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Endoscopic ultrasonography-guided celiac plexus interventions and fiducial placement

Key points Endoscopic ultrasonography (EUS)-guided celiac plexus interventions consist of the injection of neurolytic agents or steroids into ganglia to produce neurolysis or temporary block. Celiac plexus block or neurolysis is the most common EUS-guided intervention in current practice. Significant pain control is achieved with the injection of ethanol in the setting of pancreatic cancer. More modest results are seen in patients with abdominal pain arising…

Endoscopic ultrasonography-guided gallbladder drainage

Key points In patients who are unfit for surgery, percutaneous drainage, endoscopic transpapillary drainage and EUS-guided drainage are all effective and safe alternative procedures to cholecystectomy EUS-guided drainage is preferred over percutaneous technique due to similar rates of technical success and reduced rates of reintervention and unplanned readmission EUS-guided drainage is associated with a steeper learning curve and should be performed only in high-volume endoscopy centers…

Endoscopic ultrasonography-guided drainage of the biliary-pancreatic ductal systems

Key points Endoscopic ultrasonography-guided biliary drainage (EUS-BD) is now generally preferred over percutaneous methods in patients with biliary obstruction and failed biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP), and should be considered in those with an inaccessible papilla. EUS-BD is gaining popularity as an alternative for patients with nonresectable malignant hilar strictures and inadequate drainage of the left liver lobe by ERCP. EUS-guided pancreatic duct drainage…

EUS-guided drainage of pancreatic and intraabdominal fluid collections and pelvic abscesses

Key points Recognition of different types of pancreatic fluid collections is crucial for appropriate management. EUS-guided drainage is the treatment of choice in the management of pancreatic pseudocysts, with clinical outcomes comparable to surgical cystogastrostomy. The management of walled-off necrosis (WON) is more complex. If the percutaneous/surgical and the endoscopic approach are both feasible and available, the endoscopic approach is preferred. Management is multidisciplinary and is…

Cytology primer for endosonographers

Key points Communication between the endosonographer and the cytopathologist is the key to a successful EUS FNA service. A cytopathology service should be involved early in the planning process for establishing an EUS-guided tissue acquisition service. Using an algorithmic approach to diagnosing a patient will facilitate a correct diagnosis. Conceptual breakthroughs, based on developed theories, and discoveries in science bring accolades. Advances in the biotechnology field…

How to perform endoscopic ultrasonography-guided fine-needle aspiration and fine-needle biopsy

Key points Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) with cutting-type needles has replaced EUS-fine-needle aspiration (FNA) as the current gold standard for optimal tissue acquisition. EUS-FNA with or without cell block remains an excellent alternative when access to FNB is limited or deemed unnecessary. 22-g needles provide better histological yield when performing FNB on solid masses, but 25-g needles should be used for FNA. 19-g FNA…

Evaluation of the anal sphincter by anal endosonography

Key points Anal endosonography (AES) is simple to perform and visualizes the anal sphincter complex, notably the external and internal anal sphincters. AES is able to image sphincter tears and defects. AES can also characterize sphincter morphology and determine muscular quality. AES is the single most important investigation for patients with anal incontinence. Introduction First described in 1989, anal endosonography (AES) was the first technique to…

Endoscopic ultrasonography in rectal cancer

Key points The importance of nodal status guiding therapeutic decision making is increasingly recognized for rectal cancer. Endoscopic ultrasonography (EUS) fine-needle aspiration or biopsy (FNA or FNB, respectively) is recognized as being an essential component of locoregional clinical staging. Although EUS still has insufficient accuracy for T-staging, EUS FNA can accurately predict patients who have evidence of iliac vessel node disease by upstaging 7% of patients…

EUS in bile duct, gallbladder, and ampullary lesions

Key points In patients with low-to-moderate clinical probability of common bile duct (CBD) stones, EUS or MRCP is recommended before endoscopic retrograde cholangiopancreatography (ERCP) is performed. In patients with acute pancreatitis of unknown origin or right upper quadrant pain with normal transabdominal ultrasound, EUS should be considered. In patients with a CBD stricture of unknown origin, EUS should be performed and, if inconclusive, ERCP should follow…

Endoscopic ultrasonography in the evaluation of pancreatic cysts

Key points The differential diagnosis of pancreatic cystic lesions is wide: the majority of these lesions are benign, but detection of mucin-producing pancreatic cysts (IPMNs and MCNs) is important because these cysts have malignant potential and may harbor pancreatic adenocarcinoma. The diagnostic accuracy of EUS based on morphology alone is limited. A combination of EUS features, fluid cytology, CEA, and molecular markers is used to differentiate…

Endoscopic ultrasound and pancreatic tumors

Key points Endoscopic ultrasound (EUS) is the most sensitive imaging modality for the diagnosis of pancreatic ductal adenocarcinoma, especially lesions less than 2 cm in size. EUS is also the most sensitive imaging modality for the detection of small pancreatic neuroendocrine tumors (PNETs) and is superior to both computed tomography (CT) and magnetic resonance imaging (MRI). CT is the most accurate modality for the determination of…

EUS in inflammatory diseases of the pancreas

Key points EUS imaging is subjective and often nonspecific in inflammatory diseases of the pancreas; therefore, the clinical history and presentation are important when making a final diagnosis. EUS fine-needle aspiration (FNA) in inflammatory diseases of the pancreas is predominately used to exclude/diagnose superimposed malignant processes; the role of fine-needle biopsy (FNB) remains to be defined. Complementary imaging modalities such as elastography and contrast-enhanced imaging are…

How to perform an endoscopic ultrasonography examination of the pancreas, bile duct, and liver

Pancreas Successful pancreatic imaging requires the ability to image the entire gland. In general, the body and tail of the pancreas are imaged through the posterior wall of the stomach, and, in most cases, the transgastric approach provides images of the genu (neck) of the pancreas as well. Complete imaging of the pancreatic head, however, requires placement of the transducer in three different positions within the…

Subepithelial lesions

Key points EUS can accurately differentiate a mural lesion from extrinsic compression against the gut wall. Imaging diagnosis of subepithelial lesions with EUS is based on its layer of origin and internal echo characteristics. Contrast-enhanced harmonic EUS and EUS elastography can help to differentiate and predict malignancy potential of subepithelial lesions. EUS-guided tissue acquisition is useful for pathologic diagnosis of subepithelial lesions. Endoscopic therapeutic methods for…

Endoscopic ultrasound in the evaluation of posterior mediastinal lesions and lung cancer

Key points Criteria exist to differentiate benign from malignant mediastinal lymph nodes, but used alone, these criteria are not sufficiently accurate. Endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) for cytopathologic evaluation is required to make sound clinical decisions. The overall accuracy for the diagnosis of posterior mediastinal malignancies with transesophageal EUS FNA is greater than 90%. EUS FNA and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are the…

Endoscopic ultrasonography in esophageal and gastric cancer

KEY POINTS EUS is useful to stage newly diagnosed esophageal and gastric cancer with no metastatic disease on CT +/- PET – EUS is most accurate in distinguishing between T1-2 versus T3-4 disease, and in the staging of more advanced disease. EUS has a limited role in staging superficial esophageal and gastric cancer EUS-guided fine needle aspiration or biopsy of suspicious lymph nodes or metastatic disease…

How to perform an EUS examination of the esophagus and mediastinum

Esophagus Obtaining high-quality images of the esophageal wall is one of the more difficult tasks that an endosonographer will encounter. One has to deal with the “catch 22” that pits adequate coupling of the ultrasound signal to the esophageal wall against wall compression. This situation can lead to inaccurate assessment of invasion depth in patients with early esophageal cancer or to missing lesions completely in the…

New techniques in EUS: Multiparametric endoscopic ultrasound imaging

Key points EUS has improved considerably in the past years through the development of real-time EUS elastography, contrast-enhanced EUS, and fusion EUS imaging. Real-time EUS elastography provides qualitative and semiquantitative data about tissue stiffness, possibly allowing differentiation of benign and malignant tumors. Shear-wave elastography will certainly bring additional quantitative data. Contrast-enhanced harmonic EUS using specific software (with low mechanical index capabilities) is already established as a…