Eus beyond mucosa and beyond gastroenterology

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