eus beyond mucosa and beyond gastroenterology
DESCRIPTION
introductory about EUS, indications and frontiersTRANSCRIPT
EUS beyond mucosa and beyond Gastroenterology
Ahmed Alwassief MD
• A novel technology that combines visualisation of the mucosa and radiologic power to see beyond “ deep to the mucosa”
• The role of EUS has continued to expand with the introduction of EUS-guided fine needle aspiration (FNA) of mural, extra-mural, and pancreatic lesions.
• In the year 2000 guidelines for the use of EUS were established
• Equipment
• Technique
• Indications
• Staging cancers
• Benign disease
Equipment
• Radial
• Linear
Technique
• Preparation– As for normal upper GI endoscopy
• Sedation– Alfentanyl and midazolam– Propofol
• Antibiotic prophylaxis– Usual indications + biopsy / therapeutics
Indications• Staging cancers
– Oesophageal, gastric, rectal & pancreatico-biliarySpecifically for nodal disease and FNA
• Confirming EMR potential– T1 disease, excluding sub-mucosal involvement
• Diagnosis and follow up of benign lesions– GIST, lipoma, cysts
• Investigating RUQ pain “Choledocholithiasis”• Investigating pancreatitis• Therapeutic Techniques: celiac neurolysis, fudicial placment,
cyst gastrostomy , Hepatico-gastrostomy, pancreatico-doudenal fistulotomy
Staging
Hyperechoic mucosaHypoechoic muscularis mucosaHyperechoic submucosaHypoechoic muscularis propriaHyperechoic serosa
• T lesion, adenocarcinoma in lower thoracic esophagus with central depression shown by yellow arrow (a); endoscopic ultrasound (EUS)
• image showing submucosal invasion but no involvement of muscularis propria (MP) shown by yellow arrow (b).
• T3N2Mx lesion
• Gastric lymphoma causing a linitis plastic appearance. This patient with a diffusely infi ltrating B - cell lymphoma has poorly distensible thickened abnormal - appearing gastric folds on endoscopy (a). On endoscopic ultrasound (b), there is preservation of the fi ve - layer pattern but markedthickening of the gastric wall to 10.9 mm with a thickened muscularis propria to 2.5 mm (normal 1 mm or less).
Gastrointestinal Subepithelial Masses
Gastric varices
Pancreatic masses “ Solid & cystic”
• The detection of pancreatic masses < 2cm in diameter was higher for EUS:
EUS (100%) ERCP (57%) TUS (29%) CT (29%) Angiography (14%)
Pancreatic cysts
• Pseudocyst• Serous• IPMN• Mucinous Can be diagnosed by 1.Morphology2.FNA and cyst fluid analysis of Amylase and
CEA levels
8 cm Pseudocyst + debries
T3 Pancreatic Adenocarcinoma
T3 Pancreatic Tumor
Fine Needle AspirationFine Needle Aspiration
Pancreatic Mass
Liver Metastasis
EUS-Guided FNA
Reported Complications:
• Infection (cysts >>solid mass)• Pancreatitis (<1- 2%)• Bleeding
Biliary diseases
Therapeutic EUS
• CPN and CPB• Botulinum injection in achalasia• EUS-guided Ablation of tumors and cysts
Radiofrequency, or alcohol injection• EUS-guided placement of radiographic
markers• EUS-guided drainage procedures “ cysts,
abscesses, CBD, hepatic duct and pancreatic duct”
Chronic Abdominal Pain& CPB or CPN?
• Can be a clinically challenging problem especially if narcotic analgesia is indicated
At that point CPN or CPB can help in
• Pain relief• Improving quality of life
Celiac Plexus BlockCeliac Plexus Block
EUS Guided radio-frequency or ETOH tumor ablation
EUS GUIDED Hepatico-Gastrostomy
Panc. cancer
EUS GUIDED CHOLEDOCHO-DUODENOSTOMY
Extra Gastrointestinal applications
EUS guided Mediastinal LN biopsy
PA
LA
