoscopy (Lower GI Endoscopy) SigmoidoscopySigmoidoscopy Endoscopic Retrograde Endoscopic Retrograde

Cholangiopancreatogram (ERCP)Cholangiopancreatogram (ERCP)

Upper Gastrointestinal Upper Gastrointestinal EndoscopyEndoscopy

HeartburnHeartburn

Dysphagia or odynophagiaDysphagia or odynophagia

Hematemesis or melenaHematemesis or melena

Dyspepsia or upper Dyspepsia or upper abdominal painabdominal pain

Unexplained weight loss or Unexplained weight loss or anemiaanemia

Evaluation of abnormal Evaluation of abnormal Barium meal X-rayBarium meal X-ray

Suspected malabsorptionSuspected malabsorption

Control of bleedingControl of bleeding

Dilation of strictureDilation of stricture

Removal of foreign Removal of foreign bodiesbodies

Removal of polypsRemoval of polyps

Tumor ablationTumor ablation

Diagnostic Indications Therapeutic Indications


Contraindications to Upper GI EndoscopyContraindications to Upper GI Endoscopy

Uncooperative patientUncooperative patient

Hemodynamically unstable patientHemodynamically unstable patient

Suspected perforationSuspected perforation

cervical spine disorderscervical spine disorders

Soon after a myocardial infarctionSoon after a myocardial infarction

Cleaning and Disinfection Cleaning and Disinfection

Meticulous cleaning of the endoscope with clean and Meticulous cleaning of the endoscope with clean and filtered water immediately after use, is necessary to filtered water immediately after use, is necessary to keep the instrument clean of organic debris like blood, keep the instrument clean of organic debris like blood, dried gastric juice and food particles. It is scrubbed dried gastric juice and food particles. It is scrubbed with a sponge or soft brush.with a sponge or soft brush.

After a thorough cleaning, the next step is to disinfect After a thorough cleaning, the next step is to disinfect the scope against cross infection.the scope against cross infection.

The commonly used disinfectants areThe commonly used disinfectants are

a. 2% Glutarldehyde (CIDEX)a. 2% Glutarldehyde (CIDEX)

b. Iodophor (Betadine-providone Iodine)b. Iodophor (Betadine-providone Iodine)

c. 70% ethyl or isopropyl alcoholc. 70% ethyl or isopropyl alcohol

d. Ethylene oxide (ETO)d. Ethylene oxide (ETO)

e. Formaldehyde vapoure. Formaldehyde vapour

Patient preparationPatient preparation

Fasted for at least 4 – 6 hrs more time forFasted for at least 4 – 6 hrs more time for

GOO.GOO. Before the study dentures & eye glasses should be removed.Before the study dentures & eye glasses should be removed. If intervention is anticipated, a recent coagulation profile If intervention is anticipated, a recent coagulation profile

&platelet count should be within safe ranges.&platelet count should be within safe ranges. Prophylactic antibiotics indicated in Prophylactic antibiotics indicated in

a. Sclerotherapy.a. Sclerotherapy.

b. Previous endocarditis.b. Previous endocarditis.

c. Recent vascular prosthesis.c. Recent vascular prosthesis.

d. For PEG tube placements.d. For PEG tube placements.

e. Patients with prosthetic heart valves.e. Patients with prosthetic heart valves.

Method Two squirts of lidocaine sprayed into the pharynx or lidocaine viscus can be used.

Check ListCheck List

24 hours before the examination

Confirm indication Check contraindications Necessary lab tests ordered? (blood count,

coagulation) Antibiotic prophylaxis? Informed consent obtained? Patient instructed about fasting? Cardiac pacemaker? Risk factors? (heart, lung, coagulation, general

health)

Immediately before the examination

Patient welcomed to the unit, greeted by name Signed consent form? Dentures removed? Defoaming agent administered? Coagulation tested? If necessary: peripheral venous access?

(especially with sedation and for interventions) Equipment check? (air, suction) Endoscope tip lubricated Pharyngeal anesthesia (if desired) Contact with patient: “Here we go.”

During the examination Talk to the patient, explain what is

happening. Keep the patient in a left lateral position. Observe the patient (sweating,

restlessness, facial expression, gestures, pain manifestations, breathing, skin color).

If in doubt: pulse oximetry, echocardiogram (ECG) monitoring.

Inserting the Endoscope

Blind Insertion Direct-Vision Insertion In the blind insertion method, the endoscope is

first passed over the base of the tongue toward the hypopharynx under external visual control.

With proper technique, the instrument tip can be advanced just to the introitus of the upper esophageal sphincter, at which time the patient is instructed to swallow.

Endoscope insertion is contraindicated while the patient is coughing or taking a deep breath, as this will inevitably lead to tracheal intubation

Diagnostic techniqueDiagnostic technique

inspection is often easier during withdrawal, when the inspection is often easier during withdrawal, when the viscera are well distended with air.viscera are well distended with air.

-the endoscope is advanced to the esophago-gastric -the endoscope is advanced to the esophago-gastric junction. Noting the ‘Z’ LINE, where the white junction. Noting the ‘Z’ LINE, where the white sqammous esophageal mucosa meets red columnar sqammous esophageal mucosa meets red columnar gastric epithelium.gastric epithelium.

Importance of ‘Z’ Line inImportance of ‘Z’ Line in a. ph probe placement.a. ph probe placement. b. Endoscopic Anti-reflux procedures.b. Endoscopic Anti-reflux procedures. c. determine if a GE Junction lesion is gastric or c. determine if a GE Junction lesion is gastric or esophageal in origin.esophageal in origin.

-entry into the duodenal bulb is recognized by the -entry into the duodenal bulb is recognized by the typical granular, pale mucosa.typical granular, pale mucosa.

-finally, the second portion of the duodenal is entered -finally, the second portion of the duodenal is entered by advancing to the superior duodenal angle. by advancing to the superior duodenal angle.

-when scope in the antrum either prior to entering or -when scope in the antrum either prior to entering or after with drawing from the duodenal bulb tip can be after with drawing from the duodenal bulb tip can be rotated through 180 degree in either direction to rotated through 180 degree in either direction to visualize fundus &cardia.visualize fundus &cardia.


Normal Esophagus Normal Stomach Normal Duodenum

Duodenal UlcerGastric UlcerEsophagitis

Gastric ulcer

Bleeding gastric ulcersGastric ulcer

Esophageal Varices

Esophageal Varices Bleeding esophageal varices

Angiodysplasia of the stomachAngiodysplasia of the stomach

Gastric varices

Mallory Weiss Tear Esophagitis

Diagnostic proceduresDiagnostic procedures

GI- EndoscopyGI- Endoscopy Can remove Can remove

polyps, coagulate polyps, coagulate active bleeding active bleeding sites, sites, sclerotherapy of sclerotherapy of esophageal esophageal varices, dilate varices, dilate strictures & obtain strictures & obtain biopsy samplesbiopsy samples

Often guided by Often guided by ultrasoundultrasound

Therapeutic EndoscopyTherapeutic Endoscopy

Endoscopic treatmentEndoscopic treatment Upper Endoscopy is the procedure of choice in Upper Endoscopy is the procedure of choice in

majority of patients with an acute upper majority of patients with an acute upper gastrointestinal bleeding, for the following gastrointestinal bleeding, for the following reasons: reasons:

– It can define the source of bleeding in the majority of It can define the source of bleeding in the majority of patients with an upper gastrointestinal bleeding.patients with an upper gastrointestinal bleeding.

– It can stratify the patients risk of rebleeding.It can stratify the patients risk of rebleeding.

– It can provide endoscopic therapy for esophageal and It can provide endoscopic therapy for esophageal and gastric varices, peptic ulcer disease, Dieulafoy's lesion, gastric varices, peptic ulcer disease, Dieulafoy's lesion, vascular malformations and tumors.vascular malformations and tumors.

Therapeutic optionsTherapeutic options

For Non variceal bleedingFor Non variceal bleeding

1. Injection therapy1. Injection therapy

2. Thermal energy2. Thermal energy

3. Endoscopic clipping 3. Endoscopic clipping

For Variceal bleedingFor Variceal bleeding

1. Sclerotherapy1. Sclerotherapy

2. Band ligation2. Band ligation

Injection TherapyInjection Therapy

Materials Endoscope Suction pumps Water jet Single-lumen injection needles for

epinephrine and polidocanol, double-lumen needles for fibrin glue Epinephrine 1:10 000 in physiological saline

solution, 1% polidocanol, fibrin glue

Duodenal ulcer (Clipping)Duodenal ulcer (Clipping)

Argon plasma coagulationArgon plasma coagulation

Esophageal Varices (Band Esophageal Varices (Band ligation)ligation)

Band ligation of esophageal varices

Therapeutic optionsTherapeutic options

Percutaneous endoscopic Gastrostomy & Percutaneous endoscopic Gastrostomy & jejunostomyjejunostomy

for PEJ ; paediatric colonoscope with 160 cm flexible for PEJ ; paediatric colonoscope with 160 cm flexible scope is used.scope is used.

Foreign body extraction.Foreign body extraction. Dilation of strictureDilation of stricture

Instruments used for foreign Instruments used for foreign body removalbody removal

Therapeutic EndoscopyTherapeutic Endoscopy

Small bowel enteroscopySmall bowel enteroscopy

Capsule endoscopyCapsule endoscopy Double baloon endoscopyDouble baloon endoscopy Paediatric colonoscopePaediatric colonoscope

Capsule EndoscopyCapsule Endoscopy


Capsule Endoscopy is a new technology that allows the doctor to see the middle part of the intestinal tract, the jejunum where no scope can currently go.

especially helpful in finding the source of unexplained intestinal bleeding and Crohn’s disease.

Patient swallows a wireless video camera about the size of a large vitamin

Patient goes normally about their day while the capsule records images throughout the digestive tract.


Capsule endoscopy is intended for visualization of Capsule endoscopy is intended for visualization of the small bowel mucosathe small bowel mucosa

It may be used as a tool in the detection of It may be used as a tool in the detection of abnormalities of the small bowel in adults and abnormalities of the small bowel in adults and children from 10 years of age and upchildren from 10 years of age and up

Diagnostic Indications


Capsule endoscopy is contraindicated for use under the following Capsule endoscopy is contraindicated for use under the following conditions:conditions:

In patients with known or suspected gastrointestinal obstruction, In patients with known or suspected gastrointestinal obstruction, strictures, or fistulas based on the clinical picture or pre-strictures, or fistulas based on the clinical picture or pre-procedure testing and profileprocedure testing and profile

In patients with cardiac pacemakers or other implanted electro In patients with cardiac pacemakers or other implanted electro medical devicesmedical devices

In patients with swallowing disordersIn patients with swallowing disorders

Severe gastro paresisSevere gastro paresis

Pseudo obstructionPseudo obstruction

Contraindications

DisadvantagesDisadvantages

No therapeutic facilityNo therapeutic facility Long duration of procedureLong duration of procedure It does not localize the exact site of the pathologyIt does not localize the exact site of the pathology

Double balloon enteroscopy Double balloon enteroscopy

In 2000 it was introducedIn 2000 it was introduced It consists of thin endoscope with 200cm length and It consists of thin endoscope with 200cm length and

over tube 145cm length.over tube 145cm length. Soft latex balloon is attached at the tip of both the Soft latex balloon is attached at the tip of both the

tubes which can be inflated & deflated.tubes which can be inflated & deflated. It can be inserted through duodenum or anusIt can be inserted through duodenum or anus

AdvantagesAdvantages a. Tremendous diagnostic & therapeutic purpose a. Tremendous diagnostic & therapeutic purpose

in small bowel.in small bowel.

b. Altered small bowel anatomy (patients who b. Altered small bowel anatomy (patients who require ERCP after Roux-en-y gastric by pass) require ERCP after Roux-en-y gastric by pass)

DisadvantagesDisadvantages

a. Long duration; 1-3 hrs to completea. Long duration; 1-3 hrs to complete

b. Needs expertise b. Needs expertise

c. Patient discomfortc. Patient discomfort

d. Needs general anesthesia d. Needs general anesthesia

Endoscopic Retrograde Endoscopic Retrograde CholangiopancreatogramCholangiopancreatogram

William mckune a surgeon introduced ERCP IN I968William mckune a surgeon introduced ERCP IN I968


IndicationsIndications Obstructive jaundice Obstructive jaundice

(benign or malignant)(benign or malignant) Ascending cholangitis Ascending cholangitis Gallstone pancreatitisGallstone pancreatitis Unexplained jaundice or Unexplained jaundice or

elevated LFT’selevated LFT’s Bile duct injury or leak Bile duct injury or leak

after cholecystectomyafter cholecystectomy Chronic pancreatitisChronic pancreatitis Pancreatic cancerPancreatic cancer Suspected Sphincter of Suspected Sphincter of

Oddi dysfunctionOddi dysfunctionConversly, the availability of Conversly, the availability of

ERCP should not be an ERCP should not be an indication for its liberal indication for its liberal use. use.

Patient preparationPatient preparation

Normal coagulation profiles are more relevant in Normal coagulation profiles are more relevant in ERCP, especially if sphincterotomy or endoprosthesis ERCP, especially if sphincterotomy or endoprosthesis insertion is contemplated.insertion is contemplated.

Prophylactic antibiotics are usually administered.Prophylactic antibiotics are usually administered. Oropharynx is anaesthetized with local anesthesia.Oropharynx is anaesthetized with local anesthesia.

I.V. sedation and glucagon (0.5-1.0 mg) administered I.V. sedation and glucagon (0.5-1.0 mg) administered to decrease duodenal motility.to decrease duodenal motility.

Position of the patient most commonly in “ PRONE Position of the patient most commonly in “ PRONE POSITION”.POSITION”.

The I.V. access is preferred in the Right hand. The I.V. access is preferred in the Right hand.

Diagnostic technique of ERCPDiagnostic technique of ERCP 90 degree side viewing scope is used.90 degree side viewing scope is used. Scope rides along the greater curvature towards the Scope rides along the greater curvature towards the

pyloruspylorus 7F cathetar with radio opaque tip is used for 7F cathetar with radio opaque tip is used for

diagnostic purpose.diagnostic purpose. Endoscopic spincterotomyEndoscopic spincterotomy

Indications; a. CholedocholithiasisIndications; a. Choledocholithiasis

b. Sphincter of oddi dysfunctionb. Sphincter of oddi dysfunction

c. Acute cholangitisc. Acute cholangitis

d. Stent placementd. Stent placement

e. Acute gall stone pancreatitise. Acute gall stone pancreatitis


Pancreatic cancer with dilated bile duct and pancreatic duct (Double Duct sign)


Gallstone impacted at ampulla, sphincterotomy being done and stones removed

Complications of EndoscopyComplications of Endoscopy

Perforation, more in therapeutic endoscopyPerforation, more in therapeutic endoscopy

AspirationAspiration

Pancreatitis, cholangitis, perforation & bleeding after Pancreatitis, cholangitis, perforation & bleeding after ERCP.ERCP.

Lower Gastrointestinal Lower Gastrointestinal EndoscopyEndoscopy

Chronic diarrheaChronic diarrhea Rectal bleedingRectal bleeding Iron deficiency anemiaIron deficiency anemia Unexplained abdominal Unexplained abdominal

painpain Constipation, change in Constipation, change in

bowel habits or stool bowel habits or stool calibercaliber

Unexplained weight lossUnexplained weight loss Evaluation of abnormal Evaluation of abnormal

Barium enema x-rayBarium enema x-ray Personal or family history Personal or family history

of colon cancerof colon cancer Personal history of IBDPersonal history of IBD

Control of bleedingControl of bleeding Removal of polypsRemoval of polyps Tumor ablationTumor ablation Dilation of strictureDilation of stricture Colonic decompressionColonic decompression Reduction of sigmoid Reduction of sigmoid

volvulus volvulus

Diagnostic Indications Therapeutic Indications


Contraindications to Lower GI EndoscopyContraindications to Lower GI Endoscopy

Uncooperative patientUncooperative patient Hemodynamically unstable patientHemodynamically unstable patient Suspected perforationSuspected perforation Suspected colonic obstructionSuspected colonic obstruction Suspected diverticulitisSuspected diverticulitis Soon after a myocardial infarctionSoon after a myocardial infarction Deep ulcerations Severe ischemic necroses Fulminant colitis

The sigmoidoscope measures only 60 cm in total length. Because of its high degree of maneuverability, it is sometimes used in patients where the indications for examination are limited to the sigmoid colon and rectum.

(Lower GI endoscopy)(Lower GI endoscopy) PreprocedurePreprocedure Consent formConsent form LaxativeLaxative

evening before evening before & enema or & enema or suppository 1 hr suppository 1 hr before Full liquid before Full liquid diet 1-3 days diet 1-3 days beforebefore

PEGLECPEGLEC


Normal Colon Colon Cancer

Therapeutic colonoscopyTherapeutic colonoscopy

Colon Polyp and Polypectomy

PolypPolyp

Schematic illustration of endoscopic mucosal resectionusing suction cap technique

a Colonoscope with suction cap and asymmetrical snare.b Submucosal injection with NaCl solution and epinephrine.c Lifting the flat lesion after submucosal injection.d Suctioning the flat lesion into the cap and resection with a snare.e Recovering the resected lesion by suction into the cap.

Future EndoscopyFuture Endoscopy ChromoendoscopyChromoendoscopy Narrow band imagingNarrow band imaging High resolution magnification endoscopyHigh resolution magnification endoscopy

GOALS;GOALS;

a. Recognition of early gastric and colorectal a. Recognition of early gastric and colorectal cancercancer

b. To allow accurate discrimination of dysplasia b. To allow accurate discrimination of dysplasia grade in areas of Barrett’s esophagus or grade in areas of Barrett’s esophagus or quiescent quiescent ulcerative colitis ulcerative colitis

c. To aid polyp detectionc. To aid polyp detection

ChromoendoscopyChromoendoscopy

The most widely available techniqueThe most widely available technique

Chromoendoscopy refers to the intravital staining of epithelial structures during the endoscopic examination

It involves the topical application of stains or It involves the topical application of stains or pigments to improve tissue localization, pigments to improve tissue localization, characterization or diagnosischaracterization or diagnosis

Stains used in chromoendoscopy

Absorptive stains − Lugol solution − Methylene blue − Toluidine blue Contrast stains − Indigo carmine Reactive stains − Congo red − Phenol red

Absorptive stains are taken up by specialepithelial cells and can differentiate cells according to whetherthey are stained or unstained. Contrast stains cause relativelymarked enhancement of intestinal mucosa and are often used inmagnification endoscopy. Reactive stains are used to identifycertain secretions in which the stain induces a color reaction

Magnification Endoscopy

Principle. Magnification endoscopy, known also as zoom endoscopy, can be used for the detailed endoscopic evaluation of suspiciousareas, especially after staining

Endoscopic UltrasoundEndoscopic Ultrasound

The ultrasound probe is The ultrasound probe is placed at the tip of the placed at the tip of the endoscopeendoscope

Allows ultrasonography of Allows ultrasonography of organs from a close distanceorgans from a close distance

Individual layers of the GI Individual layers of the GI wall are visualized as five wall are visualized as five distinct layers of alternating distinct layers of alternating hyper and hypo ecogenicity hyper and hypo ecogenicity

Can be used to take fine Can be used to take fine needle aspiration samples needle aspiration samples from adjoining from adjoining regions/organsregions/organs

Endoscopic UltrasoundEndoscopic Ultrasound

A T3 Rectal Tumor on EUS

Indications of EUSIndications of EUSPANCREATICPANCREATIC a. FNAC of malignancya. FNAC of malignancy b. Drainage of fluid collectionsb. Drainage of fluid collections c. Lymph node samplingc. Lymph node sampling d. Assess portal venous systemd. Assess portal venous system e. Intraductal ultrasounde. Intraductal ultrasoundHEPATOBILIARYHEPATOBILIARY a. Detect stonesa. Detect stones b. Periportal lymph nodesamplingb. Periportal lymph nodesampling c. Biopsy of liver massc. Biopsy of liver mass ESOPHAGEALESOPHAGEAL a. Esophageal cancer staginga. Esophageal cancer staging GastricGastric a. Gastric cancer staging a. Gastric cancer staging b. Evaluation of submucosal massesb. Evaluation of submucosal masses

principles and practice of gi endoscopy

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