introductory about EUS, indications and frontiers

1. EUS beyond mucosa and beyond
Gastroenterology
Ahmed Alwassief MD

2. • 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

3. • Equipment
• Technique
• Indications
• Staging cancers
• Benign disease

4. Equipment
• Radial
• Linear

6. Technique
• Preparation
– As for normal upper GI endoscopy
• Sedation
– Alfentanyl and midazolam
– Propofol
• Antibiotic prophylaxis
– Usual indications + biopsy / therapeutics

7. Indications
• Staging cancers
– Oesophageal, gastric, rectal & pancreatico-biliary
Specifically 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

8. Staging

9. Hyperechoic mucosa
Hypoechoic muscularis mucosa
Hyperechoic submucosa
Hypoechoic muscularis propria
Hyperechoic serosa

10. • 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).

11. • T3N2Mx lesion

12. • 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).

13. Gastrointestinal Subepithelial Masses

15. Gastric varices

16. 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%)

17. Pancreatic cysts
• Pseudocyst
• Serous
• IPMN
• Mucinous
Can be diagnosed by
1.Morphology
2.FNA and cyst fluid analysis of Amylase and
CEA levels

18. 8 cm Pseudocyst + debries

19. T3 Pancreatic Adenocarcinoma

20. T3 Pancreatic Tumor

22. Fine Needle AspirationFine Needle Aspiration

23. Pancreatic Mass

24. Liver Metastasis

25. EUS-Guided FNA
Reported Complications:
• Infection (cysts >>solid mass)
• Pancreatitis (<1- 2%)
• Bleeding

26. Biliary diseases

27. 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”

28. 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

29. Celiac Plexus BlockCeliac Plexus Block

30. EUS Guided radio-frequency or ETOH tumor
ablation

31. EUS GUIDED Hepatico-Gastrostomy
Panc. cancer

32. EUS GUIDED CHOLEDOCHO-DUODENOSTOMY

34. Extra Gastrointestinal applications
EUS guided Mediastinal LN biopsy
PA
LA